Plain chest x-ray (radiograph) of a patient diagnosed with HAPE. Wilderness Medical Society clinical practice guidelines for the prevention and treatment of acute altitude illness: 2019 update. Managing high-altitude pulmonary edema with oxygen alone: results of a randomized controlled trial. Hartmann G, Tschop M, Fischer R, et al. van Patot MC, Leadbetter G 3rd, Keyes LE, Maakestad KM, Olson S, Hackett PH. 5:15126. A chest X-ray will likely … Both tadalafil and dexamethasone may reduce the incidence of high-altitude pulmonary edema: a … Am Fam Physician. Sign up for the free AFP email table of contents. [Medline]. StatPearls [Internet]. Dexamethasone alleviates vasogenic cerebral edema and improves endothelial integrity. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris NS. Wilderness Environ Med. Management of high altitude pulmonary edema in the Himalaya: a review of 56 cases presenting at Pheriche medical aid post (4240 m). Acetazolamide is used in the prevention of HAPE. Courtesy of Extreme Physiology & Medicine (PMID: 24636661, online at https://extremephysiolmed.biomedcentral.com/track/pdf/10.1186/2046-7648-3-6). Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness: 2014 update. In high-altitude pulmonary edema (HAPE), it's theorized that vessels in the lungs constrict, causing increased pressure. [Guideline] Alhazzani W, Moller MH, Arabi YM, et al. The most studied and preferred medication for prevention of HAPE is nifedipine, a pulmonary vasodilator which prevents the altitude induced pulmonary hypertension. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. Sci Rep. 2015 Oct 13. High-altitude pulmonary edema (HAPE) is a lethal, noncardiogenic form of pulmonary edema that afflicts susceptible individuals after rapid as-cent to high altitude above 2,500 m. Prevention of HAPE is achieved most effectively by gradual ascent allowing time for proper acclimatiza-tion. 8(2):139-46. firstname.lastname@example.org for copyright questions and/or permission requests. Abingdon, UK: Radcliffe Medical Press; 2003. 2011 Dec 15. 2006 Oct 3. Climbers with a previous history of HAPE, who ascent rapidly above 4500m have a 60% chance of illness recurrence. Both tadalafil and dexamethasone may reduce the incidence of high-altitude pulmonary edema: a randomized trial. Wilderness Environ Med. ... C Sartori, Y Allemann, H Duplain, et al.Salmeterol for the prevention of high-altitude pulmonary edema. High altitude pulmonary edema: Known for short as HAPE, the accumulation in the lungs of extravascular fluid (fluid outside of blood vessels) at high altitude, a consequence of rapid altitude ascent, especially when that ascent is accompanied by significant exercise.. HAPE leads to dyspnea (shortness of breath), cough, tachycardia (fast heart rate) and decreased arterial … Although HACE presents with similar symptoms as AMS, the cerebral edema can lead to ataxia, confusion, or altered mental status. Respir Physiol Neurobiol. [Full Text]. High-altitude pulmonary edema (HAPE). High-altitude pulmonary edema (HAPE). Available at https://www.fda.gov/media/136449/download. This causes fluid to leak from the blood vessels to the lung tissues and eventually into the air sacs. Its mechanism is via inhibition of the carbonic anhydrase enzyme which counteracts the respiratory alkalosis which occurs during ascent to altitude. The Centers for Disease Control and Prevention (CDC) strongly recommends acetazolamide prophylaxis in all individuals with a prior history of HAPE or HACE, as well as with the following Fagenholz PJ, Gutman JA, Murray AF, Harris NS. High-altitude pulmonary edema responds best when the person descends from their current altitude. They suppress inflammation and the immune response. Deshwal R, Iqbal M, Basnet S. Nifedipine for the treatment of high altitude pulmonary edema. 2019 Dec. 30 (4S):S3-S18. HAPE Prevention and Treatment Guidelines (WMS, CDC), FDA Policy for Face Masks, Face Shields, and Respirators in COVID-19 (2020), COVID-19–Related Airway Management Clinical Practice Guidelines (SIAARTI/EAMS, 2020), COVID-19 Ventilation Clinical Practice Guidelines (ESICM, 2020), https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/altitude-illness, https://www.medscape.com/viewarticle/928160, https://www.medscape.com/viewarticle/928236, https://www.fda.gov/media/136449/download, American College of Physicians-American Society of Internal Medicine. Reviewed: October 18, 2019; Accessed: April 6, 2020. High-altitude pulmonary edema (HAPE). Clinical Review, You are being redirected to
