ORIGINAL ARTICLE
The Potential Diagnostic Accuracy of Autopsy Lung Weights,
Lung-Heart Ratio, and Lung-Body Ratio in Drowning Deaths
Rexson Tse, MB, BS, BSc, FRCPA,* Jack Garland, BMed,† Kilak Kesha, MD,* Paul Morrow, MD,*
Leo Lam, MBChB,‡ Hannah Elstub, MB, BS, BSc(Hons),§ Allan Cala, FRCPA,§ Amy Spark, MBChB, FRCPA,||
Cristian Palmiere, MD,¶ and Simon Stables, MB, ChB, MNZM, DAvMed, AsFACAsM, FNZSP, FRCPA*
Abstract: Lung weights are often increased in drowning deaths as well as
in other types of deaths. Lung weights may also vary with age, sex, and
body weight. Avariety of methods have been proposed to utilize lung weight
data to assist with the diagnosis of drowning. The present study compared
lung weight, lung-heart ratio (LH), and lung-body ratio (LB) between 50
consecutive drowning and 50 nonimmersion deaths in order to assess the
accuracy in diagnosing drowning. Analysis revealed both LH and LB to
be statistically higher in drowning deaths (P < 0.05), with LB being the
most robust measurement. However, the overall diagnostic accuracies of
lung weight, LH, and LB were poor to fair, and should therefore be used
only in conjunction with the other diagnostic criteria.
Key Words: diagnostic accuracy, drowning, lung weights
(Am J Forensic Med Pathol 2018;00: 00–00)
D eaths due to drowning are commonly encountered in forensic
pathology practice. The diagnosis of drowning can be made
only with total circumstantial investigation correlated with autopsy
findings.1,2 The autopsy of bodies recovered in water can offer
“clues” as to whether a victim had drowned.1 A common autopsy
finding is an increased lung weight (L), which may be due to
water aspiration, pulmonary alveolar damage, and cardiac failure
or the combination of the three.3–5 Although seen in drowning,
increased L can also be caused by other natural and unnatural
conditions and can be nonspecific.4–12 The use of L in aiding the
diagnosis of drowning has had variable success in the past.4,5,7–12
Multiple variations in using L to aid the diagnosis of drowning
have been applied, including L, LH, lung-body ratio (LB), and
drowning index (ratio of lung and pleural effusion to spleen
weight).4,5,7–9,12 The present study was conducted to compare
the diagnostic accuracy of 3 basic variations of using L, LH, and
LB in diagnosing drowning.
Manuscript received January 7, 2018; accepted March 10, 2018.
From the *Department of Forensic Pathology, LabPLUS, Auckland City
Hospital, Auckland, New Zealand; †Hornsby Ku-Ring-Gai Hospital,
Hornsby, New South Wales, Australia; ‡Department of Biochemistry,
LabPLUS, Auckland City Hospital, Auckland, New Zealand; §Department
of Forensic Medicine, Newcastle, Forensic & Analytical Science Service,
NSW Health Pathology, John Hunter Hospital, Newcastle, New South Wales,
Australia; ||Wellington Hospital Mortuary, Wellington, New Zealand; and
¶CURML, University Center of Legal Medicine, Lausanne University
Hospital, Lausanne, Switzerland.
The authors confirm that all cases selected for this work underwent coronial
autopsies directed by the coroner. Body and organ weights measured were
part of the investigation.
The authors report no conflict of interest.
Reprints: Rexson Tse, MB, BS, BSc, FRCPA, Department of Forensic
Pathology, LabPLUS, Auckland City Hospital, Auckland 1148,
New Zealand. E-mail: rexson.tse@gmail.com; rexsont@adhb.govt.nz.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.amjforensicmedicine.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/18/0000–0000
DOI: 10.1097/PAF.0000000000000402
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
MATERIALS AND METHODS
Drowning and Nonimmersion Selection
Based on previous drowning studies with respect to organ
weights, in order to detect a combined lung difference of 300 g
with an SD of 500 g (α = 0.05, β = 0.2), the sample size (n) re-
quired was calculated to be 44.4,5,7,11 This study retrospectively
identified 50 consecutive drowning deaths and 50 consecutive
non–immersion-related deaths from January 1, 2012, to October
31, 2017 (inclusive), from the Department of Forensic Pathology,
Auckland City Hospital. A full autopsy was performed in each
case with a record of all organ and body weights. All full post-
mortem examinations performed at the forensic department are
authorized by the coroner.
All drowning deaths were identified through our database by
searching “drowning” as the primary cause of death assigned by
the attending pathologist. In New Zealand, all immersion deaths
are reported to the coroner, and a thorough police investigation
together with a full postmortem is undertaken unless unautho-
rized by the coroner. Salt water and fresh water drowning deaths
were not segregated as previous studies showed no significant
difference in L.3 Consecutive nonimmersion deaths were identified
that included all natural deaths, drug- and alcohol-related deaths,
asphyxia deaths, hypothermic deaths, and nonexsanguination trau-
matic deaths. These conditions were included in the nonimmersion
death group as there can be potential nondrowning differential
causes of death in bodies retrieved from water.
For both groups, the electronic postmortem files were
reviewed. The age, sex, cause of death, heart weight, L (left and
right), and body weight were recorded. The L was determined
as the sum of both left and right lungs in grams. The LH (in g/g)
was determined as L divided by heart weight (in g). The LB
(in g/kg) was determined as L divided by body weight (in kg).
Exclusion Criteria
Exclusion criteria are as follows:
1. an immersion death that the pathologist indicated the diagnosis
of drowning was unclear,
2. compromised bodies including incinerated, decomposed, and/or
bodies with missing body parts,
3. any traumatic or natural deaths that had resulted in exsanguination,
4. pediatrics deaths (<10 years of age) including infant deaths, and
5. postmortem interval greater than 3 days, as significant decrease
in L is noted after 3-day postmortem interval.12
Statistical Analysis
Continuous variables were described using means and SDs.
Medians, minima, and maxima are also presented. Categorical
variables are described using counts.
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Tse et al Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018

TABLE 1. Summary of Drowning Deaths and Nonimmersion Deaths

n Mean Median SD Max Min 95% CI

Nonimmersion deaths
Age, y 54 57 17 88 22 49.25–58.87
Sex 36:14 (Male:female)
L, g 1322 1330 417.80 600 2285 1203.70–1441.18
LH, g/g 2.707 2.67 1.00 5.74 1.33 2.42–2.99
LB, g/kg 15.354 13.806 6.54 38.00 5.18 13.50–17.21
Drowning deaths
Age, y 42 41 18 77 13 36.41–46.67
Sex 43:7 (Male:female)
L, g 1484 1408 496.10 2958 584 1342.75–1624.73
LH, g/g 4.14 9.99 1.64 9.62 1.91 3.67–4.60
LB, g/kg 20.45 18.23 8.83 44.51 7.09 17.95–22.96

To explore the differences between the 2 groups, nonpaired
Kruskal-Wallis test was used to compare age, and Fisher exact test
was used to compare the difference in sex distribution between
each group.
Assuming monotonic and nonparametric relationships,
Spearman correlation coefficient (ρ) was determined between
age and L, LH, and LB. The differences between L, LH, and LB
with dichotomous variables (sex and drowning) were analyzed
using nonpaired Kruskal-Wallis test. Receiver operating charac-
teristic (ROC) curves were plotted for L, LH, and LB with drown-
ing as the outcome. The optimal cutoff point was determined by
minimizing the Euclidean distance to the perfect predictor (sensi-
tivity of 1 and false-positive rate of 0). The areas under the curve
(AUC, indicator of diagnostic accuracy) for L, LH, and LB were
determined together with the 95% confidence intervals (CIs).
Statistical analysis was performed using R (version 3.4.1; The
R Foundation for Statistical Computing, Auckland, New Zealand).
A 2-tailed P < 0.05 was considered significant.
RESULTS
A summary for drowning and nonimmersion death groups
is presented in Table 1. In the nonimmersion death group,
there were 36 natural deaths (28 cardiovascular related deaths,
5 infective/inflammatory-related deaths, and 3 gastrointestinal-
related deaths), 8 drug-related deaths (6 synthetic cannabis deaths,
1 mixed prescription drug toxicity death, and 1 methamphetamine
toxicity death), 2 asphyxia-related deaths, 2 hypothermic deaths,
and 2 traumatic deaths. The mean age in the drowning group
was significantly lower in nonimmersion deaths (P = 0.001).
There was a trend toward statistical difference with higher male
sex in the drowning group, but this did not reach statistical
significance (P = 0.086).
For continuous variables (Table 2), Spearman correlation
showed statistically significant positive correlation coefficient
between age and LH (0.279, P < 0.05), and no significant corre-
lation between age with L and LB (P > 0.05).
For dichotomous variables (Table 3), male sex had statisti-
cally higher L (P < 0.05) but no statistical difference in LH and
LB (P > 0.05). Drowning deaths had statistically higher LH and
LB (P < 0.05), but no statistical difference in L (P = 0.15).
The AUCs in the constructed ROC curves were 0.584, 0.787,
and 0.678 for L, LH, and LB, respectively (Fig. 1, Table 4). The
optimal cutoff points for L, LH, and LB were 1290 g (sensitivity,
0.62; specificity, 0.48), 2.99 g/g (sensitivity, 0.78; specificity, 0.48),
and 17.26 g/kg (sensitivity, 0.6; specificity, 0.7), respectively.
DISCUSSION
Drowning is a potential cause of death in bodies retrieved
from water and is defined as the process of experiencing respira-
tory impairment from submersion in liquid.13 The mechanism of
death from drowning is from asphyxiation and hypoxia from inha-
lation of the immersed liquid, which can occur within minutes.3,14
Diagnosing drowning can be difficult and requires total circum-
stantial investigation correlating with autopsy findings.1 Not all
bodies recovered from water have drowned. Bodies recovered
from water may have died of natural disease before falling into
water or in water, died of injuries before entering or while in
water, died of effects of immersion other than drowning, or died
of drowning.3 However, in a practical level, it may be difficult
or impossible to provide a definitive cause of death in bodies im-
mersed in water, especially when unwitnessed and with a delay in
body recovery leading to decomposition.3 Furthermore, not only be-
ing a diagnosis of exclusion, drowning is commonly the final result
of different initiating causes of the victim's incapacitation in water.15
With respect to autopsy findings, although there is no single
“diagnostic test,” autopsy can provide clues to aid the diagnosis.1
A common change in drowning is in the lungs. Classic de-
scription of the lungs in drowning deaths is waterlogged and

TABLE 3. Difference Between Male Sex and Drowning and L,

LH, and LB
TABLE 2. Spearman Correlation (ρ) Between Age and L, LH,
and LB
P
Spearman Coefficient (ρ) P Drowning Male Sex
L, g −0.1385 0.1691 L, g 0.15 0.02
LH, g/g 0.279 0.004 LH, g/g <0.05 0.68
LB, g/kg −0.0139 0.752 LB, g/kg <0.05 0.4252

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Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018 Lung-Heart and Lung-Body Ratios in Drowning Deaths

FIGURE 1. Receiver operating characteristic curves for L (in g, A), LH (in g/g, B), and LB (in g/kg, C).

overdistended,3,6,14,16 and an increase in L is well recognized.3 was proposed, suggesting it might be a better measurement in di-
During drowning, the lungs can have a substantial increase in agnosing drowning.12 This was followed by using LB, which
weight by immersed liquid aspiration, pulmonary alveolar dam- showed some success.4 The most recent use of L was in the form
age, cardiac failure, or the combination of the three.3–5 Although of a drowning index, which combined L, pleural effusion, and
“dry downing” had been described, it has been reported to have an spleen weight, but was subsequently disproved.7–9 A previous
incidence of less than 2%.17 Previous studies have described in- study using combined L, LH, and LB showed significantly
creasing L from 370 to 540 g to 600 to 700 g, with combined L higher L, LH, and LB in drowning deaths and subsequently pro-
of 1411 g in drowning compared with 994 g in controls.3,10,18,19 posed an optimal cutoff of 17.5 g/kg for LB, and when opti-
Variations using L were subsequently utilized, such as combin- mized for specificity, this would be 19.5 g/kg.4 The overall
ing lung and pleural effusion weight, L corrected for heart or success using L and its variations appeared to have limited
body weights, and factoring in spleen weights.4,5,7–9,12 An LH utility, and the diagnostic accuracies of these parameters are
not established.4,5,7–10,12,18–20
The presented study was carried out to investigate the diag-
TABLE 4. Area Under the Curve and Corresponding Optimal nostic accuracy in L, LH, and LB in drowning. Establishing the di-
Cutoff Points on the Plotted ROC Curves for L, LH, and LB agnostic accuracies would enable the pathologist to have a better
With Drowning as Outcome understanding of using these parameters in diagnosing drowning.
AUC 95% CI Cutoff Point Sensitivity Specificity
L, g 0.58 0.47–0.70 1290 0.62 0.48
Robustness of L, LH, and LB With Respect to Sex
LH, g/g 0.79 0.70–0.88 2.99 0.78 0.72
and Age
LB, g/kg 0.68 0.57–0.78 17.26 0.60 0.70 Organ and body weights are known to vary between age and
sex,3,21–24 limiting the utility of L on its own as a useful measurement

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Tse et al
in diagnosing drowning. Previous studies used different methods to
adjust these factors to account for the variation from age and
sex, in which LH and LB seemed to be most accepted.4,5,7–9,12
In the presented study, the overall age was lower in drowning
deaths than in nonimmersion deaths with no difference in sex
distribution. The effects on the differences between age and sex
on the L, LH, and LB were explored using Spearman coefficient
(ρ) for continuous variables and nonpaired Kruskal-Wallis for di-
chotomous variable. Overall, L was higher in male sex and did not
correlate with age. Lung-heart ratio did not show any difference
between sexes but had a positive correlation with age, albeit weak
(ρ < 0.3). Lung-body ratio did not show any significant difference
between sexes and had no correlation with age, making it the
most robust measurement with age and sex between the 3 pa-
rameters (L, LH, LB). This finding was not inconsistent with
previous studies.4,5
Diagnostic Accuracy
Previous studies have shown that L, LH, and LB are statisti-
cally higher in drowning deaths compared with nondrowning
deaths but were reserved in its utility as reliable diagnostic test.4,5
Although showing a trend in L, our study showed statistically
significant difference only in LH and LB, which was in keeping
with previous studies.3–5,10,18,19 Furthermore, L, LH, and LB with
their respective ranges in our study were also comparable with
previous studies.4,5
Although a medical test can demonstrate a significant differ-
ence between case and control, it may not be diagnostically useful.
Receiver operating characteristic curve analysis, particularly
estimating the AUC, is an accepted way of determining and
comparing the diagnostic accuracies for medical tests.25 A test
with an AUC of 0.5 means that the diagnostic accuracy is no better
than chance, and an AUC of 1 would be the perfect test. AUC of
0.90 or greater is ranked as excellent, between 0.80 and 0.90
being good, between 0.80 and 0.70 being fair, and below 0.7 being
poor.26 Another feature of using ROC curve is that a cutoff point
can then be subsequently determined by maximizing both sensi-
tivity and specificity or either of them depending on the condition
in interest.25
In the presented study, the diagnostic accuracy, assessed using
AUCs on the plotted ROC curves, showed that LH (0.79; CI,
0.70–0.88) had the highest diagnostic accuracy, followed by LB
(0.68; CI, 0.57–0.78) and L (0.58; CI, 0.47–0.70). The 95% CIs
for the AUCs for LH and LB were above 0.5 but were overlapping,
and they were unable to be statistically determined which of LH or
LB was better than the other. The AUC determined with L had a
95% CI falling between 0.47 and 0.70, making it unable to dis-
criminate drowning better than chance.
Our study showed a difference in age between the 2 groups
and a higher proportion of male in both groups, which may possi-
bly be confounding factors particularly with L and LH. The effects
of age and sex on LB, LH, and LB were discussed in previous
section. Lung weight and LH were dependent on sex and age,
respectively, and were considered confounding factors. Although
being most robust and showing no correlation and difference with
age and sex, respectively, it cannot be entirely ruled out that age
and sex were not confounding factors for LB.
Based on the robustness of the L, LH, and LB with respect to
age and sex, and the diagnostic accuracy assessed by AUC, the
most accurate and robust diagnostic parameter would be LB. This
finding was in keeping with previous observations supporting the
use of LB over LH and L.4 The cutoff point determined in this
study for LB (17.3 g/kg) was also in keeping with previous
study (17.5–19.5 g/kg).4
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Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018
Although this study confirmed previous studies and indi-
cated that LB should be assessed in drowning death rather than
L and LH,4 its utility as a diagnostic test is limited. The diagnostic
accuracy of LB, having an AUC of less than 0.8, to diagnose
drowning was ranked as fair and may just be better than by chance
alone. This study supports the idea that there is some use in
assessing LB, rather than L or LH, in suspected drowning deaths,
but its ability to diagnose drowning is at best fair.4 Lung-body ratio
is, however, in our opinion, would not be accurate enough as a
standalone marker for drowning.
LIMITATIONS
Study Design
The study examined the diagnostic accuracy of L and its var-
iations in diagnosing drowning deaths from nonimmersion deaths.
This study did not separate fresh and salt water drownings and did
not segregate sex and stratify different age groups. Nonimmersion
deaths were used as control and not further subcategorized to
different causes of death.
Although both types of drowning deaths (salt and fresh water)
are documented to have similar increase in L, extrapolation of our
results to fresh water drowning deaths must be done with caution.
Our study did not include pediatric populations especially below
the age of 10 years, and extrapolation beyond these parameters
cannot be supported in our study. The interactions between age
and sex on L, LB, and LH were examined by correlation studies
for continuous variables and Kruskal-Wallis tests for dichotomous
variables to examine the robustness of these lung measure-
ments. It concluded that LB was the most robust measurement
and accurate measurement for diagnosing drowning, although
it was still poor as a marker on its own. Further studies separat-
ing sexes and diving into different age group may further evalu-
ate the role of sex and age might play on L in the context
of drowning.
In terms of control groups, death not due to drowning but re-
covered from water would be the ideal group. These types of
deaths are rare, and most would be excluded in the study. There
were approximately 10 cases over approximately 10-year period
from our previous experience.27,28 These cases were commonly
trauma related with disruption of the body, in which accurate
organ and body weights cannot be established. Nonimmersion
deaths would be a reasonable alternative control group for the
purpose of this study. However, in using nonimmersion death
as a control group, our study assumes that L, heart weight, and
body weight are unaffected by immersion, which, in the authors'
opinion, is reasonable. It is under this assumption that the result
of our study could be applied in differentiating drowning deaths
from death not due to drowning but recovered from water. With
the overall low number of cases, future studies collaborating with
other centers on collecting death not due to drowning but recov-
ered from water are recommended.
Subcategorization of nonimmersion deaths was not per-
formed as this study was not designed to discriminate drowning
from other specific causes of death. However, the non–immersion-
related groups had values for L, LH, and LB that were not dissimilar
to those found in other similar studies, and it is the authors' opinion
that the nonimmersion group was robust as a comparison group
for drowning for the purpose of this study.4,5,10,12
Confounding Factors
The underlying natural disease and possible role of intoxica-
tion in the drowning deaths used in the study were not recorded
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Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018
and accounted for. It is possible that drowning deaths were
overdiagnosed in these cases and were in fact natural causes
and/or from intoxication. Not taking account of these conditions
in the drowning groups would result in a more robust result and
underestimating the diagnostic ability of L. Another possible
confounding factor was the presence of resuscitation, which
was not recorded in this study. Resuscitation may alter the
intravascular volume and possibly L, which may need to be
accounted for. Further study in controlling for these conditions
is recommended.
Optimal Cutoff Points
This study was not designed to determine an optimal cutoff
point for L, LH, and LB in drowning death. An optimal cutoff
point can be determined by optimizing both sensitivity and spec-
ificity or both with different mathematical techniques, which
may yield different optimal cutoff points with the same data set.
Our study optimized both sensitivity and specificity by minimiz-
ing the Euclidean distance to the perfect predictor and established
a cutoff point that was similar to previous proposed cutoff point
for LB.4 The cutoff points determined in the presented study can
be used as a reference only but still have poor specificity to diag-
nose drowning on their own.
RECOMMENDATION
This study suggests that although LB is the most accurate
and robust parameter in diagnosing drowning among L, LH, and
LB, it was still a poor marker. The accuracy of LB, compared with
other medical tests, was low, which limits its usefulness. It is rec-
ommended that LB may provide only supplemental information
for pathologists in making a diagnosis of drowning. Lung-body
ratio should be interpreted in conjunction with the circumstances
and other signs of drowning at autopsy. When there is any evidence
of decomposition or absence of any signs of drowning, LB should
be interpreted with caution. Further studies in combining LB with
other signs or ancillary tests of drowning, such as serum or vitreous
electrolytes, may provide an additive effect in increasing the diag-
nostic accuracy of drowning.
CONCLUSIONS
Among L, LH, and LB, LB was the determined to be the
most accurate and robust parameter in diagnosing drowning.
However, the overall diagnostic accuracies of the parameters
(L, LH, and LB) were low (AUC <0.8) compared with other ac-
cepted medical tests. Overall, LB (as well as L and LH) should not
be interpreted as a discriminating test for drowning and should be
used in conjunction with the circumstances and other signs of
drowning at autopsy (Supplemental Digital Content, http://links.
lww.com/FMP/A10 and http://links.lww.com/FMP/A11).
ACKNOWLEDGMENTS
The authors acknowledge the technical support from both
the Departments of Biochemistry and Forensic Pathology at
LabPLUS, Auckland City Hospital. The authors thank the forensic
pathology technicians and operations manager, Shane French,
Claire Barker, Julie Ruddell, Bonnie To, Jennifer Sucich, Alvin
Fondling, Stacey Wilkinson-Hunt, Bonnie To, and Ross Anderson.
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