Pediatrics Gun Storage Practices

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 ( 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

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.

Tatum Simonson and Altitude Adaption: Physiologic and Genetic

Tatum Simonson is a researcher at the University of California, San Diego who is interested in high altitude medicine: specifically, how high altitude adaptations can, over hundreds of generations, become part of our genes. I read one of her publications called Altitude Adaptation: A Glimpse Through Various Lenses. It delves into the research that has been done on physiologic and genomic changes of high altitude inhabitants and how these two factors coincide.

When looking at this information, it is important to remember that the reason high altitude is so much different from sea level or lower altitude is the oxygen in the air. It is not necessarily the percentage of the oxygen in the air, because the air is 20.9% oxygen at all altitudes. It is actually the lower air pressure that makes it feel like there is less oxygen. The air pressure comes from the weight of the air above us in the atmosphere. The further you go up, the less atmosphere there is above you to press down, and therefore less air pressure. Boyle’s law (whoa physics!) basically says that because of the lower pressure, in a given volume of air there are fewer molecules. Because there are fewer molecules of everything, the percentage of oxygen remains 20.9% but it feels like there is less oxygen in the air.

This is all to say that organisms have to adapt to this lower air pressure and less molecules in a given volume. Things that we know are affected include the saturation of oxygen of our blood. With less air pressure to drive the saturation of our blood with oxygen, sometimes it leads to low oxygen levels, or hypoxia. Hypoxia is detrimental because our body needs oxygen for our cells to function.

Simonson looks at 3 populations that have lived at high altitudes (3500m-4500m or 11,483ft-14,764ft) for hundreds of generations: Qinghai-Tibetan Plateau, Andean Altiplano, and Semien Plateau of Ethiopia (see map below). In her paper she goes further into the history of these populations and the uncertainty that exists with their timeline, but for our purposes just know that these populations have inhabited these high altitude areas for anywhere from 5,000-70,000 years.

Figure 1. Map with three locations where high-altitude adapted populations have lived for hundreds of generations. (Image modified from; low elevations are purple, medium elevations are greens and yellows, and high elevations are orangered and white.) Tatum S. Simonson. High Alt Med Biol. 2015 Jun 1;16(2):125-137.

The first lens she looks through is physiologic, or how the body functions. There has been extensive research in this lens, summarized below.

  • Increased common iliac blood flow into uterine arteries in Tibetan and Andeans leads to increased utero-placental oxygen delivery at altitude, allowing less growth restriction. In other words, Tibetan and Andean populations have increased the blood flow to the growing fetus to help it grow more like someone living at lower altitudes. Furthermore, some studies show that their babies are actually bigger.
  • Tibetan and Amhara Ethiopian populations show the characteristic increase in hemoglobin levels that has long been associated with travelers to high altitude, but to a much lower extent than someone who has just traveled to altitude (i.e. native lowlander). This is in contrast even with Andean populations, who have higher hemoglobin levels than Tibetans. The Tibetan and Amhara Ethiopian populations don’t necessarily need a higher level of hemoglobin (molecule that carries oxygen) to get the oxygen that they need to their tissues.
  • Differences in the control of breathing: the hypoxic ventilation response is an increase in ventilation that is induced by low oxygen levels. The research shows that Tibetans exhibit an elevated hypoxic ventilation response while Andeans exhibit a blunted response.
  • Tibetan and Sherpa have been shown to have higher heart rates than lowlanders at altitude, as well as increased cardiac output, or blood that they are able to pump out of their hearts. There are also differences in the energy sources that some high altitude populations use for their heart to pump.
  • There are certain adaptive changes in skeletal muscle that Sherpa populations have made as well. Specifically, increased small blood vessels and increased maximal oxygen consumption.

The second lens is genomic, or the evidence for different genes in highlanders that have allowed them to survive and thrive at higher altitudes. One theory is that the ancestors of modern day highlanders had specific genes that gave them traits that were favorable for surviving at high altitudes. By matter of Darwinian selection, these genetic variants were passed down favorably over generations.

  • Many genes studies are involved in the hypoxia-inducible factor (HIF) pathway, which is involved in regulating various responses to hypoxia including making new blood vessels, making new red blood cells, iron regulation, and metabolism.
  • Specific genes studied include EPAS1has been associated with low (within sea level range rather than elevated) hemoglobin in Tibetans at altitude discussed above. EGLN1 and PPARA have also been associated with hemoglobin concentration changes.
  • There are many other specific genes that have been associated with specific adaptive changes for these high altitude populations.

It is important to realize the physiologic and genetic components of adaptation to high altitude environment. Simonson sums it up best herself:

“Understanding the associations between genetic and physiological variation in highlanders has additional application for understanding maladaptive and general responses to hypoxia, which remain an important biomedical component of hypoxia research. This is also of clinical value when considering distinct and shared hypoxia-associated genetic variants and combinations thereof may contribute to physiological responses in residents and visitors to the environmental hypoxia at altitude as well as chronic…or intermittent…states of hypoxia.

I was happy to read this article and see how high altitude medicine may be affected by genomics in the not-so-distant future. Hopefully you learned something about hypoxia, physiologic and genetic adaptations!

Hannah Evans-Hamer, MD



Simonson T. Altitude Adaptation: A Glimpse Through Various Lenses. High Alt Med Biol. 2015 Jun; 16(2):125-37. PMID: 26070057; PMCID: PMC4490743.




Trauma Related High-Altitude Pulmonary Edema

HAPE Poster

Dr. Chris will be presenting this poster at the American Thoracic Society International Conference in San Diego in May of this year! This is an exciting opportunity that will spread knowledge of high altitude medicine with the leading researchers in the field. In addition, she hopes to have this case study published to raise awareness among other healthcare providers practicing at any altitude about the potential health complications associated with rapid changes in elevation.

Katie Newton, PA-S
University of St. Francis
Albuquerque, NM


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

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


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.

A Query on Mt Quandary

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 3I 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


  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.

High Altitude Increases Longevity!

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




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. 

Chronic Mountain Sickness

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




  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.

Hypertension at Altitude

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

1. Andrew M. Luks. High Altitude Medicine & Biology. March 2009, 10(1): 11-
2. Institute For Altitude Medicine (2017). Altitude and Pre-Existing Conditions. [online]
Institute For Altitude Medicine. Available at:
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.

It’s Flu Shot Season!

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


  1. Centers for Disease Control and Prevention. (2016). Vaccination Who should do it, who should not and who should take precautions. Retrieved from :
  2. Decker, B & Herring, M. (2011). Influenza vs the common cold: Symptoms and treatment.  Pharmacy Times, 77(11): 80.  Retrieved from:|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:
  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:
  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


Asthma and High Altitude: What You Need to Know


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


  1. Centers for Disease Control. Asthma. (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