2023-10-26 12:30PM
丹木斯的兒童劑量. 2024年WMS指引更新. 每次最大劑量 250mg
筆記在這裡
野外與登山醫學-丹木斯的兒童(指含16歲以下)劑量每次最大250mg(2024WMS指引)
丹木斯的兒童劑量. 2024年WMS指引更新. 每次最大劑量 250mg
筆記在這裡
野外與登山醫學-丹木斯的兒童(指含16歲以下)劑量每次最大250mg(2024WMS指引)
兩天前去北搜教課, 提到兒童使用丹木斯的劑量. 這一篇研究建議的最大治療劑量是每次250mg.
2014年更新的指引. 針對發生AMS的兒童治療最大劑量也是寫每次 250mg.
(下面這段是引用自 2014年指引)
Acetazolamide Only 1 study has examined acetazolamide for treatment of AMS. The dose studied was 250 mg twice daily and whether a lower dose might suffice is unknown.37 Recommendation Grade: 1B. No studies have assessed treatment of AMS in pediatric patients, but anecdotal reports suggest it has utility in this regard. The pediatric treatment dose is 2.5 mg/kg/dose twice daily up to a maximum of 250 mg/dose. Recommendation Grade: 1C.
但在2019 WMS guideline 和 2024 CDC yellow book 的兒童建議最大治療劑量是 125mg.
(關於丹木斯的兒童劑量. 整理在另一篇筆記 acetazolamide--(Diamox丹木斯)- 乙酰唑胺 -乙醯胺基硫唑嘧錠-乙醯偶氮胺的歷史 2023-09-11 15:10 )
下面是舊的文.
2010 Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness 預防及治療高海拔疾病
(另一篇 2014 的在這裡 Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2014 Update)
To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.
Key words: high altitude, acute mountain sickness, high altitude pulmonary edema, high altitude cerebral edema, acetazolamide, dexamethasone, nifedipine, salmeterol, tadalafil, sildenafil
2010 Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness 預防及治療高海拔疾病
(另一篇 2014 的在這裡 Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2014 Update)
To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.
Key words: high altitude, acute mountain sickness, high altitude pulmonary edema, high altitude cerebral edema, acetazolamide, dexamethasone, nifedipine, salmeterol, tadalafil, sildenafil
Introduction 簡介
旅遊至海拔 2500 公尺以上有發生高海拔疾病的危險, AMS 高山病, HACE 高海拔腦水腫, HAPE 高海拔肺水腫, 因為到這樣高海拔的遊客眾多, 如何預防成了臨床醫師面臨的問題, 此外, 高海拔地區的醫療人員可能會遇到發病的人, 需熟悉預防方法及治療計畫. WMS 提出這項指引, 以提供醫療人員最佳策略, 每一項疾病都給出預防與治療方式. 關於疾病處置的建議, 建議則根據現有證據及利弊考量加以分級.
Travel to elevations above 2500 m is associated with risk of developing one or more forms of acute altitude illness: acute mountain sickness (AMS), high altitude cerebral edema (HACE), or high altitude pulmonary edema (HAPE). Because large numbers of people travel to such elevations, many clinicians are faced with questions from patients about the best means to prevent these disorders. In addition, healthcare providers working at facilities in high altitude regions or as part of expeditions traveling to such areas can expect to see persons who are suffering from these illnesses and must be familiar with prophylactic regimens and proper treatment protocols. To provide guidance to clinicians and disseminate knowledge about best practices in this area, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute altitude illness. Prophylactic and therapeutic modalities are presented for each disorder and recommendations made about their role in disease management. Recommendations are graded based on the quality of supporting evidence and consideration of benefits and risks/burdens for each modality.
Methods
專家小組於 2009 年在美國斯諾瑪斯 Snowmass 召開 年度大會, 由WMS臨床及研究經驗選擇成員. 相關研究則在 medline database 使用關鍵字搜尋, 回顧了與預防及治療高海拔疾病, 包括臨床隨機研究, 觀察性研究, 案例報告等等相關的同行評議研究, 也評估關於預防及治療方式的證據等級, 不包含只有簡介的研究, 建議製作不包含回顧性文章的結論,但在各項疾病與處置的下方有加註, 最為背景資料, 小組以共識方式做出每項方式的建議, 將每項建議根據 ACCP提出的方式加以分級
The expert panel was convened at the 2009 Annual Meeting of the WMS in Snowmass, CO. Members were selected by the WMS based on their clinical and/or research experience. Relevant articles were identified through the MEDLINE database using a key word search using the terms acute mountain sickness, high altitude pulmonary edema, high altitude cerebral edema, treatment, prevention, acetazolamide, dexamethasone, nifedipine, tadalafil, sildenafil, and salmeterol. Peer-reviewed studies related to prevention and treatment of acute altitude illnesses, including randomized controlled trials, observational studies, and case series, were reviewed and the level of evidence supporting various prophylaxis and treatment modalities was assessed. Abstract-only studies were not included. Conclusions from review articles were not considered in the formulation of recommendations but are cited below as part of efforts to provide background information on the various diseases and their management. The panel used a consensus approach to develop recommendations regarding each modality and graded each recommendation according to criteria stipulated in the American College of Chest Physicians statement on grading recommendations and strength of evidence in clinical guidelines (Table 1).
Acute Mountain Sickness and High Altitude Cerebral Edema
急性高山病與高海拔腦水腫. 在臨床立場. 高海拔腦水腫可以當作是高山病的末期表現, 因此, 這兩個疾病的預防及治療方式一起討論.
Information on the epidemiology, clinical presentation, and pathophysiology of AMS and HACE is provided in several extensive reviews.2-4 From a clinical standpoint, HACE represents the end stage of AMS and, as a result, preventive and treatment measures for the two disorders can be addressed simultaneously.
PREVENTION 預防.
Prophylactic measures for AMS and HACE, the evidence supporting them, and their recommendation grades are described below. Further information about how to apply these measures is then provided as part of a suggested approach to prevention.
Gradual ascent 逐步上升
控制上升速率, 指的是每天上升的海拔高度, 是預防高海拔疾病最有效的方法, 睡眠海拔比實際曾經爬到的最高海拔重要
Controlling the rate of ascent, in terms of the number of meters gained per day, is a highly effective means of preventing acute altitude illness; however, aside from two recent prospective studies,5,6 this strategy has largely been evaluated retrospectively.7 In planning the rate of ascent, the altitude at which someone sleeps is considered more important than the altitude reached during waking hours. Recommendation grade: 1B.
Acetazolamide 乙醯胺基硫唑嘧錠, 台灣登山界對於丹木斯這個名稱可能比較孰悉(丹木斯是原廠商品名,目前市面上無流通)
預防使用的建議劑量 每天早晚(每 12 小時)各 125 mg. 更高的劑量也有預防效果, 但副作用更多, 效果並沒有更好. 所以不建議, 小兒劑量每次每公斤 2.5mg, 最大劑量同成人 125mg, 每 12 小時吃一次 (50公斤以上重的兒童比照成人劑量)
(註記: 丹木斯使用在小兒預防與治療的劑量是相同的.)
(2023-09-11 查詢 uptodate 關於 acetazolamide 的說明. 兒童的預防及治療劑量. 都是每次每公斤 2.5mg. 還有2019WMS的指引也是建議相同劑量 , 兒童最多一次吃半顆. 50公斤以上體重都是吃半顆 125mg)
Multiple trials have established a role for acetazolamide in the prevention of AMS.8-10 The recommended adult dose for prophylaxis is 125 mg twice daily (Table 2).
While higher doses up to 500 mg daily are effective at preventing AMS, they are associated with more frequent and/or increased side effects, do not convey greater efficacy, and, therefore, are not recommended for prevention. Recommendation grade: 1A.
旅遊至海拔 2500 公尺以上有發生高海拔疾病的危險, AMS 高山病, HACE 高海拔腦水腫, HAPE 高海拔肺水腫, 因為到這樣高海拔的遊客眾多, 如何預防成了臨床醫師面臨的問題, 此外, 高海拔地區的醫療人員可能會遇到發病的人, 需熟悉預防方法及治療計畫. WMS 提出這項指引, 以提供醫療人員最佳策略, 每一項疾病都給出預防與治療方式. 關於疾病處置的建議, 建議則根據現有證據及利弊考量加以分級.
Travel to elevations above 2500 m is associated with risk of developing one or more forms of acute altitude illness: acute mountain sickness (AMS), high altitude cerebral edema (HACE), or high altitude pulmonary edema (HAPE). Because large numbers of people travel to such elevations, many clinicians are faced with questions from patients about the best means to prevent these disorders. In addition, healthcare providers working at facilities in high altitude regions or as part of expeditions traveling to such areas can expect to see persons who are suffering from these illnesses and must be familiar with prophylactic regimens and proper treatment protocols. To provide guidance to clinicians and disseminate knowledge about best practices in this area, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute altitude illness. Prophylactic and therapeutic modalities are presented for each disorder and recommendations made about their role in disease management. Recommendations are graded based on the quality of supporting evidence and consideration of benefits and risks/burdens for each modality.
