ALtitude Sickness Treatment

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TREATMENT

Descent

Wherever possible this has to be attempted. There is really no magic altitude to descend to, but the sick patient may suddenly feel something lift and feel hungry. This is the altitude to which the body is adjusted. Patients with HAPE need to descend slowly and with assistance: excessive exertion even during descent may increase the blood flow to the lungs and exacerbate the problem.

Oxygen

Lack of oxygen at altitude is the chief reason why people suffer from altitude sickness, so breathing supplemental oxygen is obviously going to make a difference. But oxygen is a hard commodity to come by in the mountains - cylinders of oxygen are not easily portable. When oxygen available in AMS settings, it should be used.

Drugs

Acetazolamide (Dimox)

This is the most tried and tested drug for altitude sickness prevention and treatment. Unlike dexamethasone this drug does not mask the symptoms but actually treats the problem. It seems to works by increasing the amount of alkali (bicarbonate) excreted in the urine, making the blood more acidic. Acidifying the blood drives the ventilation, which is the cornerstone of acclimatization.

For prevention, 125 mg twice daily starting the evening before and continuing for three days once the highest altitude is reached, is effective. A recent article in the British Medical Journal suggested taking a higher dosage -- 750mg daily. Our experience in the Indian subcontinent has consistently been that 250 mg per day has been rewarding, while excessive dosage may just increase the side effects.

Side effects of diamox are : an uncomfortable tingling of the fingers, toes and face (called "jhum jhum" in Nepali); carbonated drinks tasting flat; excessive urination; and rarely, blurring of vision. In most of the treks in Nepal, gradual ascent is possible and prophylaxis tends to be discouraged. Certainly if trekkers develop headache and nausea or the other symptoms of AMS, then treatment with diamox is fine. The treatment dosage is 250 mg twice a day for about three days. Dexamethasone: This steroid drug can be life saving in people with HACE, and works by decreasing swelling and reducing the pressure in the bony skull. The dosage is 4 mg three times per day, and obvious improvement usually occurs within about six hours. Like the hyperbaric bag (see below), this drug "buys time" especially at night when it may be problematic to descend. Descent should be carried out the next day. It is unwise to ascend while taking dexamethasone: unlike diamox this drug only masks the symptoms.

Trials are underway in Everest Region to see if this is effective in the prevention of HAPE.

Dexamethasone

can be highly effective; many people who are lethargic or even in coma will improve significantly after tablets or an injection, and may even be able to descend with assistance. Many pilgrims at the annual festival at Gosainkunda Lake in Nepal suffer from HACE following a rapid rate of ascent, and respond remarkably well to dexamethasone. Mountain climbers also sometimes carry this drug to prevent or treat AMS. It needs to be used cautiously, however, because it can cause stomach irritation, euphoria or depression.

It may be a good idea to pack this drug for a high altitude trek for emergency usage in the event of HACE. In people allergic to sulpha drugs (and therefore unable to take diamox) dexamethasone can also be used for prevention: 4 mg twice a day for about three days may be sufficient.

Nifedipine SR

This drug is generally used to treat high blood pressure, but also seems able to decrease the narrowing in the pulmonary artery caused by low oxygen levels, thereby improving oxygen transfer. It can therefore be used to treat HAPE, though unfortunately its effectiveness is not anywhere as dramatic that of dexamethasone in HACE. The dosage is 10mg followed by 30mg every 12 hourly release BID.

It can cause sudden lowering of blood pressure so the patient has to be warned to get up slowly from a sitting or reclining position. It has also been used in the same dosage to prevent HAPE in people with a past history of this disease.

Sildenafil (Viagra)

Like Nifedipine, also seems to decrease the pulmonary blood pressureand has been found to be useful in HAPE but headache is an important side effect and proper trials need to be carried out. It may also be useful in the prevention of HAPE and some trials have shown its effectiveness in this regard.

Beta 2 Agonists

Asthma Inhalers (eg. Ventolin) also may be useful in the treatment of HAPE by decreasing fluid accumulation in the Lungs. It may also prevent HAPE

The Hyperbaric Bag

This is a simple, effective device, made of airtight nylon; it is about 7 feet long and looks like a long duffel bag. With the patient inside, the bag is inflated with a foot pump until it becomes like a large sausage-shaped balloon. There is a one-way valve to avoid carbon dioxide build up inside, and it has transparent panels to assist communication with its occupant.

The pressure inside the bag is 2 p.s.i., so the effect is about the same as bringing the patient down a couple of thousand feet.
For both HACE and HAPE (but especially, in our experience, for HACE) the changes are usually dramatic within an hour. However there may be a "rebound" two or three hours after therapy and the patient may need to get in the bag again. Just like the dexamethasone, this bag only helps to " buy time". Descent is still mandatory as soon as possible.