Difference between revisions of "High altitude pulmonary edema"

(Management)
(Prevention)
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==Prevention==
 
==Prevention==
*Nifedipine 20mg q8hr or 30mg q12hr while ascending is effective prophylaxis in patients with prior episodes of HAPE  
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*[[Nifedipine]] 20mg q8hr or 30mg q12hr while ascending is effective prophylaxis in patients with prior episodes of HAPE  
*Tadalafil 10mg BID 24hr prior to ascent '''OR''' Sildenafil 50mg q8hr
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*Tadalafil 10mg BID 24hr prior to ascent '''OR''' [[Sildenafil]] 50mg q8hr
*Salmeterol 125 mcg inhaled BID
+
*[[Salmeterol]] 125 mcg inhaled BID
*Acetazolamide 125mg BID for prevention of hypoxia
+
*[[Acetazolamide]] 125mg BID for prevention of hypoxia
  
 
==See Also==
 
==See Also==

Revision as of 14:42, 22 August 2017

Background

  • Also known as HAPE
  • Noncardiogenic pulmonary edema due to increased microvascular pressure in the pulmonary circulation
  • Most lethal of the altitude illnesses
  • Occurs in <1/10,000 skiers in Colorado; 2-3% of Mt. McKinley climbers
  • Typical patient is strong and fit; may not have symptoms of altered mental status before onset of HAPE
  • Most commonly noticed on the second night at a new altitude

Risk Factors

  • Heavy exertion
  • Rapid ascent
  • Cold
  • Excessive salt ingestion
  • Use of a sleeping medication
  • Preexisting pulmonary hypertension
  • Preexisting respiratory infection (children)
  • Previous history of HAPE

Clinical Features

  • Early
    • Dry cough, decreased exercise performance, dyspnea on exertion, localized rales
    • Resting SaO2 is very low for the expected altitude but patients often appear clinically better than their saturation(aids in diagnosis)
  • Late
    • Dyspnea at rest, marked weakness, productive cough, cyanosis, generalized rales
    • Tachycardia and tachypnea correlate with severity of illness
    • Altered mental status and coma (from severe hypoxemia)

Differential Diagnosis

High Altitude Illnesses

Pulmonary Edema Types

Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema[1]

Evaluation

Workup

Evaluation

  • Clinical diagnosis

Management

  • Immediate descent is treatment of choice - minimize exertion
  • If cannot descend use combination of:
    • Supplemental O2 - An oxygen concentrator is often used at high altitude ski resorts after the patient is titrated down to nasal cannula. A portable oxygen tank is used for ambulation. Can completely resolve the pulmonary edema within 36-72hr
    • Hyperbaric bag - Gamow Bag
    • Keep patient warm (cold stress elevates pulmonary artery pressure)
    • Use expiratory positive airway pressure mask
    • Consider the medications listed below that are usually used for prevention

Disposition

  • Admission
    • Warranted for severe illness that does not respond immediately to descent
  • Discharge
    • Progressive clinical and X-ray improvement and a PaO2 of 60mmHg or SaO2>90%
  • May re-ascend in 2-3 days if mild-moderate symptoms resolved that only required descent as the intervention

Prevention

  • Nifedipine 20mg q8hr or 30mg q12hr while ascending is effective prophylaxis in patients with prior episodes of HAPE
  • Tadalafil 10mg BID 24hr prior to ascent OR Sildenafil 50mg q8hr
  • Salmeterol 125 mcg inhaled BID
  • Acetazolamide 125mg BID for prevention of hypoxia

See Also

References

  1. Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.