By Mark Powell

This is part of an occasional series on decompression myths. To find the previous article just click on the links for part one, two and three

Myth – Hydration is the most important factor in avoiding DCS.

The maintenance of a good state of hydration is generally considered to be very important for overall health and dehydration can have significant implications on health and exercise performance. Dehydration has long been considered by many divers to be one of the most significant, or even THE MOST significant, factor in DCS risk other than following correct dive profiles.

The idea that hydration is the most important factor in avoiding DCS has been repeated so often that it is taken as an undisputed fact. Many diving manuals repeat this misconception and there are countless articles online which make the same point.

As we have already seen in this series, just because something is repeated over and over again, does not mean it is a fact and widely believed rules are sometimes found to be based on no evidence at all.

Historically there has been very little research on this point, as it was taken to be self-evidently true by many, although rejected by others. There were only a very small number of studies investigating the topic although in recent years this gap has been slowly been addressed as researchers have tried to prove or disprove the idea,

If we look at the scientific evidence for the impact of hydration on DCS risk we can find one paper from 2007 which showed that diving causes dehydration [1]. Another showed that prehydration resulted in a reduction in bubbling post dive [2] and a third showed a reduction in DCS risk [3] although there were some queries about this study. None of these were conclusive and the reduction in bubbling and DCS risk was not huge. This seemed to imply that the benefits of hydration have been overstated at best and does not have anywhere near the impact that was believed. This is especially true when compared to the impact of other forms of preconditioning such as vibration or sauna or when compared with other factors such as temperature which provided a much bigger change in DCS risk.

However, some more recent papers seem to show that hydration does indeed have an impact on DCS risk although less than many other factors such as temperature and exercise [4].

At the same time that the benefits of hydration were being questioned, the risks of over overhydration were starting to be considered.

In particular, excessive overhydration (hyperhydration) can increase the risk of immersion pulmonary edema. However, in some circles this has been misinterpreted as meaning that a normal level of hydration is bad as it increases the risk of this condition.

MYTH – Hydration increases the risk of IPO/IPE

Immersion pulmonary odema/edema (IPO/IPE) occurs when fluid leaks into the alveoli in the lungs. This results in sudden shortness of breath, cough and sometimes blood-tinged, frothy sputum.

IPO was once considered rare, but is now more widely recognized. While the actual numbers of cases are unknown, it is most likely underdiagnosed. This might be because:

  • It is difficult to detect in fatalities.
  • It can be mistaken for drowning.
  • Mild cases of IPE can resolve spontaneously.

Factors contributing to IPO may include:

  • Hydrostatic pressure gradient
  • Cold-induced vasoconstriction
  • Exertion
  • Hydrostatic gradient between mouth and alveoli
  • Inspiratory resistance caused by the regulator
  • Increased gas density at depth
  • Excessive pre-dive hydration
  • Hypertension

Many of these factors may be present in adventurous or technical diving. Divers Alert Network (DAN) recommends that you abort the dive as quickly and safely as possible if you experience:

  • Sudden shortness of breath.
  • Persistent cough.

Upon surfacing breathe 100 percent oxygen and postpone further diving until you can consult a physician.

Although mild cases of IPO can resolve without further treatment once a diver has exited the water, respiratory distress while diving can be extremely dangerous. IPO becomes an even greater concern when you face an extended decompression obligation. Here you must balance the risks of:

  • IPE symptoms worsening if you remain under water.
  • Suffering DCS if you shorten or skip decompression stops.

You will notice that in the description above, one of the factors contributing to IPO is listed as “Excessive pre-dive hydration”. As mentioned earlier this has, in some circles, been misinterpreted as meaning that hydration is bad as it increases the risk of IPO.

When considering hydration levels, it is important to remember that there are three relative states. Which in layman’s terms we describe as dehydration, proper hydration and excessive overhydration. I have avoided the more scientific terms hypohydration, euhydration and hyperhydration in order to make this explanation more accessible to the non-scientist.

