Ski America is a company that has organized accommodations and itinerary for international athletes and vacationers at ski areas around Colorado since 1988. The Omori family, Ski America’s founders, lead their clients on tours of Colorado’s most renowned mountains, including Aspen (8,040 ft.), Vail (8,120 ft.), Beaver Creek (8,100 ft.), Copper (9,712 ft.), Keystone (9,280 ft.), Breckenridge (9,600 ft.) and Arapahoe Basin (10,780 ft.).
Jimi Omori started Ski America as a tour operator for Japanese skiers and snowboarders. Ryoko joined in 2005, and now Ski America’s service is more than tour operating, assisting from first-time skiers of age 3 to professional racers. With over 30 years of experience guiding amateur skiers and international athletes alike, the Omori’s have made some fascinating observations of how people adjust to the high altitude environment of the Rocky Mountains.
The other day, Ryoko shared some of their valuable insight and experience with me over a cup of tea:
How long do your clients typically stay at altitude?
So we have two different kinds of customers. In November until early December, we have a lot of Japanese racers from Japan. They are high school kids, college students. They stay two to four weeks here, in Frisco or Copper Mountain. Then, from December to April, we have clients from Japan who stay in Vail or Aspen. Most of them are senior skiers, over 60 years old. They stay about a week in Vail or Aspen. Six nights is very average.
How often do you get repeat customers?
Quite a lot. Not all of them come back every year, but more than once. I would say, 70%.
Do you see new customers every year?
How do you advertise in Japan?
Word of mouth.
How do you prepare your customers for the altitude?
When I set up the reservation for them, I send them the lodging confirmation and shuttle confirmation, how to get to the Colorado Mountain Express counter at Denver International Airport. With that information, I also send how to get ready for this altitude by e-mail to every customer: Don’t stay up all night before coming over here, don’t overwork before coming here, most importantly, don’t catch a cold before coming over here. That’s the most important thing. And keep yourself hydrated on the flight and on the shuttle. You can always stop at a restroom on the way from the airport to get here. Do not drink a lot [of alcohol] on the flight, and especially on the first night staying here. I encourage them to drink two liters of water a day.
They are so excited to be here, so they tend to forget about the altitude, because there are all the trees, it’s not above the tree line here. In Japan, [this elevation] is way over the tree line. So I always remind them, “You are going to be almost [at the elevation of] Mt. Fuji. So, move slow the first and second day of staying here.”
What about conditioning, physical exercise to prepare? Are they athletic?
They’re pretty much athletic. They’re avid skiers. They ski in Japan regularly. So I do not give them any athletic advice in Japan.
Do they come straight from Denver up to elevation, or do they stay in Denver a certain amount of time?
No. The flight arrives at 12:30 or 1 pm, so it’s very convenient for them to get on the shuttle in the afternoon, and they will be here before 5 or 6.
Do they ski the next day?
Most of them, yes.
What about oxygen or medication? Do you ever tell them to bring ibuprofen or anti-nausea medication?
No. But if anything happens here, I recommend taking [something] for a headache, like Advil.
What is the earliest sign that something might be wrong or that they need medical attention?
Headache. Or sometimes nausea. We had 150 racers last November, and out of 150, I took 5 kids to the clinic for altitude sickness symptoms.
Is it at the beginning of their stay?
Very beginning. [Typically] the second day of skiing. They are okay on the first day. They do not notice anything on the first morning, so they feel, “It’s okay, let’s go skiing!” and spend the day on the mountain, and they have jet-lag, and they can’t sleep well on the second night. And on the second morning most of them notice the symptoms. Those are the Copper clients. And I have 350 guests from Japan staying in Vail and Aspen. Last year, I didn’t see anyone get sick. So it’s only in Summit County, because it’s much higher.
Do you think there are any other correlating factors, like their age or where they’re from?
Age. The racers are from middle school to college, so they’re young. Their hormone level is not stable. And they are staying with their other teammates, apart from their parents, so it could have some emotional factors affecting them, too. But at the same time, the racers have a lot of muscle that needs a lot of oxygen. The higher metabolism that younger kids have [make them] more prone to high altitude sickness. The clients who stay in Vail or Aspen, they are much older, like, 40s, 50s, 60s. And they’re not as athletic as the racers. They do not do any training. So their basic metabolism is low, so I believe they do not need as much oxygen.
Does anyone come from a high elevation in Japan, or is it mostly sea level?
Mostly sea level. Only some of them are from Nozawa, it’s about 1000 m (3,280 ft.), so it’s much lower than Denver.
Is there a difference between the guests that come from Nozawa and the guests that come from sea level?
No. Whenever I see the doctor in the ER, or the Copper clinic, they always say it’s dehydration. No matter how much we tell them to keep hydrated, it’s not enough.
So what does the ER or clinic often give them besides fluids?
Oxygen. And they say it’s okay to take over-the-counter headache medication.
How long is their visit to the hospital? Is it just a couple hours, or do they stay overnight?
Just a couple of hours, or less than that.
Do they ski the next day?
Most of the time, the doctors say not to ski the next day. We carry a pulse oximeter in our office. We have 20 of them. We do not do this for the Vail clients, because they don’t get altitude sickness. So we only do this for the guests staying in Summit County. When we [check them in], we distribute pulse oximeters, one per room. We encourage them to measure [their oxygen level] every morning. Then, after the doctor’s visit, the doctors say it’s okay if your oxygen level is over 90%, 20 minutes after getting off oxygen.
What’s the lowest you’ve seen the oxygen level on any of your skiers?
38. [He was] 15. He was at the ER. He was transferred to Denver by ambulance. He was there about three nights, and he went back to Japan.
Was that the only time somebody had to go back to sea level?
Yes. But it sounds like he had a heart issue, which we didn’t know [about].
Have you witnessed any other factors that help them acclimate more effectively?
I encourage them to eat carbohydrates instead of getting a lot of oily foods. If you have a lot of french fries, it’s very oily, it will take more time and blood to get to the stomach. So the blood flow doesn’t go through the brain [well].