Cytokine. Worcester S. Is protocol-driven COVID-19 ventilation doing more harm than good?. In the setting of concomitant HAPE and HACE, WMS recommends adding dexamethasone to the treatment regimen for patients with HAPE and neurologic dysfunction that does not resolve rapidly with administration of supplemental oxygen and improvement in the patient’s oxygen saturation. High-altitude pulmonary edema (HAPE). 52 (6):485-92. Enforcement policy for face masks and respirators during the coronavirus disease (COVID-19) public health emergency : guidance for industry and Food and Drug Administration staff. [Medline]. Regardless of AMS history, people who ascend to a sleeping altitude above 9,800 ft are at moderate risk if they sleep more than 1,600 ft above the previous night's altitude but take a day to acclimatize after every increase of 3,300 ft in sleeping altitude. [Full Text]. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. N Engl J Med. Contact Guo L, Tan G, Liu P, et al. 12(3):246-52. She had continued ascending despite experiencing mild altitude symptoms at Namche (3440 m), with considerably worsened symptoms at Tengboche (3860 m). Bärtsch P, Swenson ER, Maggiorini M. Update: High altitude pulmonary edema. All rights Reserved. 2013 Mar. J Appl Physiol. High-Altitude Pulmonary Edema. Dexamethasone should be administered at the doses recommended for the treatment of HACE. 2000 Mar 15. Pandey P, Lohani B, Murphy H. Pulmonary embolism masquerading as high altitude pulmonary edema at high altitude. If not appropriately treated, AMS can progress to life-threatening HACE or HAPE, which can present together or separately. 35(4):980-7. Nancy Caroline's Emergency Care in the Streets Advantage Package (Canadian Edition). /viewarticle/926097
[Medline]. Zhou Q. High-altitude pulmonary edema (HAPE) is a potentially life-threatening condition that typically occurs in young, otherwise healthy people after rapid ascent to an altitude of 2500 m or higher. Qazi Qaisar Afzal, MD Clinical Instructor, Department of Medicine, State University of New York at Stony Brook 2015 Sep 28. The reported incidence of HAPE ranges from an estimated 0.01% of skiers traveling from low altitude to Vail, CO (2,500 m), to 15.5% of Indian soldiers rapidly transported to altitudes of 3,355 and 5,9… https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzAwNzE2LW1lZGljYXRpb24=, History of acute mountain sickness and ascending more than 2,800 m in 1 day, All people ascending to more than 3,500 m in 1 day, All people ascending more than 500 m per day (increase in sleeping elevation) above 3,000 m, without extra days for acclimatization, Oral nifedipine (generally reserved for HAPE-susceptible individuals) - 30 mg sustained-release formulation every 12 hours (same regimen for HAPE treatment). Acetazolamide promotes renal excretion of … 145(7):497-506. This article covers its milder form, Acute Mountain Sickness (AMS), as well as the more serious conditions of HACE (High-Altitude Cerebral Edema) and HAPE (High-Altitude Pulmonary Edema). Stress Doppler echocardiography for identification of susceptibility to high altitude pulmonary edema. a For individuals ascending to and remaining at a given elevation, after arrival at the target elevation, the medication should be continued for 2 d in Nifedipine, for example, can be administered at a rate of 60mg of a timed-release preparation daily, in 2 or 3 divided doses. [Guideline] Luks AM, McIntosh SE, Grissom CK, et al, for the Wilderness Medical Society. 2020 Jan. [Medline]. 