Altitude Medicine

Altitude illness

Pathophysiology
AMS
HAPE
HACE
Treatment
Other altitude conditions
Prevention

How high is high altitude?

High altitude: 1500-3000m above sea level

Very high altitude: 3000-5000m
Extreme altitude: above 5000m
Death zone: above 8000m

Altitude Stressors
Hypoxia
Over 2000m
PO2 at 5000m half that of sea level

Cold
Drop 6.5 per 1000m

Aridity
Radiation

Hypoxic responses
Respiratory
rate

Cardiovascular
rate and stroke volume
Pulmonary vasoconstriction and cerebral
vasodilatation (increases PA pressure)

Hematology
red blood cell mass and plasma viscosity
O2 Hb dissociation curve shift to left to increase
affinity for O2 (so less delivered to tissues)

Acclimatization
Acute hypoxic stress is poorly tolerated
but given time to adapt the body can
handle certain degrees of hypoxia very
well
How? Changes in ventilation, blood, fluid
balance, and cardiovascular parameters.

Acclimatisation
Process by which people gradually adjust to high altitude
Determines survival and performance at high altitude
Series of physiological changes
O2 delivery
hypoxic tolerance +++
Acclimatization depends on
severity of the high-altitude hypoxic stress
rate of onset of the hypoxia
individuals physiological response to hypoxia

Ventilatory acclimatisation
Hypoxic ventilatory response = VE
Starts within the 1st few hours of exposure 1500m
Mechanism
Ascent to altitude
Hypoxia
Decreased PCO2

Carotid body stimulation

Respiratory centres stimulation
Increased ventilation

CO2 + H2O H2CO3 HCO3- + H+

Improved hypoxia

Adjustment of respiratory
alkalosis
alkaline bicarbonate excretion in the urine
but slow process !
Progressive increase in the sensitivity of the
carotid bodies
After several hr to days at altitude (interval of
ventilatory acclimatization): cerebrospinal fluid
pH adjustment to the respiratory alkalosis
new steady state

Lung diffusion
Definition
Process by which O2 moves from the alveolar gas into the
pulmonary capillary blood, and CO2 moves in the reverse
direction

High altitude O2 diffusion, because

a lower driving pressure for O2 from the air to the blood
a lower affinity of Hb for O2 on the steep portion of the O2/Hb
curve
and inadequate time for equilibration

V/Q heterogeneity
At rest

At high altitude
interstitial oedema
heterogeneity +++

O2
- Inhaled air is not evenly distributed to alveoli
- Composition of gases is not uniform throughout lungs
- Different areas of the lungs have different perfusion
- Differences are less in recumbent position

Ventilation cont.
HVR blunted by:
Chronic hypoxia
Respiratory depressant drugs

Blood Acclimatization
Increase in EPO within 2 hours - benefit in
exercise tolerance only with long term
stays. Not important for alt. Sickness
Increase 2,3-DPG (shifts oxyhemoglobin
diss curve R). However resp alkalosis
shifts curve L so likely no net effect
If at altitude for a while, red cells (some
advise aspirin while at altitude)

Fluid Balance Acclimatisation

Peripheral venous constriction
increased central volume
decreased ADH and aldosterone
diuresis
decreased plasma volume and hyperosmolality.

Antidiuresis is sign of acute mountain

sickness

Cardiovascular Acclimatisation
Increased HR and sympathetic tone
compensates for lower stroke volume
hypoxia pulmonary circulation
constriction
helpful for pneumonia, effusions etc but
not for global hypoxia
leads to pulmonary hypertension

Exercise
VO2 max drops 10% for each 1000m up.
No acclimatisation for this

Changes during sleep

Some people have trouble sleeping above
2500m
Many have problems above 4500m
Periodic breathing may occur
Avoid sedatives and alcohol reduce
breathing further at night

When acclimatisation fails

Altitude syndromes
Acute mountain sickness (AMS): the least-threatening and
most common
High altitude pulmonary oedema
potentially lethal form
of altitude illness
High altitude cerebral oedema

