Swimming-Induced Pulmonary Edema in Open-Water Sports: Implications for Athlete Health and Event Medical Care — A Narrative Review

Abstract

Background: Swimming-induced pulmonary edema (SIPE) is an uncommon but potentially serious complication of open-water swimming and triathlon. For event medical teams, the challenge extends beyond diagnosis to safe extraction, race-side assessment, respiratory support, and decisions about transfer or discharge.
Objective: To review the clinical, physiological, and event-medicine literature on SIPE and develop a practical framework for medical care at mass-participation open-water events.
Methods: We searched PubMed/MEDLINE and supplemented the search with Google Scholar, Semantic Scholar, Crossref, publisher websites, and citation tracking. Because the review was intended to inform event medicine, studies conducted in mass-participation settings were given greatest weight, with military, diving, physiological, and other clinical literature used when directly relevant.
Results: Direct event evidence is concentrated in a small number of overlapping Vansbro cohorts. In symptomatic swimmers, pulse oximetry and auscultation performed well against LUS-confirmed pulmonary edema; at one low-altitude event, SpO₂ ≤95% or crackles gave 97% sensitivity and 86% specificity. These figures are specific to that setting. Lung ultrasound can add useful information, particularly because edema may be focal or anterior. CPAP and PEP have both been used on site with clinical improvement in observational data, but the available observational data do not establish comparative effectiveness. Crackles and B-lines may persist after symptoms and oxygenation improve. Severe, atypical, or non-resolving presentations require escalation.
Conclusions: The literature supports a coherent sequence of event care: preparation, recognition, extraction, assessment, supportive treatment, reassessment, and a decision between escalation and stable disposition, followed by handover and follow-up. The framework proposed here is intended as a practical aid for local adaptation, not as a validated clinical protocol.