Dry Drowning: Feedback

The response from readers about the Walt Bammann's experience with a dry drowning (laryngospasm) incident was excellent. It's a condition that's not well known, but has the potential to cause boating fatalities.

Several readers gave feedback on the article, by email and phone, from personal and professional experience. Thanks to all of you who responded.

Here we're printing a selection of the responses we got. Important note: we're merely passing along what some of you have sent us. We're not medical professionals (though some of the respondents are), so we can't verify any of the information below. We believe that this is an important safety issue and want to broaden the circle of information.

So, here's a selection of what some of you had to say:

"As a retired nurse anesthetist, I just wanted to let you know that after a laryngospasm has resolved, it is still possible to have pulmonary edema as an after effect. This does not require the inhalation of water, but is a result of huge pressure in the chest which results in fluid being forced into the lungs from the circulation. In the two or three cases which I saw in the recovery room, all of the victims were healthy, strong, young men. The symptoms would be a cough and frothy, pinkish sputum. It should be evaluated and treated. Thanks for the interesting article; scary situation."

Nora Connell
(Nora is a touring kayaker in the Chesapeake Bay area.)

Phone conversation with Dr. Bob Fisher DO, Anesthesiologist

Dr. Fisher has been interested in the issues around drowning, personally and professionally, for some time. He reports experiencing laryngospasm in patients from time to time in his medical practice.

He describes laryngospasm as the body's defense mechanism for preventing fluids or objects from entering the lungs. The vocal cords in the larynx, or voice box, involuntarily clamp shut, closing off the trachea (windpipe) and blocking fluids, and consequently air, from entering the lungs.

This involuntary reflex can be triggered by a number of things including fluids touching the opening of the larynx. Dr. Fisher relates that it can occur as a post-surgery complication and that cold, as in a sudden plunge in cold water, can also trigger it. He says that smokers can be susceptible because their throats are made more sensitive by the irritation of inhaled tobacco smoke. People who suffer from acid reflux, or heartburn, where stomach acids are brought back up and irritate the throat can also be predisposed to laryngospasm.

He goes on to report that it's not possible to die from laryngospasm, as long as there's air to breathe. As the oxygen level in the blood drops and before the person loses consciousness, the muscles that have contracted the larynx will relax, opening the airway. Where the person can die is if they are face down or under water, and renewed breathing sucks water into the lungs, resulting in drowning.

Dr. Fisher goes on to suggest that any boater who has experienced laryngospasm or feels they may be susceptible to it should always wear a good fitting life jacket when on the water. Also, they should consider using a PFD that is designed to float an unconscious face up. This type of PFD has significantly more of its foam flotation in the front of the jacket. Additionally they should let their paddling partners know of their susceptibility, so they can be alert to quickly offer aid if needed.

He also reinforces what was stated in Walt Bammann's original article, that the airway can be opened by giving a rescue breath. That is, starting CPR breathing and blowing air into the victim by mouth. It is always prudent to open the victim's mouth to see if debris or liquid is present first. Debris may be removed with a cautious finger sweep and liquid will drain out if the victim is 'logrolled' to their side. If they are still unresponsive a breath may be applied.

Editors note: Bob looked over the above summary of our phone conversation for accuracy. He also expanded on the issue that Nora Connell reported above. Breathing is accomplished by the expansion and contraction of the muscular diaphragm. During a laryngospasm, since the airway is blocked, when the victim tries to breathe the contraction of the diaphragm pulls a "partial vacuum" in the lungs. A fit, muscular person can create enough vacuum to actually pull fluids from the tissues surrounding the lung into the cavities of the lung itself.

Thanks for the article on "Dry Drowning", I found it quite interesting in that it fits an experience that I have had on several occasions. First let me say that I have a history of problems in my esophagus that has led to several episodes of restricted airways or a choking type of sensation over the years. I control this with medication so it is not a regular problem.

A couple of years ago I had this same sort of thing happen after flipping my canoe in a rapid. My thought at the time was that my body was just reacting to the shock of the quick trip into the water but now I understand better how something like this can happen.

