eMedicine Specialties > Pulmonology > Altitude Edema and Lung Diseases

Pulmonary Edema, High-Altitude: Treatment & Medication

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

Treatment

Medical Care

The treatment of high-altitude pulmonary edema (HAPE) includes rest, administration of oxygen, and descent to a lower altitude. If diagnosed early, recovery is rapid with a descent of only 500-1000 m. A portable hyperbaric chamber or supplemental oxygen administration immediately increases oxygen saturation and reduces pulmonary artery pressure, heart rate, respiratory rate, and symptoms. In situations where descent is difficult, these treatments can be lifesaving.
 
In one study, 11 patients at 4240 m altitude in Pheriche, Nepal were treated for HAPE with bed rest, oxygen, nifedipine, and acetazolamide.7 Sildenafil and salmeterol were used in most, but not all patients. Seven of these had serious-to-severe HAPE (Hultgren grades 3 or 4). Oxygen saturation was improved at discharge (84% ±1.7%) compared with admission (59% ±11%), as was the ultrasound comet-tail score (11 ±4 at discharge vs 33 +/- 8.6 at admission), a measure of pulmonary edema for which admission and discharge values were obtained in 7 patients.
 
A randomized, double-blinded, placebo-controlled study showed that adults with previous HAPE who received prophylactic tadalafil (10 mg) or dexamethasone (8 mg) had significantly less HAPE compared with those who received placebo twice daily. The medications were administered during ascent and at a stay at 4559 m altitude.8
 
Two participants who received tadalafil developed severe acute mountain sickness upon arrival at 4559 m and withdrew from the study; they did not have HAPE at that time. HAPE developed in 7 of 9 participants who received placebo and in 1 of the remaining 8 participants who received tadalafil, but it did not develop in any of the 10 participants who received dexamethasone (P = .007 for tadalafil vs placebo; P <.001 for dexamethasone vs placebo). Eight of 9 participants who received placebo, 7 of 10 who received tadalafil, and 3 of 10 who received dexamethasone had acute mountain sickness (P = 1.0 for tadalafil vs placebo; P = .020 for dexamethasone vs placebo).
 
At high altitude, systolic pulmonary artery pressure increased less in participants who received dexamethasone (16 mm Hg [95% confidence interval, 9-23 mm Hg]) and tadalafil (13 mm Hg [95% confidence interval, 6-20 mm Hg]) than in those who received placebo (28 mm Hg [95% confidence interval, 20-36 mm Hg]) (P = .005 for tadalafil vs placebo; P = .012 for dexamethasone vs placebo).

The conclusion was that both dexamethasone and tadalafil decrease systolic pulmonary artery pressure and may reduce the incidence of HAPE in adults with a history of HAPE. Dexamethasone prophylaxis may also reduce the incidence of acute mountain sickness in these adults.

Finally, the use of an expiratory positive airway pressure mask improves oxygenation and may be useful as a temporizing measure.

Consultations

Related clinical guideline summaries are as follows:

Diet

  • A diet rich in carbohydrates has shown to be helpful in prevention of high-altitude pulmonary edema.
  • Alcohol and sedatives should be avoided.

Medication

Drugs are not as effective as descent from altitude and oxygen in the treatment of high-altitude pulmonary edema (HAPE). Nifedipine, by reducing pulmonary arterial pressure, may be effective in treating HAPE.11 Experience with other vasodilators such as hydralazine is limited. Some studies have reported good results with furosemide. However, concerns about hypovolemia have constrained its use in the United States. Some studies have reported vascular collapse at doses of 40 mg bid. Acetazolamide may be useful in the earliest stages of the illness. The best management of this uncommon illness is early recognition and descent.

Prophylaxis is indicated for persons who have been identified (from past experience) as being susceptible to developing high-altitude illness or who must ascend rapidly to a high altitude. Acetazolamide and dexamethasone have been shown to be effective agents for prophylaxis against high-altitude illness. These agents must be started 24 h before ascent and continued for 48-72 h at altitude. Acetazolamide, which appears to hasten acclimatization, is considered the drug of choice because of a low incidence of significant adverse effects. Acetazolamide has also been shown to reduce the risk and severity of HAPE in high-risk individuals. One study showed that low-dose acetazolamide administered prior to ascent and on day 1 at 4300 m effectively reduced the incidence and severity of HAPE.12 Other preventive measures include avoiding overexertion and respiratory depressants (eg, alcohol, sedatives) and eating a high-carbohydrate diet.

