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MEDICINE (Dr.

SALVADOR)

ALTITUDE ILLNESS

26 APRIL 2018

- Sleep desaturation—a common phenomenon at high altitude—


ALTITUDE ILLNESS
is associated with AMS.
PHYSIOLOGY - Debilitating fatigue consistent with severe AMS on descent
» Ascent to a high altitude subjects the body to a decrease in from a summit is also an important risk factor for death in
barometric pressure à decreased partial pressure of oxygen in the mountaineers.
inspired gas in the lungs à less pressure driving oxygen diffusion PATHOPHYSIOLOGY
from the alveoli and throughout the oxygen cascade - The exact mechanisms causing AMS and HACE are unknown.
» A normal initial “struggle response” to such an ascent includes - AMRI studies have suggested that vasogenic (interstitial)
increased ventilation—the cornerstone of acclimation—mediated by cerebral edema is a component of the pathophysiology of
the carotid bodies. HACE.
» Hyperventilation may cause respiratory alkalosis and dehydration. - Other factors in the development of cerebral edema may be the
o Alkalosis may depress the ventilatory drive during sleep, release of calcium-mediated nitric oxide and neuronally
with consequent periodic breathing and hypoxemia. mediated adenosine, which may promote cerebral vasodilation.
o During early acclimation, renal suppression of carbonic - Increased sympathetic activity triggered by hypoxia àblood-
anhydrase and excretion of dilute alkaline urine combat brain barrier leakage.
alkalosis and tend to bring the pH of the blood to normal. - Enhanced optic-nerve sheath diameter with increasing severity
» Other physiologic changes during normal acclimation include: of AMS has been noted and suggests an important role for
• increased sympathetic tone increased intracranial pressures in the pathophysiology of
• increased erythropoietin levelsà increased hemoglobin levels AMS.
and red blood cell mass - Microhemorrhage formation caused by cytokines or damage
• increased tissue capillary density and mitochondrial numbers through increased hydrostatic pressure is an important feature
• higher levels of 2,3-bisphosphoglycerate àenhancing oxygen of HACE.
utilization. - Lesions in the globus pallidum (which is sensitive to hypoxia) à
» Ascent to a high altitude: Parkinson’s disease have also been reported to be
o decreases maximal exercise capacity (by ~1% for every 100 m complications of HACE.
gained above 1500 m) - Finally, the effect of hypoxia on ROS and the role of these
o increases susceptibility to cold injury due to peripheral species in clinical AMS are unclear
vasoconstriction. - Headache- most common and prominent symptom of AMS
» Finally, if the ascent is made faster than the body can adapt to the - The cause of high-altitude headache is multifactorial
stress of hypobaric hypoxemia, altitude-related disease states can - Various chemicals and mechanical factors activate a final
result. common pathway, the trigeminovascular system
ALTITUDE ILLNESS
GENETICS PREVENTION AND TREATMENT
§ Hypoxia-inducible factor- which is important in high-altitude § Gradual ascent, with adequate time for acclimation, is the best
adaptation, controls transcriptional responses to hypoxia method for the prevention of altitude illness.
throughout the body and is involved in the release of VEGF in the o A graded ascent of ≤400 m from the previous day’s
brain, erythropoiesis, and other pulmonary and cardiac functions at sleeping altitude is recommended above 3000 m,
high altitudes. and taking every third day of gain in sleeping
§ A gene EPAS1, which codes for transcriptional regulator HIF2α, altitude as an extra day for acclimation is helpful.
appears to play an important role in the adaptation o Spending one night at an intermediate altitude
before proceeding to a higher altitude may enhance
acclimation and attenuate the risk of AMS
ALTITUDE ILLNESS § high-altitude exposure during the preceding 2 months- another
ACUTE MOUNTAIN ILLNESS (AMS) protective factor in AMS
» AMS is a neurologic syndrome characterized by nonspecific § Any hint of HAPE or HACE mandates descent
symptoms (headache, nausea, fatigue, and dizziness), with a § Finally, proper hydration in high-altitude trekking and
paucity of physical findings, developing 6–12 h after ascent to climbing, aimed at countering fluid loss due to hyperventilation
a high altitude. and sweating, may also play a role in avoiding AMS.
» AMS is a clinical diagnosis. § Pharmacologic prophylaxis at the time of travel to high
» AMS and HACE are thought to represent opposite ends of a altitudes is warranted for people with:
continuum of altitude-related neurologic disorders. o history of AMS
o HACE is an encephalopathy whose hallmarks are o when a graded ascent and acclimation are not
ataxia and altered consciousness with diffuse possible
cerebral involvement but generally without focal § Acetazolamide is the drug of choice for AMS prevention.
neurologic deficits. o It inhibits renal carbonic anhydrase, causing a
» Retinal hemorrhages occur frequently at ≥5000 m, even in prompt bicarbonate diuresis that leads to metabolic
individuals without clinical symptoms of AMS or HACE. acidosis and hyperventilation.
RISK FACTORS: o 125–250 mg twice a day, administered for 1 day
- The most important risk factors for the development of altitude before ascent and continued for 2 or 3 days, is
illness are: effective.
o the rate of ascent o Paresthesia and a tingling sensation are common
o a prior history of high-altitude illness. side effects of acetazolamide.
- Exertion is a risk factor, but lack of physical fitness is not § Dexamethasone (8 mg/d in divided doses) is also effective.
- people >50 years of age may be less likely to develop AMS than § Ginkgo biloba is ineffective in the prevention of AMS
younger people § Ibuprofen (600 mg three times daily) was shown to be beneficial
- Most studies reveal no gender difference in AMS incidence in the prevention of AMS

