急診小醫師ymmcc的醫學筆記: 4月 2020

2020年4月30日星期四

Forxiga SGLT-2i 抑制劑 Dapagliflozin 腎功能45以下禁用

Dapagliflozin(Forxiga) 福適佳膜衣錠
可單方使用
也可與其他藥物併用, 但健保給付規定不可與 DPP4i 並用 (宜二種擇一種使用)

劑量

起始 5mg QD

可增加為 10mg QD (但健保規定只能一天開一顆)

eGFR>60 不需調整劑量

老年人不需調整劑量

肝功能不全, 不需調整劑量, 但對於嚴重肝衰竭, 無研究報告, 安全性不明

Forxiga 的建議起始劑量是5mg每天1次，早晨服用，隨餐或空腹服用皆可。
在耐受Forxiga 5mg每天1次的患者，需要額外血糖控制時，劑量可增至10mg每天1次 (但健保規定只能一天開一顆)

禁忌

eGFR < 45 不建議使用, 根據機轉, 腎功能不良患者應該沒有效

懷孕,不確定

哺乳, 不建議

不良反應, 相較於安慰劑
生殖器感染從 3.0% 增加為 7.4~14.3%
尿路感染從 5.6% 增加為 8.4-13.8%

空腹服用 2 小時到達peak最高濃度

可空腹服用, 也可隨餐服用

半衰期

單次服用後, 血中末相半衰期 12.9小時

Forxiga可單獨使用亦可與metformin、sulfonylurea、thiazolidinedione、DPP-4 抑制劑（併用或不併用metformin）、胰島素合併使用，做為附加於飲食控制及運動之外的治療藥物，藉以改善第二型糖尿病患的血糖控制效果。

在血容量不足患者，建議在開始Forxiga 之前矯正這種情況。
腎功能不全病人
eGFR 大於或等於 45mL/min/1.73m2 的病人，無須調整劑量。
當病人 eGFR 低於 45mL/min/1.73 m2 時，不建議使用 Forxiga。
當病人 eGFR 低於 30mL/min/1.73 m2 時，禁用 Forxiga。

健保給付規定
使用條件：(105/5/1)
(1)原則上第二型糖尿病治療應優先使用metformin，或考慮早期開始使用胰島素。除有過敏、禁忌症、不能耐受或仍無法理想控制血糖的情形下，可使用其他類口服降血糖藥物。
(2)TZD製劑、DPP-4抑制劑、SGLT-2抑制劑、以及含該3類成分之複方製劑，限用於已接受過最大耐受劑量的metformin仍無法理想控制血糖之第二型糖尿病病人，且SGLT-2抑制劑與DPP-4抑制劑及其複方製劑宜二種擇一種使用。
(3)第二型糖尿病病人倘於使用三種口服降血糖藥物治療仍無法理想控制血糖者，宜考慮給予胰島素治療。
(4)特約醫療院所應加強衛教第二型糖尿病病人，鼓勵健康生活型態的飲食和運動，如控制肥胖、限制熱量攝取等措施。
(5)第二型糖尿病病人使用之口服降血糖藥物成分，以最多四種(含四種)為限。
備註：本規定生效前已使用超過四種口服降血糖藥物成分之病人，得繼續使用原藥物至醫師更新其處方內容。
5.1.5. SGLT-2抑制劑及其複方：
1.Dapagliflozin (如Forxiga)、empagliflozin (如Jardiance) (105/5/1)
每日最多處方1粒。

