Altitude Illness and fitness

Altitude Illness

Peter H. Hackett, David R. Shlim

OVERVIEW

The stresses of the high-altitude environment include cold, low humidity, increased ultraviolet radiation, and decreased air pressure, all of which can cause problems for travelers. The primary concern, however, is hypoxia. At 10,000 ft (3,000 m), for example, the inspired PO₂ is only 69% of sea-level value. The degree of hypoxic stress depends on altitude, rate of ascent, and duration of exposure. Sleeping at high altitude produces the most hypoxia; day trips to high altitude with return to low altitude are much less stressful on the body. Typical high-altitude destinations include Cuzco, Peru (11,150 ft; 3,400 m), La Paz, Bolivia (12,400 ft; 3,780 m), Lhasa, Tibet (12,000 ft; 3,660 m), Everest Base Camp in Nepal (17,598 ft; 5,364 m), and Kilimanjaro in Tanzania (19,341 ft; 5,895 m).

The human body adjusts very well to moderate hypoxia, but requires time to do so (Box 2-02). The process of acute acclimatization to high altitude takes 3–5 days; therefore, acclimatizing for a few days at 8,000–9,000 ft (2,500–2,750 m) before proceeding to a higher altitude is ideal. Acclimatization prevents altitude illness, improves sleep, and increases comfort and well-being, although exercise performance will always be reduced compared with low altitude. Increase in ventilation is the most important factor in acute acclimatization; therefore, respiratory depressants must be avoided. Increased red-cell production does not play a role in acute acclimatization.

RISK FOR TRAVELERS

Inadequate acclimatization may lead to altitude illness in any traveler going to 8,000 ft (2,500 m) or higher. Susceptibility and resistance to altitude illness are genetic traits, and no simple screening tests are available to predict risk. Risk is not affected by training or physical fitness. Children are equally susceptible as adults; people aged >50 years have slightly lower risk. How a traveler has responded to high altitude previously is the most reliable guide for future trips, but is not infallible. However, given certain baseline susceptibility, risk is largely influenced by rate of ascent and exertion (see Table 2-07). Determining an itinerary that will avoid any occurrence of altitude illness is difficult because of variations in individual susceptibility, as well as in starting points and terrain. The goal for the traveler may not be to avoid all symptoms of altitude illness but to ensure that any illness remains mild.

CLINICAL PRESENTATION

Altitude illness is divided into 3 syndromes: acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE).

Acute Mountain Sickness

AMS is the most common form of altitude illness, affecting, for example, 25% of all visitors sleeping above 8,000 ft (2,500 m) in Colorado. Symptoms are those of an alcohol hangover: headache is the cardinal symptom, sometimes accompanied by fatigue, loss of appetite, nausea, and occasionally vomiting. Headache onset is usually 2–12 hours after arrival at a higher altitude and often during or after the first night. Preverbal children may develop loss of appetite, irritability, and pallor. AMS generally resolves with 24–72 hours of acclimatization.

High-Altitude Cerebral Edema

HACE is a severe progression of AMS and is rare; it is most often associated with HAPE. In addition to AMS symptoms, lethargy becomes profound, with drowsiness, confusion, and ataxia on tandem gait test. A person with HACE requires immediate descent; death from HACE can ensue within 24 hours of developing ataxia if the person fails to descend.

High-Altitude Pulmonary Edema

HAPE can occur by itself or in conjunction with AMS and HACE; the incidence is 1 per 10,000 skiers in Colorado and up to 1 per 100 climbers at >14,000 ft (4,300 m). Initial symptoms are increased breathlessness with exertion, and eventually increased breathlessness at rest, associated with weakness and cough. Oxygen or descent is life-saving. HAPE can be more rapidly fatal than HACE.

Preexisting Medical Problems

Travelers with medical conditions, such as heart failure, myocardial ischemia (angina), sickle cell disease, or any form of pulmonary insufficiency, should be advised to consult a physician familiar with high-altitude medical issues before undertaking high-altitude travel. The risk for new ischemic heart disease in previously healthy travelers does not appear to be increased at high altitudes. People with diabetes can travel safely to high altitudes, but they must be accustomed to exercise and carefully monitor their blood glucose. In travelers with type 1 diabetes, diabetic ketoacidosis may be triggered by altitude illness and may be more difficult to treat in those on acetazolamide. Not all glucose meters read accurately at high altitudes.

Most people do not have visual problems at high altitudes. However, at very high altitudes some people who have had radial keratotomy may develop acute farsightedness and be unable to climb by themselves. LASIK and other newer procedures may produce only minor visual disturbances at high altitudes.

There are no studies or case reports of harm to a fetus if the mother travels briefly to high altitudes during pregnancy. However, it may be prudent to recommend that pregnant women do not stay at sleeping altitudes >12,000 ft (3,700 m), if possible. The dangers of having a pregnancy complication in remote, mountainous terrain should also be discussed.