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HIGH ALTITUDE PULMONARY EDEMA IN
ACCLIMATIZED CHILDREN WHO HAVE NOT
TRAVELED
A RESEARCH PROPOSAL
CHRISTINE EBERT-SANTOS
November 10, 2009
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Introduction
On September 23, 2009, a 13 year old previously healthy boy died of
influenza in Summit County Colorado. He had been ill for four days when he
began having increased difficulty breathing. On the sixth day his parents
found him unresponsive and called an ambulance, but he could not be
resuscitated. Anywhere else this would be a classic case of influenza
pneumonia, or influenza with a secondary bacterial pneumonia. But Summit
County is at 9,100 feet (2800 meters) above sea level. Could this boy have
died from high altitude pulmonary edema?
High altitude pulmonary edema, or HAPE, is a well-recognized
syndrome in mountain communities all over the world. Those affected are
usually visitors and onset is during the first twelve to seventy two hours
after arrival above 8000 feet. The hypoxia at high altitude is thought to
cause uneven vasoconstriction of the pulmonary blood vessels. The areas
that are hyperperfused have increased capillary pressure on these vessels
causing them to leak protein and blood cells into the interstitial and then the
alveolar spaces (Ward, M., J. Milledge, and J. West 2000). The victim
experiences a wet cough, dyspnea, hypoxia, confusion, and eventually
cyanosis. Every year there are deaths when the progression of symptoms
and severity goes unrecognized.
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Research has shown that one of the predisposing factors for HAPE is a
viral illness at the time of arrival to altitude (Durmowicz, Noordeweir,
Nicholas and Reeves 1997). Increasingly doctors working in the mountains
such as emergency department Doctor Marshall Denkinger are suspecting
that small numbers of residents who are well acclimatized may be
experiencing HAPE as a complication of a respiratory infection.
When
someone is treated for dyspnea, cough and hypoxia, however, they are
diagnosed with pneumonia. The symptoms and even x-ray findings overlap
making it difficult to distinguish between HAPE and pneumonia.
Yet the
treatments are different: pneumonia is treated with antibiotics and oxygen,
while for HAPE victims high dose oxygen and descent to lower altitude can
be life saving (Hackett and Roach 2001).
Residents who have not recently traveled outside the area may be
susceptible to HAPE during respiratory illness and it is important to uncover
a pattern of symptoms and test results that could differentiate between
pneumonia and HAPE in these patients. Typical x-ray findings, along with
the clinical presentation and course, could raise the suspicion of HAPE. An
echocardiogram or EKG during the acute illness could reveal signs of
pulmonary
hypertension
(Allemann,
Sartori,
Lepori,
et
al.
1991).
Establishing this pattern will require a thorough analysis of clinical cases that
were diagnosed as HAPE, cases diagnosed as pneumonia and some which
could be both.
This analysis will include the age, pattern of onset, fever,
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respiratory rate, oxygen saturation, x-ray findings, toxic appearance, time to
resolution of symptoms, and laboratory test results.
Review of the Literature
There has been extensive research on the causes and treatment of both
HAPE and pneumonia. From basic laboratory studies on physiology and
microbiology to clinical studies on patients the amount of information is
constantly growing. However, there remain many questions about the
diagnosis, treatment and prevention of both entities.
Experience with High Altitude Illness and Pneumonia
I first experienced high altitude in 1977 when I was a medical student on
rotation in Peru. I worked with Carlos Monge Jr whose father wrote one of
the earliest scientific papers on altitude sickness (1948) and I experienced
the symptoms when I rode the train to Lake Titicaca. The following year I
suffered the severe headache of acute mountain sickness while climbing
Mauna Kea in Hawaii. High altitude illness did not present again in my life
until 2000, when I opened a pediatric clinic in Colorado located at 9,100
feet. Here I began observing patients with a viral illness, extremely low
oxygen saturation readings, and minimal changes on chest x-rays.
