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Med J Armed Forces India. 2011 Jul 21;60(4):384–387. doi: 10.1016/S0377-1237(04)80018-2
Treatment of Acute Mountain Sickness and High Altitude Pulmonary
Oedema
Rajan Kapoor *, AS Narula +, AC Anand #
Author information Article notes Copyright and License information
PMCID: PMC4923381 PMID: 27407680
Introduction
Acute mountain sickness (AMS) and high altitude pulmonary oedema (HAPO) are common causes of
morbidity and mortality seen in unacclimatized persons shortly after ascent to high altitude. High
altitude is de�ined as altitudes more than 3000 meters while extreme high altitude is altitudes more
than 5800 m [1]. Altitude related illnesses that develop shortly after ascent to high altitudes can
present with either cerebral or pulmonary syndromes. AMS and high-altitude cerebral oedema
(HACO) refer to the cerebral abnormalities and HAPO to pulmonary abnormalities [2]. In 2001
hospital admission rate for AMS in Indian army was reported to be 0.13/1000 personnel while
admission rate for HAPO was 0.15/1000 [3]. HAPO and HACO are signi�icant because they are
potentially fatal if not treated in time.
Acute mountain sickness
Acute mountain sickness is a syndrome of nonspeci�ic symptoms and is therefore subjective. The
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Lake Louise consensus group de�ined acute mountain sickness as the presence of headache in an
unacclimatized person who has recently arrived at an altitude above 3000m plus and the presence of
one or more of the following: a) gastrointestinal symptoms like anorexia, nausea or vomiting, b)
insomnia, c) dizziness and d) lassitude or fatigue [2]. The pathophysiological processes that cause
acute mountain sickness are unknown. However, symptoms of acute mountain sickness may be the
result of cerebral swelling, either through vasodilatation induced by hypoxia or through cerebral
oedema. Impaired cerebral auto regulation, the release of vasogenic mediators and alteration of the
blood-brain barrier by hypoxia may also be important [2]. Similar mechanisms are thought to cause
cerebral oedema at high altitude, which may represent a more severe form of acute mountain
sickness. The symptoms typically develop within 6 to 10 hours after ascent, but sometimes as early
as 1 hour. Importance of AMS lies in its early recognition as it may progress to HACO, clinically
identi�ied with onset of ataxia, altered consciousness or both in a person suffering from acute
mountain sickness [4]. Many conditions mimic acute mountain sickness and high altitude cerebral
oedema which may delay the diagnosis and early treatment. The main differential diagnoses are
acute psychosis, carbon monoxide poisoning, subdural haematoma, hypoglycemia, ingestion of
alcohol, seizures and stroke.
Treatment
Management of AMS follows three axioms: a) further ascent should be avoided until the symptoms
have resolved, b)patients with no response to medical treatment should descend to a lower altitude
and c) if and when HACO is suspected, patients should urgently descend to a lower altitude [4, 5].
Descent and supplementary oxygen are the treatments of choice and for severe illness, the
combination provides optimal therapy. Remarkably, a descent of only 500 to 1000 m usually leads to
resolution of acute mountain sickness while high-altitude cerebral oedema may require further
descent. Simulated descent with portable hyperbaric chambers, now commonly available in remote
locations, are also effective. Medical therapy becomes crucial when descent is not immediately
possible. Treatment is summarized in Table 1. Various drugs have been tried for high altitude
illnesses with variable effect (Table 2). A small, placebo-controlled study showed that the
administration of acetazolamide reduced the severity of symptoms [6]. Dexamethasone is as effective
as acetazolamide and starts acting within 12 hours while acetazolamide takes around 24 hours [7].
Other drugs which have been used are ibuprofen and sumatriptan. For high altitude related insomnia
acetazolamide is effective. Newer non-benzodiazepine sedatives like zolpidem, which do not depress
ventilation are also effective [2].
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Table 1.
Management and prevention of high altitude illness
Iclinical presentation Management Prevention
Mild acute mountain Descend 500 m or more, rest Ascend at a slow rate; spend
sickness Headahce with and acclimatize; or speed a night at an intermediate
nausea, dizziness and fatigue acclimatization with altitude; avoid overexertion;
during �irst 12 hrs after acetazolamide (125-250 mg avoid direct transport to an
ascent to high altitude (> BD); or treat symptoms with altitude of more than 3000 m;
3000 m) analgesics and antiemetics consider taking
acetazolamide (125-250 mg
BD) beginning on day before
ascent and continuing for 2
days at high altitude
Moderate acute mountain Descend 500m or more; if Ascend at a slow rate; spend
sickness Moderate to severe descent is not possible, use a a night at an intermediate
headache with marked hyperbaric chamber or altitude; avoid overexertion;
nausea, dizziness, lassitude, administer low-�low oxygen avoid direct transport to an
insomnia, and �luid retention (1-2 lts/min); if descent is not altitude of more than 3000m;
at high-altitude lasting for possible and oxygen is not consider taking
12 hrs or more. available, administer acetazolamide (125-250 mg
acetazolamide (250 mg BD), BD) beginning one day before
or dexamethasone (4 mg PO or ascent and continuing for 2
IM q 6 hourly), or both until days at high-altitude; treat
symptoms resolve. acute moutain sickness early.
