Lung physiology at play: Hemoptysis due to underwater hockey

Hemoptysis can be a very concerning symptom, and the workup of a patient with hemoptysis may be expensive and invasive. Over the past decade, there has been increasing recognition of hemoptysis that occurs in highly trained athletes under conditions of extreme physical exertion and is explained by "pulmonary capillary stress failure". This report highlights the physiological mechanisms of pulmonary capillary stress failure in the highly trained athlete, with emphasis on the predisposition to develop this condition in underwater sports. We describe the case of an otherwise healthy 34 year-old competitive underwater hockey player who reported hemoptysis following particularly strenuous games. We postulate that the hemoptysis was a result of the pulmonary capillary stress failure caused by the cumulative hemodynamic effects of a markedly elevated cardiac output, the increased central blood volume caused by the hydrostatic effects of submersion in water, and the negative intrathoracic pressure produced by voluntary diaphragmatic contractions.