For twenty years between 1980 and 2000 I treated hundreds of children
and a few adults with pneumonia while working in Saipan, at sea level in the
Pacific Ocean. The native population of Chamorros and Carolinians, like
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Hawaiians, Eskimos and Native Americans, have an increased susceptibility
to pyogenic infections. Rheumatic fever with serious heart disease was
common even in children as young as five years. Staphylococcal infections
such as osteomyelitis, joint infections, abscesses, pyoderma, and pneumonia
were common. The last patient I treated before leaving in 1999 was a four
year old who required five chest tube placements to drain purulent fluid from
her lungs.
There was every kind of pneumonia from pertussis, respiratory syncytial
virus, and tuberculosis, as well as classic lobar pneumonias presumed to be
caused by bacteria like Haemophilus influenzae and Streptococcus
pneumonia. The nearest referral hospital was 3,500 miles away so these
patients were treated on the ward or intensive care unit of the local hospital,
the Commonwealth Health Center. The symptoms were typical for
pneumonia: grunting, fast breathing, fast heart rate, poor color, poor oral
intake, lethargy, chest or abdominal pain, vomiting especially with cough,
and poor sleep due to cough. A pneumonia that caused hypoxia would also
show marked changes on chest x-ray.
Caring for patients in the mountains with respiratory illnesses has been
very different. Parents will call saying their child is congested or has a wet
cough. This could be anything from a cold to high altitude pulmonary edema
with an oxygen saturation in the 60’s (normal at 9100 feet is 92%). It is
necessary to examine all children with respiratory symptoms fairly soon after
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the onset of their illness. The classic HAPE cases would be children, usually
school age, returning from a visit to Grandma’s for Thanksgiving, who
develop trouble breathing during the first 24 hours after return to altitude.
They may be cyanotic, but once placed on supplemental oxygen they feel
fine. Radiographs are normal or show streaky increased perihilar markings,
more pronounced on the right lobe of the lung.
Then there are the children who have not recently traveled. They come
in with a runny nose and cough, and may or may not have fevers, but their
oxygen is in the 70-80’s. Albuterol treatments are not helpful, and the x-ray
shows streaky perihilar infiltrates or increased markings in the right lung.
They improve dramatically on supplemental oxygen, which they may require
for two to ten days. They are often seen in the emergency department due
to rapid onset of symptoms where they are diagnosed with pneumonia and
treated with antibiotics. What makes this different from pneumonia? The
child shows up again a year later with a viral illness, hypoxia and the same
chest x-ray abnormalities.
Respiratory illness at sea level and at high altitude have symptoms in
common but there may be different mechanisms causing these symptoms
that need a novel treatment approach.
If HAPE is a component of
respiratory infections at high altitude, can some of these episodes of severe
hypoxia be prevented?
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Incidence and significance of pneumonia and high altitude
pulmonary edema
Over 140 million people live at altitudes over 9000 feet worldwide, with
another 40 million visitors to altitude annually (Ward, J., J. Milledge, and J.
West 2000). In South America, miners commute from sea level to 14,000
feet, and in many parts of the world research stations such as telescopes are
located above this height. Estimates are that approximately 20 people die of
HAPE world wide each year (Carpenter, T., S. Niermeyer, and A. Durmowicz
1998). One study from Leadville has the incidence of HAPE in those arriving
from low altitude to be five per thousand in all ages and 14 per thousand in
children under age 14 (Scoggin, C., T. Hyers, J. Reeves and R. Grover
1977).
Two million children under five years old die every year from pneumonia.
In the US over 150,000 children under age 15 (excluding newborns) are
hospitalized for pneumonia each year (Nield, L, P. Mahajan, and D. Kamat
2005). Young children, newborns and adults over sixty are especially
susceptible to pneumonia. Pneumonia complicating influenza is more
dangerous in these age groups. Persons with immune system defects, cystic
fibrosis, sickle cell disease, malnutrition, crowded living situations, indoor air
pollution, and inadequate immunizations are more likely to die from
pneumonia.
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Pneumonia is a common medical problem found all over the world and is
more serious in the weak and vulnerable. HAPE is a rare diagnosis, confined
to certain geographic areas and affecting healthy individuals.
Diagnosis and treatment of pneumonia
The World Health Organization convened a group of experts who
reviewed the literature and wrote guidelines to simplify the diagnosis of
pneumonia based on increased respiratory rate for age, when fever is
controlled (1981). I was introduced to these guidelines at a WHO conference
for health care providers in Fiji in 1990.
A normal respiratory rate is the
best indicator that a child does not have pneumonia (Margolis, P and A.
Gadomski 1998). A child who has an abnormal chest x-ray due to
pneumonia will appear ill (Pereira, JC, and M.Escuder 1998). Other signs and
symptoms of pneumonia are not as reliable. Cyanosis is difficult to
recognize in infants and children until the oxygen saturation is below 70
(Jadavji, T. B. Law, et al 1997). Fever and cough, though often found in
patients with pneumonia, can also be caused by a common cold, asthma
with a viral infection and, in children under age two, bronchiolitis caused by
respiratory syncytial virus (RSV). Pneumonia often follows an upper
respiratory infection and some types of lung infections like RSV start out
with cold symptoms. Recurrent episodes of “pneumonia” at low altitude are
most likely asthma with atelectasis or rare diseases of the lung such as
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cystic fibrosis, immunodeficiency, an abnormality of the structures in the
lung, or a foreign body in the airway.
On examination the most reliable sign of pneumonia is abnormal sounds
in one part of the lung heard with a stethoscope in someone with symptoms
listed above.
If there are rales on both sides of the lung, asthma,
bronchiolitis, viral pneumonia, or HAPE are more likely. There are types of
pneumonia that don’t cause fevers. There are patients with pneumonia who
have normal exams except for having fevers. Tachypnea and retractions
indicate lung involvement but may be asthma, pneumonia or bronchiolitis.
A chest x-ray is the “gold standard” for the diagnosis of pneumonia. Yet
x-rays are just shadows, and interpretation varies between observers
(British Thoracic Society 2002).
A table in the Feigin and Cherry’s Textbook
of Pediatric Infectious Diseases (2004) lists 39 causes of abnormalities on
children’s radiographs that are not infectious. These include rare diseases
such as Histiocytosis X and common problems with technique such as
inadequate inspiration and under penetration of the film. HAPE is not even
mentioned. (Barson 2009)
Pathologists describe four types of pneumonia which overlap considerably
on radiographs. In lobar pneumonia during the first 24 hours there is
congestion of the blood vessels and fluid in the alveoli, with neutrophils and
bacteria. The next stage shows many red cells and fibrin in the alveoli along
with the white cells. Bronchopneumonia occurs mostly in the lower parts of
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the lung, with white cells around the airways spreading to the alveoli.
Interstitial pneumonia shows infiltration of macrophages and protein
membranes around but not in the alveoli. Miliary pneumonia, caused by
hematogenous spread of the infection, has discrete patchy areas in both
lungs (Atkuri, L. 2006).
Laboratory tests done in patients with pneumonia are helpful only if there
is a rise in the white blood cell count suggesting bacterial infection. The Creactive protein value also rises with infection and inflammation but is
nonspecific.
Treatment of pneumonia usually involves antibiotics. Although not
helpful against viruses, which cause nearly half of infections (Kronman, M.
and S. Shah 2009), antibiotics are prescribed due to the uncertainty whether
bacteria may be the primary or secondary cause of the illness. Some
patients need oxygen and a few need a thoracotomy tube because of
accumulation of pleural fluid. Antivirals can control influenza infections if
started early in the course of the illness.
High Altitude Pulmonary Edema: diagnosis and treatment
Currently the diagnosis of HAPE would not be applied to a patient with
respiratory symptoms who has not arrived at altitude within 48 hours of
onset. Cough, dyspnea, exercise intolerance, cyanosis, poor sleep, and
fever would all be consistent with the diagnosis (Ward, M., J. Milledge, and J.
West 2000). The reason I diagnose HAPE in children that others believe have
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pneumonia is due to the markedly low oxygen saturation compared to the xray findings and lack of toxicity of the child. Also suggestive of HAPE is that
these children have recurrent episodes, and some also have classic reentry
HAPE. They improve on oxygen without antibiotics. I see about 40 cases a
year with a higher incidence during the outbreak of H1N1 influenza. Khan,
Hussein, et al. also reports a higher incidence of “pneumonia” and recurrent
pneumonia among children living at high altitude in Pakistan and other
developing countries (2009). Three children from Leadville, Colorado were
suspected to have HAPE associated with a viral illness in spite of no recent
travel history in a study that included heart catheterization to measure
changes in lung vasoreactivity on exposure to hypoxia (Fasules, W, J
Wiggins and R. Wolfe 1985).
Clinical findings in patients with HAPE include cyanosis in those with
advanced disease, tachypnea, tachycardia, and rales in the lungs (Ward, M.,
J. Milledge, and J. West 2000). Early on, within the first six to eight hours,
the lung exam and x-ray may be normal. By 24 hours the x-ray will usually
show patchy infiltrates worse in the right lower lung and increased markings
centrally. There are no blood tests that aid in the diagnoses.
Those most at risk for HAPE, as opposed to pneumonia, are healthy,
athletic, children and young adults. Risk factors are rapid ascent to altitude
above 8000 feet, intense physical activity, viral infections and rarely,
underlying medical conditions such as pulmonary hypertension, absent right
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pulmonary artery, certain heart defects allowing abnormal blood flow
between the heart chambers, and Down’s syndrome (Bartsch, P. C. Dehnert,
H. Mairbaurl, and M. Berger 2007). There seems to be a genetic
susceptibility in that individuals who develop HAPE were found to have high
pulmonary artery pressures and more pronounced hypoxic pulmonary
vasoconstriction (HPV) in response to low oxygen (Bartsch, Dehnert et al.
2007). At autopsy lungs affected by HAPE will show protein and red blood
cells in the fluid filling the alveoli with clots in large and small blood vessels
(Bartsch, Mairbaurl, Maggiorini, and Swenson 2005).
Treatment consists of high flow oxygen and for severe cases, rapid
descent from altitude. Patients report a dramatic improvement as they
descend as little as 500-1000 feet. When rapid evacuation is not possible,
hyperbaric chambers are helpful and medications that reduce pulmonary
pressures such as nifedepine, sildenafil, and inhaled nitrous oxide can be
tried. Dexamethasone is helpful for acute mountain sickness but so far
studies have not shown efficacy for HAPE. Acute mountain sickness and
HAPE can be prevented by taking acetazolamide starting several days before
travel to the mountains (Hackett, P. and R. Roach 2001).
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Importance of differentiating HAPE and pneumonia
Preventable deaths are a buzzword in medicine during the last decade.
Many types of pneumonia, particularly those caused by viruses, are neither
preventable nor treatable. Early treatment can make the difference between
life and death. This is especially true with HAPE. Once the patient is seen in
the emergency room or clinic and found to have hypoxia, improvement is
rapid with oxygen supplementation. The problem is educating the general
population who live at altitude to recognize symptoms early. Once a HAPE
susceptible individual is diagnosed, measures can be taken to prevent
recurrence, such as monitoring oxygen levels with a home pulse oximeter,
keeping oxygen concentrators in the home, or possibly using medications, if
these can be shown to be effective in residents who have not recently
traveled. The commonly beta agonist bronchodilators have been shown to
reduce HAPE in mountaineers (Sartori, Alleman, Duplain, Lepori and Egli
2000). Victims of HAPE should be referred to a cardiologist for studies to
rule out flow between the upper chambers of the heart that can cause
pulmonary hypertension and increased right heart pressures. (Poets.
Samuels, and Southall 1992).
In summary, there is very little in the literature that supports the
diagnosis of HAPE in high altitude residents with respiratory symptoms and
no recent travel, but if this is as common clinically as I suspect, it is
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important to document. Careful case review and further studies with EKGs
and echocardiograms may help determine whether this entity is real.
Research Approach
Form of Knowledge
The diagnosis of high altitude pulmonary edema is easy for experienced
mountain clinicians in its classical presentation of trouble breathing and
cough during the first 48 hours after arrival above 8000 feet. When there is
no history of recent travel, can respiratory symptoms at high altitude still be
caused by HAPE? This is the question I hope to answer in my research.
Because this is a recurrent and preventable condition that can be lifethreatening, discovering a profile of symptoms or laboratory tests that could
define HAPE during a viral illness would reduce the use of antibiotics along
with the fear and discomfort of the episodes.
Three areas of data collection will be analyzed in this research. First, I
will do a retrospective review of charts on patients diagnosed with HAPE,
pneumonia, or both including vital signs, symptoms, demographics, clinical
presentation, x-ray results, and response to treatment. Second, I will
cooperate with staff at the Summit Medical Center to do a concurrent
evaluation of cases presenting in the pediatric clinic and emergency
department (ED) located at 9,100 feet. Third, I propose performing
electrocardiograms (EKGs) and echocardiograms (echo) on the concurrent
cases that have clinical and radiographic appearances of HAPE.
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Research questions
1. Are there any characteristics that distinguish between pneumonia and
HAPE?
2. Does HAPE occur in high altitude residents with no recent travel
history?
3. Is it possible to find abnormalities on EKG or echo during the acute
illness that can predict a susceptibility to recurrent episodes of
respiratory problems that could be a sign of HAPE?
Audience
There is explosive population growth in high altitude cities and towns
in the United States during the last fifty years. Ancient mountain
societies, less susceptible to HAPE, thrive in Tibet, Nepal, China, Africa,
and South America. For example, the city of Gondar, in Ethiopia, at 3000
m, has a population of over 100,000. Between migration and tourism,
many more people are ascending above 2500 m without acclimatization
that protects the natives who have lived in these locations for centuries.
Medical personnel treating persons with respiratory symptoms in these
areas need to know the various presentations of HAPE. Individuals and
families traveling to or residing in the mountains should be aware of the
dangers of HAPE. Many cases can be prevented and many vacations
salvaged by awareness and early detection.
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The research will be conducted on those who live at and travel to high
altitude and present to the clinic or ED because they are the most prone
to serious health consequences. Cases for review will be those age
seventeen and under with oxygen saturations below 86% and any
diagnosis of pneumonia.
Controlling Factors
Not every patient with cough and trouble breathing needs an x-ray.
Often pneumonia or HAPE is diagnosed clinically and treatment initiated
without referral to the ED or pediatrician. Even with the more severe
cases further testing such as echo or EKG may be limited by health care
costs and patient interest in knowing more about their susceptibility to
future episodes. If preliminary data show important information from
these tests, it may be possible to obtain funding to cover some expenses.
These tests are painless, safe, and noninvasive. The definitive research
would be cardiac catheterization for those with serious abnormalities
found by echo or lung pathology on autopsy if there were any deaths.
These are rare and not expected during the duration of this study. Finally,
I would make an effort to discuss this proposal and data produced with
experts in the field of high altitude to modify the approach outlined as
guided by the initial results.
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Proposed Schedule
The chart review can be completed in one month. These charts are
available on my computer and the review would not need to use identifying
information. The ongoing case review should extend over the winter ski
season, when there are more visitors to the mountains and viral illnesses
among visitors and residents. From past experience there could be one case
a week during the four months and hopefully close to half would have
further studies done at the time of the illness. Analyses of five echos and
five EKGs would give an idea whether these contribute useful information.
This research is now possible because the Summit Medical Center is the first
facility in the US to have permanent echo capability at an altitude above
2800 m.
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Schedule for HAPE vs. pneumonia study
WEEK
TASK
1-2 Nov
Run diagnosis search on medical records computers for
HAPE and pneumonia
3 -4Dec
Meet with ER physicians to explain study and seek input
on data collection and identification of ongoing cases.
Begin chart review. Develop protocol for new cases.
Seek input from IRB whether permission needed to
perform EKG or echo
4-18 Jan-April
Ongoing data collection and discussion with high
18 April
altitude experts
18-22 May
22-28
Finish data collection
June-July
Analysis of data
Writing1.
and publishing report
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Conclusion
Are children who live in Summit County, Colorado, who have not traveled
at risk for high altitude pulmonary edema? The coroner’s report on the
death of a thirteen year old boy with influenza and respiratory distress
showed lung findings consistent with HAPE. Autopsies, however, are not
how we want to find out about this potential problem. Is the cause of
hypoxia during viral illness in the mountains HAPE or pneumonia? Analysis
of patients with respiratory distress presenting to the clinics and emergency
room may reveal some clues. An echocardiogram or EKG during acute
hypoxic episodes may show evidence of high pulmonary pressures.
Children and young adults in mountainous areas around the world
could be experiencing HAPE complicating viral illnesses or pneumonia. A
study of hypoxemia in Peru done on children living at 3750 meters examined
423 children with respiratory symptoms and compared them to 153 healthy
children. Children with low oxygen levels were more likely to have
pneumonia, but ten percent of children who had upper respiratory infections
also had low oxygen levels (Reuland, et al. 1991). Could some of these
children be affected by HAPE?
Future studies could compare the incidence of pneumonia in children
living at high and low altitude, controlling factors such as immunization and
socioeconomic status. Viral and bacterial infections would not be more
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prevalent in the mountains than sea level so a higher incidence of
pneumonia might suggest some of these illnesses are HAPE.
One typical case, a four year old boy, was seen in the pediatric clinic with
his third episode of hypoxia, fever and cough. Repeat chest x-rays showed
very little: the radiologist asked if he had asthma. Albuterol treatments
given in clinic on several occasions for possible asthma had no effect. Is he
having recurrent HAPE?
Unlike pneumonia, HAPE is easy to treat and even easier to prevent. For
this reason, more study should be done to try and discover whether HAPE is
a component of respiratory diseases causing hypoxia in patients living at
high altitude who have not traveled.
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References
Allemann, Y., C. Sartori , M. Lepori , S. Pierre , C. Mélot , R. Naeije, U. Scherrer,
and M. Maggiorini. 2000. Echocardiographic and invasive measurements of
pulmonary artery pressure correlate closely at high altitude. American
Journal of Physiology Heart Circulation Physiology. (October)
279(4):H2013-6.
Atkuri, L. 2006. Pediatrics, pneumonia. www.emedicine.com/EMERG/topic396.htm
(accessed 8/21/07)
Barson, W. 2009. Clinical features and diagnosis of community-acquired
pneumonia in children. www.uptodate.com/online/content/topic.do?
(Accessed 10/13/09)
Bartsch, P., C. Dehnert, H. Mairbaurl, and M. Berger. 2007. Who gets high altitude
pulmonary edema and why? Problems of High Altitude medicine and
Biology, Aldashev, A. and R. Naeije eds 185-195 Springer
Bartsch P., H. Mairbaurl, M. Maggiorini, and E. Swenson. 2005. Physiological
aspects of high altitude pulmonary edema. Journal of Applied Physiology
98:1101-1110
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British Thoracic Society: Guidelines for the management of community acquired
pneumonia in children. 2002. Thorax 57(Supplement 1):1
23
Carpenter TC1, Niermeyer S, Durmowicz AG.
Altitude-related illness in children.
Curr Probl Pediatr. 1998 Jul;28(6):181-98.
Denkinger, M. 2009. personal communication
Fasule, J., J. Wiggins, and R. Wolfe. 1985. Increased vasoreactivity in children
from Leadville, Colorado, after recovery from high-altitude pulmonary
edema. Circulation 72;957-962
Hackett, P. and R. Roach. 2001. High altitude illness. New England
Journal of Medicine. 345:2 107-114
Javadi, T., B. Law, and M. Lebel et al. 1997. A practical guide for the
diagnosis and treatment of pediatric pneumonia. Clinical Medical
American Journal 156:S703
Khan, A., H. Hussain, et al. 2009. High incidence of childhood
pneumonia at high altitudes in Pakistan: a longitudinal cohort
study. Bulletin of the World Health Organization 87.3 p. 193(7)
Kronman, M. and S.Shah. 2009. Pediatric community-acquired
pneumonia. Contemporary Pediatrics (August)
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Margolis, P. and A. Gadomski. 1998. The rational clinical examination. Does this
infant have pneumonia? Journal of the American Medical Association
279:308
Monge M., C.. 1948. Acclimatization in the Andes: historical
confirmations of the ‘climatic aggression’ in the development of
Andean man. Johns Hopkins University Press, Baltimore, M.D.
Nield, L., P. Mahajan, and D. Kamat 2005 Pneumonia: update on
causes and treatment options. Consultant for Pediatricians
(September)
Pereira, J. and M. Escuder. 1998. The importance of clinical symptoms
and signs in the diagnosis of community acquired pneumonia.
Journal of Tropical Pediatrics 44:18
Poets, C., M. Samuels, and D. Southall. 1992. Potential role of
intrapulmonary shunting in the genesis of hypoxic episodes in
infants and young children. Pediatrics 90:38
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Reuland, D., M. Steinhoff, R. Gilman, M. Bara, et al. 1991. Prevalence
and prediction of hypoxemia in children with respiratory infection
in the Peruvian Andes. The Journal of Pediatrics 119:900-6
Sartori, C., Y. Allemann, H. Duplain, M. Lepori, and M. Egli. 2000.
Salmeterol and the prevention of high altitude pulmonary
edema. (October) 279(4) H 2013-2016
Scoggin, C., T. Hyers, J. Reeves, and R. Grover. 1977. High altitude
pulmonary edema in the children and young adults of Leadville,
Colorado. New England Journal of Medicine 297: 1269-72
Ward, M., J. Milledge and J. West. 2000. High altitude medicine and physiology.
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Appendix
A. Data Collection Form
Initials
Age
Sex
Travel
Fever
Cough
Coryza
Activity
Nausea/emesis
Dyspnea/RR
HR
O2 sat
Rales
Hours pre dx
Days post dx
Hospitalized
CXR typical
CXR lobar
Repeat CXR
Hx pneumonia
Hx HAPE
Assoc Dx
WBC
27
CRP
EKG
ECHO
Hx hypoxia
NB O2
Response Albut
Update 10/21/15
Data collection done in 2009-2010 from clinic and hospital
charts did not reveal any distinguishing results between
pneumonia and HAPE patients. EKG’s and
echocardiograms were not obtained since there is no
access to a pediatric echo probe in the county and
studies performed outside of the acute illness or at
lower altitude were not abnormal.
Parents whose children have had hypoxic illnesses frequently
self-refer or are referred to pediatric pulmonologists in
Denver, where pulmonary function studies are done if
age appropriate and they are treated with inhaled
albuterol and inhaled steroids. Since some do have
underlying reactive airway disease this can be
convincing as an asthma presentation. Several parents
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whose children have more frequent episodes, up to
three times a year, do not believe that albuterol or
steroids make a difference in the prevention or
duration of the hypoxic illness.
We continue to see 40-60 children a year with HAPE, most
with no history of travel. Chest x-rays are rarely done,
since they do not change the treatment, which is
oxygen.
Efforts to publish a case study were thwarted by the
institutional review board of the hospital which does
not allow any “research” on children.