MARSEILLES, FRANCE—Research suggests that high-altitude pulmonary edema (HAPE) is underdiagnosed among otherwise healthy individuals who ascend above 2,500 or 3,000 meters. A new study indicates that HAPE developing at altitudes of only 1,400 to 2,400 meters occurs more often than previously thought.[1]

“Edema developed at moderate altitude was thought to be quite unusual,” noted Claude Martin, MD, Professor of Anesthesia and Intensive Care at Marseilles School of Medicine. “We demonstrated … that it was certainly a more frequent complication than thought before our study.”

Each year, six to nine patients present with HAPE symptoms to Moutiers Hospital, a community clinic in the French Alps where the study was conducted. “You don’t have to go to the Himalayas to develop such complications,” Dr. Martin remarked. He suggests that physicians consider a diagnosis of HAPE in any young patient in previously good health who comes to the hospital with severe dyspnea and signs of pulmonary edema after a moderate ascent. Dr. Martin and colleagues examined 52 patients ages 13 to 72 who had developed symptoms at moderate altitude, typically on the second day of skiing. All patients were hypoxemic, 96% presented with dyspnea, and pulmonary examination revealed moist rales in 77%.

X-ray films demonstrated pulmonary infiltrates in all patients; infiltrates were bilateral in 83%. In addition, patients experienced sleep disturbances (62%), headaches (53%), fever (44%), and digestive disturbances (28%). Two patients (4%) were comatose; computed tomography scans revealed cerebral edema in both. None had positive blood-culture findings or signs of infectious, cardiogenic, neurogenic, or toxic pulmonary edema. White blood cell counts ranged from 5,200 to 13,800/µL.

Patients were treated with supplemental oxygen (3 to 13 L/min), bed rest, fluid restriction, and continuous positive airway pressure at 5 to 10 cm H2O. In addition, 43% received oral nicardipine. After an average of four days, patients recovered and were released.

To minimize HAPE risk during a ski trip, Dr. Martin recommends preparatory training to all skiers. Additionally, he suggests skiing for only a few hours the first two days after arrival to permit altitude adaptation. “It’s important in the case of any dyspnea, any neurologic problem, any difficulty in breathing, to go to the hospital and to take the advice of a physician specialized in emergency medicine,” he warned. “The treatment is quite simple: rest, oxygen, and maybe calcium channel blockers,” he said. “After two days (maybe three days in some cases) … patients can be discharged from the hospital.”

Identifying HAPE requires ruling out other causes of pulmonary edema, such as hypertension, coronary artery disease, and cocaine or opiate use, as well as infectious diseases, such as severe influenza. Dr. Martin recommended, “Each time a patient is admitted with signs of pulmonary troubles, whatever the severity, … he should be carefully examined”; chest films and blood gas measurements should be taken. “Doing that, instead of finding one case every five or six years, we have, during the winter season, one to three cases per month,” he noted.

—Mimi Zucker, PhD

Reference
1. Gabry AL, Ledoux X, Mozziconacci M, Martin C. High-altitude pulmonary edema at moderate altitude (< 2,400 m; 7,870 feet): a series of 52 patients. Chest. 2003;123:49-53.

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