What about caffeine or other holistic remedies?
No. We have some repeating guests who had … symptoms in past years, and we encourage them to visit a doctor in Japan [who] can prescribe … Diamox. One of the ski coaches [from Japan] … has to be here with his team. He has no choice. And he’s [had] a lot of altitude sickness in the past. So we told him, “You should see a doctor and get Diamox prescribed, and start taking it before leaving Japan,” and it’s been working great.
Is there a routine that your clients do to prevent feeling this sickness?
Just check blood oxygen level every morning.
Of the clients that come here regularly, do they acclimate quicker each time?
They learn. We always see lower numbers of altitude sickness patients, because they learn what they need to do, like drinking a lot of water and checking their blood oxygen level. And only the numbers can tell. Even if they feel good, if the numbers are bad, if they go skiing, they will have a problem. Especially for the young kids. They [don’t] trust what you say. As the years go by, the coaches will learn, and the kids will learn what they can and what they cannot do.
Is there anything different about the philosophy of treatment in Japan vs. the US?
You know what, we do not have altitude sickness in Japan. Only if you climb up Mt. Fuji, in one day, it could happen, but not everyone does that. The highest elevation of one ski area in Japan is about 2000 m (6,561 ft.). No one has experienced high altitude sickness in Japan.
When I climbed Mt. Fuji, I saw a lot of people with cans of oxygen that you can spray. Do you ever use or recommend that?
No. I don’t think it works. If you breathe it for five minutes, it will work for five minutes. So I guess it’s very effective if a ski racer uses it right before the start [of a race]. I believe some of our Vail clients [have seen] the bottle and have purchased it, but I’ve never heard anything about it, good or bad.
In closing, I asked Ryoko if she’d noticed a change in her own physiology since living at high altitude, to which she replied that she is always impressed by her increased stamina and speed when she steps on a treadmill back at sea level. I asked her if she ever experiences symptoms upon coming back to a high altitude from sea level. “No,” she says, laughing. She doesn’t typically engage in any strenuous activity the first day or two after travelling, “because I’m lazy,” she says.
Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.
A child in my clinic had a small appendage in front of her ear, called a preauricular tag. I told the mother that I had just returned from a conference where I learned these are more common at high altitude. She replied, “But his father has one also.”
“Yes,” I explained, “There is an interaction between the genes and low oxygen.”
Birth defects can be increased or decreased by the chronic hypoxia at high altitude. Geneticist Igor Salvatierra from the Hospital Materno-infantil discussed the interaction between oxygen levels and chromosomes at the Chronic Hypoxia conference in La Paz, Bolivia. He focused on a deformity we also see more commonly in Summit County, Colorado at 2800 meters: outer ear deformities – microtia. Birth defects can be structural, like the outer ear, or functional, such as deafness, and occur in 1 out of 33 infants worldwide. Only 50% of abnormalities can be linked to a specific cause. Club foot is an example of a birth defect that is less common at higher elevations. In contrast, microtia is three times more common, with preauricular tags twice as common as at sea level. This is due to the interaction between genes and the environment.
Research has identified an enzyme called Jarid1B that is affected by hypoxia, including sleep apnea, copy number variation (CNV) and epigenetic factors such as stress and diet. These act on chromosome 1q32.1 to change the coding of proteins involved in the development of ear cartilage very early in fetal development.
At lower altitudes, the hypoxic environment can be caused by sleep apnea. In early pregnancy this could be one of many factors that, if added to the genetic predispostion, could cause a deformity in the fetus. Luckily the fetus is fully formed before the sleep difficulties in late pregnancy.
Should pregnant mothers or women who are hoping to conceive sleep on oxygen?
From what I learned in La Paz, not necessarily. There are factors in our low-oxygen environment that decrease our risk of other diseases.
Dr. Christine Ebert-Santos recently sat down with Colorado Children’s Hospital’s Pediatric Emergency Medicine physician, Dr. Alison Brent, to share her experience and expertise in high altitude medicine.
After having practiced for decades in the Commonwealth of the Northern Mariana Islands, Dr. Chris opened her own practice in the high mountain community of Frisco, Colorado, where she has spent 20 years servicing natives, transplants and visitors alike. The mountain communities in Colorado are found at elevations higher than any others in North America, and are among the highest in the world. It has become her legacy to contribute to the research and improvement of medical practice in high altitude environments across the globe.
The full podcast episode from Charting Pediatrics can be found on Spotify, Google Play, and the Apple Podcast app.
Dr. Brent: “I know that sometimes in these South American countries, the high altitude illness impact for children can be even greater than what we see in the US.
Dr. Chris: Well, that’s where you get into ‘acclimatization vs. adaptation’. And what doctors in the United States need to know is that, just because a person lives at high altitude in the United States, we may be acclimatized, but we are not adapted, like the natives of La Paz and Nepal. So therefore we don’t have hundreds of generations changing their genetic adaptation to high altitude. We may have 20 years or 40 years. So the risks are still there.
Dr. Brent: Wow, it’s an amazing process. I know that when I moved to Colorado from flat-lander country, I found that there were just huge textbooks on high altitude illness. And it’s fascinating that you’ve taken this over as a very important part of your career.
Dr. Chris: Yes, well we have 5 million tourists every year coming just to Breckenridge, so it’s probably 10 million to Summit County. Plus, we take care of all the children in the surrounding communities, Park county and Lake county, which are higher: over 10,000 ft. So it’s very important to be aware of anything that can come up in both our visitors and our residents.
Dr. Brent: So this very important topic doesn’t just apply to practitioners who might live in Colorado or other mountainous areas. It really applies to practitioners all over the world who have patients who may travel to these areas. And with that in mind, when you have a practitioner and a family who live near sea level and they’re planning a trip to the mountains, how do they start to advise that family on how to get ready for a trip to a high altitude area?
Dr. Chris: I occasionally do get calls from physicians and families who are planning to bring their children, especially if they have a very young infant or a child with special needs. And so, things that I like to tell them are, Number One: If you could travel by wagon, train or mule, you would be best adapted to high altitude, because arriving to high altitude gradually helps your body adapt.
