Altitude Illness - Pulmonary Syndromes Treatment & Management

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

Prehospital Care

The mainstay of treatment is descent for anything other than mild HAPE. Descent to an altitude below that where symptoms started is always effective treatment, but it may not be practical or possible given the topography, weather, the patient's ultimate trekking or climbing goals, or group resources. Accordingly, a descent of 500-1000 m is usually sufficient. As noted above, while case series of treatment of even severe HAPE under expert care in well-equipped settings have been reported, descent for other than mild HAPE cases remains clearly indicated. Selected cases of reascent HAPE and mild HAPE at moderate altitude may be treated with oxygen and strict bedrest. If patients worsen, they must descend.

All of the following treatments are used as an adjunct to descent. Oxygen, if available, is lifesaving and should be administered at 4 L/min by mask or nasal cannula. Nifedipine should be used if descent or oxygen is not available. Nifedipine may help prevent exertional worsening in patients being evacuated on foot. Portable hyperbaric chambers (see image below) can effect a physiologic (simulated) descent when actual descent is not possible or practical. End-positive pressure masks are useful in treating HAPE but are poorly tolerated.

Hyperbaric treatment at 4250 m in a Gamow bag. Hyperbaric treatment at 4250 m in a Gamow bag.

The role of acetazolamide in the treatment of HAPE remains ill-defined but may prove beneficial. Additionally, recent reports give evidence that dexamethasone might have beneficial effect in HAPE as well. While not clearly established, there is little apparent downside risk to using either acetazolamide and dexamethasone in severe HAPE.

Inhaled salmeterol (a beta-agonist) has been demonstrated to help prevent acute HAPE in HAPE-susceptible populations. Salmeterol is thought to act by increasing alveolar fluid clearance through pulmonary sodium channels. Although its use in HAPE treatment has not been proven, it is often used in this indication.

Phosphodiesterase inhibitors have also been demonstrated to help prevent acute HAPE in HAPE-susceptible populations. These agents are thought to act by increasing availability of nitric oxide in pulmonary arterial vessels and so result in decreased pulmonary arterial tone and reduced pulmonary hypertension. Although its use in HAPE treatment has not been proven, it is often used in this indication.

Only limited studies provide any evidence that furosemide may be useful with acute HAPE, and it is not without downside risk. Furosemide should be used with substantial caution, if at all, as many patients are intravascularly depleted. Most authors discourage use of furosemide in treating HAPE.

Portable hyperbaric chambers (eg, Gamow, CERTEC, PAC) are widely used among adventure travel/trekking groups and climbing expeditions. These chambers are lightweight, coated fabric bags about 2 m in length and 0.7 m in diameter. The patient is placed inside the bag, which is sealed shut and inflated with a manually operated pump, pressurizing the inside to 105-220 mm Hg above ambient atmospheric pressure. This pressure gradient is regulated by pop-off valves set to the target pressure, and it is fixed depending on the brand of bag in use. (Refer to the following image.)

Hyperbaric treatment at 4250 m in a Gamow bag. Hyperbaric treatment at 4250 m in a Gamow bag.

Depending on the elevation, a physiologic (simulated) descent of about 2000 m (7000 ft) may be achieved within minutes. Intermittent pumping is necessary to flush carbon dioxide from the system, unless a chemical scrubber system is used. Patients with severe HAPE may need to have their head elevated to tolerate lying down. Elevation can be accomplished by placing the bag on a rigid surface, such as boards or a wooden bed, and propping up the head end by 0.3-0.5 m (12-20 inches).

In practice, most patients with moderate HAPE tolerate lying flat after reaching the physiologic lower elevation of the pressurized bag. Patients typically are treated in 1-hour increments and then are reevaluated, with additional treatments as indicated. Closely monitor patients for rebound signs and symptoms, which may occur soon after removal from the hyperbaric environment, or they may develop over a period of hours.

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Emergency Department Care

  • For cases of persistent desaturation or dyspnea, administer oxygen to keep oxygen saturation (SaO2) above 90%.
  • Consider continuing nifedipine in symptomatic patients.
  • Furthermore, consider dexamethasone, phosphodiesterase inhibitors, and inhaled beta-agonist as conditions indicate.
  • Emergency departments at altitude must assess the elevation at which the patient's illness occurred and determine whether further descent is necessary.
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Consultations

Children living at altitude who develop HAPE should undergo screening for diagnosis of underlying cardiopulmonary abnormalities, including pulmonary hypertension.

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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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