My nurse practitioner Laura Amedro and I met with local orthodontist Al Bishop yesterday. Sleep problems are more common at high altitude, and providers caring for children know that poor sleep can cause difficulties with learning and behavior, including ADHD. Dr. Bishop listed ten diseases made worse by poor sleep, including obesity, diabetes, high blood pressure, depression and others. 

How does this tie in with the person who provides braces? Dr. Bishop showed us photos of mouths and teeth that can cause airway constriction.  Expanders inserted inside the mouth (no more “head gear”) correct these problems but are more effective when started earlier. Some children can be identified and treated as early as 7 years.

Dr. Bishop has offices in Edwards and Summit County, so he is familiar with altitude issues. Night time oximetry is the recommended screening test for airway problems. This has to be ordered by a health care provider such as Laura or myself.

Both tourist and local children may need supplemental oxygen during illnesses at high altitude. There are excellent providers available 24 hours a day to set up tanks and concentrators so most don’t have to stay in the hospital, but can be comfortable at home with the family. It is a mistake to admit these children to the hospital just because they won’t keep the nasal cannula in their nose. Hospital guidelines make it difficult for nurses to implement adequate control measures over these fiesty little ones.

At Ebert Family Clinic we have found a very effective method: magazines. Tape a magazine around both child’s arms so that they cannot bend their elbows to pull off the cannula. After 30 minutes of not being able to use their arms, most children will accept the oxygen.

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.