Methods
專家小組於 2009 年在美國斯諾瑪斯 Snowmass 召開 年度大會, 由WMS臨床及研究經驗選擇成員. 相關研究則在 medline database 使用關鍵字搜尋, 回顧了與預防及治療高海拔疾病, 包括臨床隨機研究, 觀察性研究, 案例報告等等相關的同行評議研究, 也評估關於預防及治療方式的證據等級, 不包含只有簡介的研究, 建議製作不包含回顧性文章的結論,但在各項疾病與處置的下方有加註, 最為背景資料, 小組以共識方式做出每項方式的建議, 將每項建議根據 ACCP提出的方式加以分級
The expert panel was convened at the 2009 Annual Meeting of the WMS in Snowmass, CO. Members were selected by the WMS based on their clinical and/or research experience. Relevant articles were identified through the MEDLINE database using a key word search using the terms acute mountain sickness, high altitude pulmonary edema, high altitude cerebral edema, treatment, prevention, acetazolamide, dexamethasone, nifedipine, tadalafil, sildenafil, and salmeterol. Peer-reviewed studies related to prevention and treatment of acute altitude illnesses, including randomized controlled trials, observational studies, and case series, were reviewed and the level of evidence supporting various prophylaxis and treatment modalities was assessed. Abstract-only studies were not included. Conclusions from review articles were not considered in the formulation of recommendations but are cited below as part of efforts to provide background information on the various diseases and their management. The panel used a consensus approach to develop recommendations regarding each modality and graded each recommendation according to criteria stipulated in the American College of Chest Physicians statement on grading recommendations and strength of evidence in clinical guidelines (Table 1).
Acute Mountain Sickness and High Altitude Cerebral Edema
急性高山病與高海拔腦水腫. 在臨床立場. 高海拔腦水腫可以當作是高山病的末期表現, 因此, 這兩個疾病的預防及治療方式一起討論.
Information on the epidemiology, clinical presentation, and pathophysiology of AMS and HACE is provided in several extensive reviews.2-4 From a clinical standpoint, HACE represents the end stage of AMS and, as a result, preventive and treatment measures for the two disorders can be addressed simultaneously.
PREVENTION 預防.
Prophylactic measures for AMS and HACE, the evidence supporting them, and their recommendation grades are described below. Further information about how to apply these measures is then provided as part of a suggested approach to prevention.
Gradual ascent 逐步上升
控制上升速率, 指的是每天上升的海拔高度, 是預防高海拔疾病最有效的方法, 睡眠海拔比實際曾經爬到的最高海拔重要
Controlling the rate of ascent, in terms of the number of meters gained per day, is a highly effective means of preventing acute altitude illness; however, aside from two recent prospective studies,5,6 this strategy has largely been evaluated retrospectively.7 In planning the rate of ascent, the altitude at which someone sleeps is considered more important than the altitude reached during waking hours. Recommendation grade: 1B.
Acetazolamide 乙醯胺基硫唑嘧錠, 台灣登山界對於丹木斯這個名稱可能比較孰悉(丹木斯是原廠商品名,目前市面上無流通)
預防使用的建議劑量 每天早晚(每 12 小時)各 125 mg. 更高的劑量也有預防效果, 但副作用更多, 效果並沒有更好. 所以不建議, 小兒劑量每次每公斤 2.5mg, 最大劑量同成人 125mg, 每 12 小時吃一次 (50公斤以上重的兒童比照成人劑量)
(註記: 丹木斯使用在小兒預防與治療的劑量是相同的.)
(2023-09-11 查詢 uptodate 關於 acetazolamide 的說明. 兒童的預防及治療劑量. 都是每次每公斤 2.5mg. 還有2019WMS的指引也是建議相同劑量 , 兒童最多一次吃半顆. 50公斤以上體重都是吃半顆 125mg)
Multiple trials have established a role for acetazolamide in the prevention of AMS.8-10 The recommended adult dose for prophylaxis is 125 mg twice daily (Table 2).
While higher doses up to 500 mg daily are effective at preventing AMS, they are associated with more frequent and/or increased side effects, do not convey greater efficacy, and, therefore, are not recommended for prevention. Recommendation grade: 1A.
The pediatric dose of acetazolamide is 2.5 mg/kg per dose (maximum 125 mg per dose) every 12 hours.11 Recommendation grade: 1C.
Dexamethasone 地塞米松(其他名稱:得康錠（的剎美剎松）.地塞美松) 不要連續使用超過十天
類固醇,地塞米松 有預防AMS效果, 成人預防用的劑量 每次 2 mg 每 6 小時吃一次. 或 每次 4 mg 每 12 小時吃一次, 對於危險性較高的群體可以使用較高劑量 (每次 4 mg 每 6 小時吃一次), 例如軍隊或搜救人員, 需要快速上升至海拔 3500 公尺以上活動, 如果非此類緊急情況不建議這樣用. 連續使用不建議超過 10 天. 以避免產生皮質類固醇毒性或腎上腺抑制效果.
兒童預防高海拔疾病不建議使用. 因可能有副作用. 建議以逐步海拔上升或丹木斯代替.
Prospective trials have established a benefit for dexamethasone in AMS prevention.12,13 The recommended adult doses are 2 mg every 6 hours or 4 mg every 12 hours. Very high doses (4 mg every 6 hours) may be considered in very high risk situations such as military or search and rescue personnel being airlifted to altitudes greater than 3500 m with immediate performance of physical activity but should not be used outside these limited circumstances. The duration of use should not exceed 10 days to prevent glucocorticoid toxicity or adrenal suppression. Recommendation grade: 1A. Dexamethasone should not be used for prophylaxis in the pediatric population due to the potential for side effects unique to this population and the availability of other safe alternatives—specifically, graded ascent and acetazolamide.
Ginkgo biloba 銀杏
雖然有些研究說有助益, 但也有研究顯示無效. 也許與銀杏成品的來源與組成差異有關. 對於預防高山病的效果, 丹木斯優於銀杏.
Although several trials have demonstrated a benefit of Ginkgo in AMS prevention,14,15 several negative trials have also been published.16,17 This discrepancy may result from differences in the source and composition of the Ginkgo products.18 Acetazolamide is considered far superior prophylaxis for AMS prevention. Recommendation grade: 2C
Other options
在安地斯山脈, 咀嚼可可葉, 喝可可茶, 其他可可製品被當成預防高海拔疾病的方式, 據說在亞洲非洲的旅行者也有類似做法, 然而, 對於預防高海拔疾病的作用從未有系統性研究證實, 不應取代其他預防方式, 強迫喝水或過度喝水也無效. 而且喝水過量可能造成低血鈉, 不過適度飲水是必要的. 因脫水與急性高山病症狀相似.
Chewed coca leaves, coca tea, and other coca-derived products are commonly recommended for travelers in the Andes for prophylaxis, and anecdotal reports suggest they are now being used by trekkers in Asia and Africa for similar purposes. However, their utility in prevention of altitude illness has never been systematically studied, and they should not be substituted for other established preventive measures described in these guidelines. “Forced” or “over”-hydration has also never been shown to prevent altitude illness and may even increase the risk of hyponatremia; however, maintenance of adequate hydration is important because symptoms of dehydration can mimic those of AMS
SUGGESTED APPROACH TO AMS/HACE PREVENTION 預防高山病與高海拔腦水腫的建議方式
因個體對於高海拔的反應及適應速率差異很大, 臨床醫師必須要認知到, 底下建議雖然一般都有效, 但並不保證對於高海拔旅行者一定能成功, 預防AMS及HACE的方式, 應該屬於個別旅行者的風險狀況之一. 在低危險狀況, 藥物預防通常不需要, 應該靠逐漸上升 gradual ascent, 在海拔 3000 公尺以上, 個人每天睡覺海拔不要超過前一天 500 公尺, 每 3-4 天應該要有一天休息日(睡眠海拔不要提高), 對於中度危險狀況, 除了逐漸上升還可考慮使用預防藥物
(休息日可以從事體力活動, 但在同一個地方睡覺)
Because the physiologic responses to high altitude and rates of acclimatization vary considerably between individuals, clinicians must recognize that the recommendations that follow, while generally effective, will not guarantee successful prevention in all high altitude travelers. The approach to prevention of AMS and HACE should be a function of the risk profile of the individual traveling to high altitude (Table 3). In low-risk situations, prophylactic medications are not necessary and individuals should rely on a gradual ascent profile. Above an altitude of 3000 m, individuals should not increase the sleeping elevation by more than 500 m per day and should include a rest day (ie, no ascent to higher sleeping elevation) every 3 to 4 days. Prophylactic medications should be considered in addition to gradual ascent for use in moderate-to high-risk situations.
預防用藥建議使用丹木斯, 但無法使用丹木斯(副作用無法忍受,過敏)可使用類固醇地塞米松, 在少見狀況(例如軍隊或搜救隊,需在 3500 公尺以上海拔活動) 可同時使用這兩種藥物. 但這種預防方式只限於使用在需快速上升的緊急狀況
丹木斯對於磺胺類過敏的人有輕微的交叉過敏反應, 如果有磺胺類過敏的人, 在旅遊前, 尤其是要到缺發醫療資源的偏遠地區前, 可在監視下嘗試服用丹木斯, 如果曾發生磺胺類引起過敏性休克的人不要使用丹木斯 (一旦發生過敏可以迅速就醫處置)
丹木斯要在上升前一天使用, 但上升當天使用也有效果, 類固醇地塞米松在上升當天使用, 在同樣的海拔待 2-3 天之後(備註: 新的指引建議丹木斯吃四天), 如果沒有高海拔疾病症狀可考慮停用丹木斯, 如果旅程中會通過一個最高點, 在通過之後如果無症狀可以停用丹木斯
Acetazolamide is the preferred agent, but dexamethasone may be used as an alternative in individuals with a prior history of intolerance of or allergic reaction to acetazolamide. In rare circumstances (eg, military or rescue teams who must ascend rapidly to and perform physical work at altitudes 3500 m), consideration can be given to the concurrent use of acetazolamide and dexamethasone. This strategy should be avoided except in these particular or other emergency circumstances that mandate a very rapid ascent. Acetazolamide carries a low risk of cross-reactivity in persons with sulfonamide allergy, but those with a known allergy to sulfonamide medications should consider a supervised trial of acetazolamide prior to their trip, particularly if planning travel into an area that is remote from medical resources.19 A history of anaphylaxis to sulfonamide medications should be considered a contraindication to acetazolamide. Acetazolamide should be started the day before ascent (but will still have beneficial effects if started on the day of ascent); dexamethasone may be started the day of ascent. For individuals ascending to and staying at the same elevation for more than several days, prophylaxis may be stopped after 2 to 3 days at the target altitude. For an itinerary 旅程 that involves ascending to a high point and then descending to a lower elevation, prophylactic medications should be stopped once descent is initiated.