Calcium channel blockers

Nifedipine is used for its pulmonary vasodilating effects.


Nifedipine (Procardia, Adalat)

Used in HAPE for pulmonary vasodilation. Often improves SaO2 modestly within a few min.

Adult

IR: 10-20 mg PO/SL q6h initially followed by 20 mg q6h
SR: 30 mg PO q8-12h; not to exceed 120 mg/d

Pediatric

0.25-0.5 mg/kg/dose PO tid/qid prn

Caution with coadministration of any agent that can lower BP, including beta-blockers and opioids; H2 blockers (cimetidine) may increase toxicity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause lower extremity edema; allergic hepatitis has occurred but is rare

Carbonic anhydrase inhibitors

These agents are helpful in the prevention of HAPE.


Acetazolamide (Diamox)

Used in the prevention of HAPE. Not used in the treatment of this condition. Promotes renal excretion of bicarbonate, which stimulates respiration. For the prophylaxis of altitude illness, start 24-48 h before ascent and continue for 48 h after arrival at high altitude.

Adult

250 mg PO q8-12h; alternatively, 500 mg ER cap PO q12-24h

Pediatric

5 mg/kg/d PO

Can decrease therapeutic levels of lithium and alter excretion of drugs (eg, amphetamines, quinidine, phenobarbital, salicylates) by alkalinizing urine

Documented hypersensitivity; hepatic disease; severe renal disease; adrenocortical insufficiency; severe pulmonary obstruction

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Patients with impaired hepatic function may go into coma; may cause substantial increase in blood glucose in some patients who are diabetic

Corticosteroids

Have profound and varied metabolic effects. They suppress inflammation and the immune response.


Dexamethasone (Decadron)

Alleviates vasogenic cerebral edema and improves endothelial integrity.

Adult

4 mg PO q6h

Pediatric

Not established

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization

Documented hypersensitivity; active bacterial or fungal infection

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

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].

  10. [Guideline] Rice SG. Medical conditions affecting sports participation. Pediatrics. Apr 2008;121(4):841-8. [Medline].

  11. Bärtsch P, Maggiorini M, Ritter M, Noti C, Vock P, Oelz O. Prevention of high-altitude pulmonary edema by nifedipine. N Engl J Med. Oct 31 1991;325(18):1284-9. [Medline].

  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].

  13. Bärtsch P. High altitude pulmonary edema. Med Sci Sports Exerc. Jan 1999;31(1 Suppl):S23-7. [Medline].

  14. Bärtsch P. High altitude pulmonary edema. Respiration. 1997;64(6):435-43. [Medline].

  15. Goetz AE, Kuebler WM, Peter K. High-altitude pulmonary edema. N Engl J Med. Jul 18 1996;335(3):206-7. [Medline].

  16. Hackett PH, Rennie D, Levine HD. The incidence, importance, and prophylaxis of acute mountain sickness. Lancet. Nov 27 1976;2(7996):1149-55. [Medline].

  17. Klocke DL, Decker WW, Stepanek J. Altitude-related illnesses. Mayo Clin Proc. Oct 1998;73(10):988-92; quiz 992-3. [Medline].

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

  19. Naeije R. Pulmonary circulation at high altitude. Respiration. 1997;64(6):429-34. [Medline].

  20. Nayak NC, Roy S, Narayanan TK. Pathologic features of altitude sickness. Am J Pathol. Sep 1964;45:381-91. [Medline].

  21. Schoene RB. Lung disease at high altitude. Adv Exp Med Biol. 1999;474:47-56. [Medline].

  22. Schoene RB, Hackett PH, HornBein TF. High altitude. In: Murray JF, Nadel JA, eds. Textbook of Respiratory Medicine. Vol 2. Philadelphia, Pa: WB Saunders; 2000:2062-98.

  23. Singh I, Khanna PK, Srivastava MC, Lal M, Roy SB, Subramanyam CS. Acute mountain sickness. N Engl J Med. Jan 23 1969;280(4):175-84. [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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