High Altitude illness Treatment and Prevention

High Altitude illness Treatment and Prevention 高山症的治療與預防 Huang Sheng-Kang 黃聖剛 藥師 Tuesday, November 5, 2019

Outline 一.Introduction 二.Epidemiology and Risk factors 三.Physiological pathology 四.Clinical symptoms and diagnosis 五.Treatment 六.Prevention 七.Conclusion 八.Reference

1.1 Introduction How many mountains are there over 3,000 meters above sea level in Taiwan?

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1.2 Introduction • In recent years, more and more people have been expeditions to other places, and the way of travel has become more diverse. There are many places to climb mountains or go to the plateau, drive four-wheel drive vehicles, or ride bicycles. • Taiwan has 269 mountains with an altitude of over 3,000 meters. The main peak of Yushan is nearly 4,000 meters. Nearly 5 million people carry out mountaineering activities every year. When a visitor or a climber experiences dizziness, headache, or vomiting at a certain height, it is often thought to be caused by motion sickness or cold. I don't know if this is actually a manifestation of a mountain reaction, also known as mountain sickness.

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1.3 Introduction • The high altitude is defined as 1,500 to 3,500 meters, the very high al titude is 3,500 to 5,500 meters, and the more than 5,500 meters is defin ed as the extreme altitude. • Usually, most people have no problem at a height of 2,500 meters, but a fter this height, there is a chance of an altitude illness. • As the altitude increases, the proportion of mountain sickness increases.

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1.4 High Altitude Medicine Guide

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2.1 Epidemiology and risk factors •

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Acute mountain sickness is the most common symptom of mountain sickness. According t o a study in Taiwan, the incidence of acute mountain sickness is about 27% when the altitu de is above 3,000 meters. Foreign data show that acute erythema is less common than 2,00 0 meters, but about 25% of people at 2,000 to 3,000 meters will develop this symptom.

High-altitude pulmonary edema usually occurs above 2,500 meters above sea level. Above 4,500 meters, depending on the rate of ascent, the incidence of high-altitude pulmonary ed ema is about 0.2-6%, and when it reaches 5,500 meters, the incidence increases to 2-15%.

About 50% of people with high altitude pulmonary edema will develop symptoms of acute mountain sickness. High altitude pulmonary edema and cerebral edema may occur simulta neously。 At altitudes of 3,000 to 4,000 meters, the incidence of high-altitude cerebral edema is abou t 0.1-2%. The incidence of acute mountain sickness and high-altitude cerebral edema was n ot significantly different between male and female.

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2.2 The main Three factors of the onset of mountain sickness • •

Regardless of acute mountain sickness, high altitude pulmonary edema or High altitude cer ebral edema, the onset of mountain sickness depends on high Three important factors:

• Mountaineering Height • Rising speed • Personal adaptability •

According to foreign research, the danger of mountain sickness Factors include faster clim b, live at low altitudes, and live Residents who move at high altitudes have suffered from mountain sickness in the past. Young, poor heart and lung function or uncontrolled health The patient is fixed.

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3.1 Physiological pathology •

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The detailed mechanism of causing alpine disease is not yet clear. The main reason is tha t the human body adapts to the high-altitude low-pressure environment and the decrease of blood oxygen concentration, which naturally causes a series of neuroendocrine system s and hemodynamic changes in the body.

Low blood pressure and low blood oxygen environment will reduce the blood-gas barrier function of the lungs, resulting in poor gas exchange function in the lungs, increased sym pathetic nerve activity, and indirect axonal contraction of pulmonary vascular arteries, le ading to pulmonary hypertension. And the production of endothelial nitric oxide (NO) de ficiency and endothelia production, lung micro vascular pressure increased, causing fluid to flow out of the blood vessels and accumulate in tissues and alveoli, and finally lead to fluid accumulation in the lungs. Causes impaired respiratory function and can be fatal ev en in severe cases.

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4.1 Clinical symptoms and diagnosis AMS and HACE •

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Symptoms of acute mountain sickness and early high-altitude cerebral edema include headache with any of the following symptoms: loss of appetite, nausea or vomiting, feelin g of dizziness or top-heavy, difficulty sleeping, fatigue or weakness. These symptoms are e asily misdiagnosed as general viral infections. The main point of the assessment is that t he symptoms occur during recent mountain climbing and there are no other causes that ma y cause such discomfort. Acute mountain sickness usually occurs 6 to 12 hours after arrivi ng in the highlands. Mild people will relieve themselves after 24 to 48 hours, or they may be relieved by the use of oxygen and pain relief and antiemetic's. In severe cases, it may pr ogress to high altitude brain edema.

High altitude cerebral edema may be considered when acute mountain symptoms, gaze ins tability, or changes in consciousness are present. The evaluation can be performed by a hee l-to-toe walking test to determine whether there is a gait instability. In the event of mild gai t instability, the patient may stun or die within a few hours.

