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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Rapid ascent to altitude over 7200 feet

  • Symptoms and signs of pulmonary edema: breathlessness accompanied by cough, initially dry but later productive of white and then pink frothy sputum

  • Likelihood increased by higher elevations, vigorous physical activity, alcohol consumption, cold exposure, and a history of altitude sickness

GENERAL CONSIDERATIONS

  • High-altitude pulmonary edema (HAPE) is potentially life threatening

  • HAPE is a form of noncardiac pulmonary edema that typically affects healthy individuals who ascend rapidly to high altitudes

  • Typically, HAPE appears 2–4 days after arrival at high altitude

  • HAPE rarely occurs below 8000 feet (2440 meters), and most cases occur at > 10,000 feet (3050 meters)

  • The altitude at which one sleeps is as important as the altitude where activity takes place

  • In addition to pulmonary edema, HAPE leads to in situ pulmonary artery thrombosis and right heart strain

  • The pathophysiology of HAPE is poorly understood

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Dyspnea, orthopnea, cough, hemoptysis (pink frothy sputum)

  • Chest pressure

  • Headache, fatigue, nausea

PHYSICAL EXAM FINDINGS

  • Tachycardia

  • Tachydyspnea

  • Low-grade fever

  • Edema

  • Anoxia, cyanosis

  • Pulmonary rales, wheezes

DIFFERENTIAL DIAGNOSIS

  • Acute myocardial infarction

  • Exacerbation of preexisting heart condition

  • Pulmonary embolus

  • Pneumonia

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Increased hematocrit

ELECTROCARDIOGRAPHY

  • Acute right heart strain pattern

IMAGING STUDIES

  • Chest x-ray: pulmonary congestion with normal heart size

  • Echocardiogram: right heart enlargement with Doppler evidence of pulmonary hypertension

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected coronary artery disease

HOSPITALIZATION CRITERIA

  • All patients with HAPE

MEDICATIONS

  • Descend to a lower altitude as soon as possible

  • Supplemental oxygen (2–4 L/min)

  • Nifedipine 20 mg every 8 hours to lower pulmonary pressure

  • Nitric oxide inhalation (40 ppm)

THERAPEUTIC PROCEDURES

  • Hyperbaric pressure bag

MONITORING

  • ECG in hospital

DIET AND ACTIVITY

  • Low-sodium diet

  • Restrict activity

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of HAPE

FOLLOW-UP

  • None necessary because cardiac function is usually normal

COMPLICATIONS

  • Death

  • High-altitude cerebral edema

  • Hypotension

  • Pulmonary emboli

  • Arrhythmias

PROGNOSIS

  • Excellent with prompt, effective treatment

PREVENTION

  • Avoid exertion for 24 hours

  • Avoid alcohol for 24 hours

  • "Climb high, sleep low" (eg, sleep at a lower altitude than one climbs during the day)

  • Manage rate of ascent to 300 to ...

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