TRAVEL-RELATED EMERGENCIES 0733-8627/97 $0.00 + .

20

HIGH-ALTITUDE MEDICINE
Ken Zafren, MD, FACEP,
and Benjamin Honigman, MD, FACEP

Mountains and high plateaus cover about one fifth of the Earths
surface and are home to over 300 million people.O At least half of this
number live permanently above 2400 meters. They are visited every
year by tens of millions of travelers from lower elevations122
for trekking,
climbing, skiing, and other activities. Unfortunately, some of these trav-
elers fall prey to high-altitude illnesses or have medical conditions that
are exacerbated by high-altitude. This is tragic and unnecessary, because
serious altitude illness is almost completely preventable. With proper
precautions, most people should be able to enjoy visiting high mountains
and plateaus without risk of serious altitude illness.
Emergency physicians practicing travel medicine should be able to
advise prospective travelers about the prevention and treatment of high
altitude illness and should know about underlying conditions, which
may be worsened by altitude exposure. In addition, emergency physi-
cians practicing in or near high altitude areas should have a working
knowledge of high altitude acclimatization, as well as the diagnosis and
treatment of altitude maladies, especially acute mountain sickness
(AMS), high altitude pulmonary edema (HAPE), and high altitude cere-
bral edema (HACE).
Altitude illness occurs primarily above 2400 meters and is more
prevalent at higher altitudes. Most of what we know is based on studies
of well-conditioned climbers and trekkers at altitudes above 4000 meters.
More studies are now taking place at moderate altitudes accessible to

From Columbia Alaska Regional Hospital and Providence Alaska Medical Center (KZ);
Denali National Park Mountaineering Rangers and Lake Clark National Park (KZ),
Anchorage, Alaska; Himalayan Rescue Association of Nepal, Nepal (KZ); Department
of Emergency Medicine, University Hospital (BH); and Division of Emergency Medi-
cine, Department of Surgery, University of Colorado Health Sciences Center (BH),
Denver. Colorado

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

VOLUME 15 * NUMBER 1 * FEBRUARY 1997 191

192 ZAFREN & HONIGMAN

the general population where more aggressive treatments and milder

forms of the diseases are associated with mountain resorts at altitudes
of 2400 to 3000 meters. This will allow us to broaden our understanding
of the incidence and spectrum of these diseases.

ACCLIMATIZATION

Acclimatization is the process by which the body adapts to high

altitude. A person living at sea level who is suddenly taken to the
altitude of the summit of Mt. Everest would have only a few minutes of
useful consciousness without supplemental oxygen. The same person,
acclimatizing over several weeks on an expedition to Mt. Everest, may
be able to ascend to the summit breathing ambient air.118Visitors to less
extreme altitudes also need to acclimatize in order to avoid becoming ill.
Atmospheric pressure decreases with increasing altitude while the
percentage of oxygen in ambient air remains constant at about 21%. The
possibility that the actual pressure of the air plays a role in acclimatiza-
tion or the pathogenesis of high altitude illness is a recurring theme,146,
lS1
but current understanding emphasizes the role of decreased availability
of oxygen. Inspired oxygen (PI) can be calculated from atmospheric
pressure: P I O ~
= 0.21 (PB-47) (PB = atmospheric or barometric pressure,
47 = water vapor pressure at body temperature, i.e., in the airway
where inspired air is heated and humidified).
Many factors affect barometric pressure in addition to altitude.
Pressure is higher at lower latitudesz4,lZ4 The measured atmospheric
pressure at the summit of Mt. Everest (8848 meters) is 253 mm Hg. If
this peak were located not at 27"N but at the latitude of Denali (Mt.
McKinley) in Alaska at 62"N, the pressure at the summit would be only
222 mm Hg and it would be unlikely that anyone could climb it without
supplemental oxygen.lS7There are seasonal variations, also, with winter
pressures significantly lower than summer ones. Temperature and
weather also affect barometric pressure. Low pressure systems often
produce pressures 10 mm Hg below highs. The incidence of AMS at a
given location increases during periods of low

How High Is High Altitude?

There is no standard terminology for referring to different altitudes.

Physiologic effects of decreased PIO~, including decreased exercise per-
formance and increased ventilation at rest begin at about 1500 meters,
but there is only minor impairment of oxygen saturation (Sao, 2 90%)
until 3500 meters. This range is often called "moderate altitude" or just
"high altitude." Acute mountain sickness is common with rapid ascent
above 2500 meters. "Very high altitude" (3500 to 5500 meters) represents
the most common range for serious altitude illness. Hypoxemia (Sao, <
90%; Pao, < 60 mm Hg) is generally mild but may be severe during
 HIGH-ALTITUDE MEDICINE 193

exercise, sleep, and altitude illness. At "extreme altitude" (over 5500

meters) marked hypoxemia and hypocapnia are present and progressive
deterioration of physiologic function outstrips acclimatization.'", 72, 91 The
highest permanent human habitation in the world is at 5340 meters at
Aconquilcha, Chile. High-altitude deterioration above 5500 meters is
characterized by weight loss, increased lethargy, poor sleep, weakness,
headache, and polycythemia.

Ventilatory Changes

Ventilation increases immediately on ascent to altitude and stays

e1e~ated.l~~ Hyperventilation is maintained by the hypoxic ventilatory
response (HVR). Mediated by the carotid bodies, HVR varies among
individuals and is probably genetically determined. Visitors (unlike high
altitude natives) with low HVR tend to acclimatize slowly'47and are
more likely to suffer from AMS47, 94, 114, 123, 160, 176 and HAPE.55, 87. 99, 112, 113
Respiratory depressants, such as alcohol, and sedative/hypnotic drugs
decrease HVR. Drugs that increase sympathetic outflow such as caffeine
and coca and respiratory stimulants such as progester~ne~~, y5, 97, lx5and
almitrineS3increase HVR.
Initially, hypocapnia secondary to HVR limits the amount of in-
crease in ventilation, but within the first day or two of ascent, the
kidneys increase the excretion of bicarbonate, decreasing the pH of the
blood and allowing ventilation to continue to increase over the first 6 to 8
days at a given altitude.lYThe drug acetazolamide, a carbonic anhydrase
inhibitor, facilitates this process. It also stimulates respiration, but by its
effect on the central nervous system rather than the carotid bodies.
The major effect of increased ventilation is to decrease alveolar
carbon dioxide (PAC02), allowing a proportionate increase in alveolar
oxygen ( P A O ~ )as calculated in the alveolar gas equation: P A O ~= P1O2 -
PAcO,/R, where R is the respiratory q ~ 0 t i e n t . IThis
~ ~ is more important
at higher altitudes. If PACO~ was to remain at the sea level value of 40
mm Hg, ascent without supplemental oxygen would be limited to about
5000 meters where the PAO2 would be 33 mm Hg. This is the measured
value actually found in a climber on the summit of Mt. Everest (8848
meters), near the limit of human ability. This P A O ~ is achieved by
hyperventilating to a PACO~ of 10 mm Hg.

