Emergency Medicine Book

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High Altitude Pulmonary Edema

Aka: High Altitude Pulmonary Edema, HAPE
  1. See Also
    1. High Altitude Related-Conditions
    2. High Altitude Sickness (Acute Mountain Sickness)
    3. High Altitude Cerebral Edema (HACE)
    4. Portable Hyperbaric Chamber (Gamow Bag)
    5. Lake Louise Acute Mountain Sickness Score
  2. Epidemiology
    1. Incidence: 4% in travel above 15000 feet (4600 meters)
    2. Most common cause of death from high altitude illness
    3. Onset: 1-4 days after rapid ascent above 8000 feet (2400 meters)
  3. Pathophysiology
    1. Hypoxic pulmonary Vasoconstriction results in increased pulmonary capillary pressure (Pulmonary Hypertension)
    2. Results in non-inflammatory fluid extravasation into alveoli
    3. May occur in the absence of Acute Mountain Sickness
  4. Risk Factors
    1. Same as with Acute Mountain Sickness
  5. Symptoms
    1. Fatigue
    2. Weakness
    3. Dyspnea on exertion
    4. Dyspnea at rest
    5. Orthopnea
    6. Cough
    7. Frothy Sputum
    8. Pink or blood tinged Sputum
      1. Very late finding
  6. Signs
    1. Tachycardia
    2. Tachypnea
    3. Low-grade fever
    4. Cyanosis
    5. Hypoxia (decreased Oxygen Saturation)
    6. Altered breath sounds
      1. Rales
      2. Auscultate right middle lobe (right axilla)
        1. Anecdotal reports of HAPE onset in right middle lobe
  7. Imaging
    1. Chest XRay
      1. Patchy infiltrates (asymmetric)
    2. Echocardiogram
      1. Pulmonary edema with B-line artifacts
      2. Findings may be non-specific at very high altitude (even those without HAPE will have B-line artifacts at 5000 m)
  8. Diagnosis
    1. Symptom Criteria (Requires 2 or more of the following)
      1. Dyspnea at rest
      2. Cough
      3. Weakness or Decreased Exercise performance
      4. Chest tightness or congestion
    2. Sign Criteria (Requires 2 or more of the following)
      1. Rales or Wheezing in at least one lung field
      2. Central Cyanosis
      3. Tachypnea
      4. Tachycardia
  9. Differential Diagnosis
    1. Asthma Exacerbation
    2. COPD exacerbation
    3. Acute Coronary Syndrome
    4. Congestive Heart Failure
    5. Pneumonia
  10. Management
    1. Immediate descent is most critical (descend at least 500 to 1000 meters)
    2. Other measures when immediate descent is not possible
      1. High flow Supplemental Oxygen
        1. Consider Morphine if oxygen not available
      2. EPAP or PEEP pressure support
      3. Gamow Bag (Portable Hyperbaric Chamber)
      4. Dexamethasone, Nifedipine, Salmeterol, and PDE agents at same doses listed below
  11. Prevention
    1. See High Altitude Sickness for general measures
    2. Acetazolamide is not effective for HAPE prevention
      1. Contrast with Acute Mountain Sickness
    3. Effective measures for HAPE prevention (started 1 day before ascent)
      1. Dexamethasone 4 mg every 6 hours
      2. Nifedipine (Procardia) 20 mg every 8-12 hours
      3. Salmeterol (Serevent) 125 mcg inhaled every 12 hours
      4. Phosphodiesterase Inhibitors
        1. Sildenafil (Viagra) 20 mg every 6-8 hours
        2. Tadalafil (Cialis) 10 mg every 12 hours
  12. References
    1. Cardy and Contant in Herbert (2020) EM:Rap 20(3): 10-11
    2. Fiore (2010) Am Fam Physician 82(9): 1103-10 [PubMed]
    3. Luks (2008) High Alt Med Biol 9(2): 111-4 [PubMed]
    4. Voelkel (2002) N Engl J Med 346(21): 1606-7 [PubMed]

High altitude pulmonary edema (C0340100)

Concepts Disease or Syndrome (T047)
MSH C535833
SnomedCT 233707008
English Pulm edema of mountaineers, Pulm oedema of mountaineers, PULMONARY EDEMA OF MOUNTAINEERS, High altitude pulmonary edema, high altitude pulmonary edema, high altitude pulmonary edema (diagnosis), Pulmonary edema of mountaineers, High altitude pulmonary oedema, Pulmonary oedema of mountaineers, High altitude pulmonary edema (disorder)
Spanish edema pulmonar de las alturas (trastorno), edema pulmonar de las alturas, edema pulmonar de los alpinistas
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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