All these syndromes have

several features in common
respond to descent or oxygen

AMS Pathophysiology
Likely mild cerebral oedema develops
Decreased HVR need high CBF to
maximise oxygenation

Acute Mountain Sickness

Constellation of symptoms in context of
recent gain in altitude
Similar to a hangover

50% at 3500m
Most at 5000m

AMS cont.
Antidiuresis oedema (periph or pulm)
Feels like ETOH hangover
Resolves in average 15 hours, max 4 days

Acute Mountain Sickness (AMS)

Above 2400m & recent
ascent
Symptoms:

Headache
Fatigue
Nausea & Vomiting
Impaired night vision
Anorexia
Dizziness
Sleep Disturbance

Signs:
Mild tachycardia
Peripheral oedema
Ataxia may represent
severe AMS or HACE

AMS - Treatment
Mild
Rest and stop ascent
Descend if not
improved after 24
hours
Drink fluids
Simple analgesics

Moderate/Severe

Descend 100m
Acetazolamide
Dexamethasone
Hyperbaric O2
(Gamow bag)

Lake Louise Score

A diagnosis of AMS is based on:

1. A rise in altitude within the last 4 days
2. Presence of a headache
PLUS
3. Presence of at least one other symptom
4. A total score of 3 or more from the
questions below (6 or more = severe AMS)

High Altitude Cerebral Oedema

(HACE)
Usually get AMS before HACE
May lead to coma, irreversible neurology
or death

HACE: the next step of AMS

Progressive neurologic decline
Confusion, ataxia, stupor, coma, focal
neurologic signs possible

HACE: symptoms

Behavioural change
Hallucinations
Disorientation & confusion
Decreased consciousness
Coma
NB casualty may be unaware of
problems; buddy system essential

HACE: signs
Ataxia (e.g. poor heel toe
walking)
Focal neurological signs
Papilloedema & retinal
haemorrhages

HACE: treatment
IMMEDIATE DESCENT
Do NOT wait until morning if HACE
occurs at night
Oxygen
Dexamethasone 8mg and then 4mg QDS
po/ iv
Hyperbaric bag (to facilitate descent if
necessary NOT replace it)

High altitude pulmonary

oedema (HAPE)
Noticed only after 24-48hr and occurs after the
2nd night
Occurs in otherwise healthy people without
known cardiac or pulmonary disease
2% at 4000m
Occurs when people go rapidly to high altitude
Extravasation of fluid from the intra- to
extravascular space in the lung

No Caption Found

Barry, P W et al. BMJ 2003;326:915-919

Copyright 2003 BMJ Publishing Group Ltd.

Pathophysiology
Hypothesis1. Pulmonary hypertension
Strong relationship between the development
of HAPE in people with
Mild pulmonary hypertension at rest
Accentuated pulmonary vascular response to
hypoxia or exercise

But pulmonary hypertension alone not enough

to result in HAPE (Sartori et al., 2002)

Hypothesis 2. Pulmonary endothelium barrier fragility

Pulmonary endothelium barrier susceptible to
Mechanical stress
Stretching of the endothelium gaps passage of
proteins and red blood cells
Inflammation
Mediators release permeability gaps
passage of proteins, red blood cells and inflammatory
mediators
Question:
High pressure alone enough to result in extra
vascular leak ?

Hypoxic pulmonary
vasoconstriction
The stress failure theory (West et Mathieu-Costello, 1998, 99)
Exacerbated by exertion

Alveolar hypoxia
Hypoxic pulmonary vasoconstriction (uneven)
capillary pressure (some capillaries)

VA/Q heterogeneity

Damage to capillary wall (stress failure)

Exposed
basement
OEDEMA
membrane
Inflammatory mediators

Circular break of the epithelium

Full break of the blood-gas barrier

Costello et al., 1992

Red cell moving out of the capillary

lumen (c) into an alveolus (a)
West et al., 1995

Hypothesis 3. Perturbation of alveolar fluid

clearance
Role of fluid in extravascular space depends on:
Its accumulation
Efficiency of its rate of clearance
Hypoxia Na,K-ATPase activity (Dada et
al., 2003)

