Medication Summary
Treatment of HAPE is indicated upon diagnosis. High-altitude cough may be treated when the symptoms become severe enough to interfere with the individual's activities.
A literature review conducted in 2015 concluded that current evidence does not support the efficacy of either phosphodiesterase-5 inhibitors or dexamethasone in HAPE treatment. However, the review was limited by inclusion of only 3 studies representing a total of 66 patients. [34]
Calcium channel blockers
Class Summary
Nifedipine is used for its pulmonary vasodilative effects. It inhibits calcium ions from entering the slow channels or select voltage-sensitive areas of vascular smooth muscle and myocardium during depolarization, producing a relaxation of coronary vascular smooth muscle and coronary vasodilation.
Nifedipine (Adalat, Procardia)
Nifedipine is used in HAPE for pulmonary vasodilation. It often improves SaO2 modestly within a few minutes. Despite theoretical concerns about the sublingual route, it has been used in hundreds of cases without causing clinically significant hypotension. Nifedipine does not improve pulmonary hemodynamics as much as oxygen and does not have an additive effect when administered with oxygen. It is most useful when oxygen is unavailable and to help prevent exertional exacerbation of HAPE when evacuating a patient. The cap may be punctured, and the drug solution may be administered sublingually to reduce blood pressure.
Phosphodiesterase (type 5) enzyme inhibitor
Class Summary
This agent acts to increase available nitric oxide in pulmonary arterial vessels, resulting in vessel relaxation and decreased pulmonary hypertension. It has been found effective for HAPE prophylaxis in HAPE-susceptible patients.
Tadalafil (Cialis)
Tadalafil is a phosphodiesterase type 5 (PDE5) selective inhibitor. Inhibition of PDE5 increases cGMP activity, which increases the vasodilatory effects of nitric oxide. Sexual stimulation is necessary to activate the response. Increased sensitivity for erections may last 36 hours with intermittent dosing. Low-dose daily dosing may be recommended for more frequent sexual activity (ie, twice weekly); men can attempt sexual activity at anytime between daily doses. Tadalafil is available as 2.5-mg, 5-mg, 10-mg, and 20-mg tablets.
Corticosteroid
Class Summary
The exact mechanism has not yet been well defined but these agents have been found effective for HAPE prophylaxis in HAPE-susceptible patients.
Dexamethasone (AK-Dex, Alba-Dex, Baldex, Decadron, Dexone)
The mechanism in preventing HAPE is not well defined.
Beta agonists
Class Summary
Sodium-dependent absorption of liquid from the airways may be defective in persons who are susceptible to HAPE; beta-adrenergic agents up-regulate the clearance of alveolar fluid.
Salmeterol (Serevent)
Salmeterol has been shown to be effective at preventing HAPE in susceptible persons, possibly by up-regulating the clearance of alveolar fluid.
Carbonic anhydrase inhibitors
Class Summary
These agents are possibly beneficial in the prophylaxis of HAPE.
Acetazolamide (Diamox)
Acetazolamide is a carbonic anhydrase inhibitor diuretic used for its respiratory-stimulant effects. It may be administered for prophylactic use in patients with a prior history of HAPE. It is not used as treatment for HAPE. For prophylactic use, begin using the day before ascent. Therapy should begin 24-48 hours before the ascent and continue during the ascent to at least 48 hours after arrival at the highest altitude.
Antitussives
Class Summary
These agents are used for the symptomatic treatment of high-altitude cough.
Hydrocodone and acetaminophen (Lortab, Vicodin)
This drug combination is for symptomatic relief of a cough and is helpful for pain relief of intercostal muscle strain associated with cough. It is often more effective than codeine.
Codeine
Codeine is for symptomatic relief of a cough. It is helpful for the pain of intercostal muscle strain associated with a cough. Codeine binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways and altering the perception and response to pain.
Benzonatate (Tessalon Perles)
Benzonatate may help patients with cough refractory to opiates. It suppresses cough by topical anesthetic action on respiratory stretch receptors.
Analgesics
Class Summary
These agents are indicated for the treatment of mild to moderate pain and headache.
Ibuprofen (Motrin, Advil, Nuprin)
Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Acetaminophen (Tylenol)
Acetaminophen is the drug of choice for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Aspirin (Aspirin, Ascriptin, Bayer Aspirin, Bufferin)
Aspirin is used for the treatment of mild to moderate pain and headache.
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High-altitude pulmonary edema (HAPE). Image courtesy Dr Matthew Cushing.
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Hyperbaric treatment at 4250 m in a Gamow bag.
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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.
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Thoracic ultrasonography. Normal thoracic sonogram reveals only diffuse, "snow storm" appearance without comet tail sign. Courtesy of Dr Peter Fagenholz, et al.