Circulatory Changes

Increased catecholamine activity causes increased blood pressure,

heart rate, cardiac output, and venous tone.32,33, 76 Decreased plasma
volume results in decreased stroke volume6"and may limit maximum
heart rate. Hypoxic pulmonary vasoconstriction and other factors not
yet well characterized cause increased pulmonary vascular resistance
and increased pulmonary artery Cerebral blood flow, which
194 ZAFREN & HONIGMAN

depends on a balance of hypoxic vasodilation and hypocapnic vasocon-

striction, tends to increase at altitude.41,64, 74, 144, 163 These changes may not
be adaptive and may contribute to high altitude illness.

Hematologic Changes

Hemoglobin concentration increases with ascent to altitude. Within

the first 2 hours of ascent, hypoxemia causes a measurable increase in
erythropoietin. In the first 2 days, hemoglobin concentration increases
because of decreased plasma volume due to fluid shift into the extravas-
cular space rather than an increased number of red cells.176A few days
later, red cell number increases. Eventually plasma volume and red
blood cell mass both increase, leading to a higher total blood volume.
Increases in red cell mass are greater at higher altitudes. To the extent
that hematocrit rises, increased blood viscosity may be detrimental to
oxygen transport despite an increase in oxygen carrying capacity.13,1y1-1y3
Very high hematocrits are found in patients with subacute mountain
sickness and in those with chronic mountain sickness, also known as
chronic mountain polycythemia.lZ0
The other main factor affecting the ability of the blood to deliver
oxygen to body tissues is the oxyhemoglobin dissociation curve. Because
of its sigmoidal shape, oxygen saturation changes little up to 2500
meters, at which altitude the linear portion of the curve is reached. Early
in vitro work showed a right shift of the curve (less avid binding of
oxygen) owing to an increase in 2,3-DPG at This was thought
to be advantageous in promoting release of oxygen into tissues, but
comes at the expense of decreased oxygen uptake in the lungs. In vivo,
however, alkalosis causes an opposite left shift. It seems to result in little
change in the curve at moderate altitudes, while at extreme altitudes,
the curve is left shifted because of extreme alkalosis. This may be
advantageous in increasing pulmonary oxygen uptake.57,187

Tissue Changes

The final stage of oxygen transport and utilization occurs in the

tissues and is currently poorly understood. Some experiments have
shown increased capillary density at an altitude that would decrease
diffusion distance. Studies of muscle size and mitochondria1 density
have had conflicting results,129,134 whereas changes in the function of
mitochondria remain largely unknown but are potentially important.

Sleep

Disturbed sleep with disordered sleep stages is the rule, not the
exception, at a 1 t i t ~ d e . 152,
I ~ 177,
~ ~178, Periodic breathing during sleep is
 HIGH-ALTITUDE MEDICINE 195

common. It is characterized by periods of apnea followed by hyperpnea,

which gradually decreases, is followed again by apnea, and is sometimes
mistakenly referred to as Cheyne-Stokes breathing, which it resembles.
Persons with a high HVR are more susceptible to periodic
but persons with a low HVR are more subject to h y p ~ x e m i a53~ ~
and
,
more frequent arousals from sleep. Acclimatization decreases but does
not eliminate periodic breathing.137,
171, 177

Exercise

At altitude, cardiac output remains near sea level values for a given
17* although heart rate increases owing to lower stroke
volume. The maximal work load (maximal oxygen consumption) de-
creases with increasing altitude.35,139 The mechanism by which maximal
work load is limited remains unknown. Acclimatization increases the
duration of work at submaximal loads,1n8 without an increase in maximal
work

HIGH-ALTITUDE ILLNESS-A CONTINUUM

Immediately on exposure to altitude, travelers may be affected by

acute hypoxia, which may affect their abilities to perform various tasks
without causing any symptoms. Over a period of hours to days they
may suffer from AMS, which may develop into potentially life-threaten-
ing forms of altitude illness: HACE and HAPE. These three illnesses are
not clearly delineated and often overlap considerably. Over a period of
days to weeks above 5500 meters, high altitude deterioration may de-
velop. Over years, there is a risk of chronic mountain sickness. A variety
of other syndromes may affect visitors to altitude.

ACUTE MOUNTAIN SICKNESS

AMS is a set of symptoms that affects many visitors to altitude. The

diagnosis is complicated because those suffering from AMS tend to
blame the symptoms on something else. In the setting of a recent
ascent to altitude, however, appropriate symptoms should suggest the
diagnosis.
The incidence of AMS is increasing worldwide. The increasing ease
of air travel to high altitude areas, especially ski areas in the western
United States, and the increasing popularity of packaged trekking tours
have increased the population at risk. It affects two thirds of climbers
on Mt. Rainier,ln3almost half of those who fly to the Khumbu region of
and up to one fourth of those visiting Colorado ski
196 ZAFREN & HONIGMAN

Diagnosis

Symptoms are the key to early diagnosis. Physical findings are

absent in early stages of AMS. In the setting of recent ascent to altitude,
AMS is diagnosed when headache is accompanied by at least one other
symptom from the constellation of gastrointestinal disturbance (includ-
ing anorexia), dizziness, fatigue, and sleep dist~rbance.'~~ Onset is usu-
ally 12 to 24 hours after reaching a higher altitude, but may be as early
as 2 hours or, rarely, as late as 96 hours.166
The headache is usually described as throbbing, bitemporal or occip-
ital, and worse at night or on awakening. It is worsened by Valsalva
maneuvers or stooping over. Malaise may be present and in more severe
cases may lead to disabling lassitude with the patient unable to attend
to basic needs. Anorexia may be present with or without nausea. Al-
though not strictly a symptom, decreased urine output is an important
element in the patient's history.8 It correlates well with the presence of
AMS; symptoms may resolve soon after increased diuresis occurs. Pa-
tients often describe an inner chill. Any symptom that suggests AMS
should be considered caused by altitude until proven otherwise.
Pulmonary symptoms may be difficult to assess. Dyspnea on exer-
tion is common at high altitude, even in the absence of AMS. Dry cough
is also common in AMS. Dyspnea at rest is a symptom of HAPE rather
than AMS.
Specific physical findings are absent in mild AMS. Heart rate may
increase or decrease and blood pressure is usually normal. Pulse oxime-
try is normal for a given altitude or, at most, slightly decreased. Local-
ized crackles are common,46usually heard first in the right auscultatory
area (right middle lobe). Patients may have fluid retention, sometimes
manifested by peripheral edema, and decreased urine output.8,47, 166
Fever is absent unless HAPE develops. Ataxia heralds the progression
of AMS from mild to severe, that is to HACE, which is life-threatening
if left untreated.

