Kardiovaskulární Systém a Sportovní Potápění

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Kardiovaskulární Systém a Sportovní Potápění Přehledový článek | Review article Kardiovaskulární systém a sportovní potápění (Cardiovascular system and sport diving) Radek Pudil I. interní kardioangiologická klinika, Lékařská fakulta Univerzity Karlovy a Fakultní nemocnice Hradec Králové INFORMACE O ČLÁNKU SOUHRN Historie článku: Sportovní potápění patří mezi vyhledávané sportovně-rekreační aktivity, kterým se věnuje relativně početná Vložen do systému: 11. 4. 2020 skupina sportovců různého věku a úrovně fyzické zdatnosti. Sportovní potápění představují dvě hlavní dis- Přepracován: 16. 4. 2020 ciplíny: potápění s přístrojem a volné potápění (freediving). Potápění je spojeno s velkými nároky na správ- Přijat: 19. 4. 2020 nou funkci kardiovaskulárního systému. Cílem sdělení je připomenout základní faktory, které se podílejí na Dostupný online: 1. 9. 2020 funkci kardiovaskulárního systému při potápění, podat základní informace o fyziologických procesech spo- jených s potápěním a připomenout některé potenciálně rizikové stavy, které mohou významně interferovat s potápěním (perzistentní foramen ovale, arteriální hypertenze, latentní srdeční selhání, arytmie, přítomnost Klíčová slova: kardiostimulátorů a kardiovaskulární medikace). Všechny tyto stavy s sebou přinášejí specifi ka, která se mo- Diving response hou projevit v souvislosti s potápěním a mohou za určitých okolností znamenat ohrožení života potápěče Edém plic či jeho doprovodu. Znalost základních patofyziologických mechanismů spojených s potápěním umožňuje Freediving bezpečnější posuzování zdravotního stavu adeptů tohoto sportu. Kardiovaskulární systém © 2020, ČKS. Perzistentní foramen ovale Potápění s přístrojem ABSTRACT Sport diving is one of the popular sports and recreational activities, which is performed by a relatively large group of athletes of different ages and levels of physical fi tness. Sport diving represents two main Keywords: disciplines: scuba diving and freediving. Diving requires good function of cardiovascular system. The aim Cardiovascular system of the paper is to summarize basic factors infl uencing cardiovascular system during diving, to provide basic Diving response information about diving physiological processes and to inform about some danger conditions that poten- Freediving tially interfere with diving (persistent foramen ovale, arterial hypertension, latent heart failure, arrhythmias, Lung edema cardiac pacemakers, and cardiovascular medication). All these conditions can potentially endanger the life Persistent foramen ovale of the diver or his buddy. Knowledge of the basic pathophysiological mechanisms associated with diving Scuba diving allows a safer assessment of the fi tness to dive. Adresa pro korespondenci: Prof. MUDr. Radek Pudil, Ph.D., I. interní kardioangiologická klinika, Lékařská fakulta Univerzity Karlovy a Fakultní nemocnice Hradec Králové, Sokolská 581, 500 05 Hradec Králové, e-mail: [email protected], [email protected] DOI: 10.33678/cor.2020.027 Tento článek prosím citujte takto: Pudil R. Kardiovaskulární systém a sportovní potápění. Cor Vasa 2020;62:390–394. 3390_394_Prehledovy90_394_Prehledovy cclanek_Pudil.inddlanek_Pudil.indd 339090 111/09/20201/09/2020 110:21:360:21:36 R. Pudil 391 Úvod Hloubka je významný faktor. S hloubkou narůstá okolní tlak, který se podílí na stlačení hrudního koše a Potápění patří mezi činnosti, které provázejí lidstvo něko- ostatních tělesných dutin vyplněných plyny. V případě lik tisíciletí. V posledních desetiletích narůstá jeho popu- přístrojového potápění je nárůst okolního tlaku vyrov- larita a věnuje se mu řada lidí. V České republice absol- nán dýchací automatikou, která dodává dýchací plyn pod vovalo výcvik pro potápění s přístrojem více než 100 000 stejným tlakem, jaký má okolní prostředí. Problém může lidí, v poslední dekádě narůstá počet lidí, kteří se věnují nastat při rychlém vynoření bez odpovídajícího výdechu tzv. nádechovému potápění. Ve vyspělých zemích byl za- (panická reakce), kdy prudké rozepětí plic může vést znamenán trend vzestupu průměrného věku sportovních k barotraumatu a ke vzniku plynové arteriální embolie potápěčů. Tato skutečnost má řadů důvodů a přináší s se- (barotrauma z přetlaku). V případě potápění na nádech bou problematiku často snížené fyzické kondice adeptů vede stlačení hrudníku k významným změnám uložení potápění a zvyšující se počet komorbidit. Proto nabývají na nitrohrudních orgánů (např. v 10 m je tlak prostředí dvoj- významu pravidelné kontroly zdravotního stavu potápě- násobný, objem plic se sníží na polovinu, bránice se vy- čů. Podle dosavadních předpisů je doporučeno, aby každý klene směrem do hrudního koše, dochází k prostorovým potápěč absolvoval jednou ročně vyšetření lékařem s cílem změnám uložení nitrohrudních orgánů. Při nedostatečné