high altitude pulmonary edema

Respir. By continuing to use this website you are giving consent to cookies being used. However, a recent prospective, cross-sectional study demonstrated no additional benefit of nifedipine compared with placebo when used in combination with descent and supplemental oxygen (6). Response can be assessed by pulse oximetry and resting respiratory rate. You may also need any of the following: Medicines: Diuretics: This medicine is given to remove excess fluid from around your lungs and decrease your blood pressure. 11. HAPE can be prevented by a slow ascent, nifedipine, phosphodiesterase inhibitors (tadalafil, sidenafil), acetazolamide, and salmeterol. James A. Litch, Rachel A. Bishop, in The Travel and Tropical Medicine Manual (Fourth Edition), 2008. Clinically important and severe HAPE may affect some sea-level dwellers soon after arriving at a high altitude. Pulm. 19. HAPE usually does not develop on the first night at altitude, and that may be why in some high-altitude pilgrimage sites, we rarely encounter HAPE, as pilgrims do not spend more than a night at the site and rapidly descend the next day. Despite early signs and symptoms of high altitude illness, many trekkers tend to push themselves to the maximum limit. The first rule of treatment for mild symptoms of acute mountain sickness is to stop ascending until your symptoms are completely gone. Travel Med. 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 5,940 m (approximately 11,000 to 18,000 ft) … This suggests that viral infections may trigger inflammation, which makes the microvascular endothelium more vulnerable to increased pressures. Individual susceptibility is the most important determinant for the occurrence of HAPE. Similarly, moderate hypoxia by itself is not sufficient for the development of edema. This website uses cookies. HAPE is also seen in approximately 5%–10% of climbers with AMS. Therefore, as suggested by West et al., 1991, stress failure of the pulmonary capillaries is the main cause of edema, which occurs because of the mechanical failure of the thin walls of pulmonary capillaries when pressure inside them rises to very high values (40–60 mm Hg) (West et al., 1991). 1989; 2: 1241–4. Inhaled β-agonists, salmeterol (Serevent) and albuterol (Proventil) are currently under study for treatment of HAPE, as β-agonists increase the clearance of fluid from the alveolar space and might lower pulmonary artery pressure. Occurrence of HAPE at relatively low altitude or multiple previous episodes of HAPE warrant an echocardiogram to evaluate for pulmonary hypertension and cardiac abnormalities, such as patent foramen ovale or atrial septal defect, as well as lung function tests to evaluate for underlying conditions such as obstructive pulmonary disease. 1.1 Risk Factors; 2 Clinical Features. Therefore, treatment is aimed at reducing pulmonary artery pressures, improving oxygenation, and increasing fluid removal from the alveoli. 2006; 145: 497–506. The observations that prophylactic administration of the calcium channel blocker nifedipine can diminish the incidence of HAPE79 and that inhalation of nitric oxide (NO) decreases PA pressures and improves oxygenation80,81 in such patients support the speculation that HAPE is due in part to an inappropriate pulmonary vasoconstrictive response. 1997; 130: 838–40. HAPE is most typically seen at elevations over 2440 m (8000 feet) and is more common in children and younger adults than other populations. Care Med. In high-altitude pulmonary edema (HAPE), it's theorized that vessels in the lungs constrict, causing increased pressure. Crit. The use of portable hyperbaric chambers may be an effective temporizing measure, when descent and oxygen administration are impossible. Biol. A cough will develop and can have frothy or pink sputum. In patients with chest radiographic evidence of infiltrates, rapid clinical and oxygen saturation improvement with administration of supplemental oxygen … Allemann and colleagues157 documented an increased incidence of patent foramen ovale in HAPE-susceptible individuals at low and high altitude compared to healthy controls and argued its presence may increase the risk of HAPE. 2006; 114: 1410–6. Care Med. Besides hypoxia, exercise and cold temperatures-triggered increase in sympathetic drive, may also lead to pulmonary vasoconstriction and extravasation of fluid into the alveoli from the pulmonary capillaries. Bates MG, Thompson AA, Baillie JK, et al.. Sildenafil citrate for the prevention of high altitude hypoxic pulmonary hypertension: double blind, randomized, placebo-controlled trial. 