TREATMENT 高山病 AMS 及高海拔腦水腫 HACE 的治療
高山病AMS及高海拔腦水腫的治療包括下列數種
Potential therapeutic options for AMS and HACE include the following.
Descent 下降
如果可能. 下降仍然是治療 AMS 與 HACE 最佳方式, 然而並非所有狀況都必須下降, 患者應該下降至症狀改善為止, 除非因地形阻隔無法下降, 通常下降 300-1000 公尺症狀會改善, 但每個人需要的下降高度不同, 罹患AMS或HACE的人不要單獨下降, 尤其是罹患HACE的人 (下降過程遇到危險地形可能會失足甚至死亡)
When feasible, descent remains the single best treatment for AMS and HACE. However, it is not necessary in all circumstances (discussed further below). Individuals should descend until symptoms resolve, unless impossible due to terrain. Symptoms typically resolve following descent of 300 to 1000 m, but the required descent will vary between persons. Individuals should not descend alone, particularly in cases of HACE. Recommendation grade: 1A.
Supplemental oxygen 氧氣治療
以鼻導管給予氧氣將血氧濃度 SpO2 提升至 90% 以上, 可作為下降的替代治療, 但並非所有狀況都需要給氧氣, 通常是用在無法下降的嚴重個案, 在偏遠地區, 氧氣供應不像是醫療院所一樣方便, 需審慎評估何時使用.
Oxygen delivered by nasal cannula at flow rates sufficient to raise arterial oxygen saturation (SpO2) to greater than 90% provides a suitable alternative to descent. Use is not required in all circumstances and is generally reserved for severe cases when descent is not feasible. Unlike at hospitals or large clinics, the supply of oxygen may be limited at remote high altitude clinics or on expeditions, necessitating careful use of this therapy. Recommendation grade: 1C.
Portable hyperbaric chambers 加壓艙 PHA
加壓艙可有效治療嚴重高海拔疾病, 但需要由專人看護, 但可能不適合用於幽閉空間恐懼者或嘔吐的人, 移出加壓艙的時候症狀可能再發, 不要因為使用加壓艙而耽誤下降,
These devices are effective for treating severe altitude illness20,21 but require constant tending by care providers and are difficult to use with claustrophobic or vomiting patients. Symptoms may recur when individuals are removed from the chamber.22 Use of a portable hyperbaric chamber should not delay descent in situations where descent is feasible. Recommendation grade: 1B.
Acetazolamide 丹木斯
只有一篇研究檢驗丹木斯治療AMS的效果, 劑量是早晚各吃 250 mg, 低劑量是否有效仍不明.
Only one study has examined acetazolamide for treatment of AMS. The dose studied was 250 mg twice daily and whether a lower dose might suffice is unknown.23 Recommendation grade: 1B.
兒童病患目前無研究報告, 但據說有效, 劑量是 每次每公斤2.5mg, 每 12 小時吃一次. 最大劑量每次 250mg(同成人).
No studies have assessed treatment of AMS in pediatric patients, but anecdotal 傳聞 reports suggest it has utility in this regard. The pediatric treatment dose is 2.5 mg/kg per dose twice daily up to a maximum of 250 mg per dose. Recommendation grade: 1C.
Dexamethasone 地塞米松
類固醇地塞米松對於治療AMS很有效果. 但不會加速高度適應, 停藥之前不要繼續上升, 停藥之後且症狀沒有再發才能上升高度, 有廣泛的臨床研究支持使用類固醇地塞米松治療高海拔腦水腫, 初始劑量 8mg, 之後每 6 小時吃 4mg. 直到症狀改善為止, 小兒劑量每次每公斤 0.15mg. 每 6 小時吃一次,
Dexamethasone is very effective in the treatment of AMS.24-26 The medication does not facilitate acclimatization and further ascent should be delayed until the patient is asymptomatic while off the medication. Recommendation grade 1B.
Extensive clinical experience supports the use of dexamethasone in patients with HACE. It is administered as an 8-mg dose (intramuscularly, intravenously, or orally) followed by 4 mg every 6 hours until symptoms resolve. The pediatric dose is 0.15 mg/kg per dose every 6 hours.11 Recommendation grade: 1C.
SUGGESTED APPROACH TO AMS/HACE TREATMENT
要小心鑑別其他與AMS及HACE相似的症候, 例如脫水,體力不支, 低血糖, 失溫, 低血鈉等等. 有任何高海拔疾病症狀的人, 不要繼續上升, 可能須根據環境及症狀嚴重度考慮下降, 罹患AMS的人可以待在相同海拔接受治療, 頭痛可服用非鴉片類止痛藥(例如普拿疼,NSAID等等), 腸胃症狀例如嘔吐可使用止吐藥物, 可能只需要這些治療即可,.
Care should be taken to exclude disorders whose symptoms and signs may resemble those seen in AMS and HACE, such as dehydration, exhaustion, hypoglycemia, hypothermia, and hyponatremia.2 Persons with altitude illness of any severity should stop ascending and may need to consider descent depending on the clinical circumstances and severity of illness (Table 4).2 Patients with AMS can remain at their current altitude and use non-opiate analgesics for headache and anti-emetics for gastrointestinal symptom relief, which may be all that is required.
丹木斯, 藉由加速高度適應, 有助於治療AMS, 但使用於預防的效果比用於治療更好. 丹木斯可以治療輕微疾病, 類固醇地塞美松對於任何程度的AMS更加可靠有效, 尤其是對於需下降的中度至嚴重的AMS. 罹患AMS的人當症狀改善可繼續上升, 但不要帶著症狀繼續上升至前一個出現症狀的海拔高度.
Acetazolamide, by speeding acclimatization, will help treat AMS, but it works better for prevention than for treatment. While acetazolamide is good for treating mild illness, dexamethasone is a more reliably effective treatment agent for any degree of AMS, especially moderate to severe disease, which often requires descent as well. Individuals with AMS may resume their ascent once symptoms resolve, but further ascent or re-ascent to a previously attained altitude should never be undertaken in the face of ongoing symptoms.
在AMS緩解之後, 比較妥善的作法是同時服用丹木斯上升,
After resolution of AMS, reascent with acetazolamide is prudent.
高海拔腦水腫 HACE 與嚴重 AMS 的區分在於是否出現神經症狀, 例如快速上升到高海拔, 發生 AMS 後, 或同時出現HAPE 症狀, 加上出現運動失調, 神智混淆, 神智改變等. 罹患HACE的人, 在前往當地醫療院所的同時, 需開始氧氣治療及服用類固醇地塞美松. 在缺乏醫療資源的偏遠地區, 懷疑HACE或AMS治療無效的同時就要開始下降, 如果無法下降, 需考慮給氧氣或使用加壓艙, 懷疑罹患HACE病患需開始服用類固醇地塞米松, 可考慮同時服用丹木斯, 除非病患停用類固醇後仍無症狀, 否則不要考慮上升.
HACE is differentiated from severe AMS by neurological findings such as ataxia, confusion, or altered mental status in the setting of acute ascent to high altitude and may follow AMS or occur concurrently with HAPE. Individuals developing HACE in populated areas with access to hospitals or specialized clinics should be started on supplemental oxygen and dexamethasone. In remote areas away from medical resources, descent should be initiated in any suspected HACE victim or if symptoms of AMS are not responding to conservative measures or treatment with acetazolamide or dexamethasone. If descent is not feasible due to logistical issues, supplemental oxygen or a portable hyperbaric chamber should be considered. Persons with HACE should also be started on dexamethasone and consideration can be given to adding acetazolamide. No further ascent should be attempted until the victim is asymptomatic and no longer taking dexamethasone.
High Altitude Pulmonary Edema 高海拔肺水腫
多數關於HAPE的研究都來自於成人, 有些預防及治療策略與AMS/HACE相同, 但HAPE不同的病理機轉需要不同的處理及治療策略.
Information on the epidemiology, clinical presentation and pathophysiology of HAPE, the majority of which comes from studies in adults, is provided in several extensive reviews.4,27,28 While some of the prophylactic and therapeutic modalities are the same for HAPE as for AMS and HACE, important differences in the underlying pathophysiology of the disorder dictate different management and treatment approaches.
PREVENTION 預防高海拔肺水腫
Potential preventive measures for HAPE include the following: 預防方式如下
Gradual Ascent 逐漸上升
目前仍無研究指出是否限制睡眠海拔上升速率能預防HAPE. 但上升速率與疾病發生有明確的關係.
No studies have prospectively assessed whether limiting the rate of increase in sleeping elevation prevents HAPE; however, there is a clear relationship between rate of ascent and disease incidence.7,29,30 Recommendation grade: 1C.
Nifedipine 鈣離子阻斷劑. 常見商品名. adalat 冠達悅.
對於容易罹患 HAPE 的人, 有一篇RCT及廣泛的臨床經驗建立了使用 nifedipine 預防 HAPE的模式. 建議劑量: 一天總量 60mg 緩效釋放劑型分次分量使用. (每12小時吃30mg; or 每8小時吃 20mg. )
A single randomized, placebo-controlled study31 and extensive clinical experience have established a role for nifedipine in the prevention of HAPE in susceptible individuals. The recommended dose is 60 mg of the sustained release preparation administered daily in divided doses. Recommendation grade: 1A.
