Scientific Letter
High-Altitude Acute Pulmonary Edema after 48 Hours in a Ski Station
Edema agudo de pulmón por altura tras 48 horas de estancia en una estación de esquí
Paula Isabel García Flores
, Alberto Caballero Vázquez, Ángela Herrera Chilla, Ana Dolores Romero Ortiz
Corresponding author
Servicio de Neumología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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Pulmonary nodules at diagnosis and after 1 month of treatment. On the left, chest CT images showing lung nodules of varying size (circles) in the right middle and lower lobes and the paravertebral region. 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On the right, CT-angiogram (parenchymal window) showing alveolar and ground glass opacities in both lungs.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute non-cardiogenic pulmonary edema consists of the rapid appearance of alveolar edema for causes other than increased pulmonary capillary pressure.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> One of the etiologies of this entity is acute high-altitude pulmonary edema (HAPE), an uncommon but potentially fatal presentation (50% mortality in untreated patients).</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is one of the so-called “altitude sicknesses”, the benign form of which occurs in 75% of the population exposed to an altitude of between 2500 and 3000<span class="elsevierStyleHsp" style=""></span>m, manifesting as symptoms such as nausea, vomiting, asthenia, anorexia, headache, dizziness, sleep disturbances or even dyspnea. The malignant form is less frequent, and develops with acute pulmonary edema and/or cerebral edema syndrome.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a 40-year-old white man with no significant clinical history, regular athlete, former smoker, normally resident at about 11<span class="elsevierStyleHsp" style=""></span>m above sea level, who had ascended to Sierra Nevada (maximum height 3300<span class="elsevierStyleHsp" style=""></span>m) in less than 3<span class="elsevierStyleHsp" style=""></span>h. He skied intensively for a 48<span class="elsevierStyleHsp" style=""></span>h period before experiencing a feeling of tiredness that forced him to interrupt his activity.</p><p id="par0020" class="elsevierStylePara elsevierViewall">He notified the emergency department of the ski resort of symptoms of sudden dyspnea, more intense in the supine position, and cough with bubbly pinkish expectoration. On arrival in the medical center, the patient was normotensive, with signs of hypoperfusion and cyanosis, tachycardiac at 120<span class="elsevierStyleHsp" style=""></span>bpm, tachypneic (>30 breaths/min), with SatO<span class="elsevierStyleInf">2</span> of around 90% and FiO<span class="elsevierStyleInf">2</span> of 0.6 with work of breathing and low-grade fever of 37<span class="elsevierStyleHsp" style=""></span>°<span class="elsevierStyleSmallCaps">C</span>. Auscultation revealed moist rales, mainly in both lung bases. ECG showed sinus tachycardia at 110<span class="elsevierStyleHsp" style=""></span>bpm with normal axis along with the ST depression in the inferior and anteroseptal aspects. After administration of empirical treatment (oxygen therapy by reservoir cannula with FiO<span class="elsevierStyleInf">2</span> of 1.0, furosemide, acetylsalicylic acid and antibiotic coverage), the patient was transferred to the tertiary hospital.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On arrival at the hospital, arterial blood gases (FiO<span class="elsevierStyleInf">2</span> 0.6) were determined, showing normal pH, oxygen partial pressure of 69.9<span class="elsevierStyleHsp" style=""></span>mmHg, and normal carbon dioxide and lactic acid. Clinical laboratory tests were significant for slightly raised CRP and leukocytosis with neutrophilia, with normal D-dimer and cardiac markers.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Chest X-ray showed a normal cardiothoracic index with a bilateral reticular cotton–wool pattern with no central predominance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The CT-angiogram ruled out pulmonary thromboembolism and concluded findings indicative of acute pulmonary edema. Alveolar opacities and ground glass opacities were also observed, with a symmetrical, generalized distribution in the parenchyma of both lungs, slightly more predominantly in the lower lobes, which showed thickening of the interlobular septa and a significant increase in pulmonary arterial trunk diameter (35<span class="elsevierStyleHsp" style=""></span>mm) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Transthoracic echocardiogram showed signs of pulmonary hypertension with slight tricuspid insufficiency and an estimated 70<span class="elsevierStyleHsp" style=""></span>mmHg systolic pressure in the pulmonary artery, without pericardial effusion.