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High altitude medical problem
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High altitude syndrome

Jan 14, 2015

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kanjanee wachirarangsiman R3
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Page 1: High altitude syndrome

High altitude medical problem

Page 2: High altitude syndrome

ดอยลั�งกาหลัวง 2,031m

ภู�สอยดาว 2,102 m

ดอยหลัวงเชี�ยงดาว2,195 m

ดอยผ้�าห�มปก 2,285 m

Page 3: High altitude syndrome
Page 4: High altitude syndrome

Altitude Height Effect

Intermediate altitude

1520 - 2440 m (5000 - 8000 ft)

exercise performance alveolar ventilation↔arterial oxygen transport

High altitude >2440 m (>8000 ft) AMS

Very high altitude

4270 - 5490 m (14,000 - 18,000 ft)

AMS

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PATHOPHYSIOLOGY

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ventilation

• PaO2 carotid body& respiratory center

ventilation PaCO2

Performance

Chronic hypoxiaSedative agentDuring sleep

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ventilatory acclimatization

ventilation

pH (respi alkalosis)

HCO3 excrete via kidney

pH return to normal

Acetazolamide

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Blood

• EPO w/in 2 hr • Rbc mass w/in

days to wks• if excessive

chronic polycythemia

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Fluid Balance

• Reset Osm stat: plasma volume and hyperosmolality (s osm290 - 300)

• diuresis and hemoconcentration :healthy response• Antidiuresis is a hallmark of AMS

Peripheral venous constriction

in central blood

volume

ADH &aldosterone

diuresis

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Cardiovascular System

CO = SV HR

Pulm.vasoconstriction pulm.pressure

Cerebral blood volume O2 to brain ICP

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Exercise capacity

• measured by VO2max, drops dramatically on ascent to altitude

• During acclimatization, submaximal endurance after 10 days

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Sleep at High Altitude

• Sleep stages III and IV ↓ stage I frequent arousals (improve with time at altitude)

• Cheyne-Stokes respiration in those sleeping at >2700 m (>8860 ft)

• the frequent awakenings & periodic breathing not related to AMS

• mechanism of the lighter sleep →cerebral hypoxia. • Quality of sleep and arterial oxygenation during

sleep improve with acclimatization and with acetazolamide

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HIGH-ALTITUDE SYNDROMES

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High altitude syndrome

• Acute hypoxia• Acute mountain sickness• High-Altitude cerebral edema• High-Altitude pulmonary edema• Peripheral edema• High-altitude retinopathy• High-altitude pharyngitis and bronchitis• Chronic mountain polycythemia• UV keratoconjunctivitis

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Acute hypoxia

• occurs in the setting of sudden and severe• Unacclimatized persons become unconscious

at SaO2 50 - 60%, PaO2 < 30 mm Hg, or a jugular venous PO2 of <15 mm Hg

• immediate administration of oxygen, rapid descent

Page 17: High altitude syndrome

Acute Mountain Sickness

• setting of more gradual and less severe hypoxic

• characterized by headache, GI disturbances, dizziness or light-headedness, and sleep disturbance

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What’re factors determine individual susceptibility to AMS ?

• Age • Sex • Body weight • physical fitness

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Pathophysiology

• renin-angiotensin aldosterone ADH

The cerebral edema, interstitial pulmonary edema, peripheral edema, and antidiuresis

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Clinical feature

• mild : alcohol hangover• Headaches : bifrontal and worsen with

bending over or performing a Valsalva maneuver

• GI symptoms : anorexia, N/V• irritable & wants to be left alone• Sleepiness • deep inner chill also are common

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Clinical feature

• rapid ascent of an unacclimatized person to ≥2000 m

• Symptoms develop between 1 -6 hours later, but sometimes are delayed for 1 - 2 days

Severe headache vomiting oliguria Ataxia

and AOC HACE

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Physical examination

• percent SaO2 overall correlates poorly with the diagnosis of AMS

• postural hypotension may be present• Localized rales ≥ 20%• Funduscopy :tortuosity and dilatation, and

retinal hemorrhages (at altitudes >5000 m)• facial and peripheral edema is a hallmark

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The goals of treatment are to

prevent progression

abort the illness

improve acclimatization

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3 principles of Rx

(1) do not proceed to a higher sleeping altitude in the presence of symptoms

(2) descend if symptoms do not abate or become worse despite treatment

(3) descend and treat immediately in the presence of a change in consciousness, ataxia, or pulmonary edema

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Treatment

• Oxygen effectively relieves symptoms, but it is generally unavailable in the field or reserved for those with moderate to severe AMS

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Medication

Indications for acetazolamide (1) a history of altitude illness(2) abrupt ascent to >3000 m (>9840 ft)(3) AMS requiring treatment(4) bothersome periodic breathing during sleep

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Symptomatic treatment of AMS

• Headache :aspirin, acetaminophen or ibuprofen

• N/V: ondansetron• f/q wakening: zolpidem,diphenhydramine

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Prevention

• Graded ascent with adequate time for acclimatization is the best prevention

• Prophylactic acetazolamide – started 24 hr before the ascent – continued for the first 2 days at altitude– restarted if illness develops

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HACE

• HACE : progressive neurologic deterioration in someone with AMS or HAPE

• altered mental status, ataxia, stupor, and progression to coma if untreated

• severe, diffuse cerebral edema with multiple small hemorrhages and sometimes thrombosis

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Treatment of HACE

• oxygen supplementation• descent(the highest priority)• steroid therapy• acetazolamide may be used as an adjunct

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MRI findings reversible white matter edema evidenced byT2 signal, esp.in the splenium

of the corpus callosum

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HAPE

• most lethal of the altitude illnesses• easily reversible with descent and oxygen

administration• Risk factors:heavy exertion, rapid ascent, cold,

excessive salt ingestion, use of a sleeping medication

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Pathophysiology

• HAPE is a noncardiogenic, hydrostatic edema• The culprit in HAPE is high microvascular

pressure Pulmonary hypertension

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Clinical

• Early diagnosis is critical, exercise performance & dry cough are enough to raise the suspicion of early HAPE

• The condition typically worsens at night • Low-grade fever is common, and tachycardia

and tachypnea• SO2 low for altitude

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Chest radiographic

progress from interstitial localized alveolar generalized alveolar infiltrates

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Treatment

• The key to successful Rx : early recognition, early stage is easily reversible

• Immediate descent is the Rx of choice, but this is not always possible

• The optimal therapy depends on – the environmental setting, – evacuation options– availability of oxygen or hyperbaric units– ease of descent

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Portable hyperbaric bag

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medication

• Because oxygen and descent are so effective, experience with drugs has been limited

• nifedipine, phosphodiesterase 5 inhibitors:sildenafil and tadalafil

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Other high altitude medical problem

• Peripheral edema• High-altitude retinopathy• High-altitude pharyngitis and bronchitis• UV keratoconjunctivitis

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Special population

• Patients who have hypoxic cardiovascular and pulmonary diseases such as COPD or CHF , CAD, pregnant