Differential Diagnosis

Differential diagnosis is usually straightforward. Uncomplicated

AMS does not cause fever and myalgia, which would suggest a viral
syndrome. A hangover can be diagnosed by history, but may certainly
coexist with AMS. Exhaustion may be difficult to distinguish from
AMS. Dehydration improves rapidly with administration of fluid, unlike
AMS.6 Hypothermia may cause ataxia and mental slowing. Sedative-
hypnotic medicines may also cause ataxia and mental changes without
AMS, but may precipitate AMS caused by sleep hypoxemia. The effects
of carbon monoxide add to altitude hypoxia.
 HIGH-ALTITUDE MEDICINE 197

Natural History

AMS is self-limited and, unless it progresses to HAPE or HACE,

resolves in 1 to 3 days without treatment as the patient acclimatizes. A
few people never acclimatize but continue to have symptoms for days
to

Treatment

Patients with symptoms of AMS at altitude should be considered

to have AMS unless proven otherwise and should not ascend further. If
the patient has moderate symptoms, treatment is optional, but for severe
AMS as evidenced by ataxia or mental status changes, treatment is
mandatory (Table 1).
A small amount of descent (500 to 1000 meters) or oxygen, if
available, often completely and rapidly cures all symptoms of mild
AMS. Symptomatic treatment may include analgesics, such as aspirin or
acetaminophen (often available as paracetamol outside the United
States), for headache, and antiemetics, such as prochlorperazine (Stemetil
in Europe) for nausea. Prochlorperazine is preferred to other antiemetics
because it is known to increase HVR.133Acetazolamide (125 to 250 mg
orally twice daily) not only improves symptoms, especially insomnia,
but speeds acclimatization.4 Dexamethasone is not indicated in the
treatment of mild AMS except in patients who cannot take acetazolamide
or are allergic to sulfa drugs; cessation may cause a rebound effect.
Because acetazolamide works by improving acclimatization, there is no
rebound effect when the patient stops taking it. Once symptoms are
relieved by analgesics, antiemetics, or acetazolamide, the patient may
safely ascend further.
For severe or worsening AMS, descent is still the treatment of
choice. Oxygen at 0.5 to 1 L/min may be useful.51,73 Dexamethasone in
a dose of 4 mg orally every 6 hours, possibly with an 8-mg loading
dose, may be 56, lo5, and its effects may be additive to that of
a~etazolamide.~~ If dexamethasone is used, the patient should not reas-
cend until it has been discontinued for 1 to 2 days without recurrence of
symptoms as rebound effects are known to occur. A portable (inflatable)
hyperbaric chamber may be used to simulate descent in cases where
descent would be impossible or unduly dangerous and oxygen is not
available. These hyperbaric chambers have been successfully used in
remote areas where descent would be difficult or i m p ~ s s i b l e . ' ~ ~If~
oxygen or a hyperbaric chamber is not available, descent should not be
delayed in the setting of severe AMS. A patient who is ataxic in the
evening may be comatose in the morning.
Portable hyperbaric chambers (Gamow bag [Altitude Technologies,
Boulder, CO], Certec [Sourcieux, Les Mines, France], HELP systems
[Live High, Boulder, CO]) simulate descent by placing the patient in an
environment with an atmospheric pressure 2 psi (% atm) above the
198 ZAFREN & HONIGMAN

Table 1. TREATMENT OF HIGH ALTITUDE ILLNESS IN THE FIELD

AMS
Mild symptoms
No further ascent until symptoms resolve (with or without treatment)
Acetazolamide 125-250 mg orally, twice a day, to speed acclimatization
Treat symptoms with analgesics such as aspirin or acetaminophen for
headache, antiemetics such as prochlorperazine (Compazine, Stemetil) for
nausea
OR
Descend uptil symptoms improve (usually 500 meters-1500 feet or more)
If symptoms are moderate or are not resolving, consider adding
Oxygen at 1-2 Umin
Hyperbaric therapy
Dexamethasone4 mg orally, intramuscularly, or intravenously every 6 h
OR
Immediate descent until symptoms improve
If patient is ataxic or has altered mental status, treat for HACE
HACE
Immediate descent or evacuation
Oxygen at 2-4 Umin
Dexamethasone 4 mg orally, intramuscularly, or intravenously every 6 h
Hyperbaric therapy
HAPE
Minimize exertion and keep warm
Immediate descent or evacuation
Oxygen at 4-6 Umin until improving, then 2-4 Umin or to keep pulse oximetry
>go%
Nifedipine 10 mg orally every 4 h until improvement or 10 mg orally once, then
30 mg extended release every 12-24 h
Hyperbaric therapy
If pulse oximetry is >90% on oxygen at 2 L or in a hyperbaric chamber and
immediate descent or evacuation not possible, the patient may be able to
recover at altitude and may not require descent or evacuation if HAPE
resolves in 24 hours.
Poor sleep with or without periodic breathing
Acetazolamide 62.5-125 mg at bedtime as needed
Do not use sedativelhypnotic medications

See also Table 3 for medications.

AMS = acute mountain sickness; HACE = high-altitude cerebral edema; HAPE = high-altitude
pulmonary edema.

ambient pressure outside the chamber. The exact amount of descent

simulated by this pressurization increases with altitude (see Table 2).5
At 3000 meters, the pressure in the bag is equivalent to 1555 meters, a
descent of 1445 meters; at 4200 meters the simulated altitude in the bag
is 2544 meters, or 1656 meters lower; and at 6000 meters, the simulated
altitude is 3975 meters, a descent of 2025 meters (Table 2).5

Prevention of AMS
Like all altitude illnesses, AMS is preventable. The rate of acclimati-
zation varies among individuals, but many people will remain symptom
 HIGH-ALTITUDE MEDICINE 199

Table 2. SIMULATED DESCENT IN PORTABLE FABRIC HYPERBARIC CHAMBER

Ambient Conditions Imeterdfeetl Inside Chamber Imeterslfeetl
300019843 155515102
4500114,765 278719144
6000119,686 3975113,042
7500124,608 5113116,776