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§ For the treatment of mild AMS: » Chest x-ray:
o rest alone with analgesic use may be adequate o Patchy or localized opacities or streaky interstitial
o Descent and the use of acetazolamide and (if edema
available) oxygen are sufficient to treat most cases o mistaken for pneumonia due to the cold or for heart
of moderate AMS. failure due to hypoxia and exertion
o Even a minor descent (400–500 m) may be adequate o Kerley B lines or a bat-wing appearance are NOT
for symptom relief. seen on
§ For moderate AMS or early HACE: » Hypoxemia and respiratory alkalosis are consistently present
o dexamethasone (4 mg orally or parenterally) is unless the patient is taking acetazolamide
highly effective. » ABG- not necessary
§ For HACE:
o immediate descent is mandatory.
HIGH- ALTITUDE PULMONARY EDEMA
o When descent is not possible because of poor
weather conditions or darkness, a simulation of PATHOPHYSIOLOGY
descent in a portable hyperbaric chamber is effective § HAPE is a noncardiogenic pulmonary edema characterized by
and, like dexamethasone administration, “buys patchy pulmonary vasoconstriction that leads to overperfusion
time.” in some areas.
o increased pulmonary capillary pressure (>18 mmHg)
TABLE 476e1 MANAGEMENT OF ALTITUDE ILLNESS
and capillary “stress” failure.
Condition Management
o exact mechanism for the vasoconstriction is
Acute mountain sickness Discontinuation of ascent unknown.
(AMS), milda Treatment with acetazolamide (250 mg q12h) o HAPE-prone persons have reduced levels of exhaled
Descentb nitric oxide.
AMS, moderatea Immediate descent for worsening symptoms § Effectiveness of phosphodiesterase-5 inhibitors in alleviating
Use of low-flow oxygen if available altitude-induced pulmonary hypertension, decreased exercise
Treatment with acetazolamide (250 mg q12h) tolerance, and hypoxemia supports the role of nitric oxide in
and/or dexamethasone (4 mg q6h)c the pathogenesis of HAPE
Hyperbaric therapyd § Tadalafil, a phosphodiesterase-5 inhibitor, decreases the risk of
High-altitude cerebral Immediate descent or evacuation HAPE by 65% (prophylaxis)
edema (HACE) Administration of oxygen (2–4 L/min) § Bosentan, an endothelin receptor antagonist, attenuates
Treatment with dexamethasone (8 mg PO/IM/IV; hypoxia-induced pulmonary hypertension, but further field
then 4 mg q6h)
studies with this drug are necessary.
Hyperbaric therapy if descent is not possible
§ Exercise and cold lead to increased pulmonary intravascular
High-altitude pulmonary Immediate descent or evacuation pressure and may predispose to HAPE.
edema (HAPE) Minimization of exertion while patient is kept § Hypoxia-triggered increases in sympathetic drive may lead to
warm
pulmonary venoconstriction and extravasation into the alveoli
Administration of oxygen (4–6 L/min) to bring O2
e brain of a saturation to >90% from the pulmonary capillaries.
shows marked Adjunctive therapy with nifedipinee (30 mg, § Phentolamine, which elicits α-adrenergic blockade, improves
um of the cor- extended-release, q12h) hemodynamics and oxygenation in HAPE more than do other
climber, went Hyperbaric therapy if descent is not possible vasodilators.
pisode of HACE. Categorization of cases as mild or moderate is a subjective judgment based on the sever-
a § Dexamethasone reduced the incidence of HAPE by 78%—a
2004.) ity of headache and the presence and severity of other manifestations (nausea, fatigue, greater decrease than with tadalafil.
HIGH- ALTITUDE PULMONARY EDEMA
dizziness, insomnia). bNo fixed altitude is specified; the patient should descend to a point
§ Many patients with HAPE have fever, peripheral leukocytosis,
below that at which symptoms developed. cAcetazolamide treats and dexamethasone
e borne out thisRISKmasks
FACTORSsymptoms. AND MANIFESTATIONS
For prevention (as opposed to treatment), 125–250 mg of acetazol- and an increased erythrocyte sedimentation rate, inflammation
ers have yielded »4 mg ofHAPE is primarily a pulmonary problem and therefore is not has been considered an etiologic factor in HAPE
amide q12h or (when acetazolamide is contraindicated—e.g., in people with sulfa allergy)
dexamethasone q12h may be used. dIn hyperbaric therapy, the patient is placed
necessarily
ude illness, indi- in a portable preceded
altitude chamber bysimulate
or bag to AMS.descent. eNifedipine at this dose is also
nd HACE comes »effective HAPE
for the develops HAPE, as is2–4
prevention of within days(125
salmeterol after arrival
mg inhaled atdaily),
twice high altitude; it
tadalafil
(10 mg twice daily), or dexamethasone (8 mg twice daily). HIGH- ALTITUDE PULMONARY EDEMA
d in the preven- rarely occurs after more than 4 or 5 days at the same altitude,
xic upregulation probably because of remodeling and adaptation that render PREVENTION AND TREATMENT
l edema may be the § Allowing sufficient time for acclimation by gradual ascent is the
during thepulmonary vasculature
preceding 2 months; less susceptible
for example, the incidencetoand thesever-
effects of
onally mediated
ity ofhypoxia.
AMS at 4300 m are reduced by 50% with an ascent after 1 week
best way to prevent HAPE
»at anRISK FACTORS
altitude of ≥2000 : m rather than with an ascent from sea level. § Prophylaxis:
a may also con- o Nifedipine (30 mg), given once or twice daily,
tic-nerve sheath
Studies have rapid rate
o examined of ascent
whether exposure to a normobaric hypoxic
environment o (in ahistory
room orofa tent)
HAPE before an ascent can provide protec- prevents HAPE in people who must ascend rapidly or
ted and suggests
tion againstoAMS.respiratory
In double-blind
tractplacebo-controlled
infections trials, repeated who have a history of HAPE
es in the patho-
sed by cytokines
intermittento exposure (60–90 min) to temperatures
cold environmental normobaric hypoxia are risk (up to
factors § Early recognition is paramount in the treatment of HAPE,
s an important »
4500 m) or continuous exposure to 3000 m during 8 h of sleep for
Men are more susceptible than women. especially when it is not preceded by the AMS symptoms of
7 consecutive days failed to reduce the incidence of AMS at altitudes headache and nausea.
ch is sensitive to People with
»of 4300–4559 m. abnormalities of the cardiopulmonary circulation
n reported to be leading to pulmonary § Fatigue and dyspnea at rest may be the only initial
Clearly, a flexible itinerary hypertension—e.g.,
that permits additional rest days will
on reactive oxy- largetopatent foramen ovale must(4x more common) manifestations.
be helpful. o Sojourners high-altitude locations be aware of the
MS are unclear.
symptoms o mitral
of altitude stenosis
illness and should be encouraged not to ascend
§ Descent and the use of supplementary oxygen (aimed at
rominent symp-
further if these primary develop.
o symptoms pulmonary Anyhypertension
hint of HAPE (see below) or bringing oxygen saturation to >90%) are the most effective
brain itself is an therapeutic interventions.
al sensory nerve
HACE mandates o unilateral absence
descent. Finally, of hydration
proper the pulmonary (but notartery—are
overhy- at
dration) in high-altitude
increased trekking
risk ofand climbing,
HAPE , evenaimed at countering
at moderate altitudes. § Exertion should be kept to a minimum, and the patient should
ctorial. Various
»fluid The
loss initial
due to manifestation
hyperventilationofand HAPEsweating,
may be may also play a in
a reduction role
exercise be kept warm.
mmon pathway,
titude headache,
in avoiding
tolerance AMS. Pharmacologic
greater than that prophylaxis
expectedatatthe time
the of travel
given to .
altitude § Hyperbaric therapy in a portable altitude chamber may be used
and glucocorti- »
high altitudes is warranted for people with a history of AMS or when
Although a dry, persistent cough may presage HAPE and may if descent is not possible and oxygen is not available.
a graded ascent and acclimation are not possible—e.g., when rapid § Inhaled β agonists, which are safe and convenient to carry, are
the arachidonic
ascentbeis followed
necessary for the production
byrescue of blood-tinged
purposes or when sputum, cough
flight to a high-altitude
tional Headache in the mountains is almostisuniversal and the for
mechanism is useful in the prevention of HAPE
location is required. Acetazolamide the drug of choice AMS
er for migraine, poorlyItunderstood.
prevention. inhibits renal carbonic anhydrase, causing a prompt
graine share the Tachypnea
»bicarbonate diuresisand tachycardia
that leads , even
to metabolic at and
acidosis rest, are important
hyperventila-
tion. markers
Acetazolamideas illness progresses.
(125–250 mg twice a day), administered for 1 day
t, with adequate »beforeHAPE
ascentmay
and be accompanied
continued for 2 or by signs
3 days, of HACEHigher doses
is effective.
ntion of altitude are not required. A meta-analysis limited to randomized controlled
n in the rate of »trials revealed that 125 mg of acetazolamide twice daily was effective
ious day’s sleep- in the prevention of AMS, with a relative-risk reduction of ~48% from
g every third day values obtained with placebo. Paresthesia and a tingling sensation are 2
ation is helpful. common side effects of acetazolamide. This drug is a nonantibiotic
e proceeding to sulfonamide that has low-level cross-reactivity with sulfa antibiotics; as
uate the risk of a result, severe reactions are rare. Dexamethasone (8 mg/d in divided
titude exposure doses) is also effective. A large-scale, randomized, double-blind,
OTHER HIGH- ALTITUDE PROBLEMS OTHER HIGH- ALTITUDE PROBLEMS
SLEEP IMPAIREMENT PSYCHOLOGICAL/ PSYCHIATRIC
» The mechanisms underlying sleep problems: » Delirium characterized by a sudden change in mental status, a
o increased periodic breathing short attention span, disorganized thinking, and an agitated
o changes in sleep architecture, with increased time in state during the period of confusion
lighter sleep stages; » Anxiety attacks, often triggered at night by excessive periodic
