Lifeguard lung: implications for lifeguards: your lifeguards have been on duty at your indoor aquatic facility for the last several months.

Lifeguard lung: implications for lifeguards: your lifeguards have been on duty at your indoor aquatic facility for the last several months. Recently, several have noticed eye irritation, headaches, chest tightness, occasional coughing, and increasing shortness of breath with activity. It seems to start shortly after they enter the pool area and resolves only after being away from work for an extended period of time. Some also seem more tired and have difficulty concentrating, especially when on duty. Several have consulted their doctors and nothing wrong was found. General advice has been to cut back on strenuous activities. However, when away from lifeguarding for. (Aquatics)

several days, your guards feel like their old selves, again. Is this some crazy infection? Is it all in their heads? Or, is this Lifeguard Lung?

Lifeguard Lung (LGL) is a type of sick building syndrome occurring in some indoor aquatic facilities. Irritants in the air trigger an immune response in some individuals. This response is medically referred to as hypersensitivity pneumonitis (HP), an inflammation of the lungs due to an immune response. Under the right conditions, all aquatic staff and participants are potentially susceptible. Repeated exposure to improper/inadequate ventilated air, improper/inadequate water quality, and aerosolization, such as is found in indoor leisure park facilities, can contribute to triggering this response. Repeated exposures eventually cause granulomatous pneumonitis, the development of scarring in the large airways (trachea and bronchi). This is a nonreversible condition.

Dr. Cecile Rose, MD, an occupational medicine physician in Denver, CO identified this condition in 1989 after evaluating a number of symptomatic lifeguards employed at the same indoor waterpark. Symptoms were first noticed in 1986 and included wheezing, cough, shortness of breath especially with exertion, eye irritation, headache, fever/chills, muscle aches, and problems concentrating. Not all lifeguards were affected. In those who were affected, some, but not necessarily all, of the symptoms were present (Rose, 1998). Symptoms would begin as late as 24 hours following a guard shift and usually disappeared by the next day. There did not appear to be any correlation with whether or not an individual smoked, had allergies, or asthma (Rose, 1998).

Physical exams did not reveal any specific findings. Although a few individuals did have abnormal lung sounds and chest x-rays, most findings were totally normal. Lung function tests were also completely normal. One significant abnormality which was discovered in affected individuals was a marked drop in blood oxygen level during exercise. The other significant finding was scar tissue formation found on biopsies of symptomatic individuals' large airways (Rose, 1998).

Causes

LGL is a common phenomenon which, until recently, has largely gone unrecognized by both aquatic supervisory personnel and medical providers. It is triggered by repeated inhalation of organic material such as fungi spores, which are often found in humid environments, and animal and bacterial proteins, including deactivated microbes and parasites. Active chemicals such as organic chloramines, formed when free chlorine reacts with sweat, urine, and other waste products introduced by pool patrons, are also implicated (Ando, 1999).

Aerosolization from leisure park spray devices such as slides, geysers, waterfalls, flumes, and play structures, as well as from patron splashing, dissipate the organic stimuli into the air and water where they are carried by ventilation and water circulation systems. Endotoxins, immune system-stimulating proteins produced by cell walls of killed bacteria, may also be present and are capable of stimulating an immune response and subsequently, LGL (Skaros, 2001).

Indoor air quality is the result of pool sanitation/oxidation systems, hydraulic systems, water temperatures (usually elevated in the indoor setting), and patron-to-water volume ratios (Osinski, 1997). To keep overhead costs down, engineers and architects who design the indoor facilities are concerned with energy and heat conservation. Facilities are built with more insulation, sealed windows, and closed-loop energy recovery systems. The end result is severe limitation of fresh air being introduced into the facility. Organic chloramines, dissipated pool chemicals, cleaning products and other chemical vapors, as well as noxious agents normally present in building air are recirculated instead of being vented to the outside. A detectible odor of "chlorine" (really chloramines), especially outside the immediate pool area, is an indication of inadequate ventilation. Heat loss is kept to a minimum by limiting cross ventilation across the water surface. This causes air stagnation and accumulation of noxious air directly over the water, as well as within the confines of the pool (Osinski, 1997).

Water quality is determined by patron numbers and cleanliness, temperature of both the air and water, circulation systems, sanitization/oxidation systems, and the condition of features and devices in the pool such as sprays, slides, flumes, etc. Some facilities try to conserve costs by decreasing feature pump flow, or even stopping it completely during off hours. This allows mineral deposit build-up in pool features and devices over time, which, in turn, creates an ideal environment for the depositing and promulgation of bacteria. When feature pump flow is turned on or increased the next day, these bacteria and their endotoxins are sprayed out into the air in high concentration (Osinski, 1998). This spraying of a fine mist into the air is called aerosolization.

The end result is that the air and water circulation systems carry the stimuli throughout the facility. Sprays, slides, flumes, and other devices, in addition to patron splashing, dissipates the stimuli even more. Lifeguards inhale the stimuli, even if they are not in close proximity to facility devices, and an immune response can occur. Each additional exposure to these stimuli causes more symptoms, more illness, and more damage to the airways.

What can YOU do?

LGL acquired while working as a lifeguard falls under the Workman's Compensation laws. Employers are obligated to allow lifeguards to seek appropriate medical evaluation and treatment at no cost to the guard. However, guards need to do the following:

* Report their problem to their employer! Nothing can be done until and unless an employer knows a problem exists.

* Seek medical attention from someone familiar with occupational exposures--if possible, specifically pertaining to aquatics.

* Have a physical exam and testing done to determine a cause for their symptoms. Other common causes which may produce similar symptoms must be considered and ruled out before a diagnosis of LGL can be made. Tests may include but are not limited to:

--Oxygen saturation of the blood during exercise

--Chest x-ray

--Lung function testing (PFT)

--Complete blood count (CBC) with differential

* If symptoms persist (which is likely with additional exposures), request referral to a pulmonologist (lung specialist) for possible bronchoscopy (evaluation of the respiratory system with a small camera), biopsy of the large airways, and immune system evaluation (Ando, 1999)

If a number of lifeguards are symptomatic, an employer should be encouraged to close the facility, determine what is causing the problem, and ensure proper repairs are made. Introduction of fresh air (at least 40%, but 100% is best), with venting to the outside may alleviate some to the problem (Osinski, 1997). However, if medical evaluation reveals the probability of LGL, do not reopen this facility until the problem has been corrected!

Conclusion

Lifeguard Lung is not a benign process. It is cumulative, and may cause irreversible damage. It is also not readily recognized. If lifeguards at an indoor aquatic facility develop symptoms which may be attributable to LGL, they need to report their concerns to their employer immediately and seek medical evaluation from a knowledgeable provider. They should not return to work until either they know their symptoms cannot possibly be due to LGL, or if they are, proper steps have been taken to fix the problem.

References

Ando M., Suga M., Kohrogi H. A new look at hypersensitivity pneumonitis. Current Opinion in Pulmonary Medicine. September 1999. 5(5):229-304. Review.

Osinski A. Breathing fresh air into your therapeutic pool facility. Aquatics International 9(7). September/October, 1997.

--. Healthy water, healthy staff. Aquatics International 10(1). January/February, 1998.

Rose CS., Martyny JW, Newman LS, Milton DK, King TE Jr, Beebe JL, McCammon JB, Hoffman RE, Kreiss K. "Lifeguard lung": endemic granulomatous pneumonitis in an indoor swimming poll. American Journal of Public Health. December, 1998. 88(12):1795-1800.

Skaros S., Osinski A. Lifeguard lung -- is your natatorium the cause? Aquatics International. (In press).