Salmeterol 乙型作用劑,氣管擴張劑
長效型乙型作用劑 salmeterol 降低 50% 的 HAPE 發生率. 實驗用的劑量是常造成副作用的超高劑量(每次125 ug, 每天兩次). 在高海拔使用這種藥物的臨床經驗有限, 所以 salmeterol 不建議作為預防HAPE的單一方式. 但可配合鈣離子阻斷劑同時使用.
In a single randomized, placebo-controlled study, the long-acting inhaled beta-agonist salmeterol decreased the incidence of HAPE by 50% in susceptible individuals.32 Very high doses (125 ug twice daily) that are often associated with side effects were used in the study. Clinical experience with the medication at high altitude is limited. As a result, salmeterol is not recommended as monotherapy but may be considered as a supplement to nifedipine. Recommendation grade: 2B.
Tadalafil 壯陽藥.犀利士
在一篇RCT中, 每次10mg 每天兩次, 對於容易罹患HAPE患者有預防HAPE的效果, 但收錄的病患數量小. 且缺乏這類藥物使用於預防HAPE的臨床經驗, 需要更多研究資料評估其有效性.
In a single, randomized, placebo-controlled trial, 10 mg twice daily of tadalafil was effective in preventing HAPE in susceptible individuals.33 The number of individuals in the study was small and clinical experience with the medication is lacking compared to nifedipine. As a result, further data are necessary to validate these results. Recommendation grade: 1C.
Dexamethasone 類固醇..地塞米松
在評估犀利士預防HAPE效果的同樣一篇RCT. 每天使用總量 16mg 的類固醇地塞米松, 對於容易罹患HAPE的人也有預防HAPE效果. 機轉仍不明. 臨床經驗也有限.
In the same study that assessed the role of tadalafil in HAPE prevention, dexamethasone (16 mg/d in divided doses) was also shown to prevent HAPE in susceptible individuals. The mechanism for this effect is not clear and there is very little, if any, clinical experience using dexamethasone for this purpose. Further data are necessary to validate this result. Recommendation grade: 1C.
Acetazolamide 丹木斯. 乙醯胺基硫唑嘧錠,
丹木斯可加速高度適應. 應該對於任何種類高海拔疾病都有效果才對. 曾有動物實驗及一個人類試驗. 顯示可以降低低血氧對於肺部血管收縮的效應. 但沒有研究資料支持其預防 HAPE 的角色. 臨床人員建議. 丹木斯可能可以預防 "再返者高海拔肺水腫 re-entry HAPE"
所謂 re-entry HAPE 再返者高海拔肺水腫, 是居住於高海拔地區的兒童. 當移動至低海拔. 重新回到居住地方的時候發生的高海拔肺水腫.
Because acetazolamide hastens acclimatization, it should be effective at preventing all forms of acute altitude illness. It has been shown to blunt hypoxic pulmonary vasoconstriction in animal models34,35 and in a single study in humans,36 but there are no data specifically supporting a role in HAPE prevention.37 Clinical observations suggest acetazolamide may prevent re-entry HAPE, a disorder seen in children who reside at high altitude, travel to lower elevation, and then develop HAPE upon rapid return to their residence. Recommendation grade: 2C.
SUGGESTED APPROACH TO HAPE PREVENTION 高海拔肺水腫建議預防策略
個體對於高海拔的生理反應及適應速率有差異. 以下建議一般是有效的. 但無法保證每個去高海拔旅遊的人都能成功預防. 緩慢提升海拔是 HAPE 主要的預防方式. 海拔上升速率同 AMS/HACE 建議.
As noted earlier, because the physiologic responses to high altitude and rates of acclimatization vary considerably between individuals, the recommendations that follow, while generally effective, will not guarantee successful prevention in all high altitude travelers. A gradual ascent profile is the primary recommended method for preventing HAPE; the recommended ascent rate noted above for AMS and HACE prevention also applies with HAPE prevention.
藥物預防應該限於曾經有 HAPE 病史的人使用. 且 nifedipine 是首選藥物. 在上升到高海拔前一天要開始服藥. 直到下降. 或在相同海拔待五天都沒有症狀. 至於犀利士或類固醇 地塞美松 對於預防HAPE的建議指引仍需更多研究證實其效果. 服用丹木斯是預防 HAPE 合理的選擇. 臨床經驗也支持. 但缺乏研究資料. Salmeterol 只限於輔助 nifedipine 預防高危險性 HAPE 患者再次發生 HAPE. *(不可將 salmeterol 作為單一方法)
Drug prophylaxis should only be considered for individuals with a prior history of HAPE and nifedipine is the preferred option in such situations. It should be started on the day prior to ascent and continued either until descent is initiated or the individual has spent 5 days at the target elevation. Further research is needed before tadalafil or dexamethasone can be recommended for this purpose. Acetazolamide is a rational choice for HAPE prevention and clinical experience supports this, but data are lacking. Salmeterol should only be considered as a supplement to nifedipine in high-risk individuals with a clear history of recurrent HAPE.
TREATMENT 治療高海拔肺水腫.
Potential therapeutic options for HAPE include the following:
Descent 下降
如同AMS/HACE. 下降是治療 HAPE 唯一 最有效的方式. 但並非所有狀況都需要下降. 患者應該下降 1000 公尺或直到症狀改善. 下降過程盡量減少體力活動(不要負重. 騎乘動物.搭轎子.被人揹負). 因運動會進一步加重肺部血管壓力. 導致肺水腫症狀惡化.
As with AMS and HACE, descent remains the single best treatment for HAPE but is not necessary in all circumstances. Individuals should try to descend at least 1000 m or until symptoms resolve. They should exert themselves as little as possible on descent (eg, travel without a pack or via animal transportation) because exertion can further increase pulmonary artery pressure and exacerbate edema formation. Recommendation grade: 1A.
Supplemental Oxygen 給氧氣
由鼻導管或氧氣面罩給予氧氣, 將氧氣濃度 SpO2 提升至 90%. 適合做為下降的替代療法. 尤其是附近有醫療院所可提供氧氣, 且能密切監護時.
Oxygen delivered by nasal cannula or face mask at flow rates sufficient to achieve goal SpO2 90% provides a suitable alternative to descent, particularly when patients can access healthcare facilities and be monitored closely.38,39 Recommendation grade: 1B.
Portable Hyperbaric Chambers 加壓艙
如同AMS/HACE. 攜帶型加壓艙可以作為HAPE治療. 目前沒有關於這種方式的系統性研究. 但是曾有文獻報告. 使用加壓艙不要耽誤下降.
As with AMS and HACE, portable hyperbaric chambers can be used for HAPE treatment. They have not been systematically studied in this role, but their use in HAPE has been reported in the literature.40 Use of a portable hyperbaric chamber should not delay descent in situations where descent is feasible. Recommendation grade: 1B.
Nifedipine 鈣離子阻斷劑. adalat. 冠達悅
一篇 非隨機 非盲 研究顯示. 當無法使用氧氣或下降時, 使用 nifedipine 治療 HAPE. 沒有其他治療研究在進行. 但有廣泛性的臨床經驗使用 nifedipine 作為氧氣及下降的輔助治療. 除非無法給予氧氣/無法使用加壓艙或無法下降. 不要使用 nifedipine 作為單一治療選項.
A single, nonrandomized, unblinded study demonstrated utility of nifedipine in HAPE treatment when oxygen or descent is not available.41 No other treatment studies have been conducted, but there is extensive clinical expperience with its use as an adjunct to oxygen or descent. Sixty milligrams of the sustained release version is administered daily in divided doses without a loading dose. It should not be relied on as the sole therapy unless descent is impossible and access to supplemental oxygen or portable hyperbaric therapy cannot be arranged. Recommendation grade: 1C (for use as adjunctive therapy).
Beta-agonists 乙型作用劑. 氣管擴張劑.
雖然有個案報告使用乙型作用劑治療HAPE. 無臨床資料證實使用 salmeterol 或 albuterol 治療罹患 HAPE 的病患.
Although there are reports of beta-agonist use in HAPE treatment,42 no data support a benefit from salmeterol or albuterol in patients suffering from HAPE. Recommendation grade: 2C.
Phosphodiesterase Inhibitors 磷酸二酯酶抑製劑. 壯陽藥.
此類藥物有肺部血管擴張效果. 可降低肺動脈壓力. 有強烈的生理機轉可用於治療 HAPE. 雖然有個案報告. 但對於犀利士或威而鋼使用於 HAPE 的治療並無系統性研究.
By virtue of their ability to cause pulmonary vasodilation and decrease pulmonary artery pressure, there is a strong physiologic rationale for using phosphodiesterase inhibitors in HAPE treatment. While reports document their use for this purpose,42 no systematic studies have examined the role of either tadalafil or sildenafil in HAPE treatment. Recommendation grade: 2C
Continuous Positive Airway Pressure 持續性呼吸道正壓(陽壓)治療.
一項小規模研究顯示吐氣正壓呼吸治療 EPAP,. 使用一個面罩以增在吐氣的時候壓呼吸道壓力, 能改善 HAPE 病患的氣體交換. 但對於更常使用的 CPAP是否可改善病患預後並無研究資料. CPAP 使吸氣吐氣的時候都持續維持呼吸道正壓的方式, 在醫院通常用於慢性呼吸道阻塞. 或慢性肺部纖維化病患. 因為使用這種治療方式的風險並不大. 可考慮作為給氧氣的輔助療法. 但病患必須神智清楚.能配合機器. 並非所有狀況都可以使用. 治療所需的壓力也尚未建立,
A small study demonstrated that expiratory positive airway pressure (EPAP), in which a mask system is used to increase airway pressure during exhalation only, improved gas exchange in HAPE patients.43 However, no studies have established that this modality or the more commonly used continuous positive airway pressure (CPAP), in which a continuous level of pressure is applied to the airways through the entire respiratory cycle, improves patient outcomes. Given the low risks associated with the therapy, it can be considered an adjunct to oxygen administration in the hospital setting, provided the patient has intact mental status and can tolerate the mask. It is generally not feasible in the field setting and the required level of pressure has not been established. Recommendation grade: 2B.