o changes in rapid eye movement sleep breathing, are well documented.
» Acetazolamide (125 mg before bedtime) is especially useful
because this agent decreases hypoxemic episodes and
PRE- EXISTING MEDICAL ISSUES
alleviates sleeping disruptions caused by excessive periodic
breathing HYPERTENSION
» Doses of temazepam and zolpidem should not be increased by » Enhanced sympathetic activity may lead to a transient rise in
>10 mg at high altitudes blood pressure
» Trekkers with obstructive sleep apnea who are using a » The probable mechanism of high-altitude hypertension is α-
continuous positive airway pressure (CPAP) machine, the adrenergic activity, anti- α-adrenergic drugs like prazosin have
addition of acetazolamide, which will decrease centrally been suggested for symptomatic patients and those with labile
mediated sleep apnea, may be helpful. hypertension
o best to start taking the drug several weeks before the
trip and to carry a sphygmomanometer if a trekker
OTHER HIGH- ALTITUDE PROBLEMS has labile hypertension
GI ISSUES
» increased gastric and duodenal bleeding
PRE- EXISTING MEDICAL ISSUES
» Abdominal bloating and distension as well as excessive flatus
expulsion CORONARY ARTERY DISEASE
» Accompanying diarrheaà bacteria or Giardia parasites » Myocardial oxygen demand and maximal heart rate are
» Hemorrhoids are common on high-altitude treks; treatment reduced at high altitudes because the VO2 max (maximal
includes hot soaks, application of hydrocortisone ointment, and oxygen consumption) decreases with increasing altitude.
measures to avoid constipation. » Asymptomatic, fit individuals with no risk factors need not
undergo any tests for coronary artery disease before ascent.
» Persons with ischemic heart disease, previous myocardial
OTHER HIGH- ALTITUDE PROBLEMS infarction, angioplasty, and/or bypass surgery, an exercise
HIGH- ALTITUDE COUGH treadmill test is indicated
» High-altitude cough can be debilitating and is sometimes severe » A strongly positive treadmill test is a contraindication for high-
enough to cause rib fracture, especially at >5000 m altitude trips.
» Etiology is multifactorial » Patients with poorly controlled arrhythmias should avoid high-
» Hypoxia also plays a role. altitude travel
» Exercise can precipitate cough at high altitudes, possibly
because of water loss from the respiratory tract.
PRE- EXISTING MEDICAL ISSUES
» Long-acting β agonists and glucocorticoids prevent
bronchoconstriction that otherwise may be brought on by cold ASTHMA
and exercise » Asthmatic patients usually have fewer problems at high than at
» In most situations, cough resolves upon descent. low altitudes, possibly because of decreased allergen levels and
increased circulating catecholamine levels.
» Severely asthmatic persons should be cautioned against
OTHER HIGH- ALTITUDE PROBLEMS ascending to high altitudes
HIGH- ALTITUDE NEUROLOGIC EVENTS UNRELATED TO “ALTITUDE ILLNESS”
» Transient ischemic attacks (TIAs) and strokes have been well
described in high- altitude sojourners outside the setting of
PRE- EXISTING MEDICAL ISSUES
altitude sickness PREGNANCY AND OBESITY
» The population that suffers strokes and TIAs afflicted at high » low-risk pregnant women ascending to 3000m are not at
altitudes are generally younger and probably have fewer risk special risk
factors for atherosclerotic vascular disease. » Venturing higher than 3000m to altitudes at which oxygen
» Subarachnoid hemorrhage, transient global amnesia, delirium, saturation drops steeply seems unadvisable for pregnant
and cranial nerve palsies (e.g., lateral rectus palsy) occurring at women.
high altitudes but outside the setting of altitude sickness have » Obesity has also been reported to be a risk factor for AMS,
also been well described. probably because nocturnal hypoxemia is more pronounced in
» Syncope is common at moderately high altitudes, generally obese individuals.
occurs shortly after ascent, usually resolves without descent, » Hypoxemia may also lead to greater pulmonary hypertension
and appears to be a vasovagal event related to hypoxemia.
» Ophthalmologic problems: PRE- EXISTING MEDICAL ISSUES
o cortical blindness
SICKLE- CELL DSE AND DM
o amaurosis fugax
» As low as 2500m, people with sickle cell disease have been
o retinal hemorrhage with macular involvement and
known to have a vasoocclusive crisis
compromised vision, are well recognized.
» Patients with known sickle cell disease who need to travel to
» Visual problems from previous refractive surgery and blurred
high altitudes should use supplemental oxygen and travel with
monocular vision—due either to the use of a transdermal
caution.
scopolamine patch or to dry-eye syndrome—may also occur in
» At high altitudes may enhance sugar uptake
the field at high altitudes and may be confused with neurologic
» Well controlled with oral hypoglycemic agents àdo not pose
conditions.
problems
» Persons with hypercoagulable conditions who are
asymptomatic at sea level may experience cerebral venous
thrombosis

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PRE- EXISTING MEDICAL ISSUES
CHRONIC LUNG DSE AND CHRONIC KIDNEY DSE
» A proper pretravel evaluation must be conducted
» Supplemental oxygen may be required if the predicted PaO2
for the altitude is <50–55 mmHg
» Preexisting pulmonary hypertension may also need to be
assessed in these patients.
o If result is positive, patients should be discouraged
from ascending to high altitudes; if such travel is
necessary, treatment with sustained-release
nifedipine (20 mg twice a day) should be considered
» Patients with chronic kidney disease can tolerate short-term
stays at high altitudes
» Acetazolamide, the drug most commonly used for altitude
sickness, should be avoided by anyone with preexisting
metabolic acidosis, which can be exacerbated by this drug.
o glomerular filtration rate falls below 50 mL/min, and
the drug should not be used at all if this value falls
below 10 mL/min.

CHRONIC MOUNTAIN SICKNESS AND HIGH ALTITUDE


PULMONARY HYPERTENSION
§ Chronic mountain sickness (Monge’s disease) is a disease of
long-term residents of altitudes above 2500m that is
characterized by:
o excessive erythrocytosis with moderate to severe
pulmonary hypertension leading to cor pulmonale
§ High-altitude pulmonary hypertension is also a subacute
disease of long-term high-altitude residents
o characterized primarily by pulmonary hypertension
(not erythrocytosis) leading to heart failure
o bears a striking pathophysiologic resemblance to
brisket disease in cattle.
o Descent to a lower altitude is curative.