High-altitude cerebral Initiate immediate descent or Avoid direct transport to an
oedema Acute Mountain evacuation; if descent is not altitude of more than 3000m;
Sickness for 24 hrs or more, possible, use a portable ascend at a slow rate; avoid
severe lassitude, mental hyperbaric chamber; overexertion; consider taking
confusion, ataxia. administer oxygen (2-4 lts/ acetazolamide (125-250 mg
min;) administer BD) beginning one day before
dexamethasone (8 mg PO or ascent and continuing for 2
IM or IV initially and then 4 days at high-altitude; treat
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Iclinical presentation Management Prevention
mg q 6 hourly); administer acute mountain sickness
acetazolamide if descent is early.
delayed.
High-altitude pulmonary Administer oxygen (4-6 lts/ Ascend at a slow, graded rate;
oedema dyspnea at rest, min until condition improves, avoid overexertion; people
moist cough, severe and then 2-4 lts/min to with earlier episode should
weakness, drowsiness, conserve supplies); descend as avoid high altitude areas.
cyanosis, tachycardia, soon as possible, with minimal
tachypnea rales. exertion, or use a portable
hyperbaric chamber; if
descent is not possible or
oxygen is not available,
administer nifedipine (10 mg
PO initially and then 30 mg of
extended release formulations
PO q 12-24 hrs); add
dexamethasone if neurological
deterioration occurs.
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m – meters, PO – per orally, IM – Intra muscular, IV – Intra venous, BD -twice daily, lts – liters,
q – each quantity, mg – milligrams, hrs – hours
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Table 2.
Medical therapy for high-altitude illness
Agent Indication Dose Comments
Oxygen All high- 2-4 lts by cannula or mask Life saving for HAPO;
altitude initially, then 1-2 lts/min or improves headache within
illnesses titrate dose until SaO2 > minutes in AMS
90%
Portable All high- Depends on model; 2-4 psi Effects quivalent to
hyperbaric altitude for a minimum of 2 hrs; administration of low�low
chamber illnesses continued as long as oxygen; can be lifesaving;
necessary does not require oxygen; can
add supplemental oxygen by
cannula or mask if necessary.
Acetazolamide Prevention Acetazolamide (125-250 Sulfonamide reactions
of AMS mg BD) beginning one day possible; should be avoided
before ascent and by breast-feeding women;
continuing for 2 days at can be taken episodically for
high-altitude. symptoms; no rebound
effect.
Treatment of 250 mg PO BD until
AMS symptoms resolve.
Dexamethasone Prevention 2 mg q 6 hourly or 4 can be lifesaving for AMS or
of AMS mg q HAcO; effects evident in 2-8
12 hourly PO hrs;
Treatment of 4 mg q 6 hourly no effect on acclimatization;
AMS
HAcO PO/IM/IV no value in HAPO.
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Agent Indication Dose Comments
Nifedipine Prevention 20-30 mg of extended No value in AMS or HAcO;
of HAPO release formulation PO q 12 not necessary if
hourly supplemental oxygen
available.
Treatment of 10 mg PO initially, and then
HAPO 20-30 mg of extended
release formulations PO q
12 hourly
Aspirin Prevention 325 mg PO q 4 hourly for a Not proven for treatment.
of headache total of 3 doses
Ibuprofen Treatment of 400-600 mg once PO, may Not proven for prophylaxis
headache be repeated.
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HAPO – high altitude pulmonary oedema, AMS – acute mountain sickness, psi – pounds per
square inch HACO – high altitude cerebral oedema, PO – per orally, q – each quantity, hrs –
hours, SaO2 – saturation of oxygen in blood, BD – twice daily, mg – milligrams, lts – liters
Prevention
For the prevention of high-altitude illness, the best strategy is a gradual ascent to promote
acclimatization. Depending on the altitudes, acclimatization in Armed forces is carried out in three
stages.
a) First stage (3000m to 3600m) acclimatization for total 06 days
b) Second stage (3600m to 4500m) acclimatization for total 04 days
c) Third stage (>4500m) acclimatization for total 04 days
In each stage a person is made to rest for the �irst 02 days and then gradually made to walk and
subsequently climb the slopes in a graded fashion [2].
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Drug treatment for prophylaxis is recommended if rapid ascent is unavoidable. Acetazolamide is the
preferred drug [8]. Prophylactic aspirin can be used for prevention of headache [2].
