In 2015 I had been writing and speaking about children who live above 2500 feet with no history of travel who present with a respiratory illness and hypoxia. Because they do not appear very sick (toxic is the word we use in medical terms), respond to oxygen only, and have inconsistent or poor response to asthma medications, I decided this is a form of HAPE. Observations by other clinicians support this:
- Anthony Durmowicz and Ed Noordeweir et al. in Journal of Pediatrics May 1997:
- “Although no data exists to support or refute the speculation that the presence of an ongoing pulmonary inflammatory process at the time of ascent to high altitude may predispose for the development of HAPE, I have observed that many children visiting high altitude who had HAPE at presentation had evidence of a preexisting inflammation-producing illness, such as a viral URI, OM, or GAS pharyngitis, that had begun before their ascent to high altitude.”
- “Also noteworthy, the theory of increased endothelial cell permeability in response to hypoxia along with an increase in epithelial cell permeability may result in clinical pulmonary edema and the development of spontaneous HAPE in high altitude residents who acquire relatively mild respiratory tract illnesses seem to support this speculation.”
Careful review of the clinical records for these patients has not shown any factor that can reliably differentiate HAPE from other respiratory diagnoses such as asthma or pneumonia. Physical findings, symptoms, x-ray changes all overlap. The distinguishing feature to me is the clinical picture of a nontoxic patient with a low oxygen at altitude. HAPE is associated with increased pressures in the lungs, which can be diagnosed on an echocardiogram.
In 2016 I presented my data analysis on a poster at the American Thoracic Society annual meeting. Attending was Dr. Eric Swenson, a critical care physician, expert on HAPE, and editor of the Journal of High Altitude Medicine and Biology, had heard my presentation to the community in Breckenridge where he was also a lecturer on altitude the year before. He encouraged me to prepare a manuscript and it was accepted in 2017.
(Insert photo of me and Eric in front of poster from google photos)
I had also presented my observations at the annual Wilderness Medical Society and International Society of Mountain Medicine conference in Telluride. I met with strong opposition from the altitude experts including physician specialists in cardiology, pulmonology and emergency medicine who insisted someone who had not traveled could not get HAPE. Supporting my observation was a physician from Nepal, Dr. Sushi Pants, who presented a case immediately before my talk describing a cook at a settlement in the mountains who became ill with a viral illness and hypoxia that resolved rapidly with oxygen treatment. (Insert Poster from google drive with this caption: This poster prepared by Atsuhiro Saisho PA-C explaining the difference between HAPE and pneumonia with illustrations.from June 2016)
My publication was cited in an article on pulmonary edema in children written by professors in the pulmonary department at Children’s Hospital of Colorado! This was actually the first indication that anyone beside me believed in the entity I called Mountain Resident HAPE in the article published in the same journal in September 2017.
Dr. Liptzin and her colleagues wrote, “We briefly describe high-altitude illnesses and propose recommendations for evaluation and treatment of HAPE in children as well as investigate the underlying contributors to HAPE. We discuss high-altitude resident pulmonary edema (HARPE), a new entity (Ebert-Santos, 2017). We will also highlight areas for further research.” The authors do not recommend prophylactic treatment for HAPE. Rather they recommend that when symptoms develop, supplemental oxygen be applied and descent to lower altitude.
More recent citations and evidence of the broad distribution of high altitude pulmonary edema in it’s many presentations including HARPE include publications from Columbia and China. The article by Ucros et.al. reviews previously published cases from countries worldwide, while the article by Mi et. al describe children with Covid on the high plateaus developing HARPE.
3. Mi YM, Hu WL, Chao HM, Hua CZ, Chen ZM. Pediatric high-altitude pulmonary edema and acute mountain sickness: Clinical features and risk determinants. Pediatr Pulmonol. 2024 Oct;59(10):2614-2620. doi: 10.1002/ppul.27101. Epub 2024 Jun 5. PMID: 38837645.Jan 4;14:1-4. doi: 10.2147/OAEM.S334485. PMID: 35018124; PMCID: PMC8742613.
4. Ucrós S, Aparicio C, Castro-Rodriguez JA, Ivy D. High altitude pulmonary edema in children: A systematic review. Pediatr Pulmonol. 2023 Apr;58(4):1059-1067. doi: 10.1002/ppul.26294. Epub 2022 Dec 29. PMID: 36562650