Diuretics 利尿劑
雖曾有文獻報告. 目前已知利尿劑對於治療高海拔肺水腫無效. 尤其是很多HAPE患者處於血管內容積缺乏的狀態
(備註: 心因性肺水腫病患通常血管內容積過多,使用利尿劑脫水是常用心因性肺水腫治療方式)
Although their use has been documented in the literature,29 diuretics have no role in HAPE treatment, particularly because many HAPE patients have concurrent intravascular volume depletion. Recommendation grade: 2C.
SUGGESTED APPROACH TO HAPE TREATMENT 高海拔肺水腫的建議治療
在開始治療HAPE之前, 要先排除其他呼吸道症狀成因. 例如肺炎, 感冒, 氣管攣縮, 心肌梗塞等等.
Prior to initiating treatment, care should be taken to rule out other causes of respiratory symptoms at high altitude, such as pneumonia, viral upper respiratory tract infection, bronchospasm, or myocardial infarction.2
下降是治療HAPE 首選方式, 如果環境不允許下降, 應考慮給予氧氣或使用加壓艙, 如果病患可取得氧氣(在醫療院所)可以不要下降至較低海拔. 可以在相同海拔接受氧氣治療. 在無法取得氧氣且沒有失誤空間的地方. 可考慮使用 nifedipine 作為下降/氧氣治療/加壓艙的輔助方式. 只有當上述其他方式都無法取得時. 才能用 nifedipine 最為單一治療.
Descent is the first treatment priority in persons with HAPE. If descent cannot be initiated due to logistical factors, supplemental oxygen or a portable hyperbaric chamber should be used. Patients who have access to oxygen (eg, a hospital or high altitude medical clinic) may not need to descend to lower elevation and can be treated with oxygen at the current elevation. In the field setting, where resources are limited and there is a lower margin for error, nifedipine can be used as an adjunct to descent, oxygen administration, or portable hyperbaric therapy. It should only be used as primary therapy if none of these other measures is available.
壯陽藥(犀利士./威而鋼) 在無法取得 nifedipine時可以使用. 但目前不建議同時使用多種不同類型的肺血管擴張劑.
A phosphodiesterase inhibitor may be used if nifedipine is not available, but concurrent use of multiple pulmonary vasodilators is not recommended.
在醫療院所可考慮使用 CPAP 作為氧氣的輔助治療, 如果病患只使用氧氣無效也可以同時加上 nifedipine. 經過選擇的病患可以帶著氧氣補充瓶離院. 不需住院.
丹木斯/乙型作用劑/利尿劑目前對於HAPE治療沒有角色.
In the hospital setting, CPAP can be considered as an adjunct to supplemental oxygen and nifedipine can be added if patients fail to respond to oxygen therapy alone. In well-selected patients (adequate support from family or friends, adequate housing or lodging arrangements), it is feasible to discharge them from care with supplemental oxygen rather than admitting them to a healthcare facility. There is no established role for acetazolamide, beta-agonists, or diuretics in the treatment of HAPE.
發生HAPE病患在症狀緩解, 停用氧氣/血管擴張劑, 且 休息時及輕微運動時氧氣濃度穩定後, 可再次上升到更高海拔. 或上升加入隊伍行進. 在恢復上升的時候可考慮服用 nifedipine 或其他肺血管擴張劑.
Individuals who develop HAPE may consider further ascent to higher altitudes or re-ascent to join their party only when symptoms of their disease have resolved and they maintain stable oxygenation at rest and with mild exercise while off supplemental oxygen and/or vasodilator therapy. Consideration may be given to using nifedipine or another pulmonary vasodilator upon resuming ascent.
SUGGESTED APPROACH FOR PATIENTS WITH CONCURRENT HAPE AND HACE 同時罹患HAPE及HACE的病患之治療策略
同時罹患HAPE/HACE的病患應使用類固醇 地塞米松. 劑量比照HACE. 有些罹患 HAPE 的人可能因為缺氧導致出現類似 HACE 的症狀(實際上可能沒有 HACE). 但缺氧性腦病變與 HACE 基本上無法區分. 因此應使用類固醇 地塞米松 + 氧氣治療. 改善病患氧氣濃度(氧和) Nifedipine 及其他血管擴張劑可考慮使用於同時罹患 HAPE/HACE 病患. 但須避免過度降低血壓. 因為過度降低血壓會減少腦部灌注壓. 引起腦缺血.
Dexamethasone should be added to the treatment regiment of patients with concurrent HAPE and HACE at the doses described above for those with HACE. Some patients with HAPE may have neurologic dysfunction due to hypoxic encephalopathy rather than true HACE, but making the distinction between hypoxic encephalopathy and HACE in the field can be difficult and, as a result, dexamethasone should be added to the treatment regimen for HAPE patients with neurologic dysfunction that does not resolve rapidly with administration of supplemental oxygen and improvement in the patient's oxygen saturation. Nifedipine or other pulmonary vasodilators may be used in patients with concurrent HAPE and HACE, but care should be exercised to avoid overly large decreases in mean arterial pressure, as this may decrease cerebral perfusion pressure and, as a result, increase the risk for cerebral ischemia.
Conclusions 結論
此指引提供醫療人員, 針對已在高海拔或計畫至高海拔旅遊的人, 預防及治療高海拔疾病(AMS. HACE. HAPE)的實證醫學指引及各項疾病的處置建議. 雖然此指引涵蓋各項高海拔疾病的重要議題,. 仍有一些重要問題需著墨且需要未來更多研究支持. 這些議題包括: 預防兒童罹患高海拔疾病的上升最佳速率, 間歇性低氧對於高海拔疾病的預防.
To assist practitioners caring for people planning travel to or already at high altitude, we have provided evidence based guidelines for prevention and treatment of acute altitude illnesses, including the main prophylactic and therapeutic modalities for AMS, HACE, and HAPE, and recommendations regarding their role in disease management. While these guidelines cover many of the important issues related to prevention and treatment of altitude illness, several important questions remain to be addressed and should serve as a focus for future research. Such research includes the optimum rate of ascent to prevent altitude illness, the role of acetazolamide in HAPE prevention and treatment, proper dosing regimens for prevention and treatment of altitude illness in the pediatric population, and the role of intermittent hypoxic exposure in altitude illness prevention.
Dexamethasone 地塞米松(其他名稱:得康錠（的剎美剎松）.地塞美松) 不要連續使用超過十天
類固醇,地塞米松 有預防AMS效果, 成人預防用的劑量 每次 2 mg 每 6 小時吃一次. 或 每次 4 mg 每 12 小時吃一次, 對於危險性較高的群體可以使用較高劑量 (每次 4 mg 每 6 小時吃一次), 例如軍隊或搜救人員, 需要快速上升至海拔 3500 公尺以上活動, 如果非此類緊急情況不建議這樣用. 連續使用不建議超過 10 天. 以避免產生皮質類固醇毒性或腎上腺抑制效果.
兒童預防高海拔疾病不建議使用. 因可能有副作用. 建議以逐步海拔上升或丹木斯代替.
Prospective trials have established a benefit for dexamethasone in AMS prevention.12,13 The recommended adult doses are 2 mg every 6 hours or 4 mg every 12 hours. Very high doses (4 mg every 6 hours) may be considered in very high risk situations such as military or search and rescue personnel being airlifted to altitudes greater than 3500 m with immediate performance of physical activity but should not be used outside these limited circumstances. The duration of use should not exceed 10 days to prevent glucocorticoid toxicity or adrenal suppression. Recommendation grade: 1A. Dexamethasone should not be used for prophylaxis in the pediatric population due to the potential for side effects unique to this population and the availability of other safe alternatives—specifically, graded ascent and acetazolamide.
Ginkgo biloba 銀杏
雖然有些研究說有助益, 但也有研究顯示無效. 也許與銀杏成品的來源與組成差異有關. 對於預防高山病的效果, 丹木斯優於銀杏.
Although several trials have demonstrated a benefit of Ginkgo in AMS prevention,14,15 several negative trials have also been published.16,17 This discrepancy may result from differences in the source and composition of the Ginkgo products.18 Acetazolamide is considered far superior prophylaxis for AMS prevention. Recommendation grade: 2C
Other options
在安地斯山脈, 咀嚼可可葉, 喝可可茶, 其他可可製品被當成預防高海拔疾病的方式, 據說在亞洲非洲的旅行者也有類似做法, 然而, 對於預防高海拔疾病的作用從未有系統性研究證實, 不應取代其他預防方式, 強迫喝水或過度喝水也無效. 而且喝水過量可能造成低血鈉, 不過適度飲水是必要的. 因脫水與急性高山病症狀相似.
