Category Archives: Child Growth & Development

Children grow and develop differently at high altitudes than they do at sea level

Child Growth & Development, Health, High Altitude, Medicine

Mountain resident high altitude pulmonary edema (MR-HAPE)

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For five years I have been writing about children who live above 2500 feet with no history of travel who present with a respiratory illness and hypoxia. Because they do not appear very sick (toxic is the word we use in medical terms), repond to oxygen only, and have inconsistent or poor response to asthma medications, I have decided this is a form of HAPE. Observations by other clinicians support this:

  • Anthony Durmowicz and Ed Noordeweir et al. in Journal of Pediatrics May 1997:
  • “Although no data exists to support or refute the speculation that the presence of an ongoing pulmonary inflammatory process at the time of ascent to high altitude may predispose for the development of HAPE, I have observed that many children visiting high altitude who had HAPE at presentation had evidence of a preexisting inflammation-producing illness, such as a viral URI, OM, or GAS pharyngitis, that had begun before their ascent to high altitude.”
  • “Also noteworthy, the theory of increased endothelial cell permeability in response to hypoxia along with an increase in epithelial cell permeability may result in clinical pulmonary edema and the development of spontaneous HAPE in high altitude residents who acquire relatively mild respiratory tract illnesses seem to support this speculation.”

Careful review of the clinical records for these patients has not shown any factor that can reliably differentiate HAPE from other respiratory diagnoses such as asthma or pneumonia. Physical findings, symptoms, x-ray changes all overlap. The distinguishing feature to me is the clinical picture of a nontoxic patient with a low oxygen at altitude. HAPE is associated with increased pressures in the lungs, which can be diagnosed on an echocardiogram.  I am trying to organize a study to help us understand the causes of hypoxia which will include measuring pulonary pressures during acute episodes.

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

Asthma and Altitude

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She died on the Breckenridge bike path clutching her inhaler, I heard. For years I was reminded by a memorial along the path. Then another man called last week say he is selling his house located at 10,500 feet because his trouble breathing interferes with skiing and rock climbing. “I use my inhaler 50 times a day,” he told me. “The doctor said I have asthma.”  Recently two doctors in Summit County have started to question whether some people living at high altitude may have another cause of their breathing problems such at high altitude pulmonary edema or pulmonary hypertension.

I frequently see children in my office with a respiratory illness and low oxygen, with readings in the 80’s or below. They are not leaning forward, gasping for air, using their rib muscles to breathe, like a person with an asthma attack severe enough to cause low oxygen. They do not have wheezes heard with the stethoscope. We usually give a trial of albuterol, since the medicine has minimal side effects and asthma is a common condition, but it rarely makes a big difference. We also test peak flows on patients over 5 to try and measure airway resistance seen in asthmatics. Then we send them home on oxygen, the treatment for high altitude pulmonary edema, and they get better.

Many of the families whose children need oxygen during illnesses are evaluated by lung specialists at Colorado Children’s Hospital or National Jewish Hospital. They are all told they have asthma and treated with inhaled steroids and albuterol. Pulmonary testing in the older children suggests reversible airway disease in about half. Recently the pulmonologist told us he does not believe the child had HAPE and requested a chest x-ray at the time of any future episode.

“Fulminant cases of HAPE do show dramatic changes in the x-rays, such as a recent case of a six year old who returned from sea level and overnight his oxygen dropped into the 40’s. But when we see patients with milder illness they often have clear lungs and the chest x-ray will not be abnormal until a day or two later. I rarely orders x-rays to make the diagnoses.

Since the pulmonologists are skeptical about the occurrence of HAPE in residents at high altitude, Dr. Ebert-Santos is proposing the syndrome be called “Acute Hypoxia of High Altitude Residents” or AHHAR. We need to figure out what is going on with our lungs at altitude. I’m trying to organize research concerning these issues.

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

They “had” to move to lower altitude…

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Mary told me about two of her daughter’s friends whose families had to move after the girls had recurrent high altitude pulmonary edema (HAPE). This is easy to recognize in it’s classic form: a tourist has trouble breathing during the first 48 hours at altitude. But these girls lived here, and got sick returning from visits to lower latitude, which we call “reentry” HAPE. Both forms are not common, probably less than one out of one thousand people are affected. Certain people are more susceptible. Luckily it is prevented by taking diamox (acetazolamide) before traveling.

For families who live here I recommend buying a home pulse oximeter for less than $50 at Walmart or Walgreens. The affect person can have oxygen ordered by their doctor and delivered to the home if readings are below 90% saturation. The good news is that it doesn’t happen every time they travel and they tend to outgrow reentry HAPE in the teen years.