Second best to that is to stop over an intermediate altitude area. Fly into Denver and spend the night there before you come up to the very high altitude areas, especially Summit County. You start to get altitude symptoms around 8,200 ft. or 2500 m, which is the altitude of Vail. If you’re at a lower resort, most of the other resorts in the United States are below 8000 ft., and the risks of altitude illness are not as great. But the rewards of coming to the Colorado Rockies are also greater, because we have seven world-class ski resorts within an hour of where my office is, so it’s definitely worth it. Just arrive, take your time getting up there, relax, try not to do anything too strenuous the first day.
Consider taking Diamox or acetazolamide; the pediatric dose is 5 mg per kg per day, maximum of 125 BID. This has an effect of increasing your ventilatory drive, and definitely decreases the risk of acute mountain sickness when people come to visit the mountains. It’s best to start the day before, but even starting when you get up there works. And if you go to the Hypocrites app, you will find that it is listed for altitude sickness prevention.
Thirty to fifty percent of people visiting the mountains, especially when you fly right in and drive straight up, will experience some symptoms of acute mountain sickness, whether it’s a little nausea or vomiting or headache. So be prepared with some ibuprofen with dose appropriate to the age of the child, and Zofran would be a good thing to have in your pocket, too. It could save you a trip to the ER or doctor’s office. Because we’re just talking about the first 24 to 48 hours. If you could keep everybody in your travel team comfortable, you will have a great vacation.
Now, once you get there, or if you can before you arrive, we tell everybody, “You should have a pulse oximeter.” It’s just a little finger clip. At our office, they cost $17. Walgreens might sell them for $30 or $36. Knowing that oxygen level tells us everything.
You can call me anytime. I give my cell phone to all my patients, because … we need to know when someone’s oxygen is outside the normal range. If it’s below 90, we may want to see that child or even adult, because we do have family nurse practitioners, more urgently. And that is the key piece of information for knowing how sick someone is, and whether they need to be seen within a few hours or can wait until the next day.
Dr. Brent: Do you just prescribe oxygen if their oxygen saturation is low, or do you like to see them as well?
Dr. Chris: We can send oxygen anytime, day or night. We have three oxygen companies, and I can call them up and give them your number and location. I do, of course, want to see anybody that I’m prescribing oxygen for, but I may not have to see them in the middle of the night. Especially if everything sounds classic. My own patients that I’ve already identified as having a risk for Re-entry High Altitude Pulmonary Edema (R-HAPE), we can just set that up, even ahead of time.
Dr. Brent: You know, one of the things that I’ve noticed popping up in the mountains are oxygen bars, where, essentially, people can use an oxygen concentrator at a bar to relieve some of their symptoms. Should we think about preventative maintenance and getting people coming up here set up with oxygen before they come, or do you like to measure the oxygen saturation before you give oxygen? Because people say they just feel better having a little oxygen in the mountains.
Dr. Chris: Definitely the non-prescribed sources of oxygen, such as the canisters that you can buy in every store and the oxygen bars can help you with your headache and nausea. Use that for 10 or 20 minutes, feel better, that may be all you need.
Dr. Brent: And then what about the kids who you might see who have an oxygen saturation less than 90%, you see them in your office. How does the treatment plan roll out from there?
Dr. Chris: So the biggest concern we have is High Altitude Pulmonaryt Edema (HAPE). Now, don’t be scared, this is less than one percent of visitors, and probably between one and two percent of residents. The risk of developing HAPE is increased in anybody who has an inflammatory process going on, such as a cold or influenza. It definitely can occur in the first 24 to 48 hours in visitors, or even up to five days in our resident children who have a cold or some other underlying illness. So we do want them to have a pulse oximeter. This can develop fulminantly so that they’re doing fine for the first 24 hours or the first 4 days of their cold, and then all of a sudden, they kind of gas out, and they’re just lying on the couch and not eating well. Or it can develop very slowly.
So what we like to do if we know their oxygen is low, and whenever we see them in our office the first thing we do after the history and physical is to try an albuterol treatment and inhalation in case there’s some underlying broncho-constriction or asthma component. That would basically be most helpful in families with a history of asthma, or families that tell me they’ve used albuterol … before with that child or personally. It doesn’t usually change their need for oxygen. But it might help their cough.
However, once we do start somebody on oxygen in the office and call the oxygen company to set up a home concentrator, we see them back the next day and parents will tell me their cough was much better using oxygen. So oxygen is the main treatment. We are always thinking, “Could this person have pneumonia? Could this person have asthma?” Because of my experience at sea-level and taking care of very sick kids, if you have somebody with an oxygen level of 79 or 85, and they had asthma, you would certainly know that. You would hear some wheezing, there would be retractions, rails. They’d be in distress. If they had pneumonia, they’re sick, they’re not eating, they have a fever, you hear vocal changes in their respiratory findings. Most of these kids that we see, both the residents and the tourists with HAPE, we often won’t hear anything in their lungs, because children, how often can you get them to take a deep breath. And we often won’t see anything on the x-ray, so I don’t typically do an x-ray until the following day. If they’re not better and the parents are still concerned, we will do an x-ray. Often the x-ray won’t show anything. And this is where I’m hitting my head against the wall, and why it took me nine years to get my first publication. Because high altitude experts and all the pulmonologists are just freaking out that what I’m calling HAPE, or HARP, High Altitude Resident Pulmonary Edema, often does not show changes in the x-ray, and that I don’t do x-rays on all these hypoxic kids I see, because I know they’ll do fine if they just get some oxygen.
Dr. Brent: I love that approach of less is more, so we totally support that at Children’s Colorado. If you think a child has more than acute mountain illness and they actually have some degree of HAPE or HARP, how do you treat them differently?
Dr. Chris: Basically, oxygen. Now when a family arrives for their vacaction, and they’ve got, you know, ten family members in a condo, and one of the kids is sick, you know, we want to have a low threshold treatment. Influenza: we’re gonna put everyone on Tamiflu so that it doesn’t spread. You know, possible strep throat or is there any possible role for anti-biotics, we’ll have a low threshold.
