What’s up with Secondary Drowning???

Perhaps the most popular water safety story in the media these days is about Secondary Drowning. Although this phenomenon may be new to the media, it has been studied by physicians for decades. Fortunately, the condition is extremely rare. It most often occurs after a successful water rescue when a child has been pulled from a pool by a parent or lifeguard who at first appears to be perfectly fine. Then hours after the incident, the child shows subtle yet significant symptoms. Inhaling pool water can also cause chemical pneumonitis, or inflammation of the lungs due to harmful chemicals. Symptoms appear 1 to 24 hours after the incident. They can include persistent coughing, shortness of breath, chest pain, lethargy, fever and unusual mood change. If not treated, complications may develop progressing to pulmonary edema hypoxia/anoxia, respiratory and cardiac arrest, and death. This is because water gets into the lungs and injures the alveoli. Initially, this injury does not prevent oxygenation but as the mediators of injury and inflammation arrive, there is swelling, lung edema, and inflammation all of which lead basically to respiratory distress. Secondary drowning has caused deaths to children who have been rescued from the water and it is very real, such that all "near drownings" should be sent to hospital for observation and tests immediately following the incident. As aquatic professionals, I don’t think we need to scare our parents or children with the rare possibility of “Secondary Drowning,” but rather we need to teach everyone including our staff, that all water rescues that involve aspiration of water, regardless of how innocent they may appear, should require immediate follow-up with professional medical care. It is important to emphasize the water rescues NOT requiring resuscitation still need hospitalization. One of my fears relating to Secondary Drowning is now that the public has been alerted to this relatively new malady, whenever a child dies within a day of a swimming event, the aquatic facility and staff may be blamed. Sending all rescued swimmers to the hospital immediately after water aspiration may not only save a life, but also prevent a lawsuit. Secondary Drowning may mask other significant pre-existing medical conditions. The best prevention for Secondary Drowning? Life Jackets!

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Comment by Caleb Starrenburg on July 11, 2014 at 1:06am

Hi Tom,

Thanks for your reply. And no need to apologise. I absolutely understand the challenge of communicating a complex topic – such as drowning – in an accessible way. The challenge is only magnified when an inaccurate idea like ‘near drowning’ has been popularised. We see the same with ongoing use of the term ‘riptide’.


My post was intended for the aquatic professionals who frequent this site, as I believe (even without a medical background) they should have a basic grasp of the concepts of fatal and nonfatal drowning. When it comes to the general public, and the information conveyed to them by lifeguards, I think your approach is correct.

We need to discourage panic around ‘near drowning’. Instead, if a person’s mouth or nose has been in water and they’re continuously coughing, foaming at the mouth, or having any difficulty breathing, we recommend they go to a physician straight away as a precautionary measure.

The good news is that if your child is having trouble breathing and you take them to the emergency department, especially within the first 2-3 hours, one large study revealed only 20% needed additional hospitalisation.

So the message is there’s no need to be terrified your child will drown a day after swimming. Instead, if a child (or adult’s) mouth or nose were covered in water and they’re having trouble breathing or are coughing for more than a few minute, get medical help as soon as possible, and there’s a good chance they’ll recover completely. 

Comment by Tom Griffiths on July 9, 2014 at 12:17pm

Caleb,

Thank you for your accurate and thoughtful comments. I do agree with the consensus of the agencies you mentioned. Please note I placed the antiquated term “near drowning” in quotes, knowing that the more accurate term is non-fatal, but perhaps I should have been more precise. I guess old habits do die hard! But please understand my dilemma. This country has been deluged with news of “Secondary Drowning” on a daily basis. TV, radio, print media, internet and social media are continually bombarding Americans with “Secondary Drowning” and these stories are being promulgated by doctors, physiologists, and hospitalists in this country. My blog was written primarily for aquatic professionals without training in medicine or physiology. These professionals have been approached by worried parents who have listened to renowned medical experts talking about this dangerous aftermath of swimming. Currently, all the talk in America regarding water safety is now about “Secondary Drowning”. I did not think I could arm the aquatic professionals in a short blog with enough facts and physiology to educate their pool patrons who just heard about “Secondary Drowning” from the medical experts on TV. I tried to simplify matters by accepting for now that “Secondary Drowning” was in fact a type of drowning. However, the message was intended to allay the fears of families with children wanting to enroll in swim lessons and other beneficial aquatic programs. My goal was to simply educate parents to seek treatment when their children swallows water which changes their behavior. I think it would be a difficult and unrealistic challenge for the pool people to combat with medical experts in our country. Yes, my blog was more general rather than specific, but my message was to minimize the hysteria being promoted about “Secondary Drowning”. I’m not worried about “Secondary Drowning”, but I am worried about the paranoia surrounding the massive media hype which may discourage parents from enrolling their children in swim lessons and enjoying safe water play.

My apologies.

Comment by Caleb Starrenburg on July 9, 2014 at 6:25am

I’m afraid this blog post contains a number of inaccuracies, and as you're a significant part of the aquatic professionals and drowning prevention community, it’s important to be communicating the right information.

Secondary drowning, sometimes also referred to as delayed or dry drowning, simply does not exist as a phenomenon within the medical community. This is because drowning is not an outcome, but a process.

Perhaps the best way to explain this is to use the comparison of choking. Choking and drowning are both processes involving respiratory impairment. If the process is not interrupted the result is death. If the process is interrupted - for example rescue by a lifeguard - it's nonfatal. Nonfatal choking and drowning outcomes can range from no lasting damage to brain injury or disability.

So in much the same way there is no such thing as near choking, there is also no such thing as near drowning.

This is not just semantics – communicating the right information ultimately helps the drowning prevention community to save lives. Reporting and research into drowning had long been hampered by a lack of agreement on drowning terminology. A vast catalog of terms, including secondary, delayed, near, dry, wet, active, passive and silent drowning were used interchangeably, and often meant different things to different people.   

As a result, in 2002 the World Congress on Drowning reached though international consensus the definition “Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.” It determined the outcomes of drowning as death, health complications, and no complications.

This definition was subsequently adopted by the World Health Organization, the Center for Disease Control and others – who also called for the elimination of unhelpful terms such as secondary, delayed, dry and silent drowning.

So the question then becomes, what do we tell lifeguards to do if they rescue a person who is drowning? On this point your blog is absolutely correct: people who have drowned (that is experienced respiratory impairment as a result of being underwater) should always be taken to a physician for evaluation, even if they are awake, talking and have only minor breathing difficulty.

However, it’s important to note that reports of complications occurring up to 24 hours (or longer) after a drowning incident are incorrect. Studies reveal people who have experienced a nonfatal drowning and have minimal symptoms get better or worse within 2-3 hours. Most often, these people are observed in an emergency department for 4-6 hours to allow for an adequate safety margin, then sent home.

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