Chewed coca leaves, coca tea, and other coca-derived products are commonly recommended for travelers in the Andes for prophylaxis, and anecdotal reports suggest they are now being used by trekkers in Asia and Africa for similar purposes. However, their utility in prevention of altitude illness has never been systematically studied, and they should not be substituted for other established preventive measures described in these guidelines. “Forced” or “over”-hydration has also never been shown to prevent altitude illness and may even increase the risk of hyponatremia; however, maintenance of adequate hydration is important because symptoms of dehydration can mimic those of AMS
SUGGESTED APPROACH TO AMS/HACE PREVENTION 預防高山病與高海拔腦水腫的建議方式
因個體對於高海拔的反應及適應速率差異很大, 臨床醫師必須要認知到, 底下建議雖然一般都有效, 但並不保證對於高海拔旅行者一定能成功, 預防AMS及HACE的方式, 應該屬於個別旅行者的風險狀況之一. 在低危險狀況, 藥物預防通常不需要, 應該靠逐漸上升 gradual ascent, 在海拔 3000 公尺以上, 個人每天睡覺海拔不要超過前一天 500 公尺, 每 3-4 天應該要有一天休息日(睡眠海拔不要提高), 對於中度危險狀況, 除了逐漸上升還可考慮使用預防藥物
(休息日可以從事體力活動, 但在同一個地方睡覺)
Because the physiologic responses to high altitude and rates of acclimatization vary considerably between individuals, clinicians must recognize that the recommendations that follow, while generally effective, will not guarantee successful prevention in all high altitude travelers. The approach to prevention of AMS and HACE should be a function of the risk profile of the individual traveling to high altitude (Table 3). In low-risk situations, prophylactic medications are not necessary and individuals should rely on a gradual ascent profile. Above an altitude of 3000 m, individuals should not increase the sleeping elevation by more than 500 m per day and should include a rest day (ie, no ascent to higher sleeping elevation) every 3 to 4 days. Prophylactic medications should be considered in addition to gradual ascent for use in moderate-to high-risk situations.
預防用藥建議使用丹木斯, 但無法使用丹木斯(副作用無法忍受,過敏)可使用類固醇地塞米松, 在少見狀況(例如軍隊或搜救隊,需在 3500 公尺以上海拔活動) 可同時使用這兩種藥物. 但這種預防方式只限於使用在需快速上升的緊急狀況
丹木斯對於磺胺類過敏的人有輕微的交叉過敏反應, 如果有磺胺類過敏的人, 在旅遊前, 尤其是要到缺發醫療資源的偏遠地區前, 可在監視下嘗試服用丹木斯, 如果曾發生磺胺類引起過敏性休克的人不要使用丹木斯 (一旦發生過敏可以迅速就醫處置)
丹木斯要在上升前一天使用, 但上升當天使用也有效果, 類固醇地塞米松在上升當天使用, 在同樣的海拔待 2-3 天之後(備註: 新的指引建議丹木斯吃四天), 如果沒有高海拔疾病症狀可考慮停用丹木斯, 如果旅程中會通過一個最高點, 在通過之後如果無症狀可以停用丹木斯
Acetazolamide is the preferred agent, but dexamethasone may be used as an alternative in individuals with a prior history of intolerance of or allergic reaction to acetazolamide. In rare circumstances (eg, military or rescue teams who must ascend rapidly to and perform physical work at altitudes 3500 m), consideration can be given to the concurrent use of acetazolamide and dexamethasone. This strategy should be avoided except in these particular or other emergency circumstances that mandate a very rapid ascent. Acetazolamide carries a low risk of cross-reactivity in persons with sulfonamide allergy, but those with a known allergy to sulfonamide medications should consider a supervised trial of acetazolamide prior to their trip, particularly if planning travel into an area that is remote from medical resources.19 A history of anaphylaxis to sulfonamide medications should be considered a contraindication to acetazolamide. Acetazolamide should be started the day before ascent (but will still have beneficial effects if started on the day of ascent); dexamethasone may be started the day of ascent. For individuals ascending to and staying at the same elevation for more than several days, prophylaxis may be stopped after 2 to 3 days at the target altitude. For an itinerary 旅程 that involves ascending to a high point and then descending to a lower elevation, prophylactic medications should be stopped once descent is initiated.
TREATMENT 高山病 AMS 及高海拔腦水腫 HACE 的治療
高山病AMS及高海拔腦水腫的治療包括下列數種
Potential therapeutic options for AMS and HACE include the following.
Descent 下降
如果可能. 下降仍然是治療 AMS 與 HACE 最佳方式, 然而並非所有狀況都必須下降, 患者應該下降至症狀改善為止, 除非因地形阻隔無法下降, 通常下降 300-1000 公尺症狀會改善, 但每個人需要的下降高度不同, 罹患AMS或HACE的人不要單獨下降, 尤其是罹患HACE的人 (下降過程遇到危險地形可能會失足甚至死亡)
When feasible, descent remains the single best treatment for AMS and HACE. However, it is not necessary in all circumstances (discussed further below). Individuals should descend until symptoms resolve, unless impossible due to terrain. Symptoms typically resolve following descent of 300 to 1000 m, but the required descent will vary between persons. Individuals should not descend alone, particularly in cases of HACE. Recommendation grade: 1A.
Supplemental oxygen 氧氣治療
以鼻導管給予氧氣將血氧濃度 SpO2 提升至 90% 以上, 可作為下降的替代治療, 但並非所有狀況都需要給氧氣, 通常是用在無法下降的嚴重個案, 在偏遠地區, 氧氣供應不像是醫療院所一樣方便, 需審慎評估何時使用.
Oxygen delivered by nasal cannula at flow rates sufficient to raise arterial oxygen saturation (SpO2) to greater than 90% provides a suitable alternative to descent. Use is not required in all circumstances and is generally reserved for severe cases when descent is not feasible. Unlike at hospitals or large clinics, the supply of oxygen may be limited at remote high altitude clinics or on expeditions, necessitating careful use of this therapy. Recommendation grade: 1C.
Portable hyperbaric chambers 加壓艙 PHA
加壓艙可有效治療嚴重高海拔疾病, 但需要由專人看護, 但可能不適合用於幽閉空間恐懼者或嘔吐的人, 移出加壓艙的時候症狀可能再發, 不要因為使用加壓艙而耽誤下降,
These devices are effective for treating severe altitude illness20,21 but require constant tending by care providers and are difficult to use with claustrophobic or vomiting patients. Symptoms may recur when individuals are removed from the chamber.22 Use of a portable hyperbaric chamber should not delay descent in situations where descent is feasible. Recommendation grade: 1B.
Acetazolamide 丹木斯
只有一篇研究檢驗丹木斯治療AMS的效果, 劑量是早晚各吃 250 mg, 低劑量是否有效仍不明.
Only one study has examined acetazolamide for treatment of AMS. The dose studied was 250 mg twice daily and whether a lower dose might suffice is unknown.23 Recommendation grade: 1B.
兒童病患目前無研究報告, 但據說有效, 劑量是 每次每公斤2.5mg, 每 12 小時吃一次. 最大劑量每次 250mg(同成人).
No studies have assessed treatment of AMS in pediatric patients, but anecdotal 傳聞 reports suggest it has utility in this regard. The pediatric treatment dose is 2.5 mg/kg per dose twice daily up to a maximum of 250 mg per dose. Recommendation grade: 1C.
Dexamethasone 地塞米松
類固醇地塞米松對於治療AMS很有效果. 但不會加速高度適應, 停藥之前不要繼續上升, 停藥之後且症狀沒有再發才能上升高度, 有廣泛的臨床研究支持使用類固醇地塞米松治療高海拔腦水腫, 初始劑量 8mg, 之後每 6 小時吃 4mg. 直到症狀改善為止, 小兒劑量每次每公斤 0.15mg. 每 6 小時吃一次,
Dexamethasone is very effective in the treatment of AMS.24-26 The medication does not facilitate acclimatization and further ascent should be delayed until the patient is asymptomatic while off the medication. Recommendation grade 1B.
Extensive clinical experience supports the use of dexamethasone in patients with HACE. It is administered as an 8-mg dose (intramuscularly, intravenously, or orally) followed by 4 mg every 6 hours until symptoms resolve. The pediatric dose is 0.15 mg/kg per dose every 6 hours.11 Recommendation grade: 1C.
SUGGESTED APPROACH TO AMS/HACE TREATMENT
要小心鑑別其他與AMS及HACE相似的症候, 例如脫水,體力不支, 低血糖, 失溫, 低血鈉等等. 有任何高海拔疾病症狀的人, 不要繼續上升, 可能須根據環境及症狀嚴重度考慮下降, 罹患AMS的人可以待在相同海拔接受治療, 頭痛可服用非鴉片類止痛藥(例如普拿疼,NSAID等等), 腸胃症狀例如嘔吐可使用止吐藥物, 可能只需要這些治療即可,.
Care should be taken to exclude disorders whose symptoms and signs may resemble those seen in AMS and HACE, such as dehydration, exhaustion, hypoglycemia, hypothermia, and hyponatremia.2 Persons with altitude illness of any severity should stop ascending and may need to consider descent depending on the clinical circumstances and severity of illness (Table 4).2 Patients with AMS can remain at their current altitude and use non-opiate analgesics for headache and anti-emetics for gastrointestinal symptom relief, which may be all that is required.
丹木斯, 藉由加速高度適應, 有助於治療AMS, 但使用於預防的效果比用於治療更好. 丹木斯可以治療輕微疾病, 類固醇地塞美松對於任何程度的AMS更加可靠有效, 尤其是對於需下降的中度至嚴重的AMS. 罹患AMS的人當症狀改善可繼續上升, 但不要帶著症狀繼續上升至前一個出現症狀的海拔高度.
Acetazolamide, by speeding acclimatization, will help treat AMS, but it works better for prevention than for treatment. While acetazolamide is good for treating mild illness, dexamethasone is a more reliably effective treatment agent for any degree of AMS, especially moderate to severe disease, which often requires descent as well. Individuals with AMS may resume their ascent once symptoms resolve, but further ascent or re-ascent to a previously attained altitude should never be undertaken in the face of ongoing symptoms.
在AMS緩解之後, 比較妥善的作法是同時服用丹木斯上升,
After resolution of AMS, reascent with acetazolamide is prudent.
