References | Subjects | Sample size and description | Period of follow-up | Type of exposure | Case definition | Case ascertainment method | Short-term outcomes, i.e. hospitalisations and recovery | Recurrence | Long-term health sequelae | Quality of evidence (see Additional file 4 for more detail) |
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Adir et al. [12] | Military trainees (Israeli Navy) | Unknown number of males aged 18–19 in swimming trials of 2.4–3.6 km in 1998–2001 (70 cases) | 3 years but variable | Open sea of varying temperatures (19.6 °C ± 3.2), no wetsuits, supine semi-reclining position with fins | Severe shortness of breath and coughing during or after swimming in the absence of sea aspiration, and evidence of PE found on medical examination | Interview and clinical examination of swimmers presenting to medical team | No hospitalisations. All recovered from SIPE symptoms within 24 h. Chest radiographs 12–18 h after episode were all normal. A subsample of 37 trainees had restricted lung function that persisted for a week | 22.9% of cases (16 trainees) had a recurrence during the study ≥ 3 months after first episode | Not reported | No control group. Only a subsample of 37 were followed up at 7 days |
Shupak et al. [13] | Military trainees (Israeli Navy) | 35 males (21 cases, 14 comparators) aged 18–19 performing 5 swimming trials of 2.4–3.6 km over 2 months. Trials were ≥ 1 week apart | 2 months | Moderately cold open sea, (16–18 °C), diving jackets, supine position with fins | When, in the absence of prior seawater aspiration, the swimmer reported shortness of breath accompanied by coughing | Post-swim questionnaire completed by all trainees plus physical examination: oxygen saturation, changes in pulmonary function | Not reported | 31% (9 out of 29 episodes observed) were recurrences of previously observed episodes | Not reported. | No follow-up |
Weiler-Ravell et al. [14] | Military trainees (Israeli Navy) | 30 males (8 cases, 22 comparators) aged 18–19 performing a 2.4 km swimming trial | Until end of training programme | Warm open sea (23 °C), no wetsuit, supine position with fins, over- hydration (trainees drank approx. 5 l of water prior to swimming) | Dyspnoea and haemoptysis | Clinical examination of trainees presenting to medical team | All stayed overnight in hospital and recovered within 24 h | 25% of cases (2 trainees) had a recurrence later during the training programme (unknown time period) | Not reported | Only one swimming trial. Unclear when recurrences took place |
Ludwig et al. [29] | Military trainees (US Navy Special Warfare) | 20 males including 11 cases aged 19–36 who had completed the first 5 weeks of a 22-week long training programme | Study began 4–14 weeks after recovery from SIPE | Not reported | (1) acute onset of dyspnoea or haemoptysis during or immediately after swimming, (2) no history of water aspiration, laryngospasm, or preceding infections, (3) hypoxemia, as defined by an oxygen saturation < 92% by pulse oximetry or an alveolar-arterial oxygen gradient of > 30 mmHg and (4) radiographic opacities consistent with an alveolar filling process and/or interstitial pulmonary oedema that resolve within 48 h | Previous clinical diagnosis of a single episode of SIPE | All recovered at least 4 weeks prior to start of study | Not reported | No significant difference in cardio-pulmonary function between cases and controls 4–14 weeks following recovery from SIPE | No SIPE symptoms observed. Small sample size. No further follow-ups |
Braman Eriksson et al. [15] | Outdoor swimmers (elite and amateur) | 13,878 swimmers aged 12–70 (6317 males, 7561 females) in Swedish river races over 3 consecutive days, distances of 1-3 km, Approx.69 cases of SIPE reported | N/A | Moderately cold freshwater (17 °C), unknown number of swimmers wore full wetsuits | Breathing difficulties and/or cough in the absence of clinical signs of obstruction | Clinical examination of competitors presenting to medical team | All recovered following treatment on site | 31% of cases (20 swimmers) self-reported having experienced respiratory difficulties whilst swimming previously | None reported | Data only collected for those requiring treatment. Symptoms and clinical findings were not recorded for each swimmer |