All posts by Dr. Chris

Pediatrician trained at University of Michigan Medical School, University of Hawaii and University of Chicago for residencies. Spent 20 years at the Commonwealth Health Center in Saipan, CNMI, before establishing Ebert Children's later Ebert Family Clinic in Frisco, CO in 2000. Published in the Journal of High Altitude Medicine and Biology
Acclimation, High Altitude

Reentry High Altitude Pulmonary Edema (HAPE) in High Altitude Residents!

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When High Altitude Pulmonary Edema (HAPE) is diagnosed, one often thinks of the diagnosis in relation to patients who have lived long term in low/sea level altitudes coming to high altitudes for the first time. However, a new study conducted by Santosh Baniya based out of the Himalayas suggest there is a subset of HAPE in which long term high altitude residents can fall ill to HAPE upon reentry to high altitudes after even a brief stay at lower altitudes.

Baniya’s study is based off a case report of an otherwise healthy pediatric patient who was diagnosed with HAPE after returning to his village of Manag (3500m) after a winter in Besisahar (760m)- a trip that was done multiple times in his life time with no complications. One change surrounding this diagnosis was a recent construction of a road between the two villages that decreased the usual travel time from a span of several days to a single day. The pathophysiologic explanation behind this phenomenon is thought to be caused by the descent of high altitude residents to lower altitudes, leading to a decrease in the red cell mass and a compensatory rise in plasma volume, which then in turn predisposes an individual to pulmonary edema once they return to high altitudes. Had the patient taken the original route of travel- it is likely that the gradual ascent would’ve allowed his body to acclimate to the altitude change and the red cell mass and plasma levels would’ve adjusted accordingly. However, due to the decrease in overall travel time the excess plasma levels led to pulmonary edema. Manifestation of this included shortness of breath, respiratory distress, and hypoxia (an oxygen saturation of 44% in this case). Treatment included high-flow oxygen, dexamethasone to help with air way swelling, and descent to lower altitudes which resulted in immediate marked improvement.

The remarkable aspect of this case- and the reason it was published- is that the doctors in a high altitude community failed to recognize a condition familiar to medical providers in the mountains here in Colorado. More importantly the clinical symptoms that we describe here are also pertinent to Mountain Resident HAPE and Trauma Related HAPE, which is often misdiagnosed by experts in Denver and other lower altitude communities outside of Colorado. Understanding the prevalence of this phenomenon is of utmost importance as an incorrect diagnosis of influenza, pneumonia or asthma could lead to fatal consequences- as oxygen does not treat these conditions. Proper recognition, diagnosis and treatment with oxygen, rest, and if severe enough, descent into lower altitudes need to be carried out promptly for effective treatment.

 

Garkie Zhu, PA-S3
MCPHS PA Program

Reference:

Baniya, S. (2017). Reentry High Altitude Pulmonary Edema in the Himalayas. High Altitude Medicine & Biology,18(4), 425-427. Retrieved January 23, 2018.

Ebert-Santos, C. (2017). High-Altitude Pulmonary Edema in Mountain Community Residents. HIGH ALTITUDE MEDICINE & BIOLOGY, 18(3), 278-284. Retrieved February 2, 2018.

Health, High Altitude, Medicine

A Query on Mt Quandary

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A personal story of acute mountain sickness (AMS)

Disturbing the “Locals”

“Race ya down”, my friend Liz took off from the summit of Mt. Quandary. Ahead of us stood a 2 mile scrabble through a boulder field with a 1 mile decent down a winding trail through the forest where we would descend from 14,265’ to 10,850’. In my experience, a 6 mile hike with 3,400 vertical feet was no feat. However, something was different as we approached the cars at the end of the hike. I noticed the start of a headache and I held onto the car to keep myself from swaying while taking off my boots. Thinking this was merely dehydration I finished my 3 liters of water – but that did not help. Once in the car my head continued to throb as we drove over Hoosier pass. Incoherently I mentioned that we should stop for Gatorade but the 64 oz of Gatorade did not abate my symptoms. In fact they worsened, my symptoms included severe dizziness, nausea, and a pounding headache. While my memory was hazy I knew this was not dehydration, maybe this was acute mountain sickness? But how could it be? I was in shape, lived at 5,400’, and this was my 5th 14er that summer. Was it possible to have AMS on the same peak I had climbed just weeks prior?

