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Dry drowning: A distinction without a difference

      Dear Editor,
      As members of the American Red Cross Scientific Advisory Council we are concerned about the recent reports of “dry drowning” in the lay press and social media. Drowning is a major public health crisis accounting for nearly 400,000 worldwide deaths per year. Every person lost to drowning is a tragedy for their family as well as their community; and we are committed to the message of water safety.
      The use of the term “dry drowning”, however, is obsolete and confusing. Reviews of forensic records have found that increased lung weight, pulmonary oedema and intra-alveolar hemorrhage are common in drowning [
      • Bamber A.R.
      • Pryce J.W.
      • Ashworth M.T.
      • Sebire N.J.
      Immersion-related deaths in infants and children: autopsy experience from a specialist center.
      ]. “Dry drowning” is noted as an uncommon mechanism of death; and is described as a phenomenon due to “…laryngospasm, or transfer of water into the vasculature”.
      Laryngospasm can result in significant negative intra-thoracic pressures and subsequent pulmonary oedema. This is not uncommon in a number of clinical scenarios. A mechanically ventilated patient who bites the endotracheal tube can generate highly negative intra-thoracic pressures resulting in negative pressure pulmonary oedema. The pulmonary complications resulting from laryngospasm in Parkinson’s disease have also been described as similar to “dry drowning” [
      • Gan E.C.
      • Lau D.P.
      • Cheah K.L.
      Stridor in Parkinson's disease: a case of ‘dry drowning'.
      ].
      The term “dry drowning” however is needlessly ambiguous. It has recently been noted that terms such as “near, wet, dry, passive, active, secondary and silent drowning should no longer be used because they are confusing and hinder proper categorization and management” [
      • Mott T.F.
      • Latimer K.M.
      Prevention and treatment of drowning.
      ]. This is consistent with other consensus statements regarding drowning terminology which caution against distinctions between “wet” and “dry drowning” [
      • Idris A.H.
      • Berg R.A.
      • Bierens J.
      • et al.
      Recommended guidelines for uniform reporting of data from drowning: the Utstein style.
      ].
      Drowning is “…the process of experiencing respiratory impairment from submersion/immersion in liquid” [
      • van Beeck E.F.
      • Branche C.M.
      • Szpilman D.
      • Modell J.H.
      • Bierens J.J.
      A new definition of drowning: towards documentation and prevention of a global public health problem.
      ]. Bacterial pneumonia secondary to aspiration pneumonitis following an immersion event can disrupt gas exchange and result in hypoxia, similar to any number of other pulmonary processes (e.g.; adult respiratory distress syndrome). Recognition of the pathophysiology of this disease entity is needed to develop an effective treatment strategy. Indeed, the improper assignment of drowning as a diagnosis may preclude evaluation and determination of other causes of respiratory distress, respiratory failure or cardiac arrest (e.g.; seizures, infection, myocarditis, and other causes of sudden cardiac death).
      The “...I know it when I see it…” criteria would seem to apply to drowning; however, the underlying pathophysiology can be surprisingly complex. Furthermore resuscitation efforts may also complicate the diagnosis; as chest compressions during CPR may alter pulmonary hydrostatic pressures, affecting the accumulation of oedema.
      Thankfully, risk stratification tools are available to assist with the evaluation of drowning [
      • Szpilman D.
      • Bierens J.J.
      • Handley A.J.
      • Orlowski J.P.
      Drowning.
      ]. This approach provides patients and physicians with the tools that they need to become better informed on this important public health issue. Regardless of definitions, the most effective means to avoid drowning remains water safety education.

      Author declaration

      • -
        Dr. Tobin is a member of the Board of Directors of the Trauma Anesthesiology Society and is a member of the American Red Cross Scientific Advisory Council.
      • -
        Dr. Rossano is a member of the American Red Cross Scientific Advisory Council.
      • -
        Dr. Wernicki is a member of the American Red Cross Scientific Advisory Council.
      • -
        Mr. Fielding is a member of the American Red Cross Scientific Advisory Council.
      • -
        Dr. Quan is a member of the American Red Cross Scientific Advisory Council.
      • -
        Dr. Markenson is a member of the American Red Cross Scientific Advisory Council.
      We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

      References

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        • Sebire N.J.
        Immersion-related deaths in infants and children: autopsy experience from a specialist center.
        Forensic Sci Med Pathol. 2014; 10: 363-370
        • Gan E.C.
        • Lau D.P.
        • Cheah K.L.
        Stridor in Parkinson's disease: a case of ‘dry drowning'.
        J Laryngol Otol. 2010; 124: 668-673
        • Mott T.F.
        • Latimer K.M.
        Prevention and treatment of drowning.
        Am Fam Phys. 2016; 93: 576-582
        • Idris A.H.
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        • Bierens J.
        • et al.
        Recommended guidelines for uniform reporting of data from drowning: the Utstein style.
        Resuscitation. 2003; 59: 45-57
        • van Beeck E.F.
        • Branche C.M.
        • Szpilman D.
        • Modell J.H.
        • Bierens J.J.
        A new definition of drowning: towards documentation and prevention of a global public health problem.
        Bull World Health Organ. 2005; 83: 853-856
        • Szpilman D.
        • Bierens J.J.
        • Handley A.J.
        • Orlowski J.P.
        Drowning.
        N Engl J Med. 2012; 366: 2102-2110