High altitude pulmonary oedema
HAPO accounts for most deaths from high-altitude illness. In 2001, out of total number of armed
forces personnel deployed in high altitude areas, 225 were admitted with HAPO while in 2003 this
�igure was down to 90 [9]. The pathophysiological cause of HAPO is still unknown, but several
mechanisms have been proposed. One such mechanism is of patchy pulmonary hypertension, which
leads to stress failure in capillaries of overperfused areas, resulting in pulmonary oedema. As is the
case for acute mountain sickness, the incidence of high-altitude pulmonary oedema is related to the
rate of ascent, the altitude reached, individual susceptibility and exertion; cold, which increases
pulmonary-artery pressure by means of sympathetic stimulation, is also a risk factor [10].
Abnormalities of cardiopulmonary circulation increase the risk of high-altitude pulmonary oedema.
Early diagnosis is critical. Symptoms of HAPO occur most commonly two to three days after arrival at
altitude and consist of dyspnoea with exercise, progressing to dyspnoea at rest, a dry cough,
weakness and poor exercise tolerance. As the disease worsens, severe dyspnoea and frank
pulmonary oedema are obvious, followed by coma and death. Early clinical signs include tachycardia
and tachypnoea, mild pyrexia, basal crepitations and dependent oedema. Patients with HAPO tend to
have lower oxygen saturations than unaffected people at same altitude, but the degree of
desaturation by itself is not a reliable sign of HAPO. HAPO should be differentiated from asthma,
bronchitis, pneumonia and left ventricular failure. Electrocardiography demonstrates sinus
tachycardia and often, right ventricular strain. Chest radiography typically reveals a normal-sized
heart, full pulmonary arteries, patchy and �luffy in�iltrates, which are generally con�ined to the right
middle and lower lobes in mild cases and are found in both lungs in more severe cases.
Management
Increasing alveolar and arterial oxygenation is the highest priority. It is mainly achieved by
supplemental oxygen and descent. Patients with severe pulmonary oedema must be immediately
moved to a lower altitude [10]. Hyperbaric chamber may be used till the time patient is being
transported to a lower altitude. Medication like nifedipine has been tried only when supplemental
oxygen is unavailable or descent is impossible [11]. In clinical studies, although nifedipine reduced
pulmonary-artery pressure by approximately 30 percent, it barely increased the partial pressure of
arterial oxygen. Inhaled beta-agonists have also been used in the prevention as well as treatment of
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high-altitude pulmonary oedema, as they appreciably increase the clearance of �luid from the
alveolar space and might also lower pulmonary artery pressure [2]. Antibiotics are used if there is
any evidence of infection such as purulent sputum or high grade fever. Oxygen administration is
monitored by measuring oxygen saturation by a pulse oximeter with the aim of maintaining oxygen
saturation above 90%. After an episode of high altitude pulmonary oedema, a person should avoid
high altitude areas. In armed forces after an episode of HAPO, a person is not posted to high altitude
areas again.
Newer developments
Portable hyperbaric chamber
Portable hyperbaric chambers are increasingly being used in treatment of high-altitude illnesses
when rapid descent is not possible. With the use of these chambers at a pressure of 2 psi (13.8 kPa),
the equivalent altitude is roughly 2000 m lower than the ambient altitude. These chambers are
available in armed forces hospitals in high altitude areas (Fig 1).
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Fig. 1.
Open in a new tab
Portable hyperbaric chamber
Inhaled nitric oxide
Inhaled NO produces rapid decrease in pulmonary artery pressure thereby improving arterial
oxygenation [12]. Mixture of15 parts per million (ppm) of nitric oxide gas and 50 percent oxygen is
generally used. The two gases in mixture work through two independent ion channels that regulate
the expansion and constriction of blood vessels. Inhaled nitric oxide has shown lot of promise during
initial trials at armed forces hospitals in high altitude areas.
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Sildenafil
Sildena�il is a phosphodiesterase inhibitor, which causes vasodilatation. Though initially used for
erectile dysfunction it has also been shown to bene�it patients of primary pulmonary hypertension. It
was found effective in hypoxia induced pulmonary arterial hypertension. Trials are being planned at
several centers for using sildena�il in high altitude pulmonary oedema [13, 14].
Conclusions
AMS and HAPO are seen in unacclimatized personnel exposed to high altitude. They can easily be
prevented by gradual ascent to promote acclimatization. Early detection is the key in preventing
deaths. Treatment of choice for both acute mountain sickness and high altitude pulmonary oedema is
descent to lower altitude and supplemental oxygen. When immediate descent is not possible various
drugs can be used. New developments like portable hyperbaric chamber and inhaled nitric oxide
have shown promise in various trials.
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