2012; 7: e41188. Pulmonary extravascular fluid accumulation in climbers. For travelers to high altitude resort areas, this oxygen requirement may be maintained outside the hospital using a cylinder or oxygen concentrator, as an alternative to descent for informed individuals that wish to remain in the locale of family and friends. J. Respir. It is a life-threatening condition that occurs when the lungs fill with edema or fluid. Busch T, Bärtsch P, Pappert D, et al.. Hypoxia decreases exhaled nitric oxide in mountaineers susceptible to high-altitude pulmonary edema. High altitude pulmonary edema is a subtype of pulmonary edema and is caused by prolonged exposure to an environment with a lower partial oxygen atmospheric pressure. After evacuation to a lower altitude, hospitalization may be indicated for severe HAPE cases. A continued requirement of high-flow oxygen of 4–5 L/min or more to maintain oxygen saturation >90%, or concurrent HACE, requires hospitalization. Although pulmonary edema can occur during marathons conducted near sea level67 or in elite swimmers,68 it is extraordinarily rare for normoxic exercise to be associated with pulmonary edema. Mounier R, Amonchot A, Caillot N, et al.. Management of HAPE is summarized in Table 10.3. What causes pulmonary edema? What are the relative contributions of exercise and hypoxia? to maintaining your privacy and will not share your personal information without Med. If significant concern exists for the potential of HAPE in an individual determined to ascend to high altitude, Doppler echocardiography in the setting of exercise in a hypoxic chamber may be useful. Lancet. The mechanisms leading to HAPE are still incompletely understood. Fagenholz PJ, Gutman JA, Murray AF, et al.. 18. Pulmonary hypertension: Hypoxia leads to hypoxic pulmonary vasoconstriction (HPV). Although the mechanisms underlying HAPE remain incompletely understood, it appears that elevated pulmonary artery pressures play a central role in the process, in that multiple investigations have shown that affected individuals have markedly elevated pulmonary artery pressures compared to healthy controls.84,135. 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). Treatment options for HAPE are summarized and graded in Table 3. Discharge criteria include resolution of clinical dyspnea, arterial partial pressure of oxygen greater than 60 mm Hg or saturation greater than 90% on room air, and radiographic improvement of pulmonary edema (11). Low‐grade fever is not uncommon because HAPE induces an inflammatory response in the lungs. Fatal outcomes are not uncommon when HAPE presents in remote settings with limited or no clinical support. Luks AM, Swenson ER. HAPE archetypally commences at altitudes above 3000 m. In the past, many pilgrims who may have died of HAPE were thought to have succumbed to pneumonia due to the cold at high altitude. Wolters Kluwer Health If you have more severe symptoms or any symptoms of high-altitude cerebral edema, high-altitude pulmonary edema, or blurred vision, you need to move to a lower altitude as soon as possible, even if it's the middle of the night. 17. 3.2.1 Cardiogenic pulmonary edema; 3.2.2 Noncardiogenic pulmonary edema; 4 Evaluation. Wilderness Environ. 24. If you remain at your current altitude or continue going higher, the symptoms will get worse and the sickness can be fatal. Maggiorini M, Brunner-La Roca HP, Peth S, et al.. Chest. 19–25. 2002; 346: 1631–6. The cause of the Pmv is unknown, although the two favored hypotheses are an unequal pulmonary vasoconstriction with resultant overperfusion of remaining lung microvessels or an abnormal vasoconstriction of the pulmonary venules. 13. In addition, they should identify the presence of HAPE risk factors and prescribe chemoprophylaxis to those who are at high risk but insist on high-altitude travel. Inadequate acclimatization remains the most significant risk factor for developing HAPE. At the cellular level endothelial dysfunction due to the hypoxaemia may impair the release of nitric oxide, an endothelium-derived vasodilator.32,33 It has been shown that at high altitude, HAPE-prone persons have decreased levels of exhaled nitric oxide. From: Medical Secrets (Fifth Edition), 2012, Buddha Basnyat, ... Ken Zafren, in Manson's Tropical Infectious Diseases (Twenty-third Edition), 2014. Close monitoring through transparent chamber sections is mandatory in order to quickly detect patient deterioration. DAVID A. BOBAK, PAUL S. AUERBACH, in Tropical Infectious Diseases (Second Edition), 2006, 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.55,84–88,91–95 Some