free and most will develop only mild symptoms of AMS if they follow
standard guidelines for graded ascent. People with no previous expe-
rience should follow these guidelines, if possible; those with previous
experience will know if they should ascend more slowly or if they can
safely ascend more rapidly.
Because altitude illness takes time to develop and because hypo-
xemia is more likely during sleep, the critical altitude for acclimatization
is the sleeping altitude. Preventive measures differ based on the
population involved and the elevation gained. For the recreational trav-
eler who flies directly to ski or summer resorts above 2500 meters, we
advise minimal exercise or activity in the first 24 hours. A layover at
intermediate elevation (1500 to 1800 meters) for 24 to 36 hours is more
beneficial. We also recommend maintaining hydration and minimizing
alcohol intake.
For the active climber or trekker, we recommend gradual ascent to
sleeping altitudes over 3000 meters. For those coming from sea level, it
is best to spend 2 or 3 nights at 2800 to 3000 meters before further ascent
and another extra night for every additional gain of 600 to 900 meters.
This can be accomplished by limiting nightly gain to 300 meters and
going up 300 meters in sleeping altitude on a daily basis. Above 2500
meters, nightly gain should not exceed 800 meters in any one 24-
hour period.
Some additional measures help to speed acclimatization. The
mountaineers rule is: climb high, sleep low. On layover days, those
without symptoms can aid acclimatization by climbing higher and de-
scending again to sleeping altitude. Even large ascents are safe because
of the time delay to the development of altitude illness. A high carbohy-
drate diet has been found helpful., Mild exercise, avoiding overexer-
tion, also seems to aid acclimatization. Sedative/hypnotic drugs, such
as alcohol or sleeping pills, should not be used. Smoking decreases
oxygen-carrying capacity and should be avoided (at any altitude), al-
though it has not been studied as a risk factor for AMS.
Exercise training confers no benefit for acclimatization, although
aerobic conditioning is certainly as helpful to prepare for activities, such
as trekking and climbing, at altitude as it is at sea level. Those who are
more physically fit may be predisposed to AMS because they exercise
more on arrival at altitude.
There is also no evidence supporting the use of antacids in acclimati-
zation,68although their use has had some advocates in the past.136
200 ZAFREN & HONIGMAN

Use of Acetazolamide

Acetazolamide is a carbonic anhydrase inhibitor that speeds natural

acclimatization?, 21, 31, 48* 70, By inhibiting both limbs of the chemical
reaction by which carbon dioxide and water are produced from carbonic
acid with bicarbonate as the intermediate step, acetazolamide leads to
metabolic acidosis and increases carbon dioxide in tissues, including the
respiratory centers. This leads to increased ventilation and diuresis with
bicarbonate ion ex~reti0n.I~~ The net result is also an increase in arterial
oxygen saturation. Acetazolamide also decreases cerebrospinal fluid vol-
ume and pressure, which may have additional salutary effects at alti-
tude.162
Acetazolamide can be used to speed acclimatization and to prevent
as well as to treat AMS.39 The dosage to prevent AMS is 125 to 250 mg
twice a day for 24 hours (some people advocate 48 hours) before ascent
and for 1 or 2 days at altitude.3aHigher doses have been used in the
past, but lower doses are equally effective and have less severe side
effects. For improving sleep, 62.5 mg at dinner or bedtime is likely to be
effective. Another alternative for minimizing side effects is the use of
a 500-mg sustained release preparation.", 63, 194 The pediatric dose of
acetazolamide is 5 to 10 mg/kg per day up to 250 mg total in two
divided doses?" but no studies have been done in small children, so this
approach should be used with caution, if at all.
Common side effects include polyuria and distal paresthesias, which
may be very annoying. Nausea and drowsiness are less frequent. Taking
acetazolamide ruins the taste of carbonated beverages, including beer,
which depends on carbonic anhydrase in the tongue. Acetazolamide is
related to the sulfa drugs and has the potential for hypersensitivity
reactions, bone marrow suppression, and crystalluria (Table 3).

Use of Dexamethasone

Dexamethasone in a dose of 4 mg every 12 hours has been shown

to prevent AMS,27,86, lo5,154, 2a1 but rebound is common after it is discon-
tinued. Its use in prevention of AMS should be limited to susceptible
individuals who do not have time to acclimatize properly and who
cannot take acetazolamide. An adequate supply must be assured, since
dexamethasone does not aid acclimatization but appears to work by
reducing nausea and enhancing mood1@' (see Table 2).

Treatment of Insomnia With or Without AMS

Acetazolamide (62.5 to 125 mg at bedtime) decreases periodic

breathing and improves sleep (see Table 2).53,178
Sedative/hypnotic medi-
cations may be helpful for insomnia not associated with periodic breath-
ing but may cause a potentially dangerous decrease in oxygen satura-
 HIGH-ALTITUDE MEDICINE 201

Table 3. MEDICATIONS USED IN THE TREATMENT OF HIGH-ALTITUDE ILLNESS

Acetazolamide (Diamox)
Indications: Treatment of AMS, poor sleep at altitude, or for pre-acclimatization
in emergencies.
Contraindications: Known sensitivity to acetazolamide or to sulfa drugs. In
patients with underlying medical problems or taking other medications, use
only with physician guidance.
Side effects: Common: tingling extremities, increased urination, makes
carbonated beverages, including beer, taste flat. Uncommon: ringing in the
ears, loss of appetite, nausea, vomiting, myopia, drowsiness, itching. Rare
side effects include crystalluria and bone marrow suppression.
Dexamethasone (Decadron)
Indications: Treatment of AMS or HACE. Can be substituted in patients unable
to take acetazolamide (but cannot be used to speed acclimatization). Also can
be used for emergency operations in which acclimatization is not possible in
patients who cannot take acetazolamide.
Contraindications: Known sensitivity to dexamethasone. In patients with
underlying medical problems or taking other medications, use only with
physician guidance.
Side effects: May cause stomach upset. Other side effects are unlikely in short-
term use. Best taken on a full stomach.
Nifedipine (Procardia, Adalat)
Indications: Treatment of HAPE.
Contraindications: Known hypersensitivity to nifedipine. Use should be avoided in
patients with low blood pressure or in situations in which blood pressure
cannot be monitored. In patients with underlying medical problems or taking
other medications, use only with physician guidance.
Side effects: These are usually mild and include dizziness, lightheadedness,
flushing, and peripheral edema. More serious side effects may occur, but are
rare.

t i ~ n . Temazepam
~~ may not have this effect.25The decrease may be
counteracted by simultaneous respiratory stimulation using acetazolam-
ide.

HIGH-ALTITUDE CEREBRAL EDEMA

HACE is a progression of the cerebral signs and symptoms of AMS.

It is present when either ataxia or altered mental status is found. Truncal
ataxia is usually the earliest sign and is tested by tandem gait. Focal
~ ,but
neurologic defects may be p r e ~ e n t , 5 165 ~ ~ ,in general, HACE is global
in nature. HACE should be suspected in any person who can no longer
keep up with a group or who has any mental status changes whether
or not the person is ataxic. Severe lassitude is also a warning sign.
HACE is especially common in association with HAPE, and conversely,
HACE is uncommon without HAPE.43,57
If untreated, HACE is a fatal disease. Coma may develop in as little
as 12 hours or as long as 9 days22,59, 73, 166 but most commonly in 1 to 3
days. Once coma has developed, mortality is over 60%.16
202 ZAFREN & HONIGMAN

Treatment (see Table 1) should begin at the first sign of ataxia or

altered mental status. Immediate descent is the treatment of choice. If
this is not possible, oxygen at 2 to 4 L/min and dexamethasone 4 mg
orally, intramuscularly, or intravenously every 6 hours are temporizing
measures. Hyperbaric therapy may be used if oxygen supplies are lim-
ited. Comatose patients should be treated as head-injured patients with
intubation and hyperventilation. Ataxia and cognitive impairment may
persist even after recovery from HACE.59,73 Preventive measures for
HACE are the same as those for AMS.

