Atelectasis from packing — I had a hole in my lung. How? What? Learnings.
I had a hole in my lung and air leaked to places where it should never be — including my chest, neck muscles and underneath the skin. This happened while doing breathing exercises (packing) for freediving on dry land. What it feels like? How it happened? What I learned from it?
You should read this post if:
- You just want to know what it feels like to be a human bubble wrap — have air trapped in your neck muscles and underneath the skin
- If you are a fellow freediver and want to learn from my stupidity/bad luck.
- If you are a medical doctor specialised in diving/pulmonary injuries — in this case please do share your opinion on when I can return to freediving. And what should I do before?
Something doesn’t feel right
I had an amazing day of actually witnessing how my training was paying off by doing dry land breathing exercises in the morning. Holding my breath without having any contractions for 3 minutes seemed easy — I knew that I was ready to hold my breath for longer than 5 minutes if I wanted to.
But now I was about to have dinner with my friends at the freediving school and something was feeling waaaay off: “It feels like there is 10kg weight placed on my chest… Also, feel like something is strangling me and all my neck muscles are super sore as if from training. And it feels funny to swallow and funny to say some vowels.”
I placed my hand on my neck to examine the situation — it was swollen up, ok… but also I felt something that i have never felt before — it was as if something had popped under my fingers. It felt a little like popping bubble wrap.
I went to the doctor on the island and we reached a conclusion that it cannot be pneumothorax (collapsed lung) which would normally result this kind of symptoms since I didn’t do anything dangerous— did some breathing exercises on dry land; plus we couldn’t replicate the weird feeling under my fingers and the breathing was superb. The doc diagnosed sore muscles and I went home to bed.
Throughout the night the chest pain got worse and the next morning I could very clearly feel the air popping under my fingers again — I messaged the doctor and I was on my way to the hospital on main land to take my x-rays.
Turned out I did have a mild leakage from the good old lung —atelectasis . And air had made its way into my mediastinum (a membranic sack holding the heart and it’s blood vessels and many more interesting things of the such). In medical world this is called pneumomediastinum and explains the chest pain. Some of it had also travelled into my neck: underneath the skin (subcutaneous emphysema) and into the muscles pushing on my throat and vocal chords.
Back to basics
Before we get into what happened, need to explain two things: 1) how lungs work 2) wtf is freediving.
1) Lungs 101 for them non-doctors out there
Good news is that they give you 2 of these — if you happen to break one.
The lungs sit in the sub-cavity within Thoracic cavity called Pleural cavity. The heart, which is the biggest neighbour of the lungs are separated together with other bits and bobs by a little membrane sack called Mediastinum.
Against common misconception, lungs are not two big bags that hold air for breathing. Lungs are a very cool structure that consists of miniature air pockets called Alveoli that are connected to the main airways by Bronchioles (small air pipes).
Each little Alveoli is less than half a millimetre in diameter and you have around 300 million of those little things in your chest. Each one of these air pockets is covered with miniature blood vessels (capillaries) only wide enough to fit red blood cells that transport oxygen/CO2 around your body. This provides you with 140 square meters of area where the oxygen in the air can enter your blood and CO2 can make a run for it. This is more than the size of a tennis court!
When you breathe in, then the breathing muscles expand the chest cavity and the air travels through the airways to Bronchioles and then to Alveoli causing them to expand. When you breathe out, the opposite happens. There is always enough air in the Alveoli so they never completely collapse. Even when you force exhale as much air out as you can. Needless to say, air should never make its way out from the lungs unless its the atmosphere.
2) Freediving 101 for them non-diving folk
Freediving is a sport where you dive on a single breath of air. A normal dive session would consist of:
- Breathe-up (5–6 minutes)
- Taking a full breath of air
- Dive (1+ minutes / 20+ meters)
- Recovery breathing (1 minutes)
I do this because I love the meditative and relaxing aspect of it and I’d like to pick up spear fishing. You can read more from my previous blog posts:
Lung overexpansion is a common scuba diving accident that happens when you breathe in from a tank under water and then ascend while holding your breath. Lungs expand because pressure is smaller the shallower you go and the alveoli in the lungs pop. But funny enough — The injury occurred on dry land while doing breathing exercises. How is this even possible?