副作用
生殖器黴菌感染、鼻咽炎、尿路感染、背痛、排尿增加。

SGLT2抑制劑作用機轉

抑制尿糖的再吸收來增加腎臟葡萄糖排泄
可減輕體重
可降低血壓

正常人一天有 180g 葡萄糖會從腎絲球過濾但很快又吸收回體內
SGLT2 鈉-葡萄糖共同轉運蛋白負責將葡萄糖運回體內

腸泌素類相關藥物 DPP4i 與 GLP1RA

Incretin-Based Insulin Secretagogues
藉用腸泌素(Incretin)相關的生理機轉發展出來的藥物。

目前有兩類藥物： DPP4i 與 GLP1RA

當葡萄糖或是食物在腸內的時候，腸泌素會藉由腸道分泌胜肽(peptides)來增加葡萄糖刺激型胰島素的分泌，腸泌素分別是由葡萄糖依賴型促胰島素多胜肽(glucose-dependent insulinotropic polypeptide, GIP)以及類升醣素胜肽(glucagon-like peptide-1, GLP-1) 等兩個部分所組成。

腸泌素會迅速地被 DPP-4(dipeptidyl peptidase-4)所分解，因此半衰期非常短。

目前有兩類藥物： DPP4i與 GLP1RA

第一類為DPP4抑制劑dipeptidyl p e p t i d a s e i n h i b i t o r s
(sitagliptin , saxagliptin, linagliptin, vildagliptin)，藉由抑制腸泌素荷爾蒙的分解，增加胰島素分泌，控制空腹與餐後血糖。皆可用於慢性腎臟病患，但sitagliptin, saxagliptin, vildagliptin隨腎功能下降須調降劑量，

第二類為腸泌素類似物 I n c r e t i n mimetic/ GLP1RA
(Exenatide, Liraglutide)，兩者皆為皮下注射給予，作用為促進胰島素分泌、降低升醣素分泌、延緩胃排空及降低食慾。

極少數病患會引起胰臟炎，但與其他口服降血糖藥物相比整體發生率並未較高。

Exenatide主要由腎臟清除，且隨著GFR的下降，其清除率亦下降。當GFR為5mL/min/1.73m2 時清除率下降 36%，當GFR<30 mL/min/1.73m2 時清除率下降64%。

因此，Exenatide不建議用於 GFR<30 mL/min/1.73m2 的患者。

另外， Exenatide曾有造成急性腎衰竭及慢性腎病變惡化的個案報告。

Liraglutide被報告有甲狀腺C細胞腫瘤及胰臟炎風險，應要注意；針對腎功能不全患者建議無需劑量調整。

健保給付規定. GLP1RA不得與胰島素, DPP4i, SGLT2I 合併使用.

5.1.3. GLP-1受體促效劑：Exenatide (如 Byetta)、dulaglutide (如 Trulicity)；liraglutide (如 Victoza) 5.1.1.(略) 5.1.2.(略) 5.1.3. GLP-1 受體促效劑：Exenatide (如 Byetta)、dulaglutide (如 Trulicity)；liraglutide (如 3 (100/5/1、101/10/1、105/5/1) 1. 限用於已接受過最大耐受劑量的 metformin 及/或 sulfonylurea 類藥物仍無法理想控制血糖之第二型糖尿病患者。 2. 本藥品不得與 insulin、DPP-4抑制劑、SGLT-2抑制劑等藥物併用。

Nateglinide Starlix 隨餐服用 CKD stage 5 禁用

Nateglinide 屬於 GLINIDES 非磺醯尿素類促胰島素分泌劑
瑞士諾華 Novartis 藥廠生產

促胰島素分泌劑: 磺醯尿素類SU及GLINIDES

GLINIDES類藥物, 又稱 Meglitinides 類似物,

短效促胰島素分泌的非磺醯類藥物, 包含
Repaglinide = novonorm 諾和隆錠 = 安息香酸類衍生物
Nateglinide = Starlix (始糖立釋膜衣錠) = 苯丙胺酸衍生物

Nateglinide 用餐前一分鐘服用, 或餐前 30 分鐘服用

Nateglinide EAK 服藥後一小時內到達最高濃度

劑量

若一天一次, 可選擇主餐(吃最多的那一餐)前服用.
一般人 120 mgTID , 可增加至 180 mg TID (每次最大劑量 180 mg)

若HbA1C < 7.5%, 建議起始劑量 60mg TID

老年人不需減量

腎功能不良/慢性腎病可使用.