HIGH ALTITUDE PULMONARY EDEMA

HAPE is a noncardiogenic form of pulmonary edema, which is the

most common cause of death from altitude illness worldwide. Early
HAPE is characterized by fatigue, weakness, dyspnea on exertion, and
a dry cough. Symptoms of AMS, in addition to fatigue, may also be
present. Onset is sometimes abrupt, most often after the second night at
a higher altitude, but may be earlier or later.2,9, 38, 43, 77 As HAPE prog-
resses, the patient is short of breath at rest as well as with exertion.
Tachycardia, tachypnea, low-grade fever, and orthopnea are associated
findings.79* The earliest localized physical examination finding is usu-
ally the presence of crackles in the right middle lobe, best heard in the
right axilla, although this may also rarely be found in AMS without
frank HAPE.49 A chest radiograph will show patchy infiltrates and
but it is not necessary to make the diagnosis. A
normal heart size,69,77,183
cough with frothy pink sputum is a late and ominous sign. Coma or
cerebral edema may complicate the diagnosis.50 Most patients with
HAPE at moderate altitudes do not present to medical care until the
third or fourth day at altitude, which may imply that symptoms are
mild for 2 to 3 days.
Before widespread recognition of HAPE as a clinical entity, many
cases were misdiagnosed as p n e ~ m o n i a Pneumonia
.~~ may coexist with
HAPE, so when doubt exists, it might be wise to combine descent with
antibiotic therapy.

Predisposing Factors

Cold exposure14,26, 145 and exertion77,81, 84, 159, 197 at altitude have
been identified as predisposing factors for the development of HAPE.
There is a male preponderance even when corrected for numbers of
patients at this may be explained by increased exertion. Travelers
should be cautioned to avoid undue exertion immediately on arrival at
altitude. Children are also more susceptible to HAPE and are especially
at an increased risk on return to altitude if they have spent more than a
few days at a lower altitude ("reascent pulmonary edema'').8, 17n

Pulmonary hypertension is a risk factor, and a group of patients with

 HIGH-ALTITUDE MEDICINE 203

congenital absence of one pulmonary artery has been identified who

developed HAPE at moderate altitudes.44Anyone who has had HAPE
once is at increased risk for recurrence (HAPE susceptible). Such
patients should ascend more slowly than the rate that previously pro-
duced HAPE. In the unusual circumstance in which this is not possible,
nifedipine has been shown to be valuable in preventing the development
of HAPE.

Treatment of HAPE

If recognized early, HAPE can almost always be treated successfully

(see Table 2). Treatment begins with keeping the patient warm and
minimizing exertion, because cold exposure and exertion seem to worsen
the condition. Descent is indicated for all but mild cases and is manda-
tory if pulse oximetry is not available. At moderate altitudes, if oxygen
saturation can be maintained above 90% with low flow oxygen, patients
may be treated by bed rest and oxygen.2noThis treatment has also been
shown to be effective for patients with reascent pulmonary edema. At
some Colorado ski resorts, patients are allowed to return to a hotel or
condominium with home oxygen and next-day follow-up. Such pa-
tients must have a reliable person to watch them and return them to
medical care the next day or sooner if their condition worsens. Many
patients recover quickly and can safely resume skiing in a few days.
Under field conditions, descent is preferable, but the patient may reas-
cend soon after recovery at a lower altitude.38Often, the patient needs
to descend only 500 to 1000 meters and is ready to reascend in 2 or
3 days.
Oxygen, if available, should be administered at 4 to 6 L/min or
guided by pulse oximetry. Hyperbaric chamber treatment is a reasonable
alternative if oxygen is scarce or una~ailable.~~, 8y, 93, 149, 181, The head
end of the chamber may need to be elevated for orthopneic patients.
Other modalities that may have value as temporizing measures include
PEEP, which may be given by expiratory positive airway pressure
(EPAP) mask1n1* and chest p e r c ~ s s i o n . ~ ~
Medications other than oxygen are second-line treatment for HAPE.
Vasodilators, such as furosemide and morphine, have been used in the
pastTG6 but carry the risk of hypotension and may convert ambulatory
patients to litter cases. Nifedipine is also a vasodilator, less likely to
cause hypotension, which has been shown to be helpful in the treatment
of HAPE54,IZ8, 130, 131 if oxygen is unavailable. It can be given in a dose of
10 mg orally once, then 30 mg extended release every 12 to 24 hours or
10 mg every 4 hours until improvement (see also Table 3). A benefit of
nifedipine used in conjunction with bed rest and outpatient oxygen for
treatment of HAPE at moderate altitudes has not yet been demonstrated,
although this regimen is being used with increasing frequency. Inhaled
nitric oxide has also been shown to be effective158but is unlikely to be
widely
204 ZAFREN & HONIGMAN

Once descent has been accomplished, hospital admission is war-

ranted if the patient has an ambient air oxygen saturation of 90% or
less. The patient may be discharged once clinically improved and oxygen
saturation is greater than 90%. If the patient must travel by air following
discharge, additional recovery time should be allowed or supplemental
oxygen should be provided.

Prevention of HAPE

The cornerstone of prevention, as with all high-altitude syndromes,

is gradual ascent. The use of nifedipine slow release 20 mg three times
daily begun the day before ascent and continued for 3 days at altitude
has been shown to be effective in preventing development of HAPE in
susceptible individuals ascending very quickly: but it is no substitute for
gradual ascent, if possible. Acetazolamide may also help prevent HAPE.

OTHER HIGH-ALTITUDE SYNDROMES

In addition to AMS, HACE, and HAPE, a number of other syn-

dromes are found in travelers to altitude.

Thrombosis, Coagulation, and Platelet Changes

It has been postulated that coagulation abnormalities at altitude

may lead to platelet microemboli and other thromboembolic phenom-
ena.65,lB4Platelet microemboli in HAPE are probably a secondary finding.
In addition to dehydration and inactivity, abnormalities of clotting and
fibrinolysis have been proposed as contributing factors to thromboem-
bolic phenomena at altitude, which include DVT, cerebral and pulmo-
nary embolus, and thrombosi~.~~, 73

Focal Neurologic Deficits

A number of focal neurologic deficits have been described at alti-

tude.I5,42, 195 These include reversible entities, such as transient ische-
mic attacks, migraine-equivalent, watershed hypoxia, and HACE with
focal findings, as well as nonreversible conditions, such as cerebral
thrombosis, ischemic infarct, and cerebral hemorrhage. Focal neurologic
deficits are treated in the same way as at sea level, supplemented by the
use of oxygen, immediate descent, and for HACE, the use of steroids.
 HIGH-ALTITUDE MEDICINE 205

High-Altitude Syncope

High-altitude syncope is a recently described benign entity oc-

curring at moderate altitudes. It is particularly common in the first 2 to
3 days at altitude and is associated with alcohol intake and large meals.
It occurs most often at night.127

Peripheral Edema

Swelling of the face and extremities is common at altitude, espe-

cially in women, and is unpleasant but not dangerous.4hIn the absence
of AMS, HACE, or HAPE, it may be safely treated with a diuretic, such
as furosemide. It resolves completely with descent.

