Acute Altitude Illness: New management guidelines
Wilderness Medical Society (WMS) has updated evidence-based guidelines for the prevention and treatment of acute altitude illness. The guideline developed by an expert panel shall provide guidance to clinicians and disseminate knowledge about best practices for the prevention and treatment of acute altitude illness. These recommendations are intended to apply to all travellers to high altitude, whether they are travelling to high altitude for work, recreation, or various activities including hiking, skiing, trekking, and mountaineering. The guidelines have been published in the Journal of Wilderness and Environmental Medicine.
Travel to elevations above 2500 m is associated with risk of developing 1 or more forms of acute altitude illness: acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). Because large numbers of people travel to such elevations, many clinicians are faced with questions from patients about the best means to prevent these disorders. In addition, clinicians working at facilities in high altitude regions or as members of expeditions travelling to such areas can expect to see persons who are experiencing these illnesses and must be familiar with prophylactic regimens and proper treatment protocols.
Following are the major recommendations:
- Gradual ascent, defined as a slow increase in sleeping elevation, is recommended for AMS and HACE prevention.
- Acetazolamide should be strongly considered in travellers at moderate or high risk of AMS with an ascent to high altitude.
- Acetazolamide can be used in children for prevention of AMS.
- Dexamethasone can be used as an alternative to acetazolamide for adult travellers at moderate or high risk of AMS.
- Inhaled budesonide should not be used for altitude illness prophylaxis.
- Ginkgo biloba should not be used for AMS prevention
- Ibuprofen can be used for AMS prevention in persons who do not wish to take acetazolamide or dexamethasone or have allergies or intolerance to these medications.
- Acetaminophen should not be used for AMS prevention.
- When feasible, staged ascent and pre acclimatization can be considered as a means for AMS prevention.
- Hypoxic tents can be used for facilitating acclimatization and preventing AMS, provided sufficiently long exposures can be undertaken regularly over an appropriate number of weeks and other factors, such as sleep quality, are not compromised.
- The descent is effective for any degree of AMS/HACE and is indicated for individuals with severe AMS, AMS that fails to resolve with other measures, or HACE.
- When available, ongoing supplemental oxygen sufficient to raise SpO2 to >90% or to relieve symptoms can be used while waiting to initiate descent or when the descent is not practical.
- When available, portable hyperbaric chambers should be used for patients with severe AMS or HACE when the descent is infeasible or delayed and supplemental oxygen is not available.
- Acetazolamide should be considered for the treatment of AMS.
- Dexamethasone should be considered for the treatment of AMS.
- Dexamethasone should be administered to patients with HACE.
- Acetaminophen can be used to treat headache at high altitudes.
- Ibuprofen can be used to treat headache at high altitudes.
- Because of lack of data, no recommendation can be made regarding the use of CPAP for AMS treatment.
- Gradual ascent is recommended to prevent HAPE.
- Nifedipine is recommended for HAPE prevention in HAPE-susceptible people
- Salmeterol is not recommended for HAPE prevention.
- Tadalafil can be used for HAPE prevention in known susceptible individuals who are not candidates for nifedipine.
- Dexamethasone can be used for HAPE prevention in known susceptible individuals who are not candidates for nifedipine and tadalafil.
- Because of a lack of data, no recommendation can be made regarding the use of acetazolamide for HAPE prevention.
- Acetazolamide can be considered for prevention of reentry HAPE in people with a history of the disorder.
- When feasible, staged ascent and pre acclimatization can be considered as a means for HAPE prevention.
- The descent is indicated for individuals with HAPE.
- When available, supplemental oxygen sufficient achieve a SpO2 of >90% or to relieve symptoms should be used while waiting to initiate descent when the descent is infeasible and during descent in severely ill patients.
- When descent is infeasible or delayed or supplemental oxygen is unavailable, a portable hyperbaric chamber may be used to treat HAPE.
- Nifedipine should be used for HAPE treatment when the descent is impossible or delayed and reliable access to supplemental oxygen or portable hyperbaric therapy is unavailable.
- No recommendation can be made regarding beta-agonists for HAPE treatment due to a lack of data.
- Tadalafil or sildenafil can be used for HAPE treatment when the descent is impossible or delayed, access to supplemental oxygen or portable hyperbaric therapy is impossible, and nifedipine is unavailable.
- CPAP or EPAP may be considered for the treatment of HAPE when supplemental oxygen or pulmonary vasodilators are not available or as adjunctive therapy in patients not responding to supplemental oxygen alone.
- Diuretics should not be used for the treatment of HAPE.
- Acetazolamide should not be used for the treatment of HAPE.
- Because of insufficient evidence, no recommendation can be made regarding dexamethasone for HAPE treatment.
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