Hot Tub Lungs — A Clinical Challenge

Have you been visited by a patient who has an unexplainable chronic cough who mentions they’ve recently spent a lot of time in the jacuzzi? Physicians are now encouraged to be aware of the potential of deadly bacteria that hot tubs can harbor, which, among other things, could bring about a chronic cough and chest infection.

What is Hot Tub Lung?

Hot tub lung (HTL) is a diffuse granulomatous pulmonary disease that occurs due to inhaling non-tuberculous mycobacteria (NTM), resulting in most Mycobacterium avium complex (MAC) cases.

Non-tuberculous mycobacterial pulmonary disease is the term for a wide collection of pulmonary diseases. They are characterized by exposure to environmental mycobacteria other than the Mycobacterium tuberculosis complex and Mycobacterium leprae.

Why Is It Hard to Breathe After Being in a Hot Tub?

Hot tubs use chemicals such as chlorine and bromine to kill bacteria. Most jacuzzis typically run at a temperature of 90°F-104°F (26°C-40°C); this leads to steam production.

Unfortunately, through steam emission, these chemicals and bacteria can attach to air droplets or bubbles from the hot tub and efficiently aerosolize the organism and facilitate easy inhalation.

Additionally, the heat and steam in the hot tub might lower the amount of oxygen available, making it more difficult to breathe. When the steam is inhaled, the bacteria causes patches of inflammation in the lungs.

Can You Get a Respiratory Infection From a Hot Tub?

Hot tubs provide a perfect environment for the growth of bacteria; however, it mainly occurs in tubs that are not well maintained.

According to the Center for Disease Control and Prevention, people who breathe in minute droplets of water (mist) from a pool or hot tub that contains dangerous germs are at risk for respiratory diseases.

One example is a report in 2020 of a teen who contracted ‘hot tub lung’ from an indoor swimming pool in Queensland, Australia. Though the origin of the infection was not necessarily from a hot tub, the patient picked up a MAC lung infection after inhaling microbes from steam.

What Are The Symptoms Of Hot Tub Lung?

HTL may mimic other conditions and can be challenging to diagnose correctly. A study by physicians at Mayo Clinic described it as hypersensitivity pneumonitis-like lung disease.

Therefore, patients with HTL typically display the following symptoms:

• Coughing
• Shortness of breath
• Fever
• Weight loss
• Tiredness/Fatigue
• Low oxygen levels

A 2013 study raised the issue of hot tub lung as an occupational hazard. It studies the case of a 30-yr-old hotel technician with cough, dyspnoea, fever, and joint pain, which later progressed to fatigue, weight loss, and increasing dyspnoea. Chest radiography led to the conclusion that he had HTL. The researchers later discovered that the patient cleaned the hotel’s hot tub facility and its nylon filters twice weekly with a pressure washer. Five other technicians develop similar symptoms after cleaning hotel hot tubs. Inadequate ventilation and water aerosolization were identified as causes.

So your patient may not have been relaxing in a hot tub or jacuzzi but could otherwise have been exposed to the same kinds of bacteria.

Diagnosis of Hot tub Lung

Hot tub lung is a challenge in terms of diagnosis; however, according to the American Journal of Respiratory and Critical Care Medicine, the diagnostic criteria of a patient suspected of NTM) lung disease should include at minimum an evaluation of the following:

• Chest high-resolution computed tomography (HRCT) scan or a chest radiograph
• Three or more sputum specimens for acid-fast bacilli (AFB) analysis
• Exclusion of other disorders, such as tuberculosis (TB), and no other identifiable cause for the illness
• Hot tub water sample or lung tissue biopsy; to check positive mycobacterial cultures from respiratory and water samples

As part of the diagnosis, described features should include:

• The onset of respiratory symptoms after hot tub, or similar environment, exposure, and
• Characteristic radiographic findings such as diffuse centrilobular nodular or ground-glass opacities and air trapping on expiratory images

How Is Hot Tub Lung Treated?

For some patients, simply avoiding the offending hot tub may be sufficient, letting their body fight the infection naturally. This is most effective if the infection is caught in the early stages.

While some studies suggest that antimycobacterial therapy isn’t necessary in the treatment of this disease, recent research indicates that it can be utilized if other treatments fail.

Such antibiotics should only be used as a last resort, however, due to the rise in antibiotic-resistant bacteria. Tests to determine the level of bacteria in the lungs may be useful for deciding if antibiotics would be worth it — patients with higher bacterial levels in their lungs respond better to antibiotics than those with lower levels.

Studies show that corticosteroids may also be helpful in the treatment of severely affected patients, as they can relieve symptoms to allow the person to go about their life while their body fights the infection.

How Do You Prevent Hot Tub Lung?

Patients can be advised on the following to prevent them from getting hot tub lung:

• Always check the odor of the tub — a safe hot tub has a only slight odor; a strong chemical smell indicates a maintenance issue
• frequently change hot tub water in accordance with the manufacturer’s recommendations
• Ensure proper cleaning and disinfection of the hot tub, beginning with rinsing soon after leaving the tub
• Change filters on the recommended schedule to prevent the tub from being a bacteria breeding spot
• Shower before using a hot tub to not bring in further microbes
• High water temperatures make chlorine evaporate and lose much of its disinfectant properties, therefore, bromine is often substituted, but it is more reactive and may exacerbate the formation of antigens that may lead to a hypersensitivity reaction, making the patient unwilling to perform hot tub maintenance — therefore encourage the research of low-chemical hot tub treatment options rather than the avoidance of all maintenance.
• Ensure proper ventilation — aerosolized bacteria is more likely to be contained and subsequently inhaled from an indoor jacuzzi
• Always stay hydrated while spending time in the jacuzzi
• Avoidance of public hot tubs or jacuzzis because one might not have control over the chemicals used or level of hygiene