And then we really sell them on the oxygen. You guys don’t have to leave. Your kid will adjust to the oxygen. We have things on our blog on how to keep your two-year-old from taking off their oxygen canula. That can save your whole vacation if you just understand that oxygen is the treatment, that you don’t have to go downhill.
Every once in a while we do have someone sick enough that we will send them down to Denver, directly to the hospital. But a lot of parents will ask me, “Well, what if I just take my kid instead of putting on oxygen, we’ll go down and check into a hotel in Denver?”
I’m not too happy with that, because I [say] you have to be under medical supervision, you have to know that your child’s oxygen is good once you get to Denver. As long as you’re here in the mountains, I’m your physician, you can call me anytime day or night, we can change our plan if it’s not working. If you’re in the condo and you don’t think your child is doing well, we can put your child in the hospital or send them down to a lower altitude if things are not going well.
Dr. Brent: So Chris, a lot of the literature does say that … one of the treatment plans would be to go to lower altitude, but you’re saying they can just stay in the mountains with oxygen and salvage their vacation.
Dr. Chris: Absolutely. We do it many times, every week at our clinic and in the emergency room. They do it every day, I’m sure.
Dr. Brent: Absolutely. Well, often times, when they do get down to see me in the ED, it’s a pretty easy diagnosis of, usually, some variant of acute mountain illness, and often times they’re better when they get to Denver from when they were up in the mountains. They may no longer have an oxygen need. And those kids who are then going to go back up, I hate to change anything that you or another pediatrician may have done, so we usually just keep them on their oxygen, and if the family wants to try going back to salvage their ski vacation, we let them do that.
Dr. Chris: As long as they have a home pulse oximeter, that little finger clip, they will know when they need to call someone.
Dr. Brent: That is wonderful. You mentioned a few of the co-morbidities that you worry about in children who may have an underlying influenza or some reactive airway disease. Are there other conditions, like kids with Down Syndrome or any other special groups that you worry about?
Dr. Chris: Definitely Down Syndrome children are a concern. Of course, I have many Down Syndrome children in my practice, and they do fine. But Down Syndrome children do have airway problems because of their hypotonia. So they’re more likely to need CPAP or have poor oxygenation during sleep. They’re more likely to have pulmonary hypertension or cardiac defects in general. And they also have increased pulmonary vascular reactivity. So … if you’re going to take a vacation and bring your child to altitude, make sure you have a pulse oximeter and that you are watching them very carefully for signs of decreased energy, poor feeding, color, anything that … is concerning that you as a parent are wondering, “This is not normal for them.”
All children, and even adults, when they come to altitude, they do have a decreased appetite. So that can last for months. Also sleep issues. There’s central apnea that is universal when anyone comes to altitude. Sleep is not going to be the same, and it takes a couple weeks for, actually, your sleep to adjust. But if it’s really interfering, and things are just not going well, we should take a look or consider whether that child is doing okay at altitude.
The other children who should not come to altitude are children who have a cardiac shunt with increased blood circulation in the lungs. That could really put them at risk for HAPE, and children with sickle cell disease. That can be really a crisis, even at altitudes as low as Denver, can cause a problem. So you need to be in touch with someone experienced with your condition if you want to travel with those conditions.
I have read in … articles by Peter Hacket and the other altitude experts not to bring children who are less than six weeks old up to altitude. Here’s the issue: you have a family wedding, everyone’s going there, you want to bring your new baby, they’re probably going to do fine. So I would say, just know where your local pediatrician that you can call anytime day or night is, and that baby will probably be fine.
Dr. Brent: Would you say the same for premature infants?
Dr. Chris: Premature infants, they are probably going to be okay. Once again, we have babies who are born in Denver and come home a few days or a few weeks into their early life experience, and we just check their oxygen in the office, or we can send a respiratory therapist from the oxygen company to their house to check their oxygen. And that is the best way to really keep track of what’s going on. Because babies are used to being in a low-oxygen environment. Remember, the uterus, the womb is like Mt. Everest. The oxygen saturation is 40 – 60%. So they don’t tell us that they’re having oxygen problems. They’re not breathing hard, they’re not retracting, they’re not coughing. They’re just mellow, but they may not be feeding well, so we want to check their oxygen by measuring it.
Right now we don’t have inexpensive ways of measuring oxygen in infants less than one year, but I’m sure that’s coming through very soon. The Owletis out there, we haven’t found that really reliable at high altitude. But we will be able to measure babies’ oxygen in our office, and sometimes, we will send families home with one of our infant pulse oximeters if we have concerns, and it’s night-time or weekend, and we can spare that piece of equipment.
Dr. Brent: I know we’ve talked about HAPE. Let’s talk a little bit about HACE, or High Altitude Cerebral Edema, which my understanding is just a part of the spectrum of acute mountain illness where you get some vaso-dilation going on in your brain and this can be even worse. How do you evaluate and then treat patients, especially kids you think may have some HACE?
Dr. Chris: So, diagnosing HACE in children, I don’t even know of a case. Because it mostly occurs above 15,000 to 17,000 ft. That is the flurid adult onset where they have trouble walking, talking, thinking, and you’ve got to get them down the mountain as soon as possible. However, the acute mountain sickness HAPE and HACE spectrum, it’s probably a continuum.
So there’s recently an article in the Journal of High Altitude Medicine and Biology or on the Cerebral Volume. And some people have more or less space around their brain. So does their brain expand under the influence of high carbon dioxide from increased ventilation or low oxygen, and that causes the headache and the nause and the vomiting, and is that an early spectrum of HACE that you can treat with oxygen? Babies who are very fussy, just can’t calm them down, just not eating: are they having a form of Cerebral Edema, that they would feel better with oxygen? We really don’t know, but those are things that there are a lot of research going on and providers should think about when somebody gives us a call or comes through the door with their child.