High Altitude Retinopathy

A look at the fundi at altitude could prove disturbing if one regards

this vascular bed as reflecting intracerebral changes. Tortuous and di-
lated retinal veins have been described as has "disk hyperemia." Cotton
wool exudates are rare. More disturbing still is the thought of retinal
hemorrhages, which are common above 5000 meters and may be found
These are, however, usually benign
at lower altitudes, as well.34,45, 174, lYo
and asymptomatic; they resolve spontaneously without descent. Retinal
hemorrhages overlying the macula may cause blindness, which usually
resolves with descent but which may cause a central scotoma that
persists for years or is permanent.49This has been viewed as a contrain-
dication to further visits to altitude, although the location of retinal
hemorrhages are probably random. Hemorrhages not affecting vision
are of no known clinical significance and do not warrant descent.

High-Altitude Pharyngitis and Bronchitis

Sore throat and are common above 4000 meters and nearly
universal on Himalayan expeditions after 2 weeks above 5500 meters.4y
The cough, referred to in Nepal as "Khumbu Cough" or "Himalayan
Hack," may be purulent or dry and may be severe enough to cause rib
fractures. These symptoms are partly caused by cold dry air and were
uncommon in a chamber study (Operation Everest 11) simulating a climb
of Mt. Everest.49Antibiotics are not helpful. Hard candies, steam, fluids,
and breathing through a face mask are the mainstays of treatment. The
symptoms resolve with amazing rapidity after descent.
206 ZAFREN & HONIGMAN

Immune Suppression at Altitude

Infections are common at altitude and are often difficult to treat.

Because T-lymphocyte function is mildly reduced, resistance to bacterial
infections is impaired.49Antibiotics may be ineffective until combined
with descent. Resistance to viral infections is not affected. Active immu-
nization is also maintained.

High-Altitude Flatus Expulsion

No discussion of high-altitude syndromes would be complete with-

out mention of high altitude flatus expulsion (HAFE), the unwelcome
spontaneous passage of colonic gas.49Possible mechanisms include the
expansion of bowel gas with ascent, intestinal hypermotility, and a high-
fiber diet. Digestive enzymes, simethicone, and a high-carbohydrate diet
are potentially helpful in treatment.

Associated Problems

A number of environmental factors may be associated with altitude.

Because many high altitude areas are also cold, travelers in many areas
are at increased risk for hypothermia and frostbite. Hypoxia may predis-
pose to cold injury and certainly contributes to the severity of frostbite.
Ultraviolet radiation reaching the earths surface increases with increas-
ing altitude (and, more recently, latitude) and snow is common in most
high altitude areas. These conditions lead to an increased risk of sun-
burn, snow blindness, and eventually to increased rates of skin cancer
and cataracts. High-altitude areas are often located in less developed
countries or wilderness areas with all of the risks pertaining to travel
outside developed regions.
There may be an increased risk of accidents at altitude. Contributing
factors could include hypoxia itself, which is known to slow cognitive
processes and to affect judgment as well as AMS or more serious illness,
but a study of injured skiers with and without AMS who were staying
at moderate altitude did not find a difference between the two groups.lu
Activities often associated with high altitude, such as skiing and moun-
taineering, also carry inherent risks. In addition, an increased incidence
of psychological problems is associated with altitude. Travel, often in
remote areas, is probably a major contributor, but hypoxia almost cer-
tainly plays an additional role.
 HIGH-ALTITUDE MEDICINE 207

SUBACUTE MOUNTAIN SICKNESS AND CHRONIC

MOUNTAIN SICKNESS

A few reports in the literature describe subacute mountain sickness

(SMS), characterized by pulmonary hypertension and congestive heart
failure. Subacute infantile mountain sickness, described in infants born
at low altitude and then taken to Lhasa, Tibet (3600 meters), develops
rapidly and is generally fatal in a few months.173Adult SMS developed
in Indian soldiers spending several weeks at very high altitudes of 5800
to 6700 meters and resolved rapidly on return to 300 meter^.^
Although chronic mountain sickness (CMS), also referred to as
Mongks disease or chronic mountain polycythemia is not a disease of
travelers, it affects high-altitude residents lI9, lZo,135 The
role of mining in addition to prolonged residence of altitude in the
pathogenesis of CMS is not settled. Patients with CMS have very high
hematocrits (>60%) and suffer from headaches, insomnia, lethargy, and
plethora. The only definitive treatment is descent to lower altitude,
although oxygen, phlebotomy, and respiratory stimulants are ~seful.~

PREEXISTING MEDICAL CONDITIONS AT HIGH

ALTITUDE

There is no more difficult area of travel medicine than predicting

the suitability of individuals with medical problems or special conditions
to undertake certain types of travel. Travel to altitude is no exception to
this rule. Few studies have been done, so most recommendations are
primarily based on anecdotal evidence, observational experience, and
extrapolation (Table 4).

Conditions That Do Not Preclude Travel to Altitude

Most people can safely visit high altitude areas without special
precautions if they allow proper time for acclimatization. Those under
20 years of age are at increased risk for AMS., x3, 170 The incidence of
AMS in infants and very young children is unknown, but symptoms
consistent with AMS have been noted by physicians practicing at moder-
ate altitudes (R. Nicholas, personal communication, 1995). The risk for
developing AMS in the elderly seems to be less than in younger
despite a higher incidence of underlying diseases. Women have the
same risk for AMS as men but may be more susceptible to HAPE.48, 176
The less fit and the obese typically feel better at altitude than their
leaner, fitter counterparts, possibly because they are more likely to
ascend gradually and less likely to overexert themselves on arrival,
although in one study of passive transport to altitude, obesity was a risk
factor for
Patients after coronary artery bypass grafting, those with stable
208 ZAFREN & HONIGMAN

Table 4. WHO SHOULD NOT GO TO HIGH ALTITUDE?

