Correspondence

Asthma and Whirlpool Baths

N Engl J Med 2005; 353:1635-1636October 13, 2005

Article

To the Editor:

Public baths and swimming pools need to be disinfected, and this is usually accomplished by chlorination of the water. Exposure to chlorinated pools, however, may affect the lung epithelium and, along with other factors, may be associated with the increased prevalence of childhood asthma.1 In addition, the chloramines,2,3 which are generated from the reaction of hypochlorite with ammonia and amino compounds that originate from sweat and urine, are substances that are highly volatile and irritating to the airways. The magnitude of exposure to these substances depends on the number of bathers, the water temperature, and local air recirculation. Many recreation facilities offer the use of heated and chlorinated whirlpool baths (such as Jacuzzi baths and hot tubs), in which the rate of vaporization is increased proportionally to the temperature of the water and the action of the water jets.

We examined the effect of whirlpool baths on airway reactivity in patients with mild asthma. Eight patients (seven men and one woman, 20 to 42 years of age) with stable, mild, persistent asthma were enrolled, after informed consent was obtained. This study was approved by the institutional review board. Maintenance treatment including long-acting beta-agonists, inhaled corticosteroids, or both was suspended for either three or six days before the study. The use of short-acting bronchodilators was allowed. All patients had positive results on methacholine-provocation testing and had a baseline reading of forced expiratory volume in one second (FEV₁) of 80 percent of the predicted value or higher. A day before the study, the patients underwent a methacholine-provocation test; the same batch of methacholine was used the next study day. After baseline spirometric testing, the patients were immersed in an active whirlpool bath for 12 minutes. Chlorine was used as a disinfectant. The level of chlorine was continuously monitored, and evaporated chlorine was replaced. The bath was followed (two to three minutes after the patients exited the tub) by repeated spirometric testing and another methacholine-provocation test.

No patients reported symptoms during or after the whirlpool bath. After the whirlpool bath, a 20 percent reduction in FEV₁ was documented in six patients after two earlier dilutions of methacholine, as compared with baseline; in one patient after one previous dilution, as compared with baseline; and in one patient immediately after exposure to the bath mist (Table 1Table 1Results of Methacholine Provocation Testing before and after a Whirlpool Bath.). (With each dilution, there was more methacholine and less water.) Our findings suggest that hot chlorinated pools and whirlpool baths may have a detrimental effect on patients with asthma.

David Stav, M.D.
Assaf Harofeh Medical Center, 70300 Zeriffin, Israel
dstav@post.tau.ac.il

Michal Stav, B.Sc.
Bar Ilan University, 52900 Ramat Gan, Israel

3 References

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   Massin N, Bohadana AB, Wild P, Hery M, Toamain JP, Hubert G. Respiratory symptoms and bronchial responsiveness in lifeguards exposed to nitrogen trichloride in indoor swimming pools. Occup Environ Med 1998;55:258-263
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Citing Articles (6)

Citing Articles

1. 1

   Arnaud Florentin, Alexis Hautemanière, Philippe Hartemann. (2011) Health effects of disinfection by-products in chlorinated swimming pools. International Journal of Hygiene and Environmental Health
   CrossRef

2. 2

   A. Bernard. 2011. Respiratory Effects of Chlorination Products. , 845-851.
   CrossRef

3. 3

   Z.S. Uyan, S. Carraro, G. Piacentini, E. Baraldi. (2009) Swimming pool, respiratory health, and childhood asthma: Should we change our beliefs?. Pediatric Pulmonology 44:1, 31-37
   CrossRef

4. 4

   Yvonne Schoefer, Anne Zutavern, Inken Brockow, Torsten Schäfer, Ursula Krämer, Beate Schaaf, Olf Herbarth, Andrea von Berg, H.-Erich Wichmann, Joachim Heinrich. (2008) Health risks of early swimming pool attendance. International Journal of Hygiene and Environmental Health 211:3-4, 367-373
   CrossRef

5. 5

   Wenche Nystad, Siri E Håberg, Stephanie J London, Per Nafstad, Per Magnus. (2008) Baby swimming and respiratory health. Acta Paediatrica 97:5, 657-662
   CrossRef

6. 6

   Y. Kohlhammer, A. Döring, T. Schäfer, H.-E. Wichmann, J. Heinrich, . (2006) Swimming pool attendance and hay fever rates later in life. Allergy 61:11, 1305-1309
   CrossRef