Dr. Brent: That’s good to know. And I know that you have your own practice here and specialize in taking care of kids, so let’s switch gears a little bit to kids who actually live at altitude. There’s so many problems I know at altitude. I think some of the smallest babies in the country are born in Leadville, CO. So how do you handle some of these kids? What are the problems you see? Is it worth the tradeoff to have a small baby who may not grow so well, but to live in the splendor of Colorado?
Dr. Chris: Well I just came back from the Chronic Hypoxia Conference in La Paz, Bolivia, where there were researchers from sixteen different countries, and one of the things that I learned there is that one reason that newborns can tolerate hypoxia during a difficult birth or resuscitation is because they’re coming from a chronic hypoxia environment. And their metabolism and their chromosomes and mitochondria are all switched on to a low-oxygen environment. And that helps them during the first couple weeks of life. So we actually say that probably the detrimental part of living at high altitude is more than counter-balanced by the increased health that we have, decreased myocardial infarctions, decreased strokes, longer active lives. But specifically in our newborns, they have decreased birth weights of about one ounce per every thousand feet of elevation. So our newborns are more likely to be 5.5 to 6.5 lbs. rather than 7.5 to 8 lbs. And about one third to a half of our newborns go home on oxygen based on pulse oximetry studies in the nursery that are less than 90. The Heart Association or the cardiac screening is not even done in our nursery. We are … the exception of the world, because we would have to do an echo- on every baby that we see. So most of these babies go home on oxygen, but I see them in the office when they’re three or four days old, another half of them their oxygen is fine and we tell the parents, “Okay, you can have them off oxygen, but we’ll check them one more time at two weeks before we have the oxygen company pick up the tanks.” So I very rarely have children, newborns, that are on oxygen for more than two weeks. That being said, nobody really knows what’s normal. If I have a child living at 11,000 ft., should that baby be held to the same standard as the kids in Kremmling at 8,000 ft.? Or in Frisco at 9,000 ft.?
We are planning a newborn oximetry study, and we’re in contact with some of the medical device manufacturers to try and get some equipment loaned, so that we can send this home with parents and find out what is normal, and establish our own normal. My normals are based on 19 years of clinical experience. If a baby meets 89 to 90 in my office during a clinical exam while they’re quiet or sleeping or breast feeding, I will tell the parents they don’t need oxygen.
The concerns we have is if the baby is at home for long period of time with low oxygen, the changes that are supposed to take place in the heart and lungs, such as the closing of the PDA and the decreased muscular lining of the pulmonary arteries may not proceed the way they are supposed to. And that process can take up to four months. So that’s why we don’t want to leave our infants with oxygen below 89 for long periods of time. We’re not worried about a few days or a few hours, the oxygen tank runs dry or the canula falls off. We’re not worried about brain damage.
We certainly know … — I’ve been a pediatrician for 40 years — my first 20 years as a pediatrician where we would have parents who refuse surgery for their cyanotic children, and they’d be going to second grade and you wouldn’t know there was anything wrong with their brain, they’d be blue as could be. So those are the concerns that I must address with all parents, because they are going to be terrified about this.
The next thing that is going to cause an issue with these newborns is the grandma in Florida is going to absolutely freak out that her little grand-baby is on oxygen because nobody else in the world understands our situation. We have 30,000 people living in Summit County with 5,000 in each of the surrounding counties, and another 60,000 in Eagle county. Outside of that, there aren’t any communities in North America at this high elevation. So we are the only ones who really have to deal with this. The rest of the doctors and family members are totally mystified by what we’re doing.
The second thing is, not only are they born a little smaller, but we have twice the number of children who are below the normal percentiles on the WHO and CDC growth charts during the first two years of life. So instaed of three percent, we have seven percent. What that tells me is that the whole growth percentile thing is probably shifted downward. We have just analyzed 30,000 data pieces from growth charts from our clinic and the Community Care Clinic in Summit, with the help of the Minnesota Department of Epidemiology, and we are hoping to publish our own unique high altitude growth charts.
The reason this is important is because when our children come down to see a specialist at Children’s Hospital, they get told that they are not feeding their children, and that their children need to see an endocrinologist and have $2000 worth of tests done. Whereas, after my first five years as an experienced pediatrician working with feeding specialists and OT’s watching these kids grow, I decided these were normal, healthy mountain kids. Very important information.
Dr. Brent: And so, Chris, do these kids eventually catch up by the time they’re 8, 10, 12, 16, adults?
Dr. Chris: They catch up by the time they’re 2.
Dr. Brent: By the time they’re 2, perfect. So they’re not shorter than the rest of the kids in the country.
Dr. Chris: Not at all.
Dr. Brent: Just wanted to make sure. Otherwise you might not have such a huge influx of people coming in to Colorado. Anything else you’re concerned about or have to do anticipatory guidance for for kids born in Colorado?
Dr. Chris: In our population, we also see children who have Re-entry HAPE. So during spring break, they go down to visit grandma in Florida, and when they come back they have a cold, and that night, the mom calls me and says, “Oh, he’s coughing and he sounds really congested.” Well, that’s my clue that probably lungs are filling with fluid and that child needs oxygen. So we want people to be aware of that who do live at altitude.
The other thing that I’m just starting to explore is we had a case of a post-traumatic HAPE, where a student from the mountains was going to school in Denver and was hit by a car and had three broken ribs. He was hospitalized in Lakewood overnight, he had a scalp laceration, he had x-rays and CAT scans that did not show anything in the lungs. So he left the hospital at noon the next day with an O2 sat of 94. By 10 ‘o clock that night, his oxygen was 49. He had rails in both lungs, however the x-ray did not show fluid. The emergency room doctor in Summit diagnosed Re-entry HAPE, he was sent back down to Lakewood. He was on 20 liters of oxygen. He was in the ICU, he had a CT scan, which also read as normal, and by the morning, he was on 4 liters of oxygen.
Now, to me and to that ER doctor, the only thing that this could be is HAPE. However, once again, I can’t get this past the high altitude experts and pulmonologists with normal imaging. So I’m throwing a question out there. We need to be sensitive to and start to discover whether there are cases of post-surgical, post-traumatice HAPE. I hear the stories, and that brings us to the blog.