Contraindications to high-altitude travel
Uncompensated congestive heart failure
Pulmonary hypertension
Sickle cell anemia
Moderate to severe chronic obstructive pulmonary disease
Cautious travel to high altitude
Compensated congestive heart failure
Arrhythmias
Cerebrovascular disease
Sleep apnea
Seizure disorders
OK to go to high altitude
Yound and old
Fit and unfit
Obese, diabetes
Status post coronary artery bypass graft, stable angina
Asthma, mild chronic obstructive pulmonary disease
Controlled hypertension
Pregnant (see text for suggested limits)

angina, and those with compensated congestive heart failure (CHF) have
all visited altitude without problems.78,142 Likewise, asthma, mild chronic
obstructive pulmonary disease (COPD), and controlled hypertension do
not impose special risks. Asthmatics often do better at altitude because
of decreased air density and fewer airborne allergens. Altitude itself
does not appreciably affect diabetes. Pregnant women can visit moderate
altitudes without fear of harm to themselves or to the fetus.

Contraindications

Only a few conditions are definite contraindications to traveling to

altitude. These conditions, in which hypoxemia is known to be harmful,
include uncompensated CHF, pulmonary hypertension,lo7sickle cell ane-
mia, and moderate to severe COPD. People with other conditions have
visited altitude without problems, but may be at increased risk for
complications including CHF, cardiac arrhythmias, cerebrovascular dis-
ease, sleep apnea, migraine headaches, and seizure disorders.

Lung Disease

In patients with chronic lung disease, h y p ~ x e m i aand

~ ~ pulmonary
hypertension will worsen at altitude, but persons with mild to moderate
disease may do well, especially if pulmonary function is maximized
before ascent. COPD has, however, been shown to be a risk factor for
AMS.ISoArterial oxygen saturation can be predicted based on sea level
 HIGH-ALTITUDE MEDICINE 209

val~es.3
Patients
~ with a predicted SaO, < 90% should probably receive
supplemental oxygen.

Heart Disease

For patients with arteriosclerotic heart disease there are little hard
data. There is no evidence of increased coronary events.', 58, 78* Io6, 13*, 14*,

IR9, 198 In fact, there is speculation about the cardioprotective effects of

altitude exercise limitation. In a large series of trekkers in Nepal there
were no cases of myocardial infarction.'@' Increased catecholamines
might increase arrhythmias and the angina threshold may be decreased,
but studies have not shown myocardial ischemia under such
circumstance~.~~~ 198 Heart disease does not increase the risk of AMS at

moderate altitudes.67,150 Patients with well-controlled arrhythmias and

well-compensated CHF can visit high altitudes and should continue
their usual medications; those not well controlled should avoid altitude
exposure.

Hypertension

Blood pressure increases mildly in healthy persons on ascent to

altitude. This effect is transients8,ln, 139, lRo,196 and does not require treat-
ment. The effect of altitude on preexisting hypertension is unknown.
Hypertensive patients should continue taking their usual medications
while at altitude.

Sickle Cell Disease

Sickle cell crisis is a well-known complication of altitude exposure.

Patients with hemoglobin sickle cell are at risk for vaso-occlusive crises
even in commercial aircraft cabins.'09 Patients who have had vaso-occlu-
sive crises should have supplemental oxygen at altitude. Splenic in-
farction may occur in patients with sickle cell trait as low as 1500
loo but is rare. It should be in the differential diagnosis of
abdominal pain at altitude. Treatment for sickle cell crises is the same
at altitude as at sea level.

Pregnancy

There are little good data about the effects of altitude on pregnancy.
Exposure to moderate altitude does not seem to increase spontaneous
abortion, abruptio placentae, or placenta previa. Severe hypoxemia (in-
spired oxygen 60 to 90 mm Hg, 4500 to 7500 meters) can cause fetal
bradycardia.ls Patients with complicated pregnancies should avoid alti-
210 ZAFREN & HONIGMAN

tude exposure. We recommend that pregnant women from low altitudes

avoid altitudes above 4000 meters or prolonged exposure to altitude.
Although these limits have been exceeded without apparent conse-
quences, many physicians have offered even more conservative recom-
mendations. Pregnant women planning to travel to moderate or high
altitudes in remote areas should probably consider the risks of remote-
ness from medical care to be greater than that of the altitude exposure.

Contact Lens Use

Contact lens use is relatively safe at moderate altitudes, although

decreased passage of oxygen through non-gas-permeable lenses may
dictate shorter wear periods. Use at higher altitudes is controversial.
Bubbles may form underneath the but the clinical significance of
this is unclear.

AIR TRAVEL

Except for individuals with severe cardiopulmonary disease and

sickle cell disease, air travel represents a very mild hypoxic stress.
Commercial jet aircraft are pressurized to between 1500 and 2700 meters,
except for the Concorde, which is pressurized to 660 meters. Most people
with cardiopulmonary disease do not require supplemental oxygen on
commercial flights, because passengers sit upright and do not exert
themselves. Passengers with severe cardiopulmonary disease should
consult a pulmonologist before travel. The recommendation by airlines
for pregnant women to avoid air travel near term is based on the
possibility of in-flight labor and delivery rather than hypoxic risk to the
mother or fetus.

GENERAL ADVICE FOR TRAVELERS

Although the number of trekkers has risen dramatically in the

Himalayas of Nepal, the number of deaths caused by altitude illness has
decreased. The Himalayan Rescue Association was formed in 1972 to
combat a rising tide of altitude illness and deaths in the Everest region
where each year thousands of trekkers reach altitudes as high as 5700
meters. The decrease in mortality seems to be caused by two factors: (1)
a standardized trekking plan that allows for adequate acclimatization
and is followed by most organized groups as well as being promoted
by the available guide books and (2) the presence of two aid posts, one
in each of the two most popular trekking areas. The aid posts treat only
a fraction of those who are ill. They are far more valuable as a source of
information about prevention than treatment of high-altitude illness.
 HIGH-ALTITUDE MEDICINE 211

A large percentage of trekkers in Nepal is composed of adventure

travelers, many of whom have no prior experience at high altitudes or,
potentially worse, have slept single nights above 4000 meters without ill
effects other than acute mountain sickness. The latter group, which
includes a large number of European mountaineers, can be very casual
about the risks involved in sleeping at high altitude on consecutive
nights. These trekkers need a simple scheme for recognizing and pre-
venting altitude illness. This need has led to the formulation of the four
Golden Rules of altitude illness. These rules are easily remembered
and applied.
Rule 1: If you are ill at altitude, your symptoms are due to the
altitude until proven otherwise. It is surprisingly easy to rational-
ize altitude symptoms as being caused by other factors, especially
in the setting of adventure travel, when sleeping in unfamiliar
lodgings that may be smoky and crowded in places like Nepal.
Rule 2: If you have altitude symptoms, dont go any higher.
This does not preclude the use of medication to alleviate the
symptoms. If a headache resolves with acetaminophen, then the
symptom is no longer present and one can ascend. The same is
true for nausea resolving with prochlorperazine. Acetazolamide,
as mentioned before, aids acclimatization and does not mask
symptoms. Once the symptoms have resolved, it is safe to con-
tinue ascending.
Rule 3: If you are feeling very ill or are getting worse, or if you
cannot walk heel-to-toe in a straight line, descend immediately.
Severe or worsening altitude symptoms, especially ataxia (unsta-
ble or unable to perform tandem gait) signals the progression of
acute mountain sickness from mild to severe. The clinical condi-
tions of HACE or HAPE mandate descent except under unusual
circumstances.
Rule 4 emphasizes the responsibility of members of a group for
each other. A person ill with altitude illness must always be
accompanied by a responsible companion who can accomplish or
arrange for descent should it be necessary. Serious altitude illness
may be easier to recognize in others. Trekkers should be advised
to look out for others in their own and other parties. Many ill
trekkers would have died in communal lodges in Nepal but for
the fact that other trekkers noticed them trying to sleep during
the day and not taking meals.
Although the general tourist population does not attain altitudes as
high as those reached by Himalayan trekkers, all visitors to altitude
should have sufficient knowledge to minimize symptoms and to recog-
nize and respond appropriately to progressive illness. If travelers learn
these four rules, they really know all that is necessary to keep from
becoming statistics.
212 ZAFREN & HONIGMAN