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4.2 Clinical symptoms and diagnosis HAPE •

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High-altitude pulmonary edema is the most common cause of death in patien ts with mountain sickness. When it rises rapidly to an altitude of over 2,400 meters, it will occur in about 1 to 4 days. Symptoms are usually more pronou nced at night. Early symptoms include poor exercise performance (often the earliest symptoms), dry cough, fatigue, chest tightness, rapid heartbeat, and r apid breathing. Late symptoms include difficulty breathing during rest and s uffocation at night. Continuous coughing or coughing out foamy or even blo ody pink sputum, reduced blood oxygen concentration, cyanosis, and a voice in the lungs.

When high-altitude pulmonary edema is suspected, a blood oximetry can be monitored using a light pulse oximetry to confirm the diagnosis. If possible, chest X-rays can be arranged and the lungs may show uneven infiltration.

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4.3 Lake Louise Consensus Criteria

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5.1 Treatment . The treatment principles are mainly: • Early alertness, early diagnosis, and early treatment are the key s to successful treatment.

• Leave the height environment (go down immediately) • Correcting the environment that produces symptoms (gi ving oxygen and increasing environmental stress) • Rest (reduced oxygen consumption) • medical treatement

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5.2 acute mountain sickness, AMS

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Mild: If you have a headache within 12 hours of high altitude and have symptoms suc h as nausea, dizziness and fatigue, stop the ascent immediately, lower the height by ab out 300 meters or rest in place to adjust to the altitude. In addition, acetazolamide (12 5-250 mg bid) can also be given to accelerate high adaptation. At the same time, it ma y be considered to give analgesic and antiemetic drugs to relieve discomfort.

Moderate: If you have a severe headache within 12 hours of high altitude and have na usea, dizziness, fatigue, difficulty sleeping, and water retention, you should immediat ely lower the height by more than 300 meters; if you cannot reduce the height, you sh ould give appropriate high pressure. The bag is treated or given oxygen (1-2 liters/mi n); if the height is lowered and oxygen is not given, it can be given acetazolamide (25 0 mg bid) or dexamethasone (4 mg q6h, oral or IM), or both. Until the symptoms are r elieved.

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5.3 high altitude cerebral edema, HACE

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Immediately down the mountain, if you can not go down, you should give appr opriate high pressure bag treatment or give oxygen (2-4 liters / min); in additio n, give dexamethasone (8mg st, followed by 4 mg q6h, oral / IM / IV) until do wn the mountain and Symptoms are relieved. If the downhill process is delayed, acetazolamide can be given. Some reports indicate that Ginkgo biloba has its ef ficacy in the prevention and treatment of acute mountain edema and high-altitu de cerebral edema. However, the current evidence is insufficient and is not reco mmended.

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5.4 high altitude pulmonary edema, HAPE

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Give oxygen 4-6 liters/min, give 2-4 liters/min after symptom improvemen t; immediately go downhill in a less laborious way or with a high pressure bag; if you can't go down immediately, give oral long-acting nifedipine (20 mg) Q8h or q12h), oxygen, bed rest, salmeterol, phosphodiesterase-5inhibi tors (tadalafil [Cialis], sildenafil [Viagra]) to help improve oxygen concent ration and pulmonary edema.

Overall, there is currently no strong evidence that drug therapy can improv e outcomes except for immediate downhill.

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5.6 Some drugs in our Hospital 藥物名稱

藥理分類

規格

適應症

Acetazolamide

碳酸酣酶抑制劑

250mg

青光眼及下列疾患之輔助治療：水腫、 癲癇

Dexamethasone

類固醇

0.5mg

風濕性關節炎、風濕病熱、支氣管氣 喘、濕疹、皮膚炎等

Dexamethasone

類固醇

4mg/ml 1ml

風濕性關節炎、風濕病熱、支氣管氣 喘、濕疹、皮膚炎等

Tadalafil(Cialis)

第五型磷酸二酯酶 抑制劑

5mg

1.治療勃起功能障礙。 2.良性攝護腺 (前列腺)肥大症所伴隨的下泌尿道症 狀。

Sildenafil(Shilifil)(Vi agra)

第五型磷酸二酯酶 抑制劑

100mg

成年男性勃起功能障礙

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5.6.1 Drug theory-Acetazolamide •

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Carbonic anhydrase inhibitors function in the renal tubules, diuretic function. It is spec ulated that this drug may cause mild metabolic acidosis, which promotes faster breat hing, increased ventilation frequency and blood oxygen concentration. This drug help s accelerate the adaptation to the highland environment and can be used as a first-lin e medication for the prevention and treatment of acute mountain sickness. Therefore, it is also known as chemical acclimatizer. It is the only one approved by the US Food and Drug Administration for the treatment and prevention of acute high mountains.

Drugs.