individuals, however, can develop HAPE at moderate altitude (<2400 m). Finally, evidence suggests that increased sympathetic tone139 and alterations in vasoactive mediators (endothelin [ET-1], nitric oxide [NO]) produced by pulmonary endothelial cells140 may also lead to stronger HPV. Pharmacologic treatment is directed at agents that reduce pulmonary artery pressure and thereby may improve oxygenation in HAPE. This appears to be more common than generally appreciated.118 Symptoms of HAPE usually develop within 1 to 3 days following ascent and consist of orthopnea, dyspnea, and a cough productive of frothy, pink sputum. Thus, an inherent imbalance of vasoconstrictors (ET-1) and vasodilators (NO) may constitute an important predisposing factor in HAPE-susceptible subjects, an imbalance that provides potential avenues for therapeutic intervention. Deshwal R, Iqbal M, Basnet S. Nifedipine for the treatment of high altitude pulmonary edema. Phosphodiesterase inhibitors, such as tadalafil or sildenafil, are highly promising alternatives, but larger randomized, controlled trials are needed in order to recommend them as primary agents. Eur. your express consent. Early diagnosis is important as progression of the illness further limits oxygenation and worsens the degree of hypoxemia that is causing the condition. A single, nonrandomized, unblinded study in individuals with mild HAPE demonstrated that nifedipine therapy resulted in a 50% reduction in systolic pulmonary artery pressure, narrowing of the alveolar-arterial oxygen gradient, and improvement in radiographic scores as pulmonary edema cleared (18). Luks AM, McIntosh SE, Grissom CK, et al.. Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness. HAPE develops within 2–4 days after arrival at high altitude. We use cookies to help provide and enhance our service and tailor content and ads. Sildenafil citrate (Viagra) can also selectively lower pulmonary artery pressure with less effect on systemic blood pressure, and is under study for the treatment of HAPE. 8. 2010; 38: 1818–23. HAPE archetypally commences at altitudes above 3000 m. It occurs because of rapid ascent from sea level and also might affect healthy individuals who had not suffered HAPE earlier, even with repetitive altitude exposure. 2008; 19: 293–303. HAPE is commonly preceded by AMS, and one-fifth of individuals with HAPE develop HACE. Thomas E. Dietz, Peter H. Hackett, in Travel Medicine (Third Edition), 2013. Lancet. This risk of hypotension would caution the routine prescribing of nifedipine to patients requesting for travel to high altitude in a group without medical expertise and supplies. High-altitude pulmonary edema is similar to these medical conditions: Swimming-induced pulmonary edema, Transfusion-related acute lung injury, Pulmonary contusion and more. Get new journal Tables of Contents sent right to your email inbox, March/April 2013 - Volume 12 - Issue 2 - p 115-119, http://dx.crossref.org/10.1371%2Fjournal.pone.0041188, High-Altitude Pulmonary Edema: Diagnosis, Prevention, and Treatment, Articles in PubMed by Andre Pennardt, MD, FACEP, FAWM, Articles in Google Scholar by Andre Pennardt, MD, FACEP, FAWM, Other articles in this journal by Andre Pennardt, MD, FACEP, FAWM, Suggested Curricular Guidelines for Musculoskeletal and Sports Medicine in Family Medicine Residency Training, by the American College of Sports Medicine. Respiratory viral infections have been shown to predispose to HAPE in children,149 and there are anecdotal reports of viral infections preceding HAPE in adults. Med. You may urinate more often when you take this medicine. Resting pulse oximetry reveals below normal oxygen saturation for the altitude. Topic. These findings solidified the notion that HAPE starts as a result of high intravascular pressure, not due to an inflammatory process. Pulmonary arterial systolic pressure and susceptibility to high altitude pulmonary edema. Respir. 4. 3. But numerous studies have now shown that inflammation may not be a primary problem in HAPE, except when respiratory tract infections predispose patients to HAPE.33 Finally, impaired transepithelial clearance of sodium and water from the alveoli has also been proposed to cause HAPE. Left untreated, HAPE can progress and lead to resting shortness of breath, orthopnea, and the development of cough with pink, frothy sputum. On examination, one may also note tachypnea, tachycardia, crackles, and a relative cyanosis or decreased oxygen saturation compared with other healthy team members. High-altitude pulmonary edema (HAPE) is a potentially fatal form of severe high-altitude illness, a type of noncardiogenic pulmonary edema caused by hypoxia. 