Approach Considerations

The clinical diagnosis of high-altitude pulmonary edema (HAPE) generally includes at least two of the following signs/symptoms^{[1, 18]}:

Dyspnea at rest
Cough
Weakness or reduced exercise performance
Chest tightness or congestion
Tachycardia
Tachypnea
Rales/wheezes in at least one lung field
Central cyanosis

In patients with chest radiographic evidence of infiltrates, rapid clinical and oxygen saturation improvement with administration of supplemental oxygen is pathognomonic for high-altitude pulmonary edema.^[1]

Laboratory studies are general of limited use.^[1]

Always consider the possibility of concomitant acute mountain sickness and/or high-altitude cerebral edema.^{[1, 2, 3, 4]}

Note that the coronavirus disease 2019 (COVID-19) pandemic has raised concerns over whether affected patients with respiratory distress have presentations more like high-altitude pulmonary edema (HAPE) than that of acute respiratory distress syndrome (ARDS).^{[20, 21]}Therefore, the Guidelines section also contains the following COVID-19-related guidance:

For more COVID-19 information, please go to Medscape's Novel Coronavirus Resource Center, COVID-19 Clinical Guidelines, and Coronavirus Disease 2019 (COVID-19).

Laboratory Studies

Findings on laboratory studies from high-altitude pulmonary edema (HAPE) patients are nonspecific.

Arterial blood gas (ABG) measurement typically shows severe hypoxemia and respiratory alkalosis. The partial pressure of oxygen is usually between 30 and 40 mm Hg.^[7]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.^[22]

Radiography

Chest radiography in high-altitude pulmonary edema (HAPE) patients reveals bilateral patchy infiltrates, with a normal heart size/mediastinum.{ref29)^[7]If infiltrates are absent, consider an alternative diagnosis.

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).

View Media Gallery

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).

View Media Gallery

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).

View Media Gallery

Ultrasonography

B-lines consistent with pulmonary edema may be seen on sonograms^[1]

In one study, stress echocardiography was used to quantitate pulmonary artery systolic pressure responses to prolonged hypoxia and normoxic exercise.^[23]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.^[24]

Electrocardiography

Electrocardiography (ECG) in high-altitude pulmonary edema (HAPE) patients may reveal a right-sided heart strain pattern suggestive of pulmonary hypertension^[7] and/or ischemia.^[1]

Treatment & Management

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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.