The blog at highaltitudehealth.com. So as I said, it took me nine years to get my first paper published. However, in the blog, you can publish anecdotal and personal stories of your experience with altitude. And it’s out there for people to read and say, “Oh! Maybe that’s what’s happening to me or to my child. Or maybe I should know about that before I make my trip to altitude. Or maybe I should know about that with these children who are coming down to see me from altitude.”
So I highly recommend that anyone who’s interested or visiting or living at altitude read our blog, highaltitudehealth.com. And you can get some ideas and you can make some comments and give us your ideas. And that can lead to further study and research and help us understand these situations.
Dr. Brent: That is a wonderful resource for everyone, and I would hope that our listeners and our Charting Pediatrics family all over the world listen to this. There are so many children that I see in the ER, and when I mention that I think that they have some kind of acute mountain illness, they look at me like I’ve got a fork coming out of my head. They’ve never heard the concept, and … like, “How can my kid be fussy and not eating and not sleeping, and why …?” And they don’t know that. So I think the more we can get the information out there, that would just be wonderful. So glad you’re doing this. I do think that, personally, I get a little bit of re-entry illness everytime I drive from Denver to Vail. I come down Vail pass, I get a little queasy, I get a little headache, and it takes me … a day or two to get back on track, then I’m right back down to Denver and all my symptoms are gone. So, crazy that after 15 years, I still have my little own issues with altitude in this …
Dr. Chris: Well, I have an interesting anecdote that I haven’t put on the blog yet. I made a presentation to our first line, first-responders, and someone came up to me and said that he works in Denver, so he reverse-commutes. And every time he came home on weekends, he would be sick. His primary care physician in the mountains put him on acetazolamide. And that took care of his symptoms. So he’s kind of on chronic acetazolamide, which we’re seeing more and more that this is a very safe medication that you can take when you need it. It doesn’t have to be before you arrive, it can be after you arrive, it can be five days after you arrive. If you’re not sleeping well, you can try this. The only side effects are tingling in the hands and feet, and a very bad change of taste for carbonated beverages.
Dr. Brent: That could be a good thing. I think, I know when my physician talked to me about Diamox, she had mentioned that some of the side effects are headache and GI distress, which is what I had anyway, and I thought, well, why would I want to take a medicine that the side effects are the same as the disease. But you’re saying you don’t see that very often.
Dr. Chris: I have not seen that at all.
Dr. Brent: Excellent. And no issues with kids either. Do you think that, when I see kids in the ER who have some acute mountain illness that I should be starting Diamox at that low dose? The 5 mg per kg on those kids as well?
Dr. Chris: Yes, it doesn’t hurt. And it’s definitely empowering to parents. Just like, for parents to know that they can call me on my cell phone. For parents to know that there is a medication they can give. They may not need to give it, like we give anti-biotics and say, “Okay, if their ear pain gets worse, start the anti-biotic.” More than half of them will never give that anti-biotic. But having the ability to treat your child, you feel so helpless when people are uncomfortable or sick or suffering around you, but having the ability to give them a very safe medication or call somebody for information can really give them a lot of peace of mind.
Dr. Brent: And so my overall message I’m getting from you is really one of empowerment for families taking care of their kids, that there are so many solutions. They can keep their vacation. But the mainstay is oxygen, and in your back pocket you have a little Diamox, and maybe a little Zofran.
Dr. Chris: Yep. And ibuprofen.
Dr. Brent: And ibuprofen. Excellent. One quick question: Is there ever a role for inhaled steroids if there’s some inflammation going on ? You talked about a trial of albuterol.
Dr. Chris: My families whose children have had recurrent HARPE have told me that they do not feel that adding steroids has helped. Now, that being said, all the kids — and I see 30 – 40 cases per year of mountain resident children who have a hypoxic episode during an illness and have to use home oxygen — if they have more than one episode, we do refer them to the cardiologist that comes quarterly to our office to have an echo- at high altitude to rule out any hidden cardiac shunt that could predispose them. But many of these parents will self-refer to one of the many fine pediatric pulmonologists at National Jewish or Children’s Hospital. And when they go there they will inevitably be told that their child has asthma and needs to be on inhaled steroids. They will be on inhaled steroids for a year, and they will not have any more episodes, which they were not going to have anyways. So, there you go.
Dr. Brent: I love that answer.
This has been such a wonderful talk. In closing, I love to ask this of each of our guests here: What is the most rewarding aspect of your practice?
Dr. Chris: My relationship in the community and with the families is so special, because of the small size of our community. I am able to give my cell phone to the families, and I only get a few calls a week. I might be in my office, suturing up a three-year-old and save them the cost of going to the ER, you know, once a month or every second month. But because of this low-oxygen issue, I just feel that it’s important that we touch bases and have access to understanding what’s going on with both children and adults in our community. And I also have appreciated texting, because it’s less invasive, so it’s something that’s not urgent, like a rash or an eye discharge, my patients will text me or sent me pictures. and we are having a Telehealth app coming into our practice too, so that will make it more HIPA-compliant, and more comprehensive care for the Ebert Family Clinic.
Dr. Brent: Well, hopefully we can get all of you at the Ebert Family Clinic on Tiger Connect, and solve all your problems at once. But, Dr. Ebert-Santos, it has been such a pleasure to have you on the podcast today. Your passion is palpable, what you do has such a wonderful impact on kids and their families, not only in Colorado, but those visitors who can salvage their vacation to our beautiful state because of the the things you do. So on behalf of ChartingPediatrics, thank you, and hopefully we can have you on for a follow-up episode sometime in the near future.
Dr. Chris: Yes, when we finish these research studies on newborn hypoxia and normal oxygen values in adults, we’ll have more to tell you.
Dr. Brent: Well, you are on, and we can’t wait. And until next time, keep on keeping kids safe out there!