高海拔腦水腫 HACE 與嚴重 AMS 的區分在於是否出現神經症狀, 例如快速上升到高海拔, 發生 AMS 後, 或同時出現HAPE 症狀, 加上出現運動失調, 神智混淆, 神智改變等. 罹患HACE的人, 在前往當地醫療院所的同時, 需開始氧氣治療及服用類固醇地塞美松. 在缺乏醫療資源的偏遠地區, 懷疑HACE或AMS治療無效的同時就要開始下降, 如果無法下降, 需考慮給氧氣或使用加壓艙, 懷疑罹患HACE病患需開始服用類固醇地塞米松, 可考慮同時服用丹木斯, 除非病患停用類固醇後仍無症狀, 否則不要考慮上升.
HACE is differentiated from severe AMS by neurological findings such as ataxia, confusion, or altered mental status in the setting of acute ascent to high altitude and may follow AMS or occur concurrently with HAPE. Individuals developing HACE in populated areas with access to hospitals or specialized clinics should be started on supplemental oxygen and dexamethasone. In remote areas away from medical resources, descent should be initiated in any suspected HACE victim or if symptoms of AMS are not responding to conservative measures or treatment with acetazolamide or dexamethasone. If descent is not feasible due to logistical issues, supplemental oxygen or a portable hyperbaric chamber should be considered. Persons with HACE should also be started on dexamethasone and consideration can be given to adding acetazolamide. No further ascent should be attempted until the victim is asymptomatic and no longer taking dexamethasone.
High Altitude Pulmonary Edema 高海拔肺水腫
多數關於HAPE的研究都來自於成人, 有些預防及治療策略與AMS/HACE相同, 但HAPE不同的病理機轉需要不同的處理及治療策略.
Information on the epidemiology, clinical presentation and pathophysiology of HAPE, the majority of which comes from studies in adults, is provided in several extensive reviews.4,27,28 While some of the prophylactic and therapeutic modalities are the same for HAPE as for AMS and HACE, important differences in the underlying pathophysiology of the disorder dictate different management and treatment approaches.
PREVENTION 預防高海拔肺水腫
Potential preventive measures for HAPE include the following: 預防方式如下
Gradual Ascent 逐漸上升
目前仍無研究指出是否限制睡眠海拔上升速率能預防HAPE. 但上升速率與疾病發生有明確的關係.
No studies have prospectively assessed whether limiting the rate of increase in sleeping elevation prevents HAPE; however, there is a clear relationship between rate of ascent and disease incidence.7,29,30 Recommendation grade: 1C.
Nifedipine 鈣離子阻斷劑. 常見商品名. adalat 冠達悅.
對於容易罹患 HAPE 的人, 有一篇RCT及廣泛的臨床經驗建立了使用 nifedipine 預防 HAPE的模式. 建議劑量: 一天總量 60mg 緩效釋放劑型分次分量使用. (每12小時吃30mg; or 每8小時吃 20mg. )
A single randomized, placebo-controlled study31 and extensive clinical experience have established a role for nifedipine in the prevention of HAPE in susceptible individuals. The recommended dose is 60 mg of the sustained release preparation administered daily in divided doses. Recommendation grade: 1A.
Salmeterol 乙型作用劑,氣管擴張劑
長效型乙型作用劑 salmeterol 降低 50% 的 HAPE 發生率. 實驗用的劑量是常造成副作用的超高劑量(每次125 ug, 每天兩次). 在高海拔使用這種藥物的臨床經驗有限, 所以 salmeterol 不建議作為預防HAPE的單一方式. 但可配合鈣離子阻斷劑同時使用.
In a single randomized, placebo-controlled study, the long-acting inhaled beta-agonist salmeterol decreased the incidence of HAPE by 50% in susceptible individuals.32 Very high doses (125 ug twice daily) that are often associated with side effects were used in the study. Clinical experience with the medication at high altitude is limited. As a result, salmeterol is not recommended as monotherapy but may be considered as a supplement to nifedipine. Recommendation grade: 2B.
Tadalafil 壯陽藥.犀利士
在一篇RCT中, 每次10mg 每天兩次, 對於容易罹患HAPE患者有預防HAPE的效果, 但收錄的病患數量小. 且缺乏這類藥物使用於預防HAPE的臨床經驗, 需要更多研究資料評估其有效性.
In a single, randomized, placebo-controlled trial, 10 mg twice daily of tadalafil was effective in preventing HAPE in susceptible individuals.33 The number of individuals in the study was small and clinical experience with the medication is lacking compared to nifedipine. As a result, further data are necessary to validate these results. Recommendation grade: 1C.
Dexamethasone 類固醇..地塞米松
在評估犀利士預防HAPE效果的同樣一篇RCT. 每天使用總量 16mg 的類固醇地塞米松, 對於容易罹患HAPE的人也有預防HAPE效果. 機轉仍不明. 臨床經驗也有限.
In the same study that assessed the role of tadalafil in HAPE prevention, dexamethasone (16 mg/d in divided doses) was also shown to prevent HAPE in susceptible individuals. The mechanism for this effect is not clear and there is very little, if any, clinical experience using dexamethasone for this purpose. Further data are necessary to validate this result. Recommendation grade: 1C.
Acetazolamide 丹木斯. 乙醯胺基硫唑嘧錠,
丹木斯可加速高度適應. 應該對於任何種類高海拔疾病都有效果才對. 曾有動物實驗及一個人類試驗. 顯示可以降低低血氧對於肺部血管收縮的效應. 但沒有研究資料支持其預防 HAPE 的角色. 臨床人員建議. 丹木斯可能可以預防 "再返者高海拔肺水腫 re-entry HAPE"
所謂 re-entry HAPE 再返者高海拔肺水腫, 是居住於高海拔地區的兒童. 當移動至低海拔. 重新回到居住地方的時候發生的高海拔肺水腫.
Because acetazolamide hastens acclimatization, it should be effective at preventing all forms of acute altitude illness. It has been shown to blunt hypoxic pulmonary vasoconstriction in animal models34,35 and in a single study in humans,36 but there are no data specifically supporting a role in HAPE prevention.37 Clinical observations suggest acetazolamide may prevent re-entry HAPE, a disorder seen in children who reside at high altitude, travel to lower elevation, and then develop HAPE upon rapid return to their residence. Recommendation grade: 2C.
SUGGESTED APPROACH TO HAPE PREVENTION 高海拔肺水腫建議預防策略
個體對於高海拔的生理反應及適應速率有差異. 以下建議一般是有效的. 但無法保證每個去高海拔旅遊的人都能成功預防. 緩慢提升海拔是 HAPE 主要的預防方式. 海拔上升速率同 AMS/HACE 建議.
As noted earlier, because the physiologic responses to high altitude and rates of acclimatization vary considerably between individuals, the recommendations that follow, while generally effective, will not guarantee successful prevention in all high altitude travelers. A gradual ascent profile is the primary recommended method for preventing HAPE; the recommended ascent rate noted above for AMS and HACE prevention also applies with HAPE prevention.
藥物預防應該限於曾經有 HAPE 病史的人使用. 且 nifedipine 是首選藥物. 在上升到高海拔前一天要開始服藥. 直到下降. 或在相同海拔待五天都沒有症狀. 至於犀利士或類固醇 地塞美松 對於預防HAPE的建議指引仍需更多研究證實其效果. 服用丹木斯是預防 HAPE 合理的選擇. 臨床經驗也支持. 但缺乏研究資料. Salmeterol 只限於輔助 nifedipine 預防高危險性 HAPE 患者再次發生 HAPE. *(不可將 salmeterol 作為單一方法)
Drug prophylaxis should only be considered for individuals with a prior history of HAPE and nifedipine is the preferred option in such situations. It should be started on the day prior to ascent and continued either until descent is initiated or the individual has spent 5 days at the target elevation. Further research is needed before tadalafil or dexamethasone can be recommended for this purpose. Acetazolamide is a rational choice for HAPE prevention and clinical experience supports this, but data are lacking. Salmeterol should only be considered as a supplement to nifedipine in high-risk individuals with a clear history of recurrent HAPE.
TREATMENT 治療高海拔肺水腫.
Potential therapeutic options for HAPE include the following:
Descent 下降
如同AMS/HACE. 下降是治療 HAPE 唯一 最有效的方式. 但並非所有狀況都需要下降. 患者應該下降 1000 公尺或直到症狀改善. 下降過程盡量減少體力活動(不要負重. 騎乘動物.搭轎子.被人揹負). 因運動會進一步加重肺部血管壓力. 導致肺水腫症狀惡化.
As with AMS and HACE, descent remains the single best treatment for HAPE but is not necessary in all circumstances. Individuals should try to descend at least 1000 m or until symptoms resolve. They should exert themselves as little as possible on descent (eg, travel without a pack or via animal transportation) because exertion can further increase pulmonary artery pressure and exacerbate edema formation. Recommendation grade: 1A.
Supplemental Oxygen 給氧氣
由鼻導管或氧氣面罩給予氧氣, 將氧氣濃度 SpO2 提升至 90%. 適合做為下降的替代療法. 尤其是附近有醫療院所可提供氧氣, 且能密切監護時.
Oxygen delivered by nasal cannula or face mask at flow rates sufficient to achieve goal SpO2 90% provides a suitable alternative to descent, particularly when patients can access healthcare facilities and be monitored closely.38,39 Recommendation grade: 1B.
Portable Hyperbaric Chambers 加壓艙
如同AMS/HACE. 攜帶型加壓艙可以作為HAPE治療. 目前沒有關於這種方式的系統性研究. 但是曾有文獻報告. 使用加壓艙不要耽誤下降.