1985; 87: 330–3. High-altitude pulmonary edema (HAPE) typically presents with a dry cough, dyspnea on exertion, and a decrease in exercise tolerance beginning two to five days after arrival at altitude. In stenosis of the heart valves, the valve becomes narrowed and doesn't allow enough blood to be pumped out of the heart chamber, causing pressure behind it. While reports document their use for this purpose (9) and the author personally has used sildenafil to rapidly resolve mild HAPE on Mount McKinley, no systematic prospective studies have evaluated the potential benefit of phosphodiesterase inhibitors in HAPE treatment. This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe.In most cases, heart problems cause pulmonary edema. Richalet JP, Gratadour P, Robach P, et al.. Sildenafil inhibits altitude-induced hypoxemia and pulmonary hypertension. The levels of ET-1, a potent endothelial-derived pulmonary vasoconstrictor, are elevated in HAPE-susceptible individuals140 and correlate with a rise in pulmonary artery pressures, whereas the levels of NO, a universal vasodilator, are lower in HAPE-susceptible subjects.141-143 Bailey and colleagues144 confirmed lower levels of NO in HAPE subjects at high altitude and also provided evidence of increased free radicals in the pulmonary circulation during HAPE, which might contribute to development of the disorder. Hypoxia is a powerful trigger for pulmonary hypertension, which is mandatory for the processes of HAPE to begin. High-altitude pulmonary edema is a life-threatening form that is not cardiogenic pulmonary edema that occurs in healthy people, usually at altitudes above 2.500 meters. HAPE occurs 2–4 days after ascent to high altitude, often worsening at night. As HAPE progresses, dyspnea at rest worsens; the cough increases and becomes frothy and later may become blood tinged. J. Med. 2011; 12: 207–14. Their breathing usually becomes fast and shallow. Patients with HAPE usually present with cyanosis, tachypnea, tachycardia, and rales. Decreased exercise performance is the earliest symptom, usually associated with a dry cough. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Oelz O, Maggiorini M, Ritter M, et al.. Nifedipine for high altitude pulmonary oedema. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. Patchy unilateral or bilateral fluffy infiltrates and a normal cardiac silhouette on chest X-ray are characteristic of HAPE (Fig. Development of HAPE appears to be more common in young males and has been associated with pre-existing lower respiratory tract infection, cold weather, history of previous episodes, and vigorous physical activity. The pathophysiology, clinical presentation, treatment, and prevention of HAPE are reviewed here. High altitude pulmonary edema is a non-cardiogenic form of pulmonary edema that develops in unacclimatized individuals at altitudes over 2500 m. Early recognition of symptoms and immediate descent are important for successful treatment. Hultgren145 has suggested that edema results from uneven hypoxic vasoconstriction, resulting in overperfusion of the microvasculature in areas of the lung where arteriolar vasoconstriction failed to protect downstream vessels. Update on high altitude pulmonary edema: pathogenesis, prevention, and treatment. When this happens, the sufferer becomes progressively more short of oxygen, which in turn worsens the build-up of fluid in the lungs. J. Pediatr. Physiol. Find all the evidence you need on High Altitude Pulmonary Edema via the Trip Database. may email you for journal alerts and information, but is committed 2012; 23: 7–10. Hackett PH, Roach RC. Athough approximately one-third of nonexercising children who rapidly ascend to modest elevations (from 568 to 3450 m) develop acute mountain sickness (AMS), clinically obvious cerebral or pulmonary edema do not seem to occur.69 Studies have shown that these symptoms of AMS can be prevented by the administration of acetazolamide, but not the herbal supplement ginkgo biloba, just before and during ascent.70 Although exposure to even more modest hypoxia (equivalent to 2438 m altitude) is associated with small decreases in arterial saturation, it is not associated with AMS.71. In a double-blind, randomized, placebo-controlled trial of HAPE, susceptible mountaineers, prophylactic inhalation of adrenergic agonist salmeterol (which upregulates the clearance of alveolar fluids) reduced the incidence of HAPE by 50%.34, Steven W. Salyer PA‐C, ... Barbara A. Carr, in Essential Emergency Medicine, 2007. 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