What is a normal overnight oxygen saturation for a child? This question is asked frequently by parents who have a child that may be requiring oxygen after evaluation. As healthcare providers working at various altitudes and caring for children, knowing the change in baseline oxygen saturations when at different altitudes is key to educating patients. There are physiologic changes that result in transient changes in respiratory rate and volume while sleeping which will be discussed before exploring nocturnal oxygen needs at sea level versus needs at high altitude in healthy children.
To begin, I will define a few terms that may not be familiar, but may be used when discussing oxygen needs. Oxygen saturation is defined as the amount of oxygen bound to hemoglobin in the blood, expressed as a percentage of maximal binding capacity.1 The simplest and most non-invasive way to obtain this information is through a pulse oximeter, which is placed on the patient’s finger, toe, or ear when vital signs are being taken. Oxygen saturation is known as the “5th vital sign” and tells medical providers whether or not a patient is delivering enough oxygen to their body. Hypoxemia is defined as insufficient oxygenation of the blood.2 There are multiple causes of hypoxemia, however we categorize hypoxemia as an oxygen saturation of less than 90 percent on a pulse oximeter. Finally, we use the term desaturation to describe a patient whose oxygen saturation continues to go below expected values.
In healthy, full-term infants, sleeping approximately 16 to 18 out of 24 hours is expected. A majority of their sleep cycle is REM and occurs when they fall asleep, with shorter duration of NREM sleep. As the child’s nervous system matures, there will be predictable changes in their sleep cycle, which will be more similar to a child or an adolescent. In children and adolescents, NREM is entered when they initially fall asleep, and accounts for approximately 75 percent of total sleep time, with alterations every 90 to 100 minutes of REM and NREM. In addition, there is a progressive increase in REM in the final third of the night.3 Understanding these cycles, what occurs during these cycles, and how they change over time are important in understanding the physiological changes (Table 1) that occur while you are sleeping.
The physiological changes that we are focused on are decreased respiratory rate and decreased respiratory volume, which are seen in NREM and in the phasic stage of REM. In infants, periodic breathing is also an observed pattern of breathing that is expected after the first 48 hours of life until about 6 months of age. Periodic breathing is recurrent central apnea interrupted by breathing efforts. This topic will further be discussed in the high-altitude study, as these episodes are more common at high altitude.4
In a study conducted at sea level in Brisbane, Queensland, Australia, 34 healthy term infants were studied at 2 weeks, 3, 6, 12, and 24 months in a prospective longitudinal cohort study. The study mentioned that there was limited data on reference ranges for normal nocturnal oxygen in infants, but that they aimed to develop a cumulative frequency (CF) reference-curve. This curve may be used as a tool to compare a child’s nocturnal oxygen saturation to see if the infant falls within the range for infants that are similar in age (Figure 1). Overall, the median nocturnal saturation was between 98 and 99 percent, for infants living at sea level.6
In an additional study, conducted at high altitude in Bogotá, Colombia, 122 healthy full-term infants were studied in 4 various groups. These groups were coupled differently and were only monitored until 18 months of age. The groups were <45 days, 3 to 4 months, 6 to 7 months, and 10 to 18 months. In addition to these groups, 50 infants completed three overnight PSG studies and were analyzed as a longitudinal sub-cohort.
In this study, their overall data was presented differently and they also looked at SpO2 during wakefulness and respiratory events, which are more likely to occur at higher altitudes. An interesting finding, that was not present in the study at sea level in patients of similar size, age, and weight, was the increase in total, central, and obstructive apneas. In addition, there were also very high frequency oxygen desaturation events that again are not seen when living at lower altitudes. These events were reported as normal in infants living at high altitude. Overall, the median SpO2 was between 92 and 94 percent at high altitude.7
To conclude, the median oxygen saturations at sea level were between 98 and 99 percent and between 92 and 94 percent at high-altitude. This said periodic breathing, which is normal until six months of age at any altitude, causes transient desaturations and are more common at high altitude. Apneic events are more commonly seen in infants at altitude, but are considered normal. These studies have offered reference ranges and tools to better aid clinical judgement when caring for a patient that may require oxygen.
1. Oxygen saturation. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. (2003). Retrieved March 23, 2019, from https://medical-dictionary.thefreedictionary.com/oxygen+saturation.
2. Hypoxemia. The American Heritage® Medical Dictionary. (2007). Retrieved March 23, 2019, from https://medical-dictionary.thefreedictionary.com/hypoxemia.
3. Wise, M., and Glaze, D. (2018). Sleep physiology in children. UpToDate. Retrieved March 23, 2019, from https://www-uptodate-com.ezproxy.stfrancis.edu/contents/sleep-physiology-in-children?search=sleep%20physiology%20in%20children&source=search_result&selectedTitle=1~134&usage_type=default&display_rank=1#H4.
4. MacLean, J.E., Fitzgerald, D., & Waters, K. (2015). Developmental changes in sleep and breathing across infancy and childhood. Pediatric Respiratory Reviews, 16(4), 276-284.
5. Hanyang Medical Reviews. 2013 Nov;33(4):190-196. https://doi.org/10.7599/hmr.2013.33.4.190.
6. Terrill, P., Dakin, C., Hughes, I., Yuill, M., & Parsley, C. (2015). Nocturnal oxygen saturation profiles of healthy term infants. Archives of Disease in Childhood, 100(1), 18-23.
7. Duenas-Meza, E., Bazurto-Zapata, M., Gozal, D., Gonzalez-Garcia, M., Duran-Cantolla, J., Torres-Duque, C. (2015) Overnight Polysomnographic Characteristics and Oxygen Saturation of Healthy Infants, 1 to 18 Months of Age, Born and Residing at High Altitude (2,640 Meters). Chest, 148(1), 120-127.
The September 2018 issue of the Journal of High Altitude Medicine and Biology has an article reviewing statistics on newborn health in the Mountain Census Division: AR, CO, ID, MN. NM NV, UT and WY. The lead author, Robert Levine and his coauthors found that newborns in this region have “by far the lowest infant mortality rates for respiratory distress.” Conversely, there is a higher incidence of intraventricular hemorrhage, or bleeding in the brain, not caused by trauma. This can be a complication of prematurity.