As with AMS and HACE, portable hyperbaric chambers can be used for HAPE treatment. They have not been systematically studied in this role, but their use in HAPE has been reported in the literature.40 Use of a portable hyperbaric chamber should not delay descent in situations where descent is feasible. Recommendation grade: 1B.
Nifedipine 鈣離子阻斷劑. adalat. 冠達悅
一篇 非隨機 非盲 研究顯示. 當無法使用氧氣或下降時, 使用 nifedipine 治療 HAPE. 沒有其他治療研究在進行. 但有廣泛性的臨床經驗使用 nifedipine 作為氧氣及下降的輔助治療. 除非無法給予氧氣/無法使用加壓艙或無法下降. 不要使用 nifedipine 作為單一治療選項.
A single, nonrandomized, unblinded study demonstrated utility of nifedipine in HAPE treatment when oxygen or descent is not available.41 No other treatment studies have been conducted, but there is extensive clinical expperience with its use as an adjunct to oxygen or descent. Sixty milligrams of the sustained release version is administered daily in divided doses without a loading dose. It should not be relied on as the sole therapy unless descent is impossible and access to supplemental oxygen or portable hyperbaric therapy cannot be arranged. Recommendation grade: 1C (for use as adjunctive therapy).
Beta-agonists 乙型作用劑. 氣管擴張劑.
雖然有個案報告使用乙型作用劑治療HAPE. 無臨床資料證實使用 salmeterol 或 albuterol 治療罹患 HAPE 的病患.
Although there are reports of beta-agonist use in HAPE treatment,42 no data support a benefit from salmeterol or albuterol in patients suffering from HAPE. Recommendation grade: 2C.
Phosphodiesterase Inhibitors 磷酸二酯酶抑製劑. 壯陽藥.
此類藥物有肺部血管擴張效果. 可降低肺動脈壓力. 有強烈的生理機轉可用於治療 HAPE. 雖然有個案報告. 但對於犀利士或威而鋼使用於 HAPE 的治療並無系統性研究.
By virtue of their ability to cause pulmonary vasodilation and decrease pulmonary artery pressure, there is a strong physiologic rationale for using phosphodiesterase inhibitors in HAPE treatment. While reports document their use for this purpose,42 no systematic studies have examined the role of either tadalafil or sildenafil in HAPE treatment. Recommendation grade: 2C
Continuous Positive Airway Pressure 持續性呼吸道正壓(陽壓)治療.
一項小規模研究顯示吐氣正壓呼吸治療 EPAP,. 使用一個面罩以增在吐氣的時候壓呼吸道壓力, 能改善 HAPE 病患的氣體交換. 但對於更常使用的 CPAP是否可改善病患預後並無研究資料. CPAP 使吸氣吐氣的時候都持續維持呼吸道正壓的方式, 在醫院通常用於慢性呼吸道阻塞. 或慢性肺部纖維化病患. 因為使用這種治療方式的風險並不大. 可考慮作為給氧氣的輔助療法. 但病患必須神智清楚.能配合機器. 並非所有狀況都可以使用. 治療所需的壓力也尚未建立,
A small study demonstrated that expiratory positive airway pressure (EPAP), in which a mask system is used to increase airway pressure during exhalation only, improved gas exchange in HAPE patients.43 However, no studies have established that this modality or the more commonly used continuous positive airway pressure (CPAP), in which a continuous level of pressure is applied to the airways through the entire respiratory cycle, improves patient outcomes. Given the low risks associated with the therapy, it can be considered an adjunct to oxygen administration in the hospital setting, provided the patient has intact mental status and can tolerate the mask. It is generally not feasible in the field setting and the required level of pressure has not been established. Recommendation grade: 2B.
Diuretics 利尿劑
雖曾有文獻報告. 目前已知利尿劑對於治療高海拔肺水腫無效. 尤其是很多HAPE患者處於血管內容積缺乏的狀態
(備註: 心因性肺水腫病患通常血管內容積過多,使用利尿劑脫水是常用心因性肺水腫治療方式)
Although their use has been documented in the literature,29 diuretics have no role in HAPE treatment, particularly because many HAPE patients have concurrent intravascular volume depletion. Recommendation grade: 2C.
SUGGESTED APPROACH TO HAPE TREATMENT 高海拔肺水腫的建議治療
在開始治療HAPE之前, 要先排除其他呼吸道症狀成因. 例如肺炎, 感冒, 氣管攣縮, 心肌梗塞等等.
Prior to initiating treatment, care should be taken to rule out other causes of respiratory symptoms at high altitude, such as pneumonia, viral upper respiratory tract infection, bronchospasm, or myocardial infarction.2
下降是治療HAPE 首選方式, 如果環境不允許下降, 應考慮給予氧氣或使用加壓艙, 如果病患可取得氧氣(在醫療院所)可以不要下降至較低海拔. 可以在相同海拔接受氧氣治療. 在無法取得氧氣且沒有失誤空間的地方. 可考慮使用 nifedipine 作為下降/氧氣治療/加壓艙的輔助方式. 只有當上述其他方式都無法取得時. 才能用 nifedipine 最為單一治療.
Descent is the first treatment priority in persons with HAPE. If descent cannot be initiated due to logistical factors, supplemental oxygen or a portable hyperbaric chamber should be used. Patients who have access to oxygen (eg, a hospital or high altitude medical clinic) may not need to descend to lower elevation and can be treated with oxygen at the current elevation. In the field setting, where resources are limited and there is a lower margin for error, nifedipine can be used as an adjunct to descent, oxygen administration, or portable hyperbaric therapy. It should only be used as primary therapy if none of these other measures is available.
壯陽藥(犀利士./威而鋼) 在無法取得 nifedipine時可以使用. 但目前不建議同時使用多種不同類型的肺血管擴張劑.
A phosphodiesterase inhibitor may be used if nifedipine is not available, but concurrent use of multiple pulmonary vasodilators is not recommended.
在醫療院所可考慮使用 CPAP 作為氧氣的輔助治療, 如果病患只使用氧氣無效也可以同時加上 nifedipine. 經過選擇的病患可以帶著氧氣補充瓶離院. 不需住院.
丹木斯/乙型作用劑/利尿劑目前對於HAPE治療沒有角色.
In the hospital setting, CPAP can be considered as an adjunct to supplemental oxygen and nifedipine can be added if patients fail to respond to oxygen therapy alone. In well-selected patients (adequate support from family or friends, adequate housing or lodging arrangements), it is feasible to discharge them from care with supplemental oxygen rather than admitting them to a healthcare facility. There is no established role for acetazolamide, beta-agonists, or diuretics in the treatment of HAPE.
發生HAPE病患在症狀緩解, 停用氧氣/血管擴張劑, 且 休息時及輕微運動時氧氣濃度穩定後, 可再次上升到更高海拔. 或上升加入隊伍行進. 在恢復上升的時候可考慮服用 nifedipine 或其他肺血管擴張劑.
Individuals who develop HAPE may consider further ascent to higher altitudes or re-ascent to join their party only when symptoms of their disease have resolved and they maintain stable oxygenation at rest and with mild exercise while off supplemental oxygen and/or vasodilator therapy. Consideration may be given to using nifedipine or another pulmonary vasodilator upon resuming ascent.
SUGGESTED APPROACH FOR PATIENTS WITH CONCURRENT HAPE AND HACE 同時罹患HAPE及HACE的病患之治療策略
同時罹患HAPE/HACE的病患應使用類固醇 地塞米松. 劑量比照HACE. 有些罹患 HAPE 的人可能因為缺氧導致出現類似 HACE 的症狀(實際上可能沒有 HACE). 但缺氧性腦病變與 HACE 基本上無法區分. 因此應使用類固醇 地塞米松 + 氧氣治療. 改善病患氧氣濃度(氧和) Nifedipine 及其他血管擴張劑可考慮使用於同時罹患 HAPE/HACE 病患. 但須避免過度降低血壓. 因為過度降低血壓會減少腦部灌注壓. 引起腦缺血.
Dexamethasone should be added to the treatment regiment of patients with concurrent HAPE and HACE at the doses described above for those with HACE. Some patients with HAPE may have neurologic dysfunction due to hypoxic encephalopathy rather than true HACE, but making the distinction between hypoxic encephalopathy and HACE in the field can be difficult and, as a result, dexamethasone should be added to the treatment regimen for HAPE patients with neurologic dysfunction that does not resolve rapidly with administration of supplemental oxygen and improvement in the patient's oxygen saturation. Nifedipine or other pulmonary vasodilators may be used in patients with concurrent HAPE and HACE, but care should be exercised to avoid overly large decreases in mean arterial pressure, as this may decrease cerebral perfusion pressure and, as a result, increase the risk for cerebral ischemia.
Conclusions 結論
此指引提供醫療人員, 針對已在高海拔或計畫至高海拔旅遊的人, 預防及治療高海拔疾病(AMS. HACE. HAPE)的實證醫學指引及各項疾病的處置建議. 雖然此指引涵蓋各項高海拔疾病的重要議題,. 仍有一些重要問題需著墨且需要未來更多研究支持. 這些議題包括: 預防兒童罹患高海拔疾病的上升最佳速率, 間歇性低氧對於高海拔疾病的預防.
To assist practitioners caring for people planning travel to or already at high altitude, we have provided evidence based guidelines for prevention and treatment of acute altitude illnesses, including the main prophylactic and therapeutic modalities for AMS, HACE, and HAPE, and recommendations regarding their role in disease management. While these guidelines cover many of the important issues related to prevention and treatment of altitude illness, several important questions remain to be addressed and should serve as a focus for future research. Such research includes the optimum rate of ascent to prevent altitude illness, the role of acetazolamide in HAPE prevention and treatment, proper dosing regimens for prevention and treatment of altitude illness in the pediatric population, and the role of intermittent hypoxic exposure in altitude illness prevention.
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