Altitude Illness - Pulmonary Syndromes Follow-up

  • Author: N Stuart Harris, MD, MFA, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 23, 2011
 

Further Inpatient Care

  • Admission criteria are as follows:
    • Significant arterial oxygen desaturation at rest
    • Dyspnea at rest
    • Inability to descend
  • Treatment of moderate-to-severe HAPE after descent consists of bedrest and oxygen; continuation of nifedipine, tadalafil, dexamethasone, inhaled beta-agonist also may be helpful.
  • Discharge criteria are as follows:
    • Normal SaO2 on room air
    • No dyspnea at rest (mild dyspnea with exertion may persist for several days)
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Further Outpatient Care

  • Outpatient treatment of mild HAPE after descent consists of bedrest. Follow up in 24 hours to check on clearance of HAPE edema.
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Deterrence/Prevention

  • Recommendations on staged ascents are by and large adequate for the average person, but some persons will still become ill despite a slow, staged ascent. Persons traveling to high altitude should allow adequate time for acclimatization and pay careful attention to symptoms. Helpful guidelines to avoid altitude illness include the following:
    • Avoid abrupt ascent to sleeping elevations over 3000 m (10,000 ft).
    • Spend 1-2 nights at an intermediate elevation (2500-3000 m) before further ascent.
    • Above 3000 m, sleeping elevations should not increase by more than 300-400 m per night.
    • When topography or village locations dictate more rapid ascent, or after every 1000 m gained, spend a second night at the same elevation.
    • Day hikes to higher elevations, with return to lower sleeping elevations help to improve acclimatization.
    • Avoid overexertion.
    • Avoid alcohol consumption in the first 2 days at a new, higher elevation; in addition to concerns about respiratory depression and exaggerated sleep hypoxemia, an AMS headache the next morning is all too easily dismissed as a hangover.
  • Significant abnormalities of pulmonary vasculature (eg, absence of the left pulmonary artery) or pulmonary hypertension are contraindications for going to high altitude.
  • The indication for chemoprophylaxis of HAPE is repeated episodes. Whether one prior episode should encourage prophylaxis is arguable, but demonstrated susceptibility certainly requires caution. Oftentimes, a slower ascent is the only preventive method required. Effective agents for prevention of HAPE include nifedipine and salmeterol. Those with a history of HAPE should carry nifedipine to use either prophylactically or with the first signs of HAPE. Salmeterol reduced HAPE by 50% in susceptible persons, appears safe, and should be considered for treatment as well, though it has not yet been studied for this indication. Recent studies have shown evidence for a prophylactic role in HAPE for dexamethasone, but detailed study of optimal dosing protocol has not been reported. Oral phosphodiesterase-5 inhibitors (eg, sildenafil, tadalafil) have been found effective for prophylaxis of HAPE, but they have not yet been studied for treatment.
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Complications

  • Secondary pulmonary infections may occur. Note that a productive cough while recovering from HAPE is common. Use Gram stain or culture to evaluate for cases requiring antibiotic therapy.
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Prognosis

  • The prognosis is excellent for survivors, with rapid clearing of the edema fluid and no long-term sequelae. Patients may need from 3 days to 2 weeks to recover completely; after all symptoms have resolved, cautious reascent is acceptable.
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Patient Education

  • It is recommended that all HAPE cases be reported immediately to the International HAPE Registry. This Registry is owned by physician/scientists of the International Society of Mountain Medicine and seeks to improve HAPE prevention and care.
  • Patients should be educated on staged ascents (see Deterrence/Prevention).
  • The golden rules of altitude illness are as follows:
    • If a person feels sick at altitude, his or her condition is altitude illness unless proven otherwise.
    • If symptoms of acute mountain sickness (AMS) are present, go no higher.
    • If symptoms are worsening, fail to improve with treatment, or if HACE or HAPE is present, descend immediately.
  • For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries. Also, see eMedicine's patient education article Mountain Sickness.
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Contributor Information and Disclosures
Author

N Stuart Harris, MD, MFA, FACEP  Chief, Division of Wilderness Medicine, Massachusetts General Hospital (MGH) Fellowship Director, MGH Wilderness Medicine Fellowship. Attending Physician, MGH Assistant Professor in Surgery, Harvard Medical School

N Stuart Harris, MD, MFA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, International Society for Mountain Medicine, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sara W Nelson, MD  Staff Physician, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital and Massachusetts General Hospital

Sara W Nelson, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Samuel M Keim, MD  Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Thomas E Dietz, MD, to the development and writing of this article.

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High-altitude pulmonary edema (HAPE). Image courtesy Dr Peter Hackett.
Hyperbaric treatment at 4250 m in a Gamow bag.
Thoracic ultrasonography: comet tail sign. Patient with acute high-altitude pulmonary edema (HAPE). Note wedge-shaped forms extending from pleural lining. In contrast, normal thoracic sonogram (below) reveals only diffuse, "snow storm" appearance. Courtesy of Dr Peter Fagenholz, et al.
Thoracic ultrasonography. Normal thoracic sonogram reveals only diffuse, "snow storm" appearance without comet tail sign. Courtesy of Dr Peter Fagenholz, et al.
 
 
 
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