Sections

Medication

Medication Summary

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.^[29]However, in two separate studies, nifedipine did not outperform placebo or oxygen alone.^{[33, 34]}

Prevention

In general, acetazolamide facilitates acclimatization, but this agent should not be relied on as the sole preventive agent in individuals with known HAPE susceptibility.^{[2, 3]}

The Centers for Disease Control and Prevention (CDC) strongly recommends acetazolamide prophylaxis in all individuals with a prior history of HAPE or HACE, as well as with the following^[4]:

History of acute mountain sickness and ascending more than 2,800 m in 1 day
All people ascending to more than 3,500 m in 1 day
All people ascending more than 500 m per day (increase in sleeping elevation) above 3,000 m, without extra days for acclimatization
Very rapid ascents

The CDC recommends the following pharmacologic agents and regimens for HAPE prophylaxis^[4]:

Oral nifedipine (generally reserved for HAPE-susceptible individuals) - 30 mg sustained-release formulation every 12 hours (same regimen for HAPE treatment)
Oral tadalafil - 10 mg twice daily
Oral sildenafil - 50 mg every 8 hours

Treatment

Further research is needed before tadalafil or dexamethasone can be recommended over nifedipine for prophylaxis. The Wilderness Medical Society (WMS) advises that diuretics or acetazolamide should not be used for treatment of HAPE, and it makes no recommendation regarding beta-agonists or dexamethasone for HAPE treatment due to insufficient/lack of data.^{[2, 3]}Furthermore, WMS indicates there is no established role for acetazolamide, beta-agonists, diuretics, or dexamethasone in the treatment of HAPE, although dexamethasone should be considered where there is concern for concomitant high-altitude cerebral edema (HACE)

In the setting of concomitant HAPE and HACE, WMS recommends adding dexamethasone to the treatment regimen for patients with HAPE and neurologic dysfunction that does not resolve rapidly with administration of supplemental oxygen and improvement in the patient’s oxygen saturation.^{[2, 3]}If supplemental oxygen is not available, initiate dexamethasone in addition to medications for HAPE in those with mental status changes and/or suspected concurrent HACE. Note the following:

Dexamethasone should be administered at the doses recommended for the treatment of HACE.
Nifedipine or other pulmonary vasodilators may be used to treat concurrent HAPE and HACE, but avoid lowering mean arterial pressure, as this may decrease cerebral perfusion pressure and thereby increase the risk for cerebral ischemia.

Class Summary

Nifedipine is used for its pulmonary vasodilating effects.

Nifedipine (Procardia, Adalat)

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Nifedipine is used in HAPE for pulmonary vasodilation. It often improves SaO₂ modestly within a few minutes.

Class Summary

These agents are helpful in the prevention of HAPE.

Acetazolamide (Diamox)

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Acetazolamide is used in the prevention of HAPE. It is not used in the treatment of this condition. Acetazolamide promotes renal excretion of bicarbonate, which stimulates respiration. For the prophylaxis of altitude illness, start 24-48 hours before ascent and continue for 48 hours after arrival at high altitude.

Class Summary

These agents have profound and varied metabolic effects. They suppress inflammation and the immune response.

Dexamethasone (Decadron)

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Dexamethasone alleviates vasogenic cerebral edema and improves endothelial integrity.

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Media Gallery

High-altitude pulmonary edema (HAPE). Plain chest x-ray (radiograph) of a patient diagnosed with HAPE. There are patchy infiltrates throughout the lung tissue, with predominant changes in the right middle lobe/right central hemithorax. Courtesy of Wikipedia (https://en.wikipedia.org/wiki/File:Chest_XR_of_HAPE.png).
High-altitude pulmonary edema (HAPE). Medical students demonstrate the use of a portable hyperbaric chamber. Courtesy of Wikipedia (https://en.wikipedia.org/wiki/File:Portable_hyperbaric_chamber.jpg).
High-altitude pulmonary edema (HAPE). Initial chest x-ray showing pulmonary infiltrates in the right lung especially in the right mid and lower lung zones indicative of pulmonary edema. The patient was a middle-aged woman trekker who was emergency air-lifted from an altitude of 4410 m in the Nepal Himalayas to 1300 m in Kathamandu. She had continued ascending despite experiencing mild altitude symptoms at Namche (3440 m), with considerably worsened symptoms at Tengboche (3860 m). Courtesy of Extreme Physiology & Medicine (PMID: 24636661, online at https://extremephysiolmed.biomedcentral.com/track/pdf/10.1186/2046-7648-3-6).
High-altitude pulmonary edema (HAPE). Repeat chest x-ray after 2 days showing rapid resolution of the pulmonary edema in the same Himalayan trekker discussed in the previous image. The patient received bed rest, supplemental oxygen, and oral sustained-release nifedipine 20 mg twice daily. Courtesy of Extreme Physiology & Medicine (PMID: 24636661, online at https://extremephysiolmed.biomedcentral.com/track/pdf/10.1186/2046-7648-3-6).
High-altitude pulmonary edema (HAPE). Pulmonary embolism masquerading as HAPE. Axial computed tomography (CT) pulmonary angiogram showing thrombi as filling defects in the right main pulmonary artery (right arrow) extending into its branch and in the distal left pulmonary artery (left arrow) with extension into its superior branch. Courtesy of High Altitude Medicine & Biology (PMID: 27768392, online at https://www.liebertpub.com/doi/full/10.1089/ham.2016.0008).

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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, 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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Samia Qazi, MD Chief, Division of Primary Care, Nassau University Medical Center; Clinical Assistant Professor of Clinical Medicine, Renaissance School of Medicine at Stony Brook University

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 A Ward, MD, FACP Director of Population Health, Wyckoff Heights Medical Center

Laurie A Ward, MD, FACP is a member of the following medical societies: American College of Physicians, American Society of Nephrology, International Society of Nephrology, 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, 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

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP Former 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 Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

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, American Thoracic Society

Disclosure: Nothing to disclose.

High-Altitude Pulmonary Edema (HAPE) Medication

Medication Summary

Prevention

Treatment

Calcium channel blockers