Nateglinide 快速經腸胃道吸收, 由肝臟代謝為九種主要代謝物 ( M1-M9). 代謝物相較於原型藥有非常微弱的降血糖效果, M7 是唯一具有高生理活性的代謝物, 但僅佔 7% 以下, 降血糖作用主要還是靠 nateglinide, 排出至尿液的藥物, 16% 是原型藥, 84% 是代謝物.

禁忌

eGFR<10 第五期慢性腎病

T1DM 第一型糖尿病
過敏
DKA

懷孕不建議使用 (資料不足, 危險性不明, 無研究佐證)

哺乳不建議使用 (資料不足, 沒有研究證明是否會分泌至人類乳汁)

過量患者(昏迷,癲癇, 其他神經症狀), 使用血液透析HD無法有效移除, HD無效.

Nateglinide 第五期慢性腎病不要使用
Nateglinide 第四期慢性腎病可減量使用 60mg tid.

半衰期 1.5 小時

Nateglinide is also rapidly absorbed from the gastrointestinal tract and metabolized in liver to 9 main metabolites (M1-M9). These metabolites have much weaker hypoglycemic activity than the parent compound. The only metabolite that retains high activity is the metabolite M7. The concentration of this metabolite however is low (< 7%), resulting in a hypoglycemic effect, which is attributed mainly to intact nateglinide. The excretion of the drug in urine is unchanged form at 16% and by 84% in the form of metabolites.

In CKD stage 5 we avoid nateglinide, and in stage 4 we adjust the dose (60 mg × 3)

Meglitinides 類：本類藥品與 sulfonylureas 一樣會促進胰島素分泌，但開始作用時間較快，作用時間較短。

雖然 repaglinide 濃度、半衰期及曲線下面積（area under curve，AUC）會因 eGFR 降低而增加，但不需調整劑量。

Nateglinide 的活性代謝物會因 eGFR 降低造成累積，CKD 病人使用需非常小心。

Repaglinide novonorm 諾和隆錠腎衰竭可用餐前15分鐘服用

Repaglinide = novonorm 諾和隆錠 = 安息香酸類衍生物
日本研發

(不建議併用 repaglinide 及 gemfibrozil，此兩藥併用會增加低血糖風險，在歐洲是禁止同時使用這兩種藥物。如有需要使用 fibrate 類藥物，可以選擇將 gemfibrozil 改為 fenofibrate。)

劑量
肝臟代謝, 腎功能不良/慢性腎病/腎衰竭可使用.
eGFR 30 以下建議起始劑量 0.5mg, 可逐漸增加劑量

半衰期 1 小時

可降低餐前餐後血糖波動 , 餐前 15 分鐘服用, 或開始用餐時服用, 或開始用餐 30 分鐘內服用

作用時間短 , 相較於 SU, 低血糖風險降低, 適合慢性腎病使用, 因慢性腎病發生低血糖的風險上升

Glinides, repaglinide and nateglinide, are short acting secretagogues. The short duration of their action means reduced risk of hypoglycemia compared to sulfonylureas. This is an advantage for diabetic subjects with CKD because they belong in the high risk for hypoglycemia group as already mentioned.

Repaglinide 腸胃道吸收, 肝臟代謝(氧化及結合 glucuronic acid), 主要代謝物是 M1, M2, M4 會經由膽汁排出至糞便, 代謝物沒有降血糖的生理活性

Repaglinide 在第四第五期腎衰竭患者不用降低劑量
Repaglinide is absorbed from the gastrointestinal tract and metabolized in the liver by oxidation and conjugation with glucuronic acid. The major metabolites of repaglinide are M1, M2 and M4. These metabolites are excreted via the bile into the feces and have no hypoglycemic activity[20].
Repaglinide can be used even in CKD stages 4 and 5 without dose reduction.