Standing on the summit of Mt. Quandary

My name is Chris Whitcomb and I am a 3rd year PA student at the University of Colorado. This story is all too familiar for anyone who spends time at elevation. Thankfully by the time we hit Idaho Springs, 7,526’, my symptoms dramatically improved. After reviewing my case and talking it over with my peers I believe that I developed AMS with some elements of HACE mixed in. A quick calculation of the Lake Louise Score came in at 6, which would classify this episode as “severe AMS”.

Who is most susceptible to AMS?

A prospective study analyzed a total of 11,182 workers on the Quighai-Tibet railroad in Tibet. This study identified 6 independent risk factors for AMS such as: rapid ascent to elevations above 3500 m (11482’), sea-level or lowland newcomers, young people of age, heavy physical exertion, obesity, or SaO2 below 801.  Another study in 2013 looked into various other predictive indexes for AMS and found that the level of activity (higher activity) and sex (male>female) lead to increased odds of AMS 2. A quick review of the above criteria showed that I was the perfect demographic for AMS. I am a young male who was exerting myself physically at altitude.

Will this stop me from hiking at elevation?

Not one chance! Last summer alone my wife and I backpacked and hiked over 250 miles in Colorado. Since the incident I now make sure that I have the ability to seek lower elevation if needed during all our outdoor adventures. I also pay close attention to how I am feeling as we ascend.

Should I take acetazolamine/Diamox before backpacking trips because of my past AMS episode?

A meta-analysis in 2015 looked at 7021 individuals to see if a past episode of AMS warranted medication to prevent future AMS episodes. Interestingly enough they found that the literature did not support it. This was in part due to the sporadic nature of AMS 3. I personally do not take a prophylactic medication before hiking at elevation, but this would be a great conversation to have with your medical provider if you are at all concerned.

Chris Whitcomb, PA-S3
University of Colorado
Class of 2018

References

  1. Wu TY, Ding SQ, Liu JL, Jia JH, Chai ZC, Dai RC. Who are more at risk for acute mountain sickness: a prospective study in Qinghai-Tibet railroad construction workers on Mt. Tanggula. Chin Med J. 2012;125(8):1393-400.
  2. Beidleman BA, Tighiouart H, Schmid CH, Fulco CS, Muza SR. Predictive models of acute mountain sickness after rapid ascent to various altitudes. Med Sci Sports Exerc. 2013;45(4):792-800.
  3. Macinnis MJ, Lohse KR, Strong JK, Koehle MS. Is previous history a reliable predictor for acute mountain sickness susceptibility? A meta-analysis of diagnostic accuracy. Br J Sports Med. 2015;49(2):69-75.
Health, High Altitude, Medicine

High Altitude Increases Longevity!

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A new study completed by Gustavo R. Zubieta-Calleja based out of La Paz Bolivia has shown that residents of high altitude live longer and healthier lives then their sea-level companions. According to the study there are several things that high altitude offers that contribute to increased longevity of residents. Residents at high altitudes have adapted to life with less oxygen (hypoxia) thus enabling their bodies to be more suited for a longer life. The study also points out that at higher altitudes there is less of an occurrence of asthma and other lung diseases, this can be attributed to the dryness of the air and the abundance of sunshine typically found at higher altitudes.

Dr. Zubieta-Calleja goes on to point out that living at high altitude can improve longevity in many other ways as well.

  •  It alters the genetic make up populations, making them stronger and more suited to difficult living conditions
  • High altitude residents are less susceptible to many diseases that sea-level residents need to be concerned with as well. This is due to the lack of mosquitos and many other disease-carrying             insects that are unable to survive at high altitude.
  • Increased exposure to sunshine increases the bodies Vitamin D levels providing us with benefits to our hearts and well as reducing our risk of some cancers.
  • High altitude also helps our hearts become stronger, thus working more effectively, while also increasing blood flow to our body and brains.
  •  The decrease in oxygen level at high altitude helps our lungs work more effectively and increases our ventilation.

Dr. Zubieta-Calleja’s research has shown that there are more residents over 90 and 100 years of age at high altitude then there are at comparable populations at sea-level. The study compared the city of Santa Cruz Bolivia with an elevation of 416m to La Paz Bolivia with an elevation of 3800m, both cities have a population around 2.7 million people. In Santa Cruz there were 158 residents older than 90 years of age verses 974 residents older than 90 in La Paz. The trend continues for those over 100 years of age as well. In Santa Cruz there are 6 residents over 100 years of age verses 48 residents older than 100 in La Paz. Dr. Zubieta-Calleja’s study shows that as altitude increases so does longevity.

 

 

Dr. Chris’ parents! Both in their 90’s and are happy residents of high altitude living.

 

Written by Rhea Teasley-Bennett FNP student

 

Reference

 

Zubieta-Calleja, G.R., & Zubieta-DeUrioste, N.A. (2017). Extended longevity at high altitude: Benefits of exposure to chronic hypoxia. BLDE University Journal of Health Sciences. 

Acclimation, Health, High Altitude, Medicine

Chronic Mountain Sickness

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Avinell Abdool

 

Chronic Mountain Sickness (CMS) is a pathological finding that is commonly found amongst individuals that have taken up permanent residence in high altitude environments (altitudes of over 8,200 feet)1. Clinical manifestations of CMS include but are not limited to the following1;

  • HA
  • Dizziness
  • Tinnitus
  • Breathlessness
  • Palpitations
  • Sleep Disturbances
  • Fatigue
  • Loss of appetite
  • Confusion
  • Cyanosis
  • Dilation of veins

 

CMS is the outcome of progressive loss of ventilation rate, which subsequently results in hypoxemia and polycythemia2. Polycythemia is defined as by excessive erythrocytosis (EE; Hb >/= 19g/dL for women and Hb >/= 21 g/dL for men) which along with a hypoxic environment can result in pulmonary hypertension2. In advanced conditions of Chronic Mountain Sickness there can be cor-pulmonlae and congestive heart failure2 .

A study was conducted in the University of San Diego by Dr. Gabriel Haddad that researched the adaption of the Peruvian population in high altitude conditions3. It was found that CMS is highest in the Andeans (approximately 18 %), lesser in Tibetans (1%-11%) and completely absent in the Ethiopian population3. From these data points it appeared that there was was a genetic correlation between CMS sufferers and ethnicity3. In addition, this finding added another factor that mystified the conclusive pathogenesis of CMS3. By understanding exact pathogenesis of CMS, it would not only benefit those who are at potential risk for the disease but also those living at sea level, where hypoxia plays a role in certain pathology ( such as stroke, cardiac ischemia, Obstructive sleep apnea and Sickle Cell Disease)3 .

A cohort of 94 individuals were gathered and were equally categorized into CMS and non CMS subjects3. These individuals originated from Cerro de Pasco, which has an elevation of greater than 14,000 feet3. Genetic tools and a custom algorithm were utilized and the researchers identified 11 regions on the genome that contained 38 genes that proved to be statistically significant3. Nine of the eleven genes were tested in fruit flies in hypoxic experiments3. The experiment consisted of fruit flies that had these genes and ones that did not have the genes3. It was concluded that individuals with these molecular adaptions were better able to adapt to physiological stress such as hypoxia when compared to individuals that did not have this adaption3. The results of this study allowed researchers to better understand the correlation between genetics and individuals who strive in hypoxic environments3.

 

 

Figure 1- D.melanogaster (fruit fly)3

 

 

Figure 2-Cerro de Pasco3

 

Bibliography

 

  1. Villafuerte FC, Corante N. Chronic Mountain Sickness: Clinical Aspects, Etiology, Management, and Treatment. High Altitude Medicine & Biology. 2016;17(2):61-69. doi:10.1089/ham.2016.0031.
  2. Chronic mountain sickness and high altitude pulmonary hypertension. High Altitude Medicine and Physiology 5E. 2012:333-346. doi:10.1201/b13633-23.
  3. Stobdan T, Akbari A, Azad P, et al. New Insights into the Genetic Basis of Monges Disease and Adaptation to High-Altitude. Molecular Biology and Evolution. 2017. doi:10.1093/molbev/msx239.
Health, High Altitude, Medicine

Hypertension at Altitude

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Will my blood pressure be impacted when I travel to high altitude?
It is not uncommon for lowland visitors with a history of high blood pressure to
experience higher blood pressure at altitude. This can occur even if blood pressure is well
controlled with medication at sea level. However, only a small percentage of these people will
experience unusually unstable blood pressure at altitude. Increased blood pressure at altitude
usually returns to baseline after 1-2 weeks at altitude.
So why does this happen?
One explanation is due to the higher levels of adrenaline in your body due to lower oxygen
levels causing increased heart rate in attempt to increase oxygen circulation throughout the body.
This mechanism supports the findings that increased blood pressure will normalize after 1-2
weeks at increased elevation.
How can I safely plan a trip to high altitude if I have hypertension?
In general, it is unnecessary to change your blood pressure medication dosage before or upon
arrival to elevation. Increasing dosage could result in dangerously low blood pressure upon
returning to low altitude. However, if you are experiencing symptoms from your high blood
pressure such as headache, dizziness, chest pain, or shortness of breath, you should seek medical
treatment. It is also recommended to bring your own blood pressure monitor on your trip. If your
blood pressure rises above 180/90 you are at risk of entering a state of hypertensive urgency and
if it rises above 200/100 this can cause a hypertensive emergency where end organ damage is
possible. In either condition you should seek medical advice whether from your Primary Care
Physician or the Emergency Department if blood pressure is dangerously high. Unfortunately,
there is little information available about the treatment of significantly elevated blood pressure
that is secondary to a quick ascent to elevation and will likely be managed similar to a
hypertensive crisis at sea level with the use of an anti-hypertensive medication chosen by your
healthcare professional. The use of supplemental oxygen, especially at night can also reduce
symptoms and lower blood pressure in some visitors and residents in the mountains.

Written by Grace Murk, PA-S

References
1. Andrew M. Luks. High Altitude Medicine & Biology. March 2009, 10(1): 11-
15.https://doi.org/10.1089/ham.2008.1076
2. Institute For Altitude Medicine (2017). Altitude and Pre-Existing Conditions. [online]
Institute For Altitude Medicine. Available at: http://www.altitudemedicine.org/altitude-and-
pre-existing- conditions/ [Accessed 15 Oct. 2017].
3. Handler J. Altitude-related hypertension. J Clin Hypertens (Greenwich). 2009;11:161–165.
4. Gilbert-Kawai E, Martin D, Grocott M, Levett D. High altitude-related hypertensive crisis
and acute kidney injury in an asymptomatic healthy individual. Extreme Physiology &
Medicine. 2016;5:10. doi:10.1186/s13728-016- 0051-3.

Child Growth & Development, Health, High Altitude, Medicine

It’s Flu Shot Season!

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It’s flu shot season!

Ebert Family Clinic now has flu shots available for both kids and adults!  As we move into cold and flu season, there are several things for mountain residents to remember about the flu.  First, the flu and the common cold are two separate illnesses that are prevented and treated differently.  The common cold is generally a mild and self limiting viral infection, caused by one of more than 200 types of virus from the rhinovirus family (6).   Because of the vast number of virus responsible for the common cold, there is no vaccine.  While the flu may also be self limiting in some cases, it carries higher risk of severe complications than dose the common cold and is thus monitored by both the Centers for Disease Control and the World Health Organization (5).  Additionally, the flu is cased by a smaller family of viruses, influenza A and influenza B (5).   Many symptoms between the flu and the common cold overlap, often causing confusion in when to seek treatment and come see Dr. Chris.  Although both pathogens share these symptoms, fever is generally higher in influenza infections, as is severe headache, body aches, cough and even vomiting in children (2).  The only way to know for sure is by testing for flu using a rapid flu swab that can be done in the clinic.  If your flu swab is positive for influenza, antiviral medications can be used to reduce the chances of severe complications, such as oseltamivir, or Tamiflu (2).

Unfortunately, mountain residents are at a higher risk of complication from influenza infections.  Data gathered from across Mexico during the 2009 H1N1 influenza pandemic showed that rates of hospitalization and death from influenza in patients living above 1,765 meters was three times that of patient living under that altitude (7).  Frisco, CO sits at 2,766 meters above sea level.  While many remember the 2009 flu year as one of the worst in recent history with 384 pediatric flu deaths in the US, it should also be noted that last year, 101 children in the US died from influenza complications.  About 85% of those children had not been vaccinated against influenza (5).  One way influenza viruses can lead to death is by breaking down epithelia cells found along our airways and even causing macrophages and neutrophils, two type of white blood cells to malfunction.  These attacks on the immune system then allow the infected victim to be susceptible to bacterial infections, such as pneumonia (4).   Viral infections such as influenza increase the risk of a high altitude pulmonary edema (HAPE) (3).  Children ages 6 months to age four are at an even higher risk of these devastating complications of an influenza infection (4).

Receiving the flu vaccine each year is an easy way to prevent severe flu infections in your self and your loved ones.  The flu vaccine is no longer available in the nasal mist, thus an injection is necessary.  Additionally, people who were once unable to get the flu shot because of egg allergies can now get the flu shot, but will need to be monitored for reactions for 30 minutes after receiving the vaccine (1).  All preparations of the flu vaccine are either inactivated influenza virus or recombinant influenza virus (or parts of the DNA from the virus).  Neither of these preparations involve live influenza virus and they cannot cause an influenza infection.

For more information or to make an appointment to receive your flu shot, please call the Ebert Family Clinic at 970-668-1616

Erica Fitzgerald, MSN FNP student

References:

  1. Centers for Disease Control and Prevention. (2016). Vaccination Who should do it, who should not and who should take precautions. Retrieved from : https://www.cdc.gov/flu/protect/whoshouldvax.htm#flu-shot
  2. Decker, B & Herring, M. (2011). Influenza vs the common cold: Symptoms and treatment.  Pharmacy Times, 77(11): 80.  Retrieved from: http://go.galegroup.com.libproxy.uccs.edu/ps/i.do?p=AONE&u=colosprings&id=GALE|A305993419&v=2.1&it=r&sid=summon&authCount=1
  3. Hevroni, A., Goldman, A., & Kerem, E. (2015). High altitude: Physiology and pathophysiology in adults and children: A review.  Clinical Pulmonary Medicine, 22(3): 105-113.  DOI: 10.1097/CPM.0000000000000093
  4. Martin-Loeches, I., Van Someren Greve, F., & Schultz, M. J. (2017). Bacterial pneumonia as an influenza complication.  Current Opinion in Infectious Disease, 30(2): 201-207.  doi1097/QCO.0000000000000347
  5. Munoz, F. M. (2017). Seasonal influenza in children: Clinical features and diagnosis.  In G. B. Mallory & M. S. Edwards (Eds.) UpToDate Database.  Retrieved from: https://www.uptodate.com/contents/the-common-cold-in-children-management-and-prevention?source=search_result&search=cold&selectedTitle=2~150
  6. Pappas, D. E. (2017). The common cold in children: Management and Prevention.  In M. S. Edwards & M. M. Torchia (Eds.) UpToDate Database.  Retrieved from: https://www.uptodate.com/contents/the-common-cold-in-children-management-and-prevention?source=search_result&search=cold&selectedTitle=2~150
  7. Perez-Padilla, R., Garcia-Sancho, C., Fernandez, R., Franco-Marina, F., Lopez-Gatell, H., & Bojorquez, L. (2013). The impact of altitude on hospitalization and hospital mortality from pandemic 2009 influenza a (H1N1) virus pneumonia in Mexico.  Salud publica de Mexico, 55(11): 92-95.  doi: 1590/S0036-36342013000100013

 

Acclimation, Child Growth & Development, Health, High Altitude, Medicine

Asthma and High Altitude: What You Need to Know

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According to the Centers for Disease Control and Prevention: one in thirteen people suffer from
asthma—that’s 25 million people in the United States alone, seven million of which are children under the age of
eighteen. 1 With populations in high elevation towns growing each year, more individuals with asthma will be adjusting
to life “up in the clouds.” While asthma sufferers may be at increased risk of developing a high-altitude illness such as
high altitude pulmonary edema (HAPE), is it possible for them to experience any benefits living at or traveling to
higher elevation? Before we dig in, let us examine what Asthma is and its related symptoms.

Asthma is an obstructive lung disease, meaning airflow is limited due to airway narrowing brought on by
inflammation and bronchial hyperactivity. The vast majority of patients with asthma will develop symptoms of
coughing, wheezing, chest tightness, and difficulty breathing before the age of five. When these symptoms present
intermittently, they can be controlled by a short-acting bronchodilator like Albuterol. For those with more persistent
asthma, an inhaled corticosteroid and (or) a long-acting bronchodilator may be needed in addition to
Albuterol. Exercise, cold weather, upper respiratory illness, stress, air pollution, and dust mite allergens are all known
triggers of an acute asthma attack. Is it possible that high altitude can actually minimize the impact of any of these
triggers?

One of the benefits of living at high altitude is consistently breathing the clean alpine air. Significantly lower
levels of house dust mites and air pollutants are found at high elevations; great news for allergic asthma
sufferers. 2  However, if one does not fall into that category, do not worry! A study published in the European
Respiratory Journal in 2012 showed that high altitude has beneficial effects for all asthma-types, especially those
refractory to steroids. Participants in the study had improved asthma control, improved lung function, and fewer sino-
nasal symptoms after 12 weeks at an altitude of 1,600 meters. 3 Given that even those with nonallergic asthma
benefited from high altitude treatment, there has to be something other than low levels of allergens at play. Several
studies have reported increased levels of catecholamines and cortisol in the bloodstream within the first two weeks of
staying at high altitude. 4 These hormones contribute to decreasing both bronchial inflammation and bronchial
reactivity which helps in controlling asthma symptoms. Furthermore, the lower viscosity of the air and lower oxygen
pressure reduce the resistance of airflow with inspiration and expiration, making it easier to breath! 2 Mountain living
may also yield a less stressful lifestyle. 3 Lower stress equals lower levels of the stress hormones that typically elicit an
inflammatory response, thus keeping asthma symptoms in check.

So, who is at risk when climbing to higher elevations? Anyone with asthma that is not well controlled prior to
to traveling to elevations of 1,500 meters and above could be at greater risk for having an asthma exacerbation when
they arrive. 2 However, little research has been done to determine who is more susceptible to Acute Mountain
Sickness (AMS) or more perilous altitude illnesses like HAPE. A group of researchers studying the effects of high
altitude and cold air exposure on airway inflammation in patients with asthma did incidentally find that patients with
lower oxygen saturation levels during a hypoxic exercise test were more likely to suffer from AMS when climbing to
high altitude. 4

What have we learned? HIGH altitude equals a LOW trigger environment for asthma patients. That means
it’s time to take that desired mountain vacation or tell your loved ones that suffer from asthma to finally come visit you
in the mountains! Keep in mind, the cold, dry air often accompanied by high elevations can incite an inflammatory
response, in turn, worsening asthma symptoms for some. We recommend visiting in the summer months. This
adverse reaction to cold air can be thwarted by using a face mask or other protective gear that not only warms but
also humidifies inspired air. 5

Disclaimer: If you or a loved one with asthma plan on traveling to high altitude be sure to check in with your primary
care provider first. If your asthma is not well controlled you may want to avoid any travel as it could increase your risk
of an attack.  Be prepared! Always carry your rescue inhaler and if you plan on going up in elevation be extra
cautious and bring inhaled or oral steroids as well. 

Laura Greenberg, PAS-II
Midwestern University Physician Assistant Program
Clinical Rotation—September 2017

Resources

  1. Centers for Disease Control. Asthma. http://www.cdc.gov/asthma/default.htm. (retrieved September 24, 2017)
  2. Mendenhall, A.M. & Forest, C.P. (2017). Out of air: Is going to high altitude safe for your patient. JAAPA, 30(8), 10-15.
  3. Rijssenbeek-Nouwens, L.H., Fieten, K.B., Bron, A.O., Hashimoto, S., Bel, E.H., and Weersink, E.J. (2012). High-altitude treatment in atopic and nonatopic patients with severe asthma. Eur Respir J. 40(6): 1374-1380
  4. Seys, S.F., Daenen, M., Dilissen, E., Thienen, R.V., Bullens, D.M.V., Hespel, P., Dupont, L.J. (2013). Effects of high altitude and cold air exposure on airway inflammation in patients with asthma. Thorax BMJ. 68: 906-913
  5. Cogo, A., Fiorenzano, G. (2009). Bronchial Asthma: Advice for Patients Traveling to High Altitude. High Alt Med & Biol. 10(2): 117-121
  6. Vinnikov, D., Khafagy, A., Blanc, P.D., Brimkulov, N., Steinmaus, C. (2016). High-altitude alpine therapy and lung function in asthma: systematic review and meta-analysis. ERJ open research, DOI: 10.1183/23120541.00097-2015.
  7. Grissom, C.K., Jones, B.E. (2017). Respiratory Health Benefits and Risks of Living at Moderate Altitude. High Alt Med & Biol. 00(00): 1-7
Acclimation, Child Growth & Development, Health, High Altitude, Medicine

Children’s Ears and Changes in Altitude

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Children’s Ears and Changes in Altitude Changes

The middle ear is where problems originate during changes in altitude like flying in a plane or driving over mountain passes. The middle ear contains Eustachian tubes that open and expand/contract to accommodate for changing air pressures in the environment. Adults have the knowledge and ability to actively “pop” our ears with intention so the pressure doesn’t become too high. Children that are too young to understand this process are at a higher risk for developing problems related to pressure related changes in the middle ear. So if you have descended on a plane or over a mountain pass and your child has been screaming the whole time…this is probably why!!! Their Eustachian tubes are also narrower and shorter than adults putting them at higher risk for problems equalizing pressure changes. Descending is usually when the most intense pressure changes occur but it can become a concern at any point in a trip.

Things you can do to help your baby/children:

  1. Encouraging them to swallow (this will help the Eustachian tubes to expand)
  2. Giving them a pacifier (in babies and much younger children this sucking can mimic swallowing and help to expand the Eustachian tubes)
  3. Give them a bottle (this is even more effective than a pacifier at opening the Eustachian tubes)
  4. If they are old enough to chew gum this can be very helpful!
  5. If they are old enough to follow directions but don’t have the natural instinct to pop their ears then have them pinch their nostrils closed, fill their cheeks with air, and blow out with the mouth closed directing the air toward the ears. This may have to be repeated several times to achieve effect. (These directions seem to help with understanding the technique)
  6. NEVER EVER LET YOUR BABY SLEEP DURING THE DESCENT. Allowing the pressure to build up without relieving it for an entire descent can put your child at risk for an ear drum rupture, especially if they have been congested or have a cold already. You should keep your baby awake for any descent and follow the above advice for pacifier or bottle feeding during this time.
  7. Decongestants are okay to pre-medicate adults for altitude changes but not the best option for very young children or babies. If you are planning on traveling with a congested or sick baby and have concerns about altitude pressure changes in the plane or mountains, speak with your healthcare provider before administering any medications.
  8. If your baby or child remains fussy, irritable, congested, feverish, or is pulling at their ears they should see a healthcare provider to assess if there is an ear infection (this may be related or unrelated to the altitude changes)

American Academy of Otolargyngology. (2017). Ears and altitude. Retrieved from: http://www.entnet.org/content/ears-and-altitude

Tara Taylor RN, BSN, CEN, CCRN

tarat@ebertfamilyclinic.com

Tara Taylor, FNP

Tara Taylor is a Family Nurse Practitioner at Ebert Family Clinic where she provides adult patient care and participates in high altitude research. She is a passionate advocate for mental health, women’s health, and affordable health care.

Acclimation, Child Growth & Development, Health, High Altitude, Medicine, Mountaineering

P.L.A.Y. AT ALTITUDE CAMPAIGN

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This summer, as part of my RN to BSN program with UCCS, I needed to complete a public health course with clinical. I decided on an unusual path by joining the team of pediatrician and public health activist, Dr. Ebert-Santos.

Dr. Ebert-Santos has been the primary care giver for my two boys, now 8 and 4 years old, since birth. I would venture to say that Dr. Chris, as we call her, is known by most families in Summit County. Not only are we a mountain community but we are a community committed to growing in mindful ways. A lot of thought goes into how we operate our community events and care for our families. Dr. Ebert-Santos has been very active on more community issues than I can address here. But, let’s include water quality, health insurance/coverage initiatives, and pretty much every community health walk for a cause, healthy community eating and garden initiatives, bike to work week, trail maintenance…you get the picture. For these reasons, I finagled my way into her office this summer.

Our community is one of the healthiest in the nation according to national statistics. We are one of the lowest on obesity, adult diabetes, and hypertension. For this reason, along with the beauty of the Rocky Mountains, we have a lot more people moving here than ever before. “Summit County has recently exceeded a permanent resident population of 30,000. This is a 28.7% increase in full-time residents since 2000” (Summit County Colorado, 2017).

One major health issue that Dr. Ebert-Santos is bringing to light with her current research shows that high altitude kids are often born at lower birth weights, catching up on the national growth charts within the first few years. These babies are not unhealthy by high altitude standards. The problem is that statewide and nationally, we have yet to set standards specific to high altitude children. Dr. Ebert-Santos is making a big push to address this.

Dr. Ebert-Santos is also the doctor most likely to check your newborn for wellness and release them home, safe and sound, following birth. Many of our mountain babies go home with an infant oxygen tank that you will see parents wearing as backpacks. Dr. Ebert-Santos has been collecting and analyzing data on high altitude kids for years now. At higher altitudes, we have lower air pressure and that means decreased bioavailable oxygen. While many people are aware that acute mountain sickness and high altitude pulmonary edema (HAPE) are potential obstacles to overcome when travelling up into the Rockies, many people do not know that our resident children, who haven’t even travelled down from altitude and back up, are also prone to these illnesses. High altitude pulmonary edema in children living at altitude can follow the sort of respiratory infections that kids are prone to catching as they make their way through school while their immune systems are developing. This is often entirely treatable with oxygen alone.

The problem Dr. Ebert-Santos has identified is that, assuming residents are acclimated and therefore unlikely to have HAPE, kids here are often diagnosed with pneumonia instead of HAPE. Treatment of pneumonia often involves a hospital stay with antibiotics and other medications on board. Dr. Ebert-Santos sees dozens of children each year who have what she would like others in the medical community to recognize as Mountain Resident HAPE. With proper diagnosis, these children can be treated with oxygen and improve within a matter of days. Awaiting recovery from pneumonia when there is no pneumonia present can be detrimental to children.

Dr. Ebert-Santos will have her research published this year in the Journal of High Altitude Medicine and Biology. I had the fortunate experience of working this summer, with Dr. Ebert-Santos and her dedicated team, to create a public health message relevant to her work. Office manager Meaghan Zeigler, who has a master’s in public health, was invaluable to my education there.  I was happy to find that our local oxygen companies were ready to join in this effort to educate the public. Big thanks to Summit Oxygen Inc. in Frisco, AlpinAire in Breckenridge, and AeroCare in Silverthorne! Below you can see the acronym I created to help high altitude families recognize the signs and symptoms of high altitude illnesses, including HAPE and Mountain Resident HAPE.

Stay safe and keep breathing Summit County!

Juli Joyce, RN

 

Acclimation, Health, High Altitude, High Altitude Training & Fitness, Medicine

High Altitude Training for Better Sea Level Performance

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High altitude training has become very popular among endurance athletes over the past few years. This trend has developed due to emerging evidence that chronic exposure to altitude improves overall performance at sea level. There have been multiple peer reviewed studies proving that physiologic changes which occur with high altitude training are beneficial for low altitude performance. The physiological changes that occur in response to decreased oxygen availability include increased erythropoietin response, leading to an increase in red blood cell production. These physiological changes lead to an improvement in oxygen carrying capacity and the delivery of oxygen to muscles. The ability to store iron is also increased. Even though these physiological responses appear to have beneficial effects, they can also be detrimental. Some studies have indicated a “detraining effect” associated with long term high altitude training. The low oxygen available at high altitude impairs the ability to train at high intensity, which can in turn negate the improvement in VO2 max.

Given the most recent data collection, the mantra of “Live High, Train Low” has been adapted. The idea behind this thought process is that the athlete is able to gain all of the beneficial physiological changes of training at high altitude, while still being able to train at high intensities at a lower elevation. In order to gain the highest advantage from high altitude training, a series of clinical guidelines has been published. The guidelines state that the optimal altitude at which to live and train is between 2000-2500m. Although altitudes about 2500m provide the beneficial physiologic effects previously stated, they are also associated with negative effects such as decrease in quality of sleep. The guidelines also recommend all training performed at altitude to be of low intensity, and to reserve high intensity workouts for lower altitudes. Furthermore, it is recommended that in order to maximize the benefits of altitude training, one should remain at altitude for a minimum of 21 days. Finally, it is recommended to compete either within 48-72 hours after returning to sea level or to wait approximately 14 days before competing.

Altitude training is nothing new to the elite athlete. This has been a tool used by many top athletes over the years in order to gain as much advantage as they can on the day of a competition. It is these specific guidelines which have been recently been published that give more precise strategies to optimize sea level performance. It is, however, always important to keep in mind that although the above guidelines can give both professional endurance and everyday athletes the best chance of improving their competitive performances, the response to high altitude training can vary from one individual to another.

Anna Miller, PA-S

Carly Stillman, PA-S

Red Rocks Community College Physician Assistant Program

Resources:

Constantini, K., Wilhite, D. P., & Chapman, R. F. (2017). A Clinician Guide to Altitude Training for Optimal Endurance Exercise Performance at Sea Level. High Altitude Medicine & Biology. 18(2), 93-101.