The authors analyzed about 70 million births and 12,000 deaths in over 3000 counties between 2007-2015. They compared maternal education, age, and marital status. The mean elevation of the mountain division counties is 5,725 feet, with the mean for the rest of the US being 2,500 ft. Colorado ranges from a low of 3317 ft to 14440 with a mean of 6800 ft. There were 30 counties above 8000 ft.
Their conclusion :”…we believe the most plausible interpretation of the present data is that they raise questions abut whether maternal residnce at high altitude has uniformly adverse health effects on infant mortality.”
In other words, maybe it’s not all that bad to live in the mountains!
Dr. Deborah Liptzen, pediatric pulmonologist from Children’s Hospital of Colorado,
Presents a talk on high altitude to the Ebert Family Clinic staff
I learned several new facts about adaptation to altitude that make us better athletes. First, our muscles have more capillaries to deliver blood to the cells. Second, the cells have more mitochondria which are organelles involved in the chemistry of respiration and energy production.
Other ways our bodies respond to altitude include: increased breathing rate (instant), increased red blood cells (peaks in three months), hemoglobin in red cells holds on to more oxygen, and blood vessels in the lungs constrict (immediate).It is this constriction of blood vessels in the lungs that can go haywire putting pressure on the capillaries causing fluid leaks that lead to pulmonary edema or HAPE.
The American Academy of Pediatrics published a new study titled “Firearm Storage in Homes with Children with Self-Harm Risk Factors.” The conclusion of this article was that parent’s decision to have firearms in the home as well as their storage practices were not influenced by the presence of a child with a mental health condition in the home. The study was comprised of a web-based survey, which was completed by parents of 3,949 households in the US. The results showed that approximately 42% of households that contained children confirmed having a firearm in the house. This percentage did not change when comparing household in which children with mental health reside to those whose children had no mental health issues. The study also showed that of those parents/ caregivers who own firearms only 1 in 3 stored all firearms locked and unloaded. This ratio did differ between households that contained children with mental health issues versus those that did not.
This study led me to question the role of pediatrics in determining the ownership and storage of firearms in homes with children. At every well child visit for children above a certain age we ask if there are any firearms in the house and if so, how are they stored. I found myself wondering “Have studies shown a decrease in injury by firearms following pediatrician intervention and education?” A study published in 2000 concluded that “a single firearm safety counseling session during well child care combined with economic incentives to purchase safe storage devices, did not lead to changes in household gun ownership and did not lead to statistically significant overall changes in storage patterns.” However a randomized controlled trial published more recently, in 2008, concluded that a brief office-based violence prevention approach resulted in increased safe firearm storage.
The American Academy of Pediatrics first issued guidelines in 1992 noting that the safest home for a child is one without firearms. These guidelines also note that if firearms are going to be in households they should be locked and unloaded with ammunition stored separately. I grew up in a house of avid hunters and gun owners and I can just hear them saying, “What good is a gun in the case of an intruder if it is not immediately accessible?” One study in the Journal of Trauma found that “guns kept in homes are more likely to be involved in a fatal or nonfatal accidental shooting, criminal assault, or suicide attempt than to be used to injure or kill in self-defense.” This article claims that the benefit of having a gun in the house for self-defense does not outweigh the risk of accidental injury by that same “protective” weapon. Other’s who advocate for firearm use and ownership claim that if children are properly educated and trained in gun safety there would be less accidental shootings. However, one study published in 2002 had children participate in a weeklong firearm safety program on reducing children’s play with firearms. Following this training period the children were exposed to an unloaded firearm. 53% of the children played with the gun as if it was a toy gun. This study cast doubt on the effectiveness of skills-based gun safety programs for children.
I recognize that it would be naïve of me to think that every gun owner with children in the house is going to forfeit his or her right to their firearms because of this data. That is why there are important organizations such as Project Childsafe (http://www.projectchildsafe.org/parents-and-gun-owners) that cater towards gun owners. This organization provides comprehensive information about gun safety in the home and offers free resources such as cable-style gunlocks to further protect children in their homes.
Jocelyn Rathbone PA-S
References: Scott J, Azrael D, Miller M. Firearm Storage in Homes With Children With Self-Harm Risk Factors. Pediatrics 2018 March; 141(3): e20172600. Retrieved March 11, 2018.
Kellermann AL, Somes G, Rivara FP, Lee RK, Banton JG. Injuries and deaths due to firearms in the home. J Trauma. 1998 Aug; 45(2):263-267. Retrieved March 11, 2018.
Barkin SL, Finch SA, Ip EH, Scheindlin B, Craig JA, Steffes J, Weiley V, Slora E, Altman D, Wasserman RC. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics. 2008; 122(1): e15. Retrieved March 11, 2018.
Grossman DC, Cummings P, Koepsell TD, Marshall J, D’Ambrosio L, Thompson RS, Mack C. Firearm safety counseling in primary care pediatrics: a randomized, controlled trial. Pediatrics. 2000; 106(1 Pt1): 22. Retrieved March 11, 2018.
Hardy MS. Teaching firearm safety to children: a failure of a program. J Dev Behav Pediatr. 2002;23(2):71. Retrieved March 11, 2018.
Gill AC, Wesson DE. Firearm Injuries in Children: Prevention. UptoDate. Literature review current through Feb 2018. Last updated March 14, 2018. Retrieved March 11, 2018.
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
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
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
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
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
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
Mendenhall, A.M. & Forest, C.P. (2017). Out of air: Is going to high altitude safe for your patient. JAAPA, 30(8), 10-15.
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
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
Cogo, A., Fiorenzano, G. (2009). Bronchial Asthma: Advice for Patients Traveling to High Altitude. High Alt Med & Biol. 10(2): 117-121
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.
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
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:
Encouraging them to swallow (this will help the Eustachian tubes to expand)
Giving them a pacifier (in babies and much younger children this sucking can mimic swallowing and help to expand the Eustachian tubes)
Give them a bottle (this is even more effective than a pacifier at opening the Eustachian tubes)
If they are old enough to chew gum this can be very helpful!
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)
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.
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.
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)