2020年4月29日星期三

B型肝炎表面抗原

B肝帶原者, 如果測不到B肝表面抗原, 稱為B肝表面抗原「陰轉」, 但病患仍為帶原者
仍須持續追蹤
.
B肝表面抗原「陰轉」（HBsAg seroconversion），表面抗原消失，表面抗體（Anti-HBs）由陰轉陽。

仍然是B肝帶原者，抽血檢測B肝病毒DNA（HBV DNA）很可能仍呈陽性, 仍應定期長期追蹤。

即使血中已測不到HBV DNA，若罹患淋巴癌或自體免疫疾病而接受類固醇或免疫抑制治療時，可能會激活肝細胞核內的B肝病毒cccDNA(covalently closed circular DNA))再度大量複製，B肝病毒表面抗原（HBsAg）會再度呈現陽性反應，病毒顆粒也會再度出現。

極少數潛在的B肝帶原者過去從未驗過B肝病毒標記，首次檢驗即呈現此等結果

2020年4月28日星期二

野外與登山醫學---0--WMS 2019 acute altitude illness update 目錄

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update

統一名詞翻譯

AMS 急性高山病 (不建議使用高山症, 症通常是指不同病因但有相似症狀的疾病)
舉例: 類流感症候群, 發燒合併其他呼吸道症狀, 類流感症狀的原因很多, 例如登革熱, 鉤端螺旋體感染, 虐疾等等)
(流感之外的其他疾病,呼吸道症狀並非典型症狀)
(流感患者也可能沒有呼吸道症狀)
HACE 高海拔腦水腫
HAPE 高海拔肺水腫

Acute altitude illness (AAI) 急性高海拔疾病/高山症
(民眾常將急性高山病AMS與 acute altitude illness 高山症/高海拔疾病搞錯)

AAI (acute altitude illness) 包含AMS, HACE, 及 HAPE

acetazolamide 丹木斯
Dexamethasone 類固醇(地塞米松, 類固醇種類繁多,為了方便閱讀, 以類固醇代替)
Inhaled budesonide 吸入性類固醇(吸入性類固醇不僅這一種)
Staged ascent 分段爬升
Preacclimatization 高度適應
Hypoxic tents 低氧帳

高海拔定義,何時可使用本指引

Acute mountain sickness and high altitude cerebral edema
PREVENTION
Gradual ascent 建議緩慢爬升睡眠海拔高度, 以預防AMS/HACE
Acetazolamide 中度或高度風險時,強烈建議使用丹木斯預防AMS/HACE, 兒童也可以使用
Dexamethasone 中度或高度罹患AMS風險等級, 建議作為丹木斯替代藥物, 兒童不建議使用
Inhaled budesonide 吸入性類固醇不建議做為預防AMS藥物
Ginkgo biloba 不建議使用銀杏預防AMS(或其他高海拔疾病)
Ibuprofen 不想或不能吃丹木斯/類固醇的人, 可服用布洛芬預防AMS. 證據等級 2B
Acetaminophen 不建議使用普拿疼替代丹木斯或類固醇, 做為預防AMS藥物
Staged ascent and preacclimatization
Hypoxic tents
Other options

AMS/HACE/HAPE 發生率(急性高山病/高海拔腦水腫/高海拔肺水腫)

https://ymmcc2019.blogspot.com/2023/08/amshacehape.html

201711080910 AMS HAPE HACE 海拔 3600 西藏機場調查高海拔疾病發生率

https://ymmcc2019.blogspot.com/2019/12/3600-ams-hape-hace.html

野外及登山醫學---WMS 2019 acute altitude illness update 目錄

https://ymmcc2019.blogspot.com/2020/04/wms-2019-acute-altitude-illness-update_28.html

HAPE + HACE TREATMENT APPROACH 39

https://www.blogger.com/blog/post/edit/preview/1858837996889081076/3409425706749151133

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT SUGGESTED APPROACH 38

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_21.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Diuretics/Acetazolamide 36

https://www.blogger.com/blog/post/edit/preview/1858837996889081076/8596568490877058325

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Dexamethasone 37

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_88.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Continuous positive airway pressure 35

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_72.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Phosphodiesterase inhibitors 34

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_60.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Nifedipine 32

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_87.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Beta-agonists 33

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_69.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Portable hyperbaric chambers 30

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_70.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Supplemental oxygen 29

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_29.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE TREATMENT Descent 28

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_54.html

野外及登山醫學---27--WMS 2019 update HAPE PREVENTION SUGGESTED APPROACH

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-ilness-wms-2019-update_19.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE PREVENTION Preacclimatization and staged ascent 26

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_83.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE PREVENTION Acetazolamide 25

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_42.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE PREVENTION Dexamethasone 24

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_3.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE PREVENTION Tadalafil 23

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_55.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE PREVENTION Salmeterol 22

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_1.html

野外及登山醫學---Acute altitude illness WMS 2019 update HAPE PREVENTION Nifedipine 21

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_14.html

野外及登山醫學---20--WMS 2019 update HAPE PREVENTION Gradual ascent

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_25.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment SUGGESTED APPROACH 19

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_76.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment Acetaminophen/ Ibuprofen 17

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_15.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment Continuous positive airway pressure 18

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_63.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment Acetazolamide 15

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_4.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment Dexamethasone 16

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Tre

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_7.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment Portable hyperbaric chambers 14

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_32.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment Supplemental oxygen 13

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_73.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE Treatment Descent 12

Wilderness Medical Society Clinical Practice Guidelines for the Pr

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_0.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE prevention suggested approach 11

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_13.html

野外及登山醫學---Acute altitude illness WMS 2019 update AMS/HACE prevention others 10

https://ymmcc2019.blogspot.com/2020/04/acute-altitude-illness-wms-2019-update_96.html

WMS 2019 update -- Conclusions 40(最後一篇了) (done)

下面是導向隨意窩 xuite 連結. 已經失效. 多數有轉貼到這個blogger

2020年4月27日星期一

野外與登山醫學--40-- WMS 2019 update -- Conclusions 40(最後一篇了) (done)

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
中文翻譯目錄

統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Conclusions

這篇文章提供了以實證為基礎的高海拔疾病指引. 包括AMS, HACE, HAPE 預防及治療方式. 以及各種方法的在疾病中扮演的角色, 仍有很多重要的問題, 需要更多未來的研究., 包括避免高海拔疾病的最適當上升速率, 丹木斯對於預防及治療HAPE的角色, 預防及治療兒童高海拔疾病的最適當藥物劑量, 階段性上升的角色. 高度適應, 使用低氧帳篷預防高海拔疾病.

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. Although 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 determining the optimal 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 staged ascent, preacclimatization, and hypoxic tents in altitude illness prevention.

野外與登山醫學---39--WMS 2019 update HAPE + HACE TREATMENT APPROACH 39

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update

中文翻譯目錄

統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

同時罹患高海拔肺水腫 HACE 與高海拔腦水腫 HAPE 的建議處置
SUGGESTED APPROACH FOR PATIENTS WITH CONCURRENT HAPE AND HACE

應使用類固醇, 劑量與 HACE 治療相同
有些罹患 HAPE 的病患可能會因為缺氧性腦病患而出現神經功能異常, 而非由 HACE 引起, 但在野外環境無法將缺氧的腦病變與 HACE 區隔, 因此 HAPE 患者若出現神經功能異常, 給予氧氣治療後, 如果血氧飽和度改善, 但症狀沒有迅速改善, 應使用類固醇
如果無法提供氧氣, 對於HAPE患者若出現神智改變,或懷疑有高海拔腦水腫, 應給予類固醇
同時罹患 HAPE 與 HACE 的患者可以服用鈣離子阻斷劑 Nifedipine 或其他肺血管擴張劑, 但要小心不要讓平均動脈壓降太低, 平均動脈壓降低可能減少腦部血流灌注. 增加腦缺血風險.

Dexamethasone should be added to the treatment regimen of patients with concurrent HAPE and HACE at the doses described earlier for patients with HACE. Some patients with HAPE may have neurologic dysfunction caused by hypoxic encephalopathy rather than caused by HACE, but making the distinction between hypoxic encephalopathy and HACE in the field can be difficult. Therefore, dexamethasone should be added to the treatment regimen for patients with HAPE with neurologic dysfunction that does not resolve rapidly with administration of supplemental oxygen and improvement in oxygen saturation. If supplemental oxygen is not available, dexamethasone should be started in addition to the medications for HAPE in patients with altered mental status and/or suspected concurrent HACE. Nifedipine or other pulmonary vasodilators may be used in patients with concurrent HAPE and HACE, with care to avoid lowering mean arterial pressure, as this may decrease cerebral perfusion pressure and thus increase the risk for cerebral ischemia.

野外與登山醫學---38 Acute altitude illness WMS 2019 update HAPE TREATMENT SUGGESTED APPROACH 38

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update

中文翻譯目錄

統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

高海拔肺水腫治療建議
SUGGESTED APPROACH TO HAPE TREATMENT

開始治療之前, 要考慮其他在高海拔會造成呼吸症狀的情況, 例如氣喘, 氣管痙孿, 痰卡住, 肺炎, 氣胸, 肺栓塞, 感冒, 心肌梗塞.
Before initiating treatment, consideration should be given to other causes of respiratory symptoms at high altitude, such as asthma, bronchospasm, mucous plugging, pneumonia, pneumothorax, pulmonary embolism, viral upper respiratory tract infection, or myocardial infarction.

如果懷疑罹患 HAPE. 若有氧氣應開始給氧治療, 並降低海拔高度, 若無法立即下降高度或需要延緩下降, 應考慮持續給氧, 或使用加壓艙, 若患者能接受氧氣治療, 且在醫療環境受到適當的監視, 例如加護病房或急診室, 可以不用下降至低海拔, 在相同的海拔使用氧氣治療.
If HAPE is suspected or diagnosed, oxygen should be started if available, and descent to lower elevation should be initiated. If descent is infeasible or delayed, supplemental oxygen should be continued or the individual should be placed in a portable hyperbaric chamber. Patients who have access to supplemental oxygen and can be adequately monitored in a medical setting (eg, urgent care clinic or emergency department) may not need to descend to lower elevation and can be treated with oxygen alone at the current elevation.

如果給氧或使用持續性陽壓呼吸器之後, 氧氣飽和度沒有改善. 或氧氣飽和度改善(>90%)但仍病況惡化, 或經過適當處置之後, 病況沒有改善, 應立即下降.
Descent should be initiated, however, if oxygenation fails to improve with supplemental oxygen and/or CPAP, if the patient’s condition deteriorates despite achieving an oxygen saturation >90%, or if the patient fails to show signs of improvement with appropriate interventions for HAPE.

In more remote settings, early descent should be considered. Addition of nifedipine may not yield additional benefit in well-monitored settings.93,96 In the field setting, where resources are limited, nifedipine can be used as an adjunct to descent, supplemental 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 the patient fails to respond to oxygen therapy alone. There is no established role for beta-agonists, diuretics, acetazolamide, or dexamethasone in the treatment of HAPE, although, as noted below, dexamethasone should be considered when concern is raised for concurrent HACE. Selected patients (able to achieve an oxygen saturation >90%, with adequate support from family or friends, with adequate housing or lodging arrangements) may be discharged from direct medical care if they can continue using supplemental oxygen rather than being admitted to a healthcare facility. Individuals treated in this manner should be admitted to the hospital if they develop worsening symptoms and/or oxygen saturation while on supplemental oxygen. Descent to lower elevation should be pursued if oxygenation or other aspects of their condition worsen despite appropriate interventions for HAPE, as this suggests they may have alternative pathology that requires further evaluation and management. Individuals who develop HAPE may consider further ascent to higher altitude or reascent only when symptoms of HAPE have completely 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

野外與登山醫學~~---36--WMS 2019 update HAPE TREATMENT Diuretics/Acetazolamide 36

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Diuretics
Although their use is documented in older reports,100 diuretics have no role in HAPE treatment, particularly because many patients with HAPE have intravascular volume depletion. Recommendation. Diuretics should not be used for treatment of HAPE. Recommendation Grade: 1C.

Acetazolamide
Although clinical reports document use of acetazolamide for treatment of HAPE,97,98 there are no systematic studies examining its role in HAPE treatment. The diuretic effect might provoke hypotension in the intravascularly depleted patient, and the added stimulus to ventilation might worsen dyspnea. Recommendation. Acetazolamide should not be used for treatment of HAPE. Recommendation Grade: 1C

野外與登山醫學---37-WMS 2019 update HAPE TREATMENT Dexamethasone 37

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Dexamethasone
Considering its potential role in HAPE prevention noted earlier and studies demonstrating effects on maximum exercise capacity,101 pulmonary inflammation, and ion transporter function in hypoxia,102 dexamethasone may have a role in HAPE treatment. Although reports document clinical use in this regard,98 no study has established whether it is effective for this purpose. Recommendation. Because of insufficient evidence, no recommendation can be made regarding dexamethasone for HAPE treatment.

野外與登山醫學~~---35--WMS 2019 update HAPE TREATMENT Continuous positive airway pressure 35

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Continuous positive airway pressure As noted earlier, positive airway pressure works by increasing transmural pressure across alveolar walls, thereby increasing alveolar volume and improving ventilation-perfusion matching and, as a result, gas exchange. A small study demonstrated that EPAP, in which a mask system is used to increase airway pressure during exhalation only, improved gas exchange in patients with HAPE.99 However, although several reports document use of CPAP for management of HAPE in hospital and field settings,6,78 there is no systematic evidence that CPAP or EPAP improves patient outcomes compared to oxygen alone or in conjunction with medications. Given the low risks associated with the therapy, CPAP can be considered an adjunct to oxygen administration in a medical facility, provided the patient has normal mental status and can tolerate the mask. Although lithium batteryepowered devices and decreased size and weight of CPAP machines have increased feasibility of field use, logistical challenges remain and currently limit overall utility in this setting. Recommendation. CPAP or EPAP may be considered for treatment of HAPE when supplemental oxygen or pulmonary vasodilators are not available or as adjunctive therapy in patients not responding to supplemental oxygen alone. Recommendation Grade: 2C

野外與登山醫學~~---34--WMS 2019 update HAPE TREATMENT Phosphodiesterase inhibitors 34

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

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,97,98 no systematic study has examined the role of tadalafil or sildenafil in HAPE treatment as either mono- or adjunctive therapy. Combined use of nifedipine and sildenafil or tadalafil should be avoided because of risk of hypotension. Recommendation. Tadalafil or sildenafil can be used for HAPE treatment when descent is impossible or delayed, access to supplemental oxygen or portable hyperbaric therapy is impossible, and nifedipine is unavailable. Recommendation Grade: 2C

野外與登山醫學~~---32--WMS 2019 update HAPE TREATMENT Nifedipine 32

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Nifedipine
A single, nonrandomized, unblinded study demonstrated utility of nifedipine (10 mg of the short-acting version followed by 20 mg slow-release every 6 h) for HAPE treatment when oxygen or descent was not available.9 Although participants in this study received a loading dose of the short-acting version of the medication, this initial dose is no longer employed because of concerns about provoking systemic hypotension. Although hypotension is less common with the extended-release preparation, it may develop when nifedipine is given to patients with intravascular volume depletion. A prospective, cross-sectional study of individuals with HAPE demonstrated that addition of nifedipine (30 mg sustained release every 12 h) to descent, oxygen, and rest offered no additional benefit in terms of time to resolution of hypoxemia and radiