The n e w e ng l a n d j o u r na l of
Review Article
From the Division of Pulmonary, Critical
Care, and Sleep Medicine, University of
Washington, Seattle (A.M.L.); and the Al-
titude Research Center, Division of Pul-
monary Sciences and Critical Care Medi-
cine, Department of Medicine, University
of Colorado Anschutz Medical Campus,
Aurora (P.H.H.). Dr. Luks can be contact-
ed at a­ luks@​­uw​.­edu or at the Division of
Pulmonary, Critical Care, and Sleep Medi-
cine, Harborview Medical Center, 325 Ninth
Ave., Box 359762, Seattle, WA 98104.
N Engl J Med 2022;386:364-73.
DOI: 10.1056/NEJMra2104829
Copyright © 2022 Massachusetts Medical Society.
364
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m e dic i n e
C. Corey Hardin, M.D., Ph.D., Editor
Medical Conditions and High-Altitude Travel
Andrew M. Luks, M.D., and Peter H. Hackett, M.D.​​
A
s interest in adventure travel grows and transportation net-
works expand, more people are traveling to terrestrial high altitudes for
active and sedentary endeavors, including hiking, skiing, sightseeing, reli-
gious pilgrimages, and work.1 Often, travelers seek medical advice on trip safety,
with the primary focus on prevention and treatment of acute altitude illnesses,
including high-altitude headache, acute mountain sickness, high-altitude cerebral
edema, and high-altitude pulmonary edema. Given the prevalence of diseases such
as asthma and hypertension,2 many people planning high-altitude travel are likely
to have a preexisting medical condition. In such cases, clinicians should broaden
their pretravel counseling and consider how reductions in barometric pressure and
subsequent decreases in the ambient partial pressure of oxygen (Po2) — known as
hypobaric hypoxia — will affect the underlying condition and the safety of a
planned high-altitude excursion.
Clinicians and patients may be unaware of these concerns, and patients may
either proceed with travel in the face of unrecognized risks or be overly cautious
and forgo travel when it is actually feasible. This review is intended to help clini-
cians by providing a framework for advising persons with medical conditions who
are considering high-altitude travel. After reviewing the prevalence of common
diseases among high-altitude travelers and the physiological responses to hypo-
baric hypoxia, we discuss the altitudes at which persons with medical issues are
at risk for problems and offer general advice that clinicians can provide for all
travelers. We then consider the safety of travel for persons with preexisting condi-
tions and describe an approach to evaluation and counseling. Although some is-
sues covered in this review have relevance for people traveling on commercial
aircraft when the cabin altitude at cruising elevation ranges from 1500 to 2400 m,
depending on the distance traveled,3 the focus throughout is on unacclimatized
lowlanders ascending to terrestrial high altitude. Commercial flight for persons
with medical conditions is reviewed elsewhere.4
Pr e va l ence of Medic a l C ondi t ions a mong
High-A lt i t ude T r av el er s
Although the number of unacclimatized lowlanders with medical conditions who
travel to high altitude is unknown, it may be relatively high because of the increas-
ing number of older persons who travel to high altitude. Whereas only about 10%
of trekkers in Nepal were over 50 years of age in 1992,5 a more recent survey of
670 trekkers in the Solukhumbu region of Nepal showed that 47% were over 50
years of age and 15% were over 60.6 Of the survey respondents, 33% reported
preexisting medical problems. The most common conditions were hypertension
(in 9% of the respondents), thyroid disease (in 6%), asthma (in 5%), and diabetes
mellitus (in 2%), but a noteworthy finding was the wide spectrum of less com-
monly reported problems, such as inflammatory bowel disease, systemic lupus
n engl j med 386;4  nejm.org  January 27, 2022
The New England Journal of Medicine
 Medical Conditions and High-Altitude Tr avel
erythematosus, thalassemia minor, and von
Willebrand’s disease.
Of Colorado tourists visiting areas at altitudes
between 1900 m and 2950 m, 24% reported use
of long-term medications.7 The prevalence of
underlying conditions and medication use may
vary according to the type of activity, with more
physically demanding activities selecting for
healthier persons, as indicated by the lower pro-
portion of cardiovascular diseases (arrhythmias,
coronary artery disease, and hypertension) among
alpine mountaineers (7.4%) as compared with
hikers (12.7%) and skiers (11.2%) in the Euro-
pean Alps.8,9
Ph ysiol o gic a l R e sp onse s
t o H y p ob a r ic H y p ox i a
Although decreased humidity and air tempera-
ture and increased exposure to ultraviolet light
are noteworthy features of the mountain envi-
ronment, the most important environmental
variable is the decrease in barometric pressure
that occurs with ascent. The reduction in baro-
metric pressure decreases the Po2 all along the
oxygen transport chain, from inspired air to
organs and tissues, which sets in motion a series
of physiological responses (Fig. 1), many of which
help restore the concentration of oxygen in the
blood (oxygen content) and supply tissues with
adequate oxygen to support metabolic demand
(oxygen delivery). The specific mechanisms for
these responses, collectively referred to as accli-
matization, vary among organ systems, but a key
mediator is hypoxia-inducible factor, a gene tran-
scription factor that serves as the master regula-
tor of cellular responses to hypoxia, including
but not limited to cellular metabolism, angio-
genesis, and erythropoiesis.10,11
Many physiological responses show a dose–
response relationship, with greater hypoxia pro-
voking stronger responses. The timing of the
responses also varies; for example, cerebral
blood flow, heart rate, and ventilation increase
within minutes after the ascent, whereas plasma
volume and serum erythropoietin concentrations
change over a period of 1 to 2 days. The full
increases in ventilation and hemoglobin concen-
tration occur over a period of weeks after the
ascent. The pattern and timing of the responses
are similar among persons, but their magnitude
varies markedly, as indicated by interindividual
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Low High Altitude
Altitude (Hypoxia)
CEREBRAL BLOOD FLOW
VENTILATION
PULMONARY-ARTERY PRESSURE
HEART RATE
CARDIAC OUTPUT
STROKE VOLUME
PLASMA VOLUME
BICARBONATURIA
EPO
RCM
Hb
Minutes Hours Days Weeks
Figure 1. Physiological Responses to Hypoxia.
Major responses to an ascent to high altitude involve the brain, lungs, heart,
kidneys, and blood. Qualitative changes are depicted over time, ranging
from minutes to weeks at high altitude. Values that increase from low to
high altitude are shown in purple, and values that decrease are shown in
blue. The pattern and timing of the responses are similar among persons,
but the magnitude of the responses can vary markedly. EPO denotes erythro-
poietin, Hb hemoglobin, and RCM red-cell mass.
differences in the hypoxic ventilatory response,12,13
hypoxic pulmonary vasoconstriction,14,15 and
changes in cerebral blood flow.16 Recognition of
this variation and the effect of medical condi-
tions on the observed responses is critical in
considering the risks of high-altitude travel,
since the magnitude of the responses deter-
mines the degree of hypoxemia and the adequacy
of oxygen delivery for a given altitude and baro-
metric pressure.
W h at D ose of H y p ob a r ic H y p ox i a
P ose s a R isk t o T r av el er s?
Although the risk of acute altitude illness begins
with an ascent above 2000 m, and particularly
above 2500 m, some persons with chronic
medical conditions are at risk at lower eleva-
tions, as indicated by the development of high-
nejm.org January 27, 2022 365
 The n e w e ng l a n d j o u r na l of m e dic i n e

altitude pulmonary edema at an elevation of only
1500 m in persons with unilateral absence of a
pulmonary artery.17
In addition to the absolute altitude reached,
the risk is a function of the time and degree of
exertion at that altitude, with multiday expo-
sures and heavy exertion associated with in-
creased risk. A traveler with underlying health
problems might tolerate a sedentary ride on a
cable car for a short visit (e.g., 1 to 2 hours) to a
mountain lodge, whereas a longer stay at that
altitude or the addition of physical exertion
might pose problems.
Ultimately, the altitude at which the risk in-
creases is based on the particular medical condi-
tion and its severity. As a result, strict altitude
thresholds should be avoided in considering the
need for further evaluation and planning.
A dv ice for A l l High-A lt i t ude
T r av el er s
The physiological responses to hypoxia are gen-
erally protective, but in some cases maladaptive
responses occur, leading to some form of acute
altitude illness. All high-altitude travelers, re-
gardless of their underlying health, are at risk
for these problems and should receive counsel-
ing regarding recognition, prevention, and treat-
ment. Key features of these illnesses are sum-
marized in Table 1, and further information is
provided in several reviews.18-20 High-altitude
headache and acute mountain sickness are by far
the most common illnesses, with the former
noted in 37% of people ascending to 4559 m21
and the latter developing in 25 to 43% of travel-
ers at altitudes between 2000 and 4300 m, depend-
ing on the altitude attained and the rate and
method of ascent.7,22 Some of the highest rates of
acute mountain sickness have been reported on
Mt. Kilimanjaro (5895 m)23 and among religious
pilgrims traveling to high-altitude festivals24 be-
cause of very rapid ascent rates. Although precise
data are lacking, the incidences of high-altitude
cerebral edema and of high-altitude pulmonary
edema are quite low, but each condition is poten-
tially fatal if not recognized and treated appro-
priately. Disrupted sleep and central sleep apnea
are common at high altitude, even in the absence
of acute altitude illness.25
The primary risk factor for acute altitude ill- further counseling should be provided to people
ness is rapid ascent, as measured by the rate of with medical problems regarding their particu-
increase in the sleeping elevation. For this rea-
son, a review of the planned ascent rate, which
varies substantially among commonly visited
areas, should be part of the pretravel evaluation.
In general, the slower the ascent, the greater the
time for acclimatization and the lower the risk
of altitude illness. More specifically, once above
3000 m, travelers should not increase their
sleeping elevation by more than 500 m per night
and should include rest days every 3 to 4 days;
during rest days, they should sleep at the same
elevation for at least 2 consecutive nights. Al-
though widely recommended in published re-
views and guidelines,20,26,27 this rule of thumb is
supported primarily by observational data22 and
by only one randomized study.28 Exposure to
hypoxia (preacclimatization) or spending time at
intermediate altitudes before ascending to the
target elevation (referred to as staged ascent)
may also reduce the risk of altitude illness, de-
pending on the duration and timing before the
planned trip.29,30
Pharmacologic prophylaxis is readily available
and typically directed toward prevention of acute
mountain sickness. Prophylaxis is not necessary
in all travelers; it is reserved for those with a
history of acute altitude illness, particularly re-
current episodes, and those planning a moder-
ate-to-high-risk ascent, as defined in current
guidelines.27 Prediction rules have been devel-
oped to assess the risk of severe altitude illness
and guide decisions about pharmacologic pro-
phylaxis31,32 but can be difficult to implement
in routine practice. Pharmacologic prophylaxis
against high-altitude pulmonary edema with pul-
monary vasodilators, including nifedipine33 and
tadalafil,34 is reserved for persons with a history
of this condition.27 Descent remains the best
treatment for all acute altitude illnesses but is
necessary only for persons with acute mountain
sickness that worsens or fails to improve with
standard treatment (Table 1) and for persons
with high-altitude cerebral edema or high-alti-
tude pulmonary edema.
Pr e t r av el E va luat ion for
Per sons w i th Medic a l
C ondi t ions
In addition to these general recommendations,

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 Medical Conditions and High-Altitude Tr avel

Table 1. Clinical Problems at High Altitude.*

Illness and Clinical Presentation Prevention Treatment

High-altitude headache
Common above 2500 m
Onset within 4–24 hr after ascent
Dull or pulsating bifrontal, temporal, or
diffuse headache, often worsened by
movement
Acute mountain sickness
Common above 2500 m
Onset within 1–2 days after ascent
Headache, plus one or more of the following:
poor appetite, nausea, vomiting, lethargy,
persistent lightheadedness
Normal neurologic examination and mental
status
High-altitude cerebral edema
Unusual below 3500 m unless accompanied
by high-altitude pulmonary edema
Onset within first few days after ascent; often
preceded by symptoms of acute mountain
sickness
Global encephalopathy, with altered mental
status, ataxia, or both; focal neurologic
deficits uncommon
Can progress to coma
High-altitude pulmonary edema
Unusual below 3000 m
Onset 2–4 days after ascent
Early signs: increasing dyspnea with activity, ­
decreased exercise performance, dry
cough
Late signs: dyspnea with simple activities or
at rest, cyanosis, cough with pink frothy
sputum, respiratory distress
Central sleep apnea
Very common above 2500 m
Onset during first night at high altitude; may If indicated, acetazolamide, 125 mg
persist with continued stay or further
ascent
Associated with reduced subjective sleep qual-
ity, frequent awakenings, and sensation of
panic on awakening
Allow time for proper acclimatization Stop ascent and rest at current elevation
For moderate- or high-risk ascent pro- NSAIDs or acetaminophen
files: acetazolamide, 125 mg every Consider dexamethasone (4 mg once) for severe
12 hr, or dexamethasone, headache
2 mg every 6 hr If headache persists or worsens, descend or use
supplemental oxygen
Allow time for proper acclimatization Stop ascent and rest at current elevation
For moderate- or high-risk ascent pro- NSAIDs or acetaminophen for headache; antiemetics
files: acetazolamide, 125 mg every if needed
12 hr, or dexamethasone, For mild illness: consider acetazolamide, 250 mg
2 mg every 6 hr every 12 hr
For severe illness: dexamethasone, 4 mg every 6 hr
for 24 hr; consider adding acetazolamide
If symptoms persist or worsen, descend or use
supplemental oxygen
No specific preventive measures aside Descend if feasible; otherwise, use supplemental
from those for acute mountain oxygen or portable hyperbaric chamber
sickness and high-altitude pulmo- Dexamethasone, 8 mg once, then 4 mg every 6 hr
nary edema until descent has been achieved or symptoms
and signs have resolved
Allow time for proper acclimatization In resource-limited settings: descend if feasible;
Sustained-release nifedipine, 30 mg otherwise, use supplemental oxygen or portable
every 12 hr, for travelers with his- hyperbaric chamber
tory of high-altitude pulmonary Sustained-release nifedipine, 30 mg every 12 hr if oxy-
edema gen is not available and descent is not feasible
In well-resourced settings: supplemental oxygen and
bed rest
Prophylaxis generally unnecessary Descent not necessary
Treatment reserved for severe sleep disturbance or
every 12 hr, or nocturnal oxygen interference with daytime activity: acetazolamide,
125 mg every 12 hr; nocturnal oxygen
Temazepam, zolpidem, and zaleplon improve sleep
quality but do not reduce central sleep apnea

* NSAIDs denotes nonsteroidal antiinflammatory drugs.

lar condition and the potential risks at high alti-
tude. Evaluation and planning are challenging
because of the wide spectrum of medical prob-
lems and the paucity of data for many condi-
tions. In light of these challenges, clinicians can
use a general approach, framed by four ques-
tions, to identify persons who require further
attention before their intended trip.
The first question is whether the traveler is at
risk for severe hypoxemia or impaired oxygen
delivery at high altitude. Persons with lung dis-
eases of sufficient severity, such as chronic ob-
structive pulmonary disease (COPD),35 interstitial
lung disease36 or cystic fibrosis,37 and cyanotic
congenital heart disease,38 are at risk for exag-
gerated hypoxemia at any elevation, which may
increase dyspnea, decrease exercise tolerance,
and increase the risk of acute altitude illness.

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 The n e w e ng l a n d j o u r na l
Altitude, m SpO2
5500 70–80%
4500 75–85%
3500 82–88%
2500 90–95%
1500 93–97%
Sea level >96%
Figure 2. Expected Changes in Resting Oxygen Saturation with Increasing
Altitude.
With the decline in barometric pressure and the ambient partial pressure of
oxygen during ascent to a high altitude, the partial pressure of arterial oxygen
and the oxygen saturation as measured by pulse oximetry (Spo2) are reduced.
The normal Spo2 at a given elevation decreases to a range of values rather
than to a single value because of interindividual variation in the hypoxic
ventilatory response and other physiological responses to hypoxia. The val-
ues shown are estimates of the expected ranges 24 to 48 hours after ascent
to a high altitude, which have been derived from values reported in pub-
lished studies conducted at various altitudes (see the Supplementary Ap-
pendix, available with the full text of this article at NEJM.org).
Expected oxygen saturation values in healthy
persons at various altitudes are shown in Fig-
ure 2. Excessive hypoxemia may not develop in
persons with moderate-to-severe heart failure or
anemia, but they may have similar symptoms
because of impaired oxygen delivery, particularly
during exercise.
The second question is whether the traveler
is at risk for impaired ventilatory responses. As
described above, one of the key responses to
hypoxemia is the hypoxic ventilatory response,
which helps maintain adequate alveolar and
arterial Po2. In persons with severely impaired
lung mechanics, as indicated by chronic hyper-
carbia or severe impairments on pulmonary-
function testing, ventilation may not increase
sufficiently, and as a result, such persons may be
at risk for exaggerated hypoxemia and its associ-
ated problems (e.g., very severe COPD, neuro-
muscular disease, or obesity hypoventilation
syndrome). Impaired carotid-body function after
carotid-artery surgery39 or neck irradiation40
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of m e dic i n e
Table 2. Contraindications to Travel above 2500 m.*
Advanced COPD (FEV1 <30% of predicted value or
requirement for continuous oxygen therapy)
Advanced cystic fibrosis (FEV1 <30% of predicted value)
Advanced restrictive lung disease (TLC <50% of predicted
value or requirement for continuous oxygen therapy)
Decompensated heart failure
High-risk pregnancy
Myocardial infarction or stroke within the past 90 days
Poorly controlled seizure disorder
Pulmonary hypertension (systolic PAP >60 mm Hg)
Sickle cell disease
Unstable angina
Untreated, high-risk cerebrovascular abnormality
(aneurysm or arteriovenous malformation)
* COPD denotes chronic obstructive pulmonary disease,
FEV1 forced expiratory volume in 1 second, PAP pulmo-
nary-artery pressure, and TLC total lung capacity.
could pose similar risks. Any such problems
would worsen with exertion when ventilation
requirements increase substantially.41
The third question is whether the traveler is
at risk for problems due to pulmonary vascular
responses to hypoxia. Alveolar hypoxia triggers
hypoxic pulmonary vasoconstriction,42 which in-
creases pulmonary vascular resistance and pul-
monary-artery pressure. This response is usually
well tolerated, but in persons with pulmonary
hypertension (mean pulmonary-artery pressure
>20 mm Hg at sea level), right-heart failure, or
both, it may confer a predisposition to high-alti-
tude pulmonary edema or worsening right-heart
function.43
The fourth question is whether hypoxia poses
a risk of complications due to the underlying
condition. Hypobaric hypoxia poses a clear risk
of clinical deterioration in persons with certain
conditions, including, for example, those with
sickle cell disease,44 inadequately controlled cor-
onary artery disease or heart failure, high-risk
pregnancy, or neurologic conditions such as
vascular malformations or space-occupying le-
sions (Table 2).
On the basis of the answers to these four
questions, high-altitude travelers with medical
conditions fall into one of two groups: those
with affirmative answers to one or more ques-
tions, and those with negative answers to all
nejm.org January 27, 2022
 Medical Conditions and High-Altitude Tr avel
questions. The former group is at risk for prob-
lems at high altitude, which warrants further
pretravel evaluation, and persons in this group
may even need to cancel their travel plans. The
latter group can travel safely without further as-
sessment but may benefit from disease-specific
planning. Each situation is considered below.
F ur ther E va luat ion a nd R isk
Mi t ig at ion for High-R isk
Per sons
Depending on the medical condition, various
assessments can be performed to evaluate the
risks of planned high-altitude travel. Multiple
prediction rules incorporating values obtained
on pulmonary-function testing,45 measurement
of arterial blood gases,46 and cardiopulmonary
exercise testing,47 as well as the hypoxia altitude
simulation test,48 have been used to assess the
risk of hypoxemia and guide supplemental oxy-
gen use during commercial flight. However, the
applicability of these tools to high-altitude travel
has not been established. The tools were de-
signed to assess the risk of hypoxemia at a nar-
row range of elevations — the maximum al-
lowed cabin altitude — and do not adequately
reflect the duration of or the anticipated degree
of exertion while engaging in high-altitude
travel. Echocardiography or cardiopulmonary
exercise testing under hypoxic conditions can
provide information about physiological re-
sponses to hypoxia but are available only in
specialized centers that have the capacity to ad-
minister normobaric or hypobaric hypoxia.31
Given these challenges, perhaps the best tool for
assessing the safety of exposure to hypobaric
hypoxia is graded exposure to high altitude in
safe settings. Tolerance can be assessed with
travel to areas such as a ski-resort community in
Colorado, where medical resources are readily
available or descent to a lower altitude can eas-
ily be achieved in the event of problems. After a
period of rest and monitoring of symptoms and
pulse oximetry49 at moderate altitude, persons
who do well can move to steadily higher eleva-
tions or increase their physical activity. Exercise
is feasible for some persons with cardiopulmo-
nary diseases, although tolerance of exertion
varies among such persons.35,50
Supplemental oxygen is the best tool for re-
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versing hypoxemia and preventing problems that
might occur at high altitude, but its use poses
logistical challenges. Although commercial
airlines prohibit transport of personal oxygen
cylinders, they do permit small, battery-powered
oxygen concentrators, which can be useful at the
intended destination if electricity is available for
recharging batteries. Alternatively, travelers may
be able to rent portable or stationary oxygen
concentrators or other devices at some high-alti-
tude destinations, such as a ski-resort commu-
nity, although prescriptions are usually required
in North America.51 The cost of these interven-
tions is another consideration, since insurance
coverage for persons not already using supple-
mental oxygen at home is limited, if available at
all. Use of hypoxic tents for several weeks before
a planned trip may reduce the risk of acute alti-
tude illness,52 but there is no evidence to support
the safety or effectiveness of hypoxic tents in
mitigating the effects of high altitude on people
with high-risk medical conditions.
T r ip Pl a nning for L ow-R isk
Per sons
Most people with medical conditions can safely
travel to high altitude without further evalua-
tion. In fact, many persons with common condi-
tions, such as diabetes mellitus, and even those
with uncommon issues, such as a history of
solid-organ transplantation, have summitted very
high mountains, including Kilimanjaro (5895 m)
and Cho Oyu (8201 m).53,54 Nevertheless, pre-
travel planning may still be necessary because of
the risk that hypobaric hypoxia or other aspects
of travel may alter disease control. A detailed
consideration of the effects of high altitude on
common conditions is beyond the scope of this
review, but a summary of key issues with com-
mon diseases, as well as appropriate mitigation
measures, is provided in Table 3. More detailed
information can be found in reviews of common
conditions.55-65 Data are lacking regarding high-
altitude travel for persons who have had corona-
virus disease 2019 (Covid-19), but recommenda-
tions drawing on return-to-play guidelines for
sports66 have been published.67
Regardless of the specific condition, several
principles should guide pretravel planning. For
diseases such as asthma or heart failure, in
369
 The n e w e ng l a n d j o u r na l of m e dic i n e

Table 3. Approach to Common Medical Conditions in Travelers Planning Ascent to High Altitude.*

Condition Concerns at High Altitude Mitigation Strategies

Cardiac conditions
Arrhythmia Possible exacerbation of tachyarrhythmia due to
increased sympathetic stimulation
CAD Increased risk of ischemia with inadequately con-
trolled or occult disease; risk of sudden car-
diac death for travelers with prior myocardial
infarction or risk factors for CAD
Heart failure with Impairment in exercise tolerance directly propor-
preserved or reduced tional to the severity of heart failure; potential
ejection fraction for fluid retention
Hypertension Variable changes in BP after ascent
Defibrillators and pace- Insufficient data on device performance at high
makers altitude
Hematologic conditions
Anemia Impairment in exercise tolerance directly propor-
tional to the severity of anemia; no specific
hemoglobin concentration precludes travel
Sickle-cell trait Risk of splenic crisis
Thrombophilia and VTE No clear evidence of increased risk of VTE at high Advise patients to maintain hydration and mobility; do not in-
altitude; changes in diet at high altitude may
affect INR for patients using warfarin
Neurologic conditions
Migraine Hypoxia may trigger migraine, which may be
difficult to distinguish from high-altitude
headache or acute mountain sickness
Seizures Low risk of worsening seizure control in persons
receiving seizure medication; risk of seizures
for those with history of seizures who are not
currently receiving medication
Respiratory conditions
Asthma Greater hypoxemia and dyspnea with exacerba-
tions than at lower altitude; exposure to urban
areas with poor air quality while traveling to
destination; exercise-induced bronchocon-
striction due to cold, dry air
COPD and interstitial lung Worsening hypoxemia and dyspnea, particularly
diseases with exertion; variable decrements in exercise
tolerance
History of SARS-CoV-2 Persistent deficits in lung mechanics, gas
infection exchange, and cardiac function may cause
worsening hypoxemia and exercise limitation
Pulmonary hypertension Increased pulmonary-artery pressure with risk of
reduced right-heart function or high-altitude
pulmonary edema
Advise patients to travel with a plan and medications to
address worsening tachyarrhythmia and to avoid travel
with uncontrolled arrhythmia
Administer pretravel cardiac stress test if patients have
history of or risk factors for CAD; after ACS, evaluate for
revascularization; advise patients to delay travel for 4 wk
after uncomplicated ACS and for 3 mo after complicated
ACS, to limit physical activity for 1–2 days after ascent, to
avoid exertion exceeding level of exertion at low elevation
Monitor weight and increase diuretics as necessary; advise
patients to limit physical activity after ascent
For well-controlled hypertension, no monitoring is necessary;
for poorly controlled hypertension, advise patients to
travel with a plan to monitor BP and alter medications
Consider device interrogation before sojourn, particularly
with high-risk activities
Improve hemoglobin concentration; consider iron infusions
in cases of iron deficiency
Advise patients to avoid overexertion and dehydration and to
seek medical attention for left-upper-quadrant pain
troduce anticoagulant treatment for patients not already
receiving it; when suitable, change warfarin to DOAC
Advise patients to travel with abortive therapy; if hypoxia is
a known trigger, consider prophylaxis for patients not
receiving regular medications
Advise patients with poorly controlled seizures to avoid high
altitude; for patients not receiving medication for prior
seizures, consider prophylaxis; avoid concurrent use of
topiramate and acetazolamide
Advise patients with poorly controlled asthma to avoid high
altitude; advise patients to travel with medications for
exacerbations and to keep inhalers warm
Advise patients to monitor Spo2 during travel, to consider
using supplemental oxygen, and to practice graded
exposure to high altitude and physical exertion
For asymptomatic infection, advise patients to defer travel
until 2 wk after positive test; for symptomatic infection,
defer travel until 2 wk after symptom resolution; admin-
ister pretravel evaluation for patients who have ongoing
symptoms or who required intensive care
Advise patients to avoid travel if PASP >60 mm Hg or NYHA
class III or IV disease and to consider supplemental
oxygen

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 Medical Conditions and High-Altitude Tr avel

Table 3. (Continued.)

