Difference between revisions of "High altitude pulmonary edema"

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#Typical pt is strong and fit; may not have symptoms of AMS before onset of HAPE  
 
#Typical pt is strong and fit; may not have symptoms of AMS before onset of HAPE  
 
#Most commonly noticed on the second night at a new altitude  
 
#Most commonly noticed on the second night at a new altitude  
#Risk Factors:
+
 
#*Heavy exertion  
+
===Risk Factors===
#*Rapid ascent  
+
*Heavy exertion  
#*Cold  
+
*Rapid ascent  
#*Excessive salt ingestion  
+
*Cold  
#*Use of a sleeping medication  
+
*Excessive salt ingestion  
#*Preexisting pulmonary HTN  
+
*Use of a sleeping medication  
#*Preexisting respiratory infection (children)  
+
*Preexisting pulmonary HTN  
#*Previous history of HAPE
+
*Preexisting respiratory infection (children)  
 +
*Previous history of HAPE
  
 
== Clinical Features ==
 
== Clinical Features ==
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==Differential Diagnosis==
 
==Differential Diagnosis==
 +
*[[Asthma]]
 +
*[[Bronchitis]]
 +
*[[CHF]]
 +
*[[COPD]]
 +
*[[MI]]
 +
 
{{High altitude DDX}}
 
{{High altitude DDX}}
*Asthma
 
*Bronchitis
 
*CHF
 
*COPD
 
*MI
 
  
 
== Treatment ==
 
== Treatment ==
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== Disposition ==
 
== Disposition ==
#Admission  
+
*Admission  
##Warranted for severe illness that does not respond immediately to descent  
+
**Warranted for severe illness that does not respond immediately to descent  
#Discharge  
+
*Discharge  
##Progressive clinical and X-ray improvement and a PaO2 of 60mmHg or SaO2>90%
+
**Progressive clinical and X-ray improvement and a PaO2 of 60mmHg or SaO2>90%
  
 
== Prevention ==
 
== Prevention ==
#Nifedipine 20mg q8hr while ascending is effective prophylaxis in pts who had HAPE before  
+
*Nifedipine 20mg q8hr while ascending is effective prophylaxis in pts who had HAPE before  
#Tadalafil 10mg BID 24hr prior to ascent  
+
*Tadalafil 10mg BID 24hr prior to ascent  
#Salmeterol inhaled BID
+
*Salmeterol inhaled BID
  
 
==See Also==
 
==See Also==
[[High Altitude Medicine]]
+
*[[High Altitude Medicine]]
  
 
==Source==
 
==Source==
Tintinalli
+
 
  
 
[[Category:Environ]]
 
[[Category:Environ]]

Revision as of 03:49, 2 March 2015

Background

  • Also known as HAPE
  1. Noncardiogenic pulm edema d/t increased microvascular pressure in the pulm circulation
  2. Most lethal of the altitude illnesses
  3. Occurs in <1/10,000 skiers in Colorado; 2-3% of Mt. McKinley climbers
  4. Typical pt is strong and fit; may not have symptoms of AMS before onset of HAPE
  5. 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 HTN
  • Preexisting respiratory infection (children)
  • Previous history of HAPE

Clinical Features

  1. Early
    • Dry cough, decreased exercise performance, dyspnea on exertion, localized rales
    • Resting SaO2 is low for the altitude and drops markedly w/ exertion (aids in the dx)
  2. Late
    • Dyspnea at rest, marked weakness, productive cough, cyanosis, generalized rales
    • Tachycardia and tachypnea correlate with the severity of illness
    • Altered mental status and coma (from severe hypoxemia)
  3. ECG
    • Right strain pattern
  4. CXR
    • Progresses from interstitial to localized-alveolar to generalized-alveolar infiltrates
  5. ABG
    • Hypoxemia with respiratory alkalosis

Differential Diagnosis

High Altitude Illnesses

Treatment

  • Immediate descent is treatment of choice - minimize exertion
  • If cannot descend use combination of:
    • Supplemental O2 - Can completely resolve the pulmonary edema within 36-72hr
    • Hyperbaric bag
    • Keep pt warm (cold stress elevates pulm 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%

Prevention

  • Nifedipine 20mg q8hr while ascending is effective prophylaxis in pts who had HAPE before
  • Tadalafil 10mg BID 24hr prior to ascent
  • Salmeterol inhaled BID

See Also

Source