High Altitude Pulmonary

Oedema (HAPE)
Above 3000m
Symptoms:

Dyspnoea
Reduced exercise
tolerance
Dry cough
Blood stained
sputum

Signs:
Tachycardia
Resting tachycardia

Tachypnoea
Crackles
Fever
Signs of RV strain
RV heave, Loud P2

HAPE or not?
If oedema does not resolve with Rx or
occurs lower that 2500m another cause
must be investigated
HAPE casualty can be discharged when
stable and O2 saturation > 90%.

Treatment

Sit the patient upright and give O2

Descent
Nifedipine
Salmeterol
Sildenafil
Hyperbaric O2/PEEP eg purse lip
breathing
Keep warm

HAPE Rx
NO - 10-40 ppm with O2 - lowers pulm
HTN and redistributes blood away from
edematous areas
recent Lancet article found high altitude
animals and Himalayan dwellers exhale
higher % of NO. Give a NO inhibitor and
animals develop HAPE faster ??PDE5
inhib (slows NO breakdown) as future Rx

Drugs used to treat high altitude

illnesses

Acetazolamide
Carbonic anhydrase inhibitor
Enhances ventilation and renal
bicarbonate excretion
Peripheral tingling, nausea, altered taste
Avoid if allergic to sulfa drugs
Need to work hard to ensure adequate
hydration

Nifedipine
10mg stat then 20 mg qds for 1 day
assuming BP does not fall too much
Prick 10mg capsule and give SL for most
rapid effect

Dexamethasone
Reduces cerebral oedema
8mg bolus then 4mg qds
Beware mood changes in some

Sildenafil
Reduces PA pressure
Useful in HAPE
Not in the books yet

Salmeterol
May reduce risk of HAPE
6 puffs BD starting day before ascent

Gamow
Bag

Gamow Bag
Can simulate 500m
descent in 5 10
minutes
Cant do anything to
casualty while they
are in bag
Claustrophobic
ALWAYS descend
after using bag

Portable altitude chamber

Peripheral Edema

20% of trekkers in Nepal get some

not dangerous if no other Sx
resolves upon descent
More common in women

High Altitude Retinopathy

Retinal edema, vessel tortuosity and
dilation, disc hyperemia, hemorrhages +/cotton wool exudates
asymptomatic unless macular bleed
dont have to descend unless vision
decreases
resolves without Rx

High Altitude
Pharyngitis/Bronchitis
Khumbu cough
Purulent bronchitis and painful throat near
universal at very high altitude
respiratory heat loss, bronchospasm and
mucosal cracking (dry and cold effects)
coughing can lead to rib #s
Antibiotics no use
wear your balaclava there are face
masks that act as HME

UV Keratitis
5% increase in UV rays/ 300m gain +
snow reflection
Cornea burns with in 1 h & symptomcs
within 6-12 h
pain, like f.b., photophobia, tearing,
erythema, chemosis, eyelid swelling
24 h to heal, analgesics and cold comp.
Wear sunglasses

UV radiation and skin

Use sunblock
Need high SPF
Needs to block UVA and B

Single application of betnovate 0.1% for

severe sunburn

Avoiding Problems

Plan trip in advance and train beforehand

Cant predict who will get altitude illness
Increase calorie and fluid intake
Acclimatization:

Start below 3000m and walk up

Climb only 300m per day
1 day rest for every 900m
Climb high and sleep low
1 week above 3500m before going above 5000m

? Prophylactic acetozolamide
minimum effective dose is not known
There are side effects

Questions???

3 rules to avoid dying of altitude

illness
1. Learn the early symptoms of altitude illness so
they are recognised promptly
2. Never ascend to sleep at a higher level when
you have any symptoms of altitude illness
3. Descend if you dont get better or immediately
if:

Severe SOB after resting 15 minutes

Ataxia
Confusion
Deteriorating