Condition Concerns at High Altitude Mitigation Strategies

Obstructive sleep apnea No change in number of obstructive apneas but
increased central apneas; exaggerated hypox-
emia with apneas
Other conditions
Diabetes mellitus Unclear effects on insulin requirements; dexameth- Patients should avoid dexamethasone for acute mountain
asone can worsen glucose control; changes
in diet and activity may affect glucose control;
glucose monitor and insulin pump function not
established at extremes of elevation
Pregnancy No established risk at any stage of low-risk preg-
nancy; risk to fetus increased in high-risk
pregnancy
Refractive eye surgery Radial keratotomy: decreased visual acuity due to
hyperopic shifts at elevations >5000 m
LASIK: potential for mild blurring of vision and
myopic shifts
Patients should continue CPAP therapy; oral appliances can
be used if access to power is insufficient; acetazolamide
sickness prophylaxis, increase frequency of blood glucose
monitoring, and travel with backup plan for glucose mon-
itoring and insulin administration if monitor or pump
malfunctions
Provide a checkup for patients before travel to ensure preg-
nancy is low risk; advise maintenance of hydration, avoid-
ance of greater level of exertion than at low elevation, and
limiting sleeping elevation to <3000 m
After patients have undergone radial keratotomy, advise
travel with a backup pair of eyeglasses that has added
plus power; there are no particular mitigation strategies
after LASIK

* ACS denotes acute coronary syndrome, BP blood pressure, CAD coronary artery disease, CPAP continuous positive airway pressure,
DOAC direct oral anticoagulant, INR international normalized ratio, LASIK laser-assisted in situ keratomileusis, NYHA New York Heart
Association, PASP pulmonary-artery systolic pressure, SARS-CoV-2 severe acute respiratory syndrome coronavirus 2, Spo2 peripheral oxygen
saturation, and VTE venous thromboembolism.

which symptoms can fluctuate over time, high-
altitude travel should be undertaken only when
the disease is under good control. Providers
should adhere to guideline-directed medical
therapy ahead of planned travel. Travelers should
continue taking their medications during their
trip, and for many conditions, such as heart
failure or difficult-to-control hypertension, they
should establish plans for monitoring and re-
sponding to changes in disease activity. Persons
with diseases subject to exacerbations, such as
asthma, atrial fibrillation, migraine, or inflam-
matory bowel disease, should travel with the
necessary medications for treating an exacerba-
tion until definitive care can be obtained. Hypo-
baric hypoxia and extremely cold temperatures
at high altitude can affect the function of certain
medical devices, such as glucose monitors,60 in-
sulin pumps,68 and metered-dose inhalers.69 In
addition, many devices are certified for use only
up to certain elevations, and accuracy at ex-
tremely high altitude is unknown. Travelers
should therefore protect devices from the cold
and travel with alternative means for monitoring
or administering medications in the event that
the primary method fails.
A ddi t iona l C onsider at ions
Additional considerations apply to all travelers
with medical conditions, regardless of their
risk category. Care is warranted in choosing
medications for altitude illness. Dose adjust-
ments are necessary for persons with chronic
kidney or liver disease, whereas others may be
at risk for drug–drug interactions or other side
effects, such as hyperglycemia with the use of
dexamethasone in persons with diabetes melli-
tus or hypokalemia with concurrent use of
acetazolamide and loop diuretics. These issues
have been reviewed elsewhere.70
Travelers with medical conditions should
check on the availability of medical resources
in the area to which they will travel and in-
form a designated trip leader about their con-
dition, since worsening of the condition could
affect the plans of the entire travel party. Be-
cause unanticipated problems can arise even
with thorough pretravel planning, it is recom-
mended that persons obtain travel insurance
to facilitate evacuation to a medical facility at
a lower elevation, if necessary.

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 The n e w e ng l a n d j o u r na l of m e dic i n e

C onclusions who have never before been at high altitude, but

Travel to a high-altitude destination may ini-
tially appear to be infeasible for many people
who have medical conditions, but with careful
evaluation and pretravel planning, high-altitude
excursions are possible for many, but not all,
such persons. There will always be an element of
uncertainty, particularly in the case of travelers
steps can be taken to monitor disease control,
respond to changes in a medical condition, and
mitigate risk. Further research can clarify the
specific risks associated with various conditions
and the best means for helping affected persons
safely enjoy time in the mountains.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.

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