As proof that this myth exists, I have included below an extract from a genuine email I received from one of my students;

“I genuinely believed (I don’t know where I got this from) that if you drink anything before a dive, you’re putting yourself at risk of getting IPO. I didn’t realise the shear amount you actually had to drink to increase that risk. So on occasion I’ve had a tea between dives and then jumped in for a second dive and in the back of my mind be thinking ‘I hope I don’t start coughing uncontrollably now and give myself IPO because of that tea'”

One of the most commonly referenced articles on IPO, and an article that the student above had definitely read, contains the following quote [6] “I am particularly concerned that many divers overhydrate with fluids before a dive, in the belief that it will protect them against decompression illness. The evidence that it protects is not convincing. In contrast there is unequivocal evidence that excessive hydration increases the risk of IPO in both divers and swimmers. Overhydration has an additive effect on the increase in alveolar capillary pressure resulting from immersion. So I strongly advise divers not to overhydrate before diving.”

As you can see this does not state that an extra cup of tea will cause IPO but you can see how a myth could grow from this. It is easy to take the statement “I strongly advise divers not to overhydrate before diving.” and misremember it as “I strongly advise divers not to hydrate before diving.” This advice does not distinguish or give any advice on where is the line between hydration and overhydration? Is that extra cup of tea enough to tip us over the line into overhydration?

To answer the question about the difference between hydration and excessive hydration it worth looking at the article described as ‘unequivocal evidence’ in [5]. This refers to a study carried out on military swimmers.[6]  An extract of the study is shown below; “Thirty young men on a military fitness training programme were engaged in a swimming time trial over 2.4 km in the open sea. The sea was calm and the measured water temperature 23°. They swam in the supine position wearing only a bathing suit and using fins. Because of the high heat load expected, the swimmers had been instructed to drink large quantities of water before the swim, to avoid becoming dehydrated. They each drank about five litres of water during the two hours preceding the exercise.”

Five litres (8.8 pints) is a huge volume of water to drink in a two-hour period. For someone who was already well hydrated it could easily put them into a position of hyperhydration. Although it might not be a problem for someone who started out in a dehydrated state. The key point is that there is a big difference between proper hydration and excessive overhydration (hyperhydration). A large glass of water, a 1 litr bottle of water or even a large mug of tea is not excessive overhydration.

Conclusion – Myth or not?

Hydration does indeed seem to be a factor in DCS risk and it seems clear that being properly hydrated is a good thing for health in general and also for diving. Hydration is not be the most important factor in reducing DCS risk but anything that reduces DCS risk at all is a positive thing. Excessive overhydration can increase the risk of IPO but excessive overhydration is not the same as being properly hydrated.

Being properly hydrates gives some advantages in reducing DCS risk and likely does not create undue IPO risk. As in so many areas of life there is a balance. Do not dive while you are excessively dehydrated and do not dive while you are excessively overhydrated. Stick to the Goldilocks zone – not underhydrated, not over hydrated but just right.

How to hydrate

The other conclusion we can draw from this discussion is that educators, scientists, researchers, speakers and writers need to be careful about the impression we create. An article or conference presentation may contain perfectly truthful information but that can be misinterpreted and be seen as promoting a very different conclusion to the one intended. This is exactly how myths develop.

Thank you to Neal Pollock who reviewed several early drafts of this article to ensure that my attempts to explain these concepts in non-scientific language did not lose any of the scientific validity. Any errors or misunderstandings are still down to me.

References

[1] Williams ST, Prior FG, Bryson P. Hematocrit change in tropical scuba divers. Wilderness Environ Med. 2007;18(1):48-53.

[2] Gempp E, Blatteau JE, Pontier J-M, Balestra C, Louge P. Preventive effect of pre-dive hydration on bubble formation in divers. Br. J. Sports Med. 2009;43:224–228.

[3] Fahlman A, Dromsky DM. Dehydration effects on the risk of severe decompression sickness in a swine model. Aviat Space Environ. Med. 2006;77:102–106.

[4] Wang Q, Guerrero F, Theron M. Pre-hydration strongly reduces decompression sickness occurrence after a simulated dive in the rat. Diving Hyperb Med. 2020;50(3):288-291.

[5] https://www.bsac.com/news-and-blog/the-hidden-killer-immersion-pulmonary-oedema-ipo/

[6] Weiler-Ravell D, Shupak A, Goldenberg I, Halpern P, Shoshani O, Hirschhorn G, et al. Pulmonary oedema and haemoptysis induced by strenuous swimming. BMJ. 1995;311:361.

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