2020 Apr 15;101(8):505-507. Grunig E, Mereles D, Hildebrandt W, et al. Are Diabetes, CVD Associated With Worse COVID-19 Prognosis? Rohit Goyal, MD is a member of the following medical societies: American College of Chest Physicians, American Medical Association, American Thoracic SocietyDisclosure: Nothing to disclose. 10(11):469-74. Ann Intern Med. 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 incidence of High Altitude Pulmonary Edema (HAPE) among unacclimatized travelers to altitude is largely dependent on genetic susceptibility, the rate of ascent, and the final altitude achieved. April 2020; Accessed: April 7, 2020. Standardization of methods for early diagnosis and on-site treatment of high-altitude pulmonary edema. 14 (3):11562-72. See the CME Quiz Questions. 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 Effects of altitude and exercise on pulmonary capillary integrity: evidence for subclinical high-altitude pulmonary edema. 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 FoundationDisclosure: Nothing to disclose. Both tadalafil and dexamethasone may reduce the incidence of high-altitude pulmonary edema: a randomized trial. Bartsch P, Maggiorini M, Ritter M, Noti C, Vock P, Oelz O. Treatment of high altitude pulmonary edema at 4240 m in Nepal. Prophylactic low-dose acetazolamide reduces the incidence and severity of acute mountain sickness. 2020 Mar 27. 362571-overview
HACE is typically encountered at higher elevations unless presenting with HAPE. Scherrer U, Rexhaj E, Jayet PY, Allemann Y, Sartori C. New insights in the pathogenesis of high-altitude pulmonary edema. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Prevention and treatment of high altitude pulmonary edema (HAPE) February 2020; Journal of Education, Health and Sport 10(2):114; DOI: 10.12775/JEHS.2020.10.02.015 [Medline]. [Full Text]. 2006 Oct 3; 145(7):497–506. High-altitude pulmonary edema (HAPE) is a lethal, noncardiogenic form of pulmonary edema that afflicts susceptible individuals after rapid ascent to high altitude above 2,500 m. Prevention of HAPE is achieved most effectively by gradual ascent allowing time for proper acclimatization. 100(3):972-80. Intensive Care Med. 131(4):1013-8. 2016 Dec. 17 (4):294-9. Maggiorini M. Prevention and treatment of high-altitude pulmonary edema. [Medline]. Environmental emergencies. Rohit Goyal, MD Fellow, Division of Pulmonary Medicine, Lenox Hill Hospital, New York University School of Medicine There are patchy infiltrates throughout the lung tissue, with predominant changes in the right middle lobe/right central hemithorax. Antibiotics may be given if a fever is present and pneumonia is possible. Nifedipine , a medication for high blood pressure, has been shown to be beneficial for high-altitude pulmonary edema. Copyright © 2020 American Academy of Family Physicians. [Medline]. Phosphodiesterase type 5 inhibitors in the treatment and prevention of high altitude pulmonary edema. Kilimanjaro [19,341 ft (5,895 m)] in fewer than seven days); or (3) ascend to a sleeping altitude above 9,800 ft, then sleep more than 1,600 ft above the previous night's altitude without allowing a day off to acclimatize. 2002
It often improves SaO2 modestly within a few minutes. 131 (6):582-90. Wilderness Environ Med. Want to use this article elsewhere? [Medline]. 325 (18):1284-9. April 5, 2020; Accessed: April 6, 2020. 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. Diseases & Conditions, 2003
