野外與登山醫學-2014 WMS Practice Guidelines 4 高海拔疾病預防及治療 4

1. 高山病及高海拔腦水腫預防 http://blog.xuite.net/ymmcc/twblog/540135871
2. 高山病及高海拔腦水腫治療 http://blog.xuite.net/ymmcc/twblog/540164931
3. 高海拔肺水腫預防 http://blog.xuite.net/ymmcc/twblog/540171169
4. 高海拔肺水腫治療 http://blog.xuite.net/ymmcc/twblog/540177927
5. 同時罹患HACE及HAPE的治療 http://blog.xuite.net/ymmcc/twblog/540188730

這是文章翻譯的第四節  TREATMENT 治療高海拔肺水腫

Potential therapeutic options for HAPE include the following.

1. 下降 Descent，如同AMS 及 HACE，下降仍是治療HAPE最佳選擇，但並一定必要，患者可先嘗試下降 1000 公尺海拔，或下降至症狀改善，下降過程盡量避免過度活動，例如不要背東西，使用乘坐動物，運動會增加肺動脈壓力，促使肺水腫產生

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.

2. 氧氣，Supplemental oxygen，使用鼻導管或氧氣面罩，讓血氧飽和度超過 90％，可作為下降的替代治療，尤其是周遭可取得醫療設備的狀況，病患需密集監測

Oxygen delivered by nasal cannula or face mask at flow rates sufficient to achieve goal SpO2 greater than 90% provides a suitable alternative to descent, particularly when patients can access healthcare facilities and be monitored closely.51,52 Recommendation Grade: 1B.

3. 加壓艙 Portable hyperbaric chambers，如同AMS和HACE，加壓艙可治療HAPE，雖然缺乏系統性研究，但用加壓艙治療HAPE已經有文獻報告，可以下降的時候，不要因為使用加壓艙而耽誤下降

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.53 Use of a portable hyperbaric chamber should not delay descent in situations in which descent is feasible. Recommendation Grade: 1B.

4. Nifedipine 鈣離子阻斷劑，有一篇非隨機研究證明，當無法下降也無氧氣時，可使用nifedipine治療 HAPE，雖然沒有其他研究繼續進行，但很多人有使用 nifedipine 輔助氧氣或下降治療的臨床經驗，30 mg 長效型 每天吃兩次，如果不是完全無法下降，或無法取得氧氣，或無法取得加壓艙，不要將 nifedipine 當成HAPE 唯一的治療手段。

A single, nonrandomized, unblinded study demonstrated the utility of nifedipine in HAPE treatment when oxygen or descent is not available.54 No other treatment studies have been conducted, but there is extensive clinical experience with its use as an adjunct to oxygen or descent. Thirty milligrams of the extended-release version is administered twice daily 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).

5. 乙型作用劑，有個案報告，但無研究資料支持 salmeterol 或 albuterol 對於HAPE 的治療效果

β-Agonists Although there are reports of β-agonist use in HAPE treatment,55 no data support a benefit from salmeterol or albuterol in patients suffering from HAPE. Recommendation Grade: 2C.

6. 犀利士、威而鋼，能擴張肺動脈，降低肺動脈壓力，有很強的生理機轉理由讓我們用來治療 HAPE，有個案報告，無系統性研究

Phosphodiesterase inhibitors

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. Although reports document their use for this purpose,55 no systematic studies have examined the role of either tadalafil or sildenafil in HAPE treatment. Recommendation Grade: 2C.

7. 持續性正壓呼吸 Continuous positive airway pressure 使用EPAP增加吐氣時的呼吸道壓力，能改善HAPE病患的氣體交換，EPAP使用比較少，使用較多的是 CPAP，而CPAP是否能使用於HAPE則沒有研究資料，這類治療風險不高，在醫院內可考慮作為氧氣治療的輔助療法，但病患需神智清醒，能配合呼吸器使用。未來科技更發達，能做出更小的裝置，使用也許可以更廣泛。

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.56 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 at present but may become more feasible in the future as technology improves and smaller, batterypowered devices become more widely available. Recommendation Grade: 2B.

8. 利尿劑 Diuretics 對於 HAPE 治療無效，因為 HAPE 病患通常血管內容積是不足的

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.

9. 類固醇 Dexamethasone 可預防HAPE，有些研究也顯示其對於缺氧狀態最大體適能、肺發炎、離子交換功能的影響，類固醇對於治療 HAPE 可能有用。但目前缺乏研究資料證實其效果

Considering its potential role in HAPE prevention, noted above, and studies demonstrating effects on maximum exercise capacity,57 pulmonary inflammation, and iontransporter function in hypoxia,58 dexamethasone may have a role in HAPE treatment. Although reports document its clinical use in this regard,59 no study has established whether it is effective for this purpose. Recommendation Grade: 2C.

總結

1. 開始治療HAPE前，應排除其他呼吸道問題，例如肺炎，感冒，痰液卡住、氣管痙攣、心肌梗塞

2. 下降是HAPE首選治療

3. 無法下降時可考慮給氧、加壓艙

4. 能取得氧氣的時候（醫院、診所）可能不一定要下降到較低海拔，可在相同海拔接受氧氣治療

5. 如果資源有限，沒有犯錯空間時，nifedipine 可作為下降、氧氣、加壓艙的輔助治療。當其他治療都無法進行時，才可單獨使用 nifedipine 作為單一治療手段

6. 如果無法取得 nifedipine 時，可以使用犀利士、威而鋼，但不建議同時使用這兩類不同類型的肺動脈擴張劑

7. 在醫院，可考慮使用 CPAP，作為氧氣的輔助治療，單獨使用氧氣效果不好的病人可考慮使用 nifedipine 

8. 在經過慎選的病患，可帶著氧氣補給離院，不一定需要住院

9. 關於丹木斯，乙型擴張劑，利尿劑治療HAPE，目前不建議

10. 發生 HAPE 的患者，當疾病緩解，脫離氧氣治療時症狀不再發，在休息狀態及輕度活動狀態仍可維持良好氧和，才能考慮再次上升，並且在上升時給予 nifedipine 或其他肺部血管擴張劑預防再次發生

Suggested approach to HAPE treatment

Before 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, mucus plugging, bronchospasm, or myocardial infarction.8 Descent is the first treatment priority in persons with HAPE. If descent cannot be initiated as a result of 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, or portable hyperbaric therapy. It should only be used as primary therapy if none of these other measures is available. A phosphodiesterase inhibitor may be used if nifedipine is not available, but concurrent use of multiple pulmonary vasodilators is not recommended. 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 wellselected 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, β-agonists, or diuretics in the treatment of HAPE. Individuals who develop HAPE may consider further ascent to higher altitudes or reascent 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 or vasodilator therapy. Consideration may be given to using nifedipine or another pulmonary vasodilator on resuming ascent.