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was admitted to the ward, and his oxygen requirements decreased progressively in the first 24<span class="elsevierStyleHsp" style=""></span>h. Treatment continued with the patient placed in a sitting position, receiving low-flow oxygen therapy (nasal prongs at 2<span class="elsevierStyleHsp" style=""></span>l/min), and minimum-dose furosemide. After 3 days of hospitalization, he was completely asymptomatic at discharge. Follow-up echocardiography and cardiopulmonary exertion test one year later were both normal.</p><p id="par0045" class="elsevierStylePara elsevierViewall">HAPE generally occurs within 2–5 days after arrival at high altitudes, and around 50% of cases are associated with acute mountain sickness. High altitude is considered to be between 1500 and 3700<span class="elsevierStyleHsp" style=""></span>m, 3700–5500<span class="elsevierStyleHsp" style=""></span>m very high (the incidence of HAPE at this altitude is 0.6–6%), and >5500<span class="elsevierStyleHsp" style=""></span>m extreme (2–15%).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Onset of clinical symptoms is insidious, with decreased exercise tolerance, progressive dyspnea, orthopnea, wet cough, hemoptysis, chest pain, headache, and confusion.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a> Saturation is estimated to be 10% lower than expected according to the altitude, and the patient's general status is usually better than expected from their level of hypoxemia.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The main risk factor is individual susceptibility due to a low hypoxic ventilatory response.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a>The risk factor most susceptible to modification is the rate of ascent,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> and altitude gained during sleep is more significant than that gained during the day. Other factors include the intensity of the exercise (more than the exercise itself), male sex, anxiolytic medication, and low temperatures. A previous episode of HAPE carries a risk of recurrence of 60%, so it is very important that the patient is warned. A gradual ascent of about 500<span class="elsevierStyleHsp" style=""></span>m per day to levels above 2500<span class="elsevierStyleHsp" style=""></span>m allows the physiological processes in the body to compensate adequately for the reduced partial pressure of oxygen at the new altitude. Avoiding exercise and alcohol during the first 48<span class="elsevierStyleHsp" style=""></span>h until acclimatization also minimizes the risk. Pre-existing conditions that lead to increased pulmonary blood flow, such as pulmonary hypertension, increased pulmonary vascular reactivity, or a patent foramen ovale, are predisposing factors for the appearance of the HAPE.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The key factor in the pathophysiology of the disease is the initial adaptation to altitude, in which the individual will typically increase ventilation. Activation of the pulmonary and cerebral hypoxic vasoconstriction reflex results in an exaggerated vasoconstriction response, raising pulmonary artery systolic pressure.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The subsequent transudative capillary leak and the increase in perfusion increase blood pressure and hydrostatic pressure, causing damage to the alveolar–capillary barrier, and ultimately, increased vascular permeability leading to acute, non-uniform pulmonary edema.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment consists of oxygen therapy and descending around 1000<span class="elsevierStyleHsp" style=""></span>m or to a level where symptoms resolve, minimizing exertion during the descent. Pharmacological treatment mentioned in the literature includes vasodilators, such as nifedipine (dihydropyridinic calcium channel blocker antagonists)<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> or sildenafil,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> phosphodiesterase inhibitors,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> and dexamethasone. Acetazolamide is also used as a treatment because it creates alkalemia, which leads to increased ventilation by increasing the arterial oxygen content of blood, and study is ongoing into its prophylactic use for ascents to more than 2700<span class="elsevierStyleHsp" style=""></span>m.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,6,7</span></a> Potential new therapies, such as ibuprofen, nitrates, and intravenous iron supplements are recommended.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García Flores PI, Caballero Vázquez A, Herrera Chilla Á, Romero Ortiz AD. Edema agudo de pulmón por altura tras 48 horas de estancia en una estación de esquí. Arch Bronconeumol. 2019;55:107–108.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 593 "Ancho" => 1500 "Tamanyo" => 97094 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">On the left, chest X-ray with bilateral reticular cotton–wool infiltrates. On the right, CT-angiogram (parenchymal window) showing alveolar and ground glass opacities in both lungs.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actitudes diagnósticas en edema de pulmón no cardiogénico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.M. Rodríguez Rodríguez" 1 => "A.M. Martínez Riera" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2002" "volumen" => "202" "paginaInicial" => "152" "paginaFinal" => "153" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11996743" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cefalea de elevada altitud y mal de altura" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.J. Carod-Artal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nrl.2012.04.015" "Revista" => array:6 [ "tituloSerie" => "Neurologia" "fecha" => "2014" "volumen" => "29" "paginaInicial" => "533" "paginaFinal" => "540" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22703629" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Wilderness medicine at high altitude: recent developments in the field" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Shah" 1 => "S. Hussain" 2 => "M. Cooke" 3 => "J. O’Hara" 4 => "A. Mellor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2147/OAJSM.S89856" "Revista" => array:6 [ "tituloSerie" => "Open Access J Sports Med" "fecha" => "2015" "volumen" => "6" "paginaInicial" => "319" "paginaFinal" => "328" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26445563" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="https://www.ncbi.nlm.nih.gov/books/NBK430819">https://www.ncbi.nlm.nih.gov/books/NBK430819</a> [accessed 10.01.18]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Altitude illness, pulmonary syndromes, high altitude pulmonary edema (HAPE)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.D. Jensen" 1 => "A.L. Vincent" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "StatPearls [Internet]" "fecha" => "2017" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" target="_blank" id="intr0015" href="http://www.nature.com/articles/s41598-017-14947-z">http://www.nature.com/articles/s41598-017-14947-z</a> [accessed 09.01.18]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subclinical pulmonary dysfunction contributes to high altitude pulmonary edema susceptibility in healthy non-mountaineers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.K. Gupta" 1 => "P. Soree" 2 => "K. Desiraju" 3 => "A. Agrawal" 4 => "S.B. Singh" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Sci Rep [Internet]" "fecha" => "2017" "volumen" => "7" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" target="_blank" id="intr0020" href="http://europepmc.org/books/NBK430716">http://europepmc.org/books/NBK430716</a> [accessed 06.10.17]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute mountain sickness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.S. Prince" 1 => "W.G. Gossman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Europe PMC [Internet]" "fecha" => "2017" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" target="_blank" id="intr0025" href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009761.pub2/full">http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009761.pub2/full</a>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Interventions for preventing high altitude illness: Part 1. Commonly-used classes of drugs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "V.H. Nieto Estrada" 1 => "D. Molano Franco" 2 => "R.D. Medina" 3 => "A.G. Gonzalez Garay" 4 => "A.J. Martí-Carvajal" 5 => "I. Arevalo-Rodriguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2017" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005500000002/v1_201902020656/S1579212918304233/v1_201902020656/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005500000002/v1_201902020656/S1579212918304233/v1_201902020656/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212918304233?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 2 | 9 |
| 2024 October | 79 | 24 | 103 |
| 2024 September | 63 | 24 | 87 |
| 2024 August | 76 | 46 | 122 |
| 2024 July | 54 | 19 | 73 |
| 2024 June | 68 | 54 | 122 |
| 2024 May | 77 | 33 | 110 |
| 2024 April | 50 | 28 | 78 |
| 2024 March | 53 | 18 | 71 |
| 2024 February | 39 | 16 | 55 |
| 2023 August | 1 | 0 | 1 |
| 2023 March | 8 | 3 | 11 |
| 2023 February | 64 | 24 | 88 |
| 2023 January | 64 | 28 | 92 |
| 2022 December | 78 | 32 | 110 |
| 2022 November | 94 | 16 | 110 |
| 2022 October | 112 | 56 | 168 |
| 2022 September | 95 | 30 | 125 |
| 2022 August | 114 | 54 | 168 |
| 2022 July | 66 | 41 | 107 |
| 2022 June | 84 | 32 | 116 |
| 2022 May | 82 | 35 | 117 |
| 2022 April | 88 | 37 | 125 |
| 2022 March | 84 | 45 | 129 |
| 2022 February | 73 | 43 | 116 |
| 2022 January | 81 | 38 | 119 |
| 2021 December | 50 | 50 | 100 |
| 2021 November | 56 | 37 | 93 |
| 2021 October | 68 | 47 | 115 |
| 2021 September | 74 | 45 | 119 |
| 2021 August | 83 | 36 | 119 |
| 2021 July | 55 | 26 | 81 |
| 2021 June | 57 | 29 | 86 |
| 2021 May | 65 | 49 | 114 |
| 2021 April | 130 | 93 | 223 |
| 2021 March | 71 | 27 | 98 |
| 2021 February | 38 | 20 | 58 |
| 2020 March | 72 | 6 | 78 |
| 2020 February | 83 | 13 | 96 |
| 2020 January | 34 | 16 | 50 |
| 2019 December | 67 | 12 | 79 |
| 2019 November | 49 | 16 | 65 |
| 2019 October | 36 | 18 | 54 |
| 2019 September | 24 | 13 | 37 |
| 2019 August | 21 | 7 | 28 |
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