2017 Jan. 26 (143):[Medline]. High altitude pulmonary edema (HAPE). 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 SocietyDisclosure: Nothing to disclose. Galcanezumab (Emgality) for Migraine and Cluster Headaches. [Medline]. [Full Text]. 2015 Feb 10. N Engl J Med, 346 (21) (2002), pp. Staged ascent and preacclimatization to hypoxia also reduce risk. [Full Text]. In: MacDonald RD, ed. High Altitude Pulmonary Edema (HAPE) ... you will need supplemental oxygen and may need medications, as well as moving to a lower altitude. High Alt Med Biol. High-altitude pulmonary edema (HAPE) is a life-threatening noncardiogenic form of pulmonary ede-ma (PE) that afﬂicts susceptible persons after rapid ascent to high altitude above 2500 m. Its patho-genesis is related to increased sympathetic tone, exaggerated hypoxic pulmonary vasoconstriction, Emergency Medicine Clinics of North America: Wilderness and Environmental Medicine. Unacclimatized people are at high risk of acute altitude illness when ascending above 8,200 ft (2,500 m), but AMS can occur as low as 6,500 ft (2,000 m). Eldridge MW, Braun RK, Yoneda KY, Walby WF. [Medline]. Initial chest x-ray showing pulmonary infiltrates in the right lung especially in the right mid and lower lung zones indicative of pulmonary edema. 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 2007 Summer. 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. The best way to prevent getting altitude sickness is to travel to altitudes above 2,500m slowly. It is not used in the treatment of this condition. These agents have profound and varied metabolic effects. Circulation. Wilkins MR, Ghofrani HA, Weissmann N, Aldashev A, Zhao L. Pathophysiology and treatment of high-altitude pulmonary vascular disease. It is not used in the treatment of this condition. Maggiorini M, Brunner-La Rocca HP, Peth S, et al. HAPE is characterized by reduced exercise tolerance, exertional dyspnea, and cough, followed by dyspnea at rest, cyanosis, and productive cough with pink frothy sputum. Medscape Medical News. [Medline]. Courtesy of Wikipedia (https://en.wikipedia.org/wiki/File:Portable_hyperbaric_chamber.jpg). [Medline]. 2007 Apr. Fischer R, Lang SM, Bergner A, Huber RM. This content is owned by the AAFP. The Wilderness Medical Society (WMS) advises that diuretics or acetazolamide should not be used for treatment of HAPE, and it makes no recommendation regarding beta-agonists or dexamethasone for HAPE treatment due to insufficient/lack of data. Drugs are not as effective as descent from altitude and oxygen in the treatment of high-altitude pulmonary edema (HAPE). 2010 May-Jun. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Jensen JD, Vincent AL. Nifedipine or other pulmonary vasodilators may be used to treat concurrent HAPE and HACE, but avoid lowering mean arterial pressure, as this may decrease cerebral perfusion pressure and thereby increase the risk for cerebral ischemia. • The most important treatment for altitude illness is descent of 1,000 to 3,300 ft, with supplemental oxygen if available. The recommendation for its use is strongest for individuals with a history of HAPE. Courtesy of Extreme Physiology & Medicine (PMID: 24636661, online at https://extremephysiolmed.biomedcentral.com/track/pdf/10.1186/2046-7648-3-6). 55, 84–88, 91–95 Some individuals, however, can Prevention of high-altitude pulmonary edema by nifedipine. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. Adv Exp Med Biol 2001; 502:89. Oxygen, if available, should be provided. Immediate, unlimited access to all AFP content. Pulm Med. Laurie A Ward, MD, FACP Director of Population Health, Wyckoff Heights Medical Center High-altitude … [Medline]. 2006 Mar. Wu AL, Xiong YS, Li ZQ, Liu YG, Quan Q, Wu LJ. Please confirm that you would like to log out of Medscape. If you log out, you will be required to enter your username and password the next time you visit. 1,5 However, for ascents greater than 5500m the … Samia Qazi, MD is a member of the following medical societies: American College of Physicians-American Society of Internal MedicineDisclosure: Nothing to disclose. Susceptible individuals can prevent HAPE by slow ascent, average gain of altitude not exceeding 300 m/d above an altitude of 2500 m. If progressive high altitude acclimatization would not be possible, prophylaxis with nifedipine or tadalafil for long sojourns at high altitude or dexamethasone for a short stay of less then 5 days should be recommended. High-altitude travel & altitude illness. Regardless of AMS history, all people are at high risk of AMS if they: (1) make a one-day ascent to a sleeping altitude above 11,500 ft (3,500 m); (2) make extremely rapid ascents (e.g., climbing Mt. 