SPECIAL SITUATIONS

With increasing ease of air travel and travelers on ever tighter

schedules, there are many places in the world in which most visitors do
not have adequate opportunity to acclimatize. Some examples of this
phenomenon are Lhasa, Tibet (3600 meters), which is usually reached
by airplane from Kathmandu; Nepal (1300 meters; Cusco, Peru (3400
meters), which is almost always reached by air nonstop from Lima (sea
level); and La Paz, Bolivia (3600 meters), which has the worlds highest
airport (4000 meters) and is usually reached by air from sea level
locations. An increasing number of North American resorts at 2500 to
3000 meters can now be reached directly by air.
Mt. Kilimanjaro (5890 meters) in Africa deserves special mention,
because the hike to its summit begins from low footings and usually is
done in several days with a nightly rise in sleeping altitude well beyond
the acclimatization potential of most people. Acquiring AMS and failing
to reach the summit is the rule. A more leisurely pace is recommended.
In South America, those newly arrived at altitude are often treated
to mate de coca, which is a mild respiratory stimulant. More logical aids
to acclimatization include acetazolamide (or dexamethasone for those
who cannot take acetazolamide) to prevent AMS and nifedipine for
HAPE susceptibles as discussed in the relevant sections above. Heavy
exertion soon after arrival at altitude may increase symptoms of AMS
and is probably best avoided. A set of suggested guidelines for rescuers
(Table 5) intended for use in Denali National Park, Alaska, summarizes
an approach to the problem of travel to high altitude without adequate
acclimatization.

CONTROVERSIES IN HIGH-ALTITUDE TRAVEL

MEDICINE

Prevention and treatment of high altitude illness are no longer very

controversial subjects, with most experts agreeing at least on the general
principles. However, groups traveling in remote areas may have limited
resources. Most nonmedical groups cannot afford to take a pulse oxi-
meter. Oxygen is heavy and expensive; it will not be available on
wilderness trips except on mountaineering expeditions to the worlds
highest mountains. The presence of a physician or other medical profes-
sional, once considered by many to be important on certain expeditions
and trekking trips, may be a mixed blessing, especially if the would-be
expert does not have experience or proper training in treating altitude
illness in a remote location.
The availability of relatively lightweight portable hyperbaric cham-
bers has led to the issue of which groups should carry one. As the price
and weight decrease, more groups will be tempted to carry a chamber.
Group leaders should recognize that the availability of a chamber may
predispose to a more casual attitude about acclimatization or illness by
 HIGH-ALTITUDE MEDICINE 213

Table 5. SUGGESTED GUIDELINES FOR OPERATIONS AT ALTITUDE INVOLVING

UNACCLIMATIZED RESCUERS
Whenever possible, rescuers should be flown to 3000 meters and allowed to
acclimatize for 1 or 2 days before operating at higher elevations. Rescuers who
are known to be at increased risk for any form of altitude illness should be
excluded from these operations.
Oxygen, if available, should be used throughout the rescue.
These guidelines apply to rescuers residing at or acclimatized to elevations below
1500 meters (5000 feet). They may be modified for rescuers acclimatized to high
altitudes.
Category 0: Operations conducted entirely below 3000 meters (10,000 feet) or
commencing below 3000 meters and not expected to exceed a rate of ascent of
300 meters (1000 feet) per day. No medications are recommended. For rescuers
who develop high altitude illness, refer to treatment guidelines.
Category 1: Operations commencing below 3000 meters but expected to exceed a
rate of ascent of 300 meters per day above 3000 meters. Rescuers should take
acetazolamide 125 mg twice a day for up to 2 days before ascent and for 2 days
after ascent.
Category 2: Operations commencing at 3000-4000 meters (10,000-1 3,000 feet).
Rescuers should not remain on the ground longer than a few hours. In the event
that rescuers are stranded, they should take acetazolamide 125 mg twice a day
until able to descend below 3000 meters.
Category 3: Operations commencing above 4000 meters (13,000 feet). Rescuers
should not remain on the ground longer than 1-2 hours. They should breathe
oxygen throughout the operation. In the event that rescuers are stranded they
should take acetazolamide 125 mg twice a day until able to descend to 3000
meters. Rescuers should make every effort to descend to 3000 meters as rapidly
as is feasible.

Note: These are emergency guidelines only, for operations in which there is no alternative to using
unacclimatized rescuers.

promoting the illusion that because the group has the means to treat
altitude illness, prevention is less important. One approach would be to
limit use of the chamber to groups in which a physician (or other
suitably trained health care professional) with a pulse oximeter is pres-
ent. The chamber would only be used to treat symptoms of AMS,
following the four "Golden Rules." Other groups that would benefit are
those that must exceed the usual guidelines for acclimatization, such as
those traveling to Lhasa, Cusco, or La Paz. Groups of elite mountaineers
planning rapid ascents of very high mountains are another possible
market for hyperbaric chambers, but these groups also tend to travel
very light and will be less interested. Inevitably, the availability of
portable hyperbaric chambers will be used as a marketing tool for
trekking and climbing companies. Prospective clients would be well
advised to ask why a chamber would be necessary, because altitude
illness is preventable.
A similar situation exists with regard to medications. Acetazolamide
and dexamethasone can be used safely by lay persons with suitable pre-
trip medical advice. Nifedipine is potentially more dangerous. There is
214 ZAFREN 81 HONIGMAN

a very limited number of physicians with actual experience in treating

altitude illness who are qualified to advise groups going to altitude.
Judgment, rather than medications, is paramount. Prevention of altitude
illness is the primary goal; in the event of illness, it is impossible to
overemphasize the importance of descent. Medications other than those
used to treat mild AMS are merely temporizing measures and their
availability should neither lead to a false sense of confidence nor
jeopardize the rapidity of descent.

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