What is the presentation, workup, and diagnosis of delayed drowning (also known as secondary drowning or dry drowning)?

From the Guidelines

Dry drowning is a term that should not be used, as it is not a medically recognized condition, and instead, the focus should be on the diagnosis and management of drowning-related respiratory symptoms. Presentation typically includes coughing, chest pain, difficulty breathing, extreme fatigue, and altered mental status that occurs within 24 hours after water exposure. The workup should begin with a thorough history of the submersion event, followed by a physical examination focusing on respiratory status, oxygen saturation, and neurological assessment.

Diagnostic Approach

Diagnostic tests include:

• Chest X-ray to identify pulmonary edema or aspiration pneumonia
• Arterial blood gases to assess oxygenation and acid-base status
• Continuous pulse oximetry monitoring Diagnosis is based on the combination of a recent history of water submersion or struggle in water, followed by the development of respiratory symptoms despite initial recovery.

Management

Management includes:

• Supplemental oxygen as needed
• Close monitoring for deterioration
• Hospital admission for observation in symptomatic patients In severe cases, mechanical ventilation may be required. The pathophysiology involves either laryngospasm leading to hypoxia without significant water aspiration, or delayed effects of small amounts of aspirated water causing inflammatory damage to the alveolar-capillary membrane, as described in the Utstein style guidelines for uniform reporting of data from drowning 1. It's essential to note that all submersion victims with any symptoms should be evaluated promptly, as respiratory complications can develop rapidly even after seemingly minor incidents, and immediate resuscitation to restore oxygenation and ventilation is crucial for survival after a drowning incident 1. Additionally, the routine use of abdominal thrusts or the Heimlich maneuver for drowning victims is not recommended, as it is unnecessary and potentially dangerous 1.

From the Research

Presentation of Dry Drowning

• Dry drowning is a term that is often misunderstood, and its existence is debated among medical professionals 2
• According to the World Health Organization, drowning is defined as "the process of experiencing respiratory impairment from submersion or immersion in liquid" 3
• The presentation of dry drowning is not well-defined, but it is often associated with respiratory impairment without the presence of water in the lungs

Workup and Diagnosis of Dry Drowning

• The diagnosis of dry drowning is often made based on the patient's history and physical examination, rather than on specific laboratory or radiological findings 4
• The workup for dry drowning typically involves assessing the patient's respiratory status, including oxygen saturation and lung function tests 5
• The Szpilman classification system can be used to grade the severity of drowning, including dry drowning, based on the patient's clinical presentation and respiratory status 5

Pathophysiology of Dry Drowning

• The key pathophysiological feature of drowning, including dry drowning, is hypoxia, which can lead to respiratory impairment and other systemic complications 3, 6
• The aspiration of water into the airways can cause coughing, acute lung injury, and altered oxygen exchange, leading to respiratory impairment 3
• The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability can result in decreased lung compliance, increased right-to-left shunting, atelectasis, and alveolitis, a noncardiogenic pulmonary edema 3

Treatment and Management of Dry Drowning

• The treatment of dry drowning typically involves supportive care, including oxygen therapy and ventilation, to manage respiratory impairment and prevent further complications 4, 5
• Non-invasive ventilation (NIV) can be effective in managing pulmonary edema and improving oxygenation in patients with dry drowning 5
• The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions, as well as the need for close monitoring and supportive care 3