Take it from the day before departure to the high ground, and take it to the high groun d for 2 days and then stop taking the medicine. Those who are allergic to sulfa drugs, pregnant women, liver or kidney failure, or those with “G-6-PD deficiency” may not be used. Possible side effects include nausea,vomiting, burnout, tinnitus, paresthesia, t aste abnormalities, acidosis, hypokalemia, etc.

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5.6.2 Drug theory-Dexamethasone

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This drug contains steroids, and the effect on the symptoms of mountain sickness is not clear, and there is no evidence to help accelerate the body's adaptation to the highland e nvironment, and may even cause a rebound effect. Once the passengers who are contin uously rising, they are likely to appear quickly. Alpine disease is therefore used as a sec ond-line medication for the prevention and treatment of acute mountain edema and hig h-altitude cerebral edema. This drug is not approved by the US Food and Drug Adminis tration for use in prevention or treatment.

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5.6.3 Drug theory-Tadalafil(Cialis) Drug theory-Sildenafil (Viagra)

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This type of drug includes Sildenafil, Tadalafil, dilating pulmonary vessels, and improvi ng pulmonary hypertension, and studies have shown a reduction in the incidence of hig h-altitude pulmonary edema. Possible side effects include: headache, dizziness, hot flas hes.

In particular, the drug is used to treat male erectile dysfunction because it has the effect of selectively dilating the pulmonary artery, so it is less likely to cause side effects of sy stemic hypotension, so it can be used to prevent or treat HAPE, but the public is using it.

It must be evaluated by a physician before use and cannot be used without authorization.

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6.1 Prevention •

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Avoid rising speed too fast, stay at mid-altitude the night before to strengthen adaptation, a void direct access to high altitude, oral acetazolamide one night before climbing, until the s econd or third night of high altitude, stop the drug, etc. For effective preventive measures.

In those who have had pulmonary edema, nifedipine can be given to prevent high-altitude pulmonary edema.

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6.2 To avoid mountain sickness, follow the reco mmendations: 1.

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Avoid overactivity Avoid suddenly climbing to altitudes above 3,000 meters above sea level At an altitude of 2,500 meters above sea level, stay at a fixed point for 1 to 2 days before continuing to climb 4. t an altitude of 3,000 meters above sea level, the daily climb does not exceed 300 t o 400 meters or the climb height does not exceed 1,000 meters every two days.

5. Avoid drinking alcoholic beverages two days before reaching the new height 6. As soon as symptoms appear, they stop rising, and if the symptoms do not improv e, they fall. In addition, there is the so-called golden rule of the mountain disease: • golden rule 0： • golden rule I： • golden rule II： • golden rule III： • golden rule IV： 23

7.1 Conclusion Prevention is Better than Cure •

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Mountaineering is good for promoting physical and mental health, strengthens hear t and lung function, and enhances individual strength and endurance. It is a leisure activity that is worth encouraging. However, many people have insufficient knowled ge about mountain sickness, and then ignore it and cause unmanageable conditio ns. Since almost all severe mountain sicknesses are preventable, only a full under standing of mountain sickness can really prevent problems before they occur and ensure mountaineering safety.

Prevention is better than cure. To minimize the possibility and severity of mountain sickness, the most important criteria must be to slowly rise to a height, allowing the body enough time to adapt to height changes. Before climbing, remember to be pr epared to prepare for the prevention of mountain sickness and to understand how t o use it, and to make proper planning for the itinerary. If you have a history of chro nic disease, it is best to ask your doctor before climbing to make your trip safer and more enjoyable.

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8.1 Reference 1.

David CF, Scott H, Pantea S: Altitude Illness :Risk Factors, Prevention, Presentation, and Tre atment: Am Fam Physician 2010; 82:1103-10.

2. CDC Travelers Health: Yellow Book, 2012; The Pre-Travel Consultation, Altitude illness. (ht tp://www.cdc.gov/, accessed on February 10, 2012.)

3. Scott AG, Peter H: Acute mountain sickness and high altitude cerebral edema. UpToDate. 20 12.

4. High Altitude Medicine Guide. The Lake Louise consensus on the definition of altitude illnes s.(http://www.high-altitude-medicine.com/AMSLakeLouise.html, accessed on February 10,2 012.)

5. Scott AG, Peter H: High altitude pulmonary edema. UpToDate. 2012.

6. 衛生福利部疾病管制署.(http://www.cdc.gov.tw, accessed on February 12, 2012.)

7. Hackett PH, Roach RC: High-Altitude illness. NEngl J Med 2001; 345:107-14.

8. 林聖閔、李智貴、陳楷琳：高山症。基層醫學。2007；22：254-7。 9. Barry PW, Pollard AJ: Altitude illness. British Medical Journal 2003; 326: 915-9.

10. 羅佳琳：旅遊保健諮詢。劉文俊等編，家庭醫學臨床手冊。第三版。台北：台灣家庭 醫學醫學會，2010：586。 26

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