posoudit zdravotní způsobilost pro potápění (tzv. fi tness fl exibilitě hrudního koše může dojít při sestupu výjimečně to dive). Základní vyšetření u rekreačně sportovních potá- k barotraumatu z podtlaku („lung squeeze“). pěčů provádějí praktičtí lékaři, kteří se v případě přítom- Teplota vody je významným faktorem, který se podílí nosti onemocnění kardiovaskulárního systému obracejí na nejenom na tepelných ztrátách, ale také na procesu re- kardiology. Z těchto důvodů je nutné, aby se kardiologové distribuce cirkulace, vazokonstrikce v periferii a vzestupu orientovali v základní problematice potápění. afterloadu. Teplota vody u nádechových potápěčů iniciu- je tzv. diving response. Hustota dýchací směsi narůstá s hloubkou, což se pro- Druhy potápění, výstroj jevuje zvýšením dechové práce. Svoji roli má také správná funkce dýchací automatiky. Mezi základní druhy sportovně-rekreačního potápění pa- tří potápění s přístrojem a volné potápění (freediving). Potápění s přístrojem zahrnuje potápění v teplých i chlad- Reakce kardiovaskulárního systému na ponor ných vodách zpravidla do hloubek menších než 40 metrů. Potápění na nádech zahrnuje vedle tzv. rekreačního šnor- Základní reakcí kardiovaskulárního systému na fyzickou chlování a lovu ryb na nádech (spearfi shing), dále spor- zátěž je zvýšení srdeční frekvence, zvýšení tepového obje- tovní disciplíny bazénové (plavání v apnoi na vzdálenost mu, redistribuce cirkulace s přednostním zásobením moz- s ploutvemi/bez ploutví, statickou apnoi), dále hloubkové ku, srdce, plic a pracujících svalů. Stav je provázen změ- disciplíny (dosažení maximální hloubky s ploutvemi s pří- nami afterloadu a preloadu s cílem zajistit vyšší minutový tahy lana a podobně). výdej. Potápění s přístrojem zahrnuje potápění se zásobou Vodní prostředí tyto základní procesy ovlivňuje. Ochla- dýchacího média (nejčastěji vzduchu, případně směsí – zení těla vodou vede k zesílené periferní vazokonstrikci, nitrox aj.), které potápěč přes dýchací automatiku dýchá zvýšení afterloadu, redistribuce oběhu je významnější. pod tlakem, který je roven okolnímu tlaku vody v závis- Stav je provázen zvýšenou diurézou. Zvýšení tlaku v dý- losti na hloubce, ve které se potápěč nachází. Tepelnou chacím systému je provázeno vzestupem tlaku v arteria ochranu zajišťuje tzv. mokrý oblek (zpravidla neoprenový pulmonalis. Následkem je zvýšení nároků na správnou oblek) nebo suchý oblek (upravený neopren, trilaminát, funkci myokardu.1 Na tomto místě je nutné připomenout, kordura), který poskytuje větší tepelný komfort, avšak že potápění se velmi často provozuje celoročně (zimní omezuje volnost pohybu potápěče. Ke kontrole vztlaku měsíce nevyjímaje), v mnoha evropských zemích potápění jsou používány kompenzátory vztlaku (tzv. žaket, křídlo, ve sladké vodě představuje ponory v jezerech či lomech, kobliha) a zátěž. Potápěč se pod vodou pohybuje prací kde je celoročně již ve střední hloubce relativně nízká dolních končetin vybavených ploutvemi. Za pozornost teplota (4–10 °C). stojí váha výstroje sportovně rekreačního potápěče s pří- Fyzická aktivita při potápění je velmi rozdílná, řada strojem, která je na suchu kolem 25–30 kg. Potápěč na ná- ponorů s přístrojem se vyznačuje velmi nízkou inten- dech je při každém z ponorů omezen jedním nádechem. zitou fyzické zátěže. Stav se může velmi rychle změnit Jeho výstroj zahrnuje potápěčskou masku (zpravidla níz- s nástupem krizové situace, kdy je třeba vynaložit rela- koobjemovou), neoprenový oblek, zátěž (opasek či tzv. tivně velkou námahu. Fyzickou náročnost pohybu zvy- neck weight) a ploutve (dlouhé tzv. bi-fi ns nebo mono- šuje velký odpor, který klade tělo potápěče s plnou vý- ploutev). strojí vodnímu prostředí. Podobně potápění v místech, kde jsou proudy, vyžaduje poměrně vysokou intenzitu fyzické práce. Fyzikální vlivy uplatňující se při potápění Velmi zajímavý fenomén, který se uplatňuje především při nádechovém potápění, představuje tzv. diving respon- Mezi základní fyzikální faktory, které mají vliv na funkci se (někdy označován jako „diving mammalian refl ex“ či kardiovaskulárního a respiračního systému při potápění, „diving refl ex“).2 Jde o odpověď kardiovaskulárního sys- patří hloubka, teplota vody a v případě potápění s pří- tému na ponoření těla (především obličeje) do vody, kte- strojem změny hustoty dýchací směsi. rý indukuje relativně významný pokles tepové frekvence, 3390_394_Prehledovy90_394_Prehledovy cclanek_Pudil.inddlanek_Pudil.indd 339191 111/09/20201/09/2020 110:21:360:21:36 392 Kardiovaskulární systém a sportovní potápění Obr. 1 – Cirkulující mikrobubliny po ponoru s přístrojem a dýcháním stlačeného vzduchu. Echokardio- grafi cký obraz apikální projekce potápěče před ponorem (vlevo) a bezprostředně po ponoru (vpravo). Po ponoru jsou v pravostranných oddílech detekovatelné mikrobubliny (archiv autora). významně
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