How it happened
CO2 tolerance training
In order to be able to hold to breath for longer, freedivers use many different training methods. One of them is “CO2 table” which consists of breathing for an ever-decreasing amount of time between holding your breath for an extended period of time. That is exactly what I had my mind set on doing.
My CO2 table plan that I followed is shown below. Holding my breath for 2 minutes 48 seconds and decreasing the interim breathing time from 2 minutes to 15 seconds. Meaning the time that I could breathe between the last two 2:48 breath-holds was 15 seconds. This means that in the time-frame of 31 minutes and 24 seconds I held my breath for total of 22 minutes and 24 seconds.
Warm-up and packing. This is where I fucked up!
But before I got to the CO2 table, I thought that I do a quick warm-up and stretching. Normally I would take more than 30 minutes to warm up before dives — warming up the breathing muscles and stretching them.
But I felt lazy that day so I didn’t do a proper warm-up — I thought that CO2 table is a good warm-up by itself. I did a few Uddiana Bandas (exercise to stretch diaphragm) and then had a ‘brilliant’ idea of stretching my lungs using packing.
Packing?
Packing is a technique where you take a full breath of air and then use your mouth as a pump to add pressure. I knew the dangers of packing so I did it in the most careful way. I’ll explain what packing is by describing what I did:
- I lay on my back on a yoga matress. With my eyes closed and body relaxed.
- I take a full breath of air. In 4 sections, so I fill my belly, sides, chest and the tip of my lungs.
- I wait 5 seconds for the body to get used to the increased chest cavity.
- I pinch my nose close with my fingers for the air not to escape through it.
- I pump air into my lung by opening up my mouth as big as i can while keeping the air in my lungs with closed throat. I close the full mouth and force the air into the lungs with my mouth. I repeat this 3 times.
- I hold my breath with pressurised lungs for 30 seconds or so.
- I repeat the above for 3 times.
Most probably I hurt my lung during this process and by holding my breath for 22 minutes straight after there was a hole in my lung, meant that there was plenty of time for the air to leak into my body. Which is actually a good news since this means that the hole wasn’t very big.
I felt excellent while doing the exercise and straight after it. I developed the symptoms throughout the day.
What happened
Option 1 — Alveoli bursted and collapsed
While I was doing packing one or several Alveoli were under so much pressure that the tensile strength of Alveoral cells was exceeded and the Alveoli ruptured; letting air into the chest. Straight after this happens, Alveoli normally collapses and glues itself shut.
Option 2 — precondition
Other explanation is that there was a precondition:
- Scar tissue from previous mild lung overexpansion that isn’t as flexible as the normal wall of alveoli. Only thing that I can think of is that I had a slight discomfort in the chest straight after scuba diving a few years back. I had taken a full lung of air to become more buoyant to avoid a coral and had a semi-scetchy ascend of a half a meter or so. A possibility.
- Blebs. These are blister-like air pockets that can form on the surface of the lung. Weak structure sacks that are most commonly associated with spontaneous pneumothorax (lung randomly collapses for no apparent reason). I doubt that this was the case as it would have happenedsooner.
Apparently it heals itself
This happened a month ago from posting this. The doc said I am good to dive already since the follow-up x-rays showed that the air was absorbed by my body. Some other docs have expressed contrary opinions— hence the blog post.
I am no doctor. This is how my engineering brain understands whats going on. So medical people out there, please leave your thoughts in the comments.
Learnings
- Do a proper warm-up before your CO2 tables!
- DO NOT pack before CO2 tables
- DO NOT pack if you haven’t done proper warm-up
- DO NOT PACK when you are new to freediving! You get way more benefit from learning how to relax and stretching the breathing muscles. Not worth the effort.
- Packing is a cool tool when used properly, but I will never pack again
It all sounds a bit scary up there. But it was a super mild case of Atelectasis causing Pneumomediastinum… and actually it’s a lot of fun popping them bubbles in the neck… Plus it heals itself.
Can’t wait to get back under water.