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 The medication is effective in preventing acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), and high altitude cerebral edema (HACE). This series is coordinated by Sumi Sexton, MD, editor-in-chief. AMS,acute mountain sickness; HACE, high altitude cerebraledema; IM, intramuscularly; ER, extendedrelease;HAPE, highaltitude pulmonary edema. 24 (1):32-6. S… 2012 Mar. 209:33-8. These agents are helpful in the prevention of HAPE. The patient received bed rest, supplemental oxygen, and oral sustained-release nifedipine 20 mg twice daily. Available at https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/altitude-illness. HAPE is the most common cause of death related to high altitude. [Medline]. High-altitude pulmonary edema (HAPE) is a life-threatening, noncardiogenic form of pulmonary edema afflicting certain individuals after rapid ascent to high altitude above 2,500 m (approximately 8,200 ft). 101/No. PDE-5-esterase inhibitors, like tadalafil at 10 mg by mouth twice a day can also be used. [Medline]. Prevention and Treatment of High-Altitude Pulmonary Edema Marco Maggiorini⁎ Intensive Care Unit, Department of Internal Medicine, University Hospital, Rämistrasse 100, CH-8091 Zurich, Switzerland Abstract We distinguish two forms of high altitude illness, a cerebral form called acute mountain A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. In those with no prior history of HAPE who ascend to 4500m the incidence is relatively low, ranging from 0.01-0.2%. [2, 3]. [Guideline] Hackett PH, Shlim DR. CDC Yellow Book 2018. [Medline]. J Travel Med. J Am Coll Cardiol. [Medline]. Acute altitude illness comprises acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). Altitude sickness, the mildest form being acute mountain sickness (AMS), is the negative health effect of high altitude, caused by rapid exposure to low amounts of oxygen at high elevation. 2015 Nov 3. 43. Don't miss a single issue. 179 (2-3):294-9. In: Weiss EA, Sward DG, eds. The recommended regimen for adults with HACE is an initial 8-mg dose given orally, intravenously, or intramuscularly, then 4 mg every six hours until symptoms resolve. Prevention. Nifedipine is used in HAPE for pulmonary vasodilation. High-Altitude Pulmonary Edema: Diagnosis, Prevention, and Treatment Andre Pennardt, MD, FACEP, FAWM Abstract High-altitude pulmonary edema (HAPE) is a lethal, noncardiogenic form of pulmonary edema that afflicts susceptible individuals after rapid as-cent to high altitude above 2,500 m. Prevention of HAPE is achieved most effectively by gradual ascent allowing time for … Acetazolamide is used in the prevention of HAPE. Courtesy of High Altitude Medicine & Biology (PMID: 27768392, online at https://www.liebertpub.com/doi/full/10.1089/ham.2016.0008). 1631-1636. People can live comfortably at moderately high altitudes, but the body must make some adjustments, and this takes time. Davis C, Hackett. Copyright © 2020 by the American Academy of Family Physicians. 3rd ed. Nifedipine, by reducing pulmonary arterial pressure, may be effective in treating HAPE.  : The CDC recommends the following pharmacologic agents and regimens for HAPE prophylaxis Pulmonary embolism masquerading as HAPE. 8(April 15, 2020)
[33, 34], In general, acetazolamide facilitates acclimatization, but this agent should not be relied on as the sole preventive agent in individuals with known HAPE susceptibility. Wilderness Environ Med. Prog Cardiovasc Dis. 2008 Sep-Oct. 15(5):315-22. / Journals
All people with a history of HACE or HAPE are at high risk of AMS, regardless of sleeping elevation or rate of ascent. Mir Omar Ali, MD is a member of the following medical societies: American College of Physicians, Society of Critical Care MedicineDisclosure: Nothing to disclose. 2015 Apr. • Acetazolamide and dexamethasone can be used to prevent acute mountain sickness and high altitude cerebral edema, but only acetazolamide aids in acclimatization.