What is interesting is that it happened twice in a fairly short time frame but neither was in a particularly big rapid, actually both were while "playing" in known rapids with no fear of anything serious happening. I just hit the water and lost the ability to get a good breath of air. I did not panic as it was similar to the problems that I had before which were food related, not water or shock related. I just kept calm and floated for a bit until I could "catch my breath." In one instance another paddler nearby asked if I was okay as he said I looked a bit funny and was not talking. I indicated that I would be fine and then just relaxed in the water and it went away.

I have since swam in larger rapids and did not have the sensation so it does appear to have some sort of trigger. My guess is that because of my existing problems I am more apt to have something like this happen and will be sure that my paddling partners know of the issue in case it were to happen again.

Again my thanks for the information.

Si Brantley
(Si says further that he has been paddling for about 30 years and never without a life jacket.)

One of the notes from Charlie Walbridge at the end of the article makes the point that cold water seems to be a culprit in setting off laryngospasm. I have heard this same thing many times from fellow sea kayakers here on the Atlantic coast. As someone whose favorite words on NOAA radio are "small craft advisory," I can attest to the value of a hood and helmet to attenuate the shock of cold water.

Yesterday (11/6/07), we had gusts registering at near gale on the Beaufort scale in the Chesapeake and the water temp is dropping like the leaves. I put on my NRS Storm Hood and then slid through the neck gasket on my dry suit for a super warm and toasty neck seal. Add the helmet and PFD (because you never know) and you're good to go. I may look like an extra from a Star Trek pilot episode (my girlfriend took a picture of me making the Vulcan hand sign), but I'm warm around the neck and head.

It's not fool-proof, but everything I've read suggests that this is pretty much the gold standard for safety. Now that the wind has died down a bit, I'm back indoors doing work and sending emails. Bah!

Mat Rose
(Mat further reports that he's been a firm believer in wearing a helmet while sea kayaking since a catamaran from a sailing school ran right over the bow of his boat.)

I am a retired Certified Registered Nurse Anesthetist (CRNA). In 40+ years of practice, I have "broken up" many laryngospasms. To be able to do this in the controlled setting of an operating room, ICU, or emergency department is one thing, but to deal with the phenomenon in or along a river would be a whole ‘nuther matter!

The use of positive pressure oxygen is usually the quickest thing to do. It's usually effective fairly quickly. This would involve the use of an anesthesia gas machine, or a rescue bag/valve/mask. Of course, anesthesia personnel have an array of drugs to use, as well.

In the water, as your article describes, it would follow that rescue breathing would be effective. It would be very important to position the head and neck as best as could be, so as to open the airway to maximum advantage. Air pressure blown into the mouth has several places to go, one of them being the esophagus and stomach. This could cause a rebound of stomach contents—further endangering the airway, besides compounding the mess.

Few things would be more alarming than the situation described in the first person in your article! The airway is protected by probably the strongest, most insistent reflexes in the body. A person experiencing this would certainly be taken up totally with solving his airway crisis, and things like locating equipment wouldn't happen. That sure points to the need to be aware of others in the situation.

Thanks again for you ongoing efforts in safety education.

Karen Moore
(Karen paddles a lot with a group called Outdoor Women of South Dakota. She and her best friend, Sarah Nelson, regularly give canoe and kayak demonstration presentations, doing their best to spread the news about the joys of boating.)

Editors note: The original article, Bob and Karen all mention using rescue breathing to "unlock" a closed larynx. The best way to learn the proper technique for doing this is by taking a Cardiopulmonary Resuscitation (CPR) class. This class, which is part of First Aid Training, is something that all of us boaters should take, to prepare ourselves for dealing with on-the-water emergencies.

I work in natural medicine. There is a trigger release point at the base of the throat/neck that is useful for stopping bronchial spasms, asthma attacks, and even hiccups. I wonder if it might be helpful for this condition too? This point can easily be reached and manipulated by the afflicted individual so you do not need to depend on outside help to do this.

To locate this point on yourself, take your index finger and trace down the length of the front of your neck until you feel the V of the collar bone. You will be working with the soft area just above this bone. Once you arrive at this spot, take your index finger and slowly but with even pressure start pushing your finger in towards the back of the neck. You do not want to move straight back but instead you want your finger to travel back and down at a slight angle just past the V in the collar bone. You should be able to feel a slight pressure on the trachea. You will know that you have found the right spot when the constriction of the spasms release. Hold this spot with your finger for about 10 - 20 seconds. Slowly begin releasing the pressure on the point. If you feel the spasm returning, reapply pressure to the point and try again. If the spasm does not abate, try shifting your finger position and trying again.

I would encourage people to experiment with finding this point during a less traumatic time such as a hiccupping episode. You will know you have the right spot because the urge to hiccup immediately stops and you will be familiar with how pressing on this trigger point feels should you ever need it during a more dire emergency.

Margit Maxwell
(Margit and her husband are kayakers.)

Editor’s Note: The tragic death, that was attributed to dry drowning, of a 10-year old South Carolina boy has brought additional feedback on the subject. Here are comments from Walt Bammann, the writer of the original article, and two other readers:

I did hear about the recent incident with the child dying later after apparently inhaling pool water. It wasn't a laryngospasm but definitely an odd way to "drown."

Glad my article has helped. I haven't fallen in a river since, so don't know what the outcome will be. I still boat but haven't been excited about doing rivers where my odds of swimming are high. It is one extremely uncomfortable feeling, to say the least, and I prefer to never suffer it again.

Oddly, right after I wrote the article, my brother and I were talking about it and he told me he suffered two laryngospasms while swallowing cough syrup. Seems he had a bad cough and let the syrup trickle down the back of his throat, and his larynx spasmed. Not knowing what was happening he prepared to pass out, but it relaxed after a minute. Then, stubborn as he is, he tried it again: same result! So, I’m not sure if there might be a genetic tendency here, but it’s something to ponder.

Keep me posted as the subject is of huge interest to me and I'm still trying to figure out a few things.

I'd love to chat with a doctor or coroner to learn how they would know someone "dry drowned" if water is found in the lungs; how they would determine if it was "actively" breathed in or just flowed in. In one of your feedback comments, the doctor said that the larynx would relax before you go unconscious. This would seem to indicate that one would then inhale. See the confusion I'm having?

I'm also baffled as to why my larynx relaxed the moment I sat on that rock on the bank. Is there a psychological element here? Questions, questions…

Thanks again,
Walt

I am a 58 year old biologist. Ex-smoker with frequent, if not chronic, heartburn. I also have a deviated septum, which results in my breathing through my mouth on a frequent basis. I have had my larynx "lock-up" on me several times.

1. "Swallowing down the wrong pipe" has triggered episodes (liquids).
2. Seeds and crumbs (i.e. rice, sesame seeds, toast crumbs) have triggered attacks.
3. Stomach acid (coughed up when I have heartburn) has triggered attacks, mostly when sleeping or lying down. (A most RUDE way to wake up).
4. My doctor confirms you should begin breathing when you pass out (haven't gotten that far, yet).
5. As oxygen/CO2 build up, so will pressure. Try forcefully breathing OUT and GENTLY breathing in. Keep trying and keep cool.

Thanks for the tips!

Greg Van Stralen

I, too, experience this horrifying phenomenon. I had never heard of the idea that a splash of water could set this off, but it makes a lot of sense to me as I have had a terrible episode while in the shower, and several while eating foods that make my mouth water. I have learned to control the frequency and severity of the attacks by:

1. I am very careful to take small bites of fruit, and be aware while chewing/ swallowing not to let my mouth fill with secretions.
2. When chewing gum, I only chew very small pieces. This way I can also swallow frequently as my mouth waters while the piece of gum is new.
3. If an attack occurs, I do my best to remain calm. I used to panic every time, which made it much worse. Now I try to tell myself this will pass, and make sure I am near someone in case it doesn’t.

Another piece of advice I can give: If this has ever happened to you once, it will probably happen again. Tell your loved ones, co-workers, and anyone else you spend a lot of time with. The first time my husband saw me have an attack, he panicked himself. Now that he is aware, he knows what to do and this helps me remain calm.

Michele Armstrong

Boat Often & Boat Safe,
Clyde