eMedicine Specialties > Pulmonology > Altitude Edema and Lung Diseases

Pulmonary Edema, High-Altitude: Differential Diagnoses & Workup

Author: Rohit Goyal, MD, Fellow, Division of Pulmonary Medicine, Lenox Hill Hospital, New York University School of Medicine
Coauthor(s): Mir Omar Ali, MD, Fellow, Department of Pulmonary Medicine, Lenox Hill Hospital, New York University; Samia Qazi, MD, Director of the Travel and Immunization Clinic, Nassau County Medical Center; Assistant Professor, Department of Internal Medicine, State University of New York Health Science Center at Stony Brook; Laurie Ward, MD, Chief, Co-Director of Travel and Immunization Clinic, Nassau County Medical Center; Assistant Professor, Department of Internal Medicine, Division of Primary Care, State University of New York at Stony Brook; Qazi Qaisar Afzal, MD, Clinical Instructor, Department of Medicine, State University of New York at Stony Brook; Mir Mustafa Ali, Deccan College of Medical Sciences, Owaisi Hospital and Research Center, Princess Esra Hospital, India; Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Contributor Information and Disclosures

Updated: Sep 17, 2009

Differential Diagnoses

Asthma
Bronchitis
Myocardial Infarction

Other Problems to Be Considered

Anxiety
Viral syndromes
Thromboembolic disease

Workup

Laboratory Studies

  • Findings on laboratory studies from high-altitude pulmonary edema (HAPE) patients are nonspecific.
  • Arterial blood gas measurement may show acute respiratory alkalosis. A mild leukocytosis also may be present.
  • Some studies have demonstrated increase in interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1ra), and cross-reacting protein (CRP) in response to high altitude. The systemic increase of these inflammatory markers may reflect considerable local inflammation.4

Imaging Studies

  • Chest radiography in high-altitude pulmonary edema (HAPE) patients reveals bilateral patchy infiltrates.
  • In one study, stress echocardiography was used to quantitate pulmonary artery systolic pressure responses to prolonged hypoxia and normoxic exercise.5 The data from the study indicate that individuals who are susceptible to HAPE have abnormal vascular responses not only to hypoxia but also to supine bicycle exercise under normoxic conditions. Thus, this modality may be a useful noninvasive screening method to identify subjects susceptible to HAPE.
  • Chest ultrasonography was evaluated in one study and showed that the comet-tail technique, which has been shown in cardiogenic pulmonary edema, effectively recognizes and evaluates the degree of pulmonary edema in HAPE patients.6

Other Tests

  • ECG in high-altitude pulmonary edema (HAPE) patients may reveal a right-sided heart strain pattern suggestive of pulmonary hypertension.

Procedures

  • Portable hyperbaric chambers (Gamow, CERTEC) are in wide use by trekkers. A physiologic (simulated) descent of approximately 2000 m may be achieved in a few minutes. Patients are typically treated in 1-hour increments. Patients should be closely observed for rebound symptoms after hyperbaric treatments.

More on Pulmonary Edema, High-Altitude

Overview: Pulmonary Edema, High-Altitude
Differential Diagnoses & Workup: Pulmonary Edema, High-Altitude
Treatment & Medication: Pulmonary Edema, High-Altitude
Follow-up: Pulmonary Edema, High-Altitude
References
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References

  1. Fischer R, Lang SM, Bergner A, Huber RM. Monitoring of expiratory flow rates and lung volumes during a high altitude expedition. Eur J Med Res. Nov 16 2005;10(11):469-74. [Medline].

  2. Eldridge MW, Braun RK, Yoneda KY, Walby WF. Effects of altitude and exercise on pulmonary capillary integrity: evidence for subclinical high-altitude pulmonary edema. J Appl Physiol. Mar 2006;100(3):972-80. [Medline].

  3. Leshem E, Pandey P, Shlim DR, Hiramatsu K, Sidi Y, Schwartz E. Clinical features of patients with severe altitude illness in Nepal. J Travel Med. Sep-Oct 2008;15(5):315-22. [Medline].

  4. Hartmann G, Tschop M, Fischer R, et al. High altitude increases circulating interleukin-6, interleukin-1 receptor antagonist and C-reactive protein. Cytokine. Mar 2000;12(3):246-52. [Medline].

  5. Grunig E, Mereles D, Hildebrandt W, et al. Stress Doppler echocardiography for identification of susceptibility to high altitude pulmonary edema. J Am Coll Cardiol. Mar 15 2000;35(4):980-7. [Medline].

  6. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris NS. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Chest. Apr 2007;131(4):1013-8. [Medline].

  7. Fagenholz PJ, Gutman JA, Murray AF, Harris NS. Treatment of high altitude pulmonary edema at 4240 m in Nepal. High Alt Med Biol. Summer 2007;8(2):139-46. [Medline].

  8. [Best Evidence] Maggiorini M, Brunner-La Rocca HP, Peth S, et al. Both tadalafil and dexamethasone may reduce the incidence of high-altitude pulmonary edema: a randomized trial. Ann Intern Med. Oct 3 2006;145(7):497-506. [Medline].

  9. [Guideline] Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. Dec 15 2006;43(12):1499-539. [Medline].

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  12. van Patot MC, Leadbetter G 3rd, Keyes LE, Maakestad KM, Olson S, Hackett PH. Prophylactic low-dose acetazolamide reduces the incidence and severity of acute mountain sickness. High Alt Med Biol. Winter 2008;9(4):289-93. [Medline].

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  18. Krieger BP, de la Hoz RE. Altitude-related pulmonary disorders. Crit Care Clin. Apr 1999;15(2):265-80, viii. [Medline].

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Further Reading

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Keywords

high-altitude pulmonary edema, mountain sickness, altitude illness, HAPE, high-altitude illness, cerebral edema, acute mountain sickness, retinal hemorrhages, peripheral edema, noncardiogenic pulmonary edema

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Contributor Information and Disclosures

Author

Rohit Goyal, MD, Fellow, Division of Pulmonary Medicine, Lenox Hill Hospital, New York University School of Medicine
Rohit Goyal, MD is a member of the following medical societies: American College of Chest Physicians, American Medical Association, and American Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Mir Omar Ali, MD, Fellow, Department of Pulmonary Medicine, Lenox Hill Hospital, New York University
Mir Omar Ali, MD is a member of the following medical societies: American College of Physicians and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Samia Qazi, MD, Director of the Travel and Immunization Clinic, Nassau County Medical Center; Assistant Professor, Department of Internal Medicine, State University of New York Health Science Center at Stony Brook
Samia Qazi, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

Laurie Ward, MD, Chief, Co-Director of Travel and Immunization Clinic, Nassau County Medical Center; Assistant Professor, Department of Internal Medicine, Division of Primary Care, State University of New York at Stony Brook
Laurie Ward, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, International Society of Nephrology, and National Kidney Foundation
Disclosure: Nothing to disclose.

Qazi Qaisar Afzal, MD, Clinical Instructor, Department of Medicine, State University of New York at Stony Brook
Qazi Qaisar Afzal, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Mir Mustafa Ali, Deccan College of Medical Sciences, Owaisi Hospital and Research Center, Princess Esra Hospital, India
Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

Medical Editor

Gregory Tino, MD, Director of Pulmonary Outpatient Practices, Associate Professor, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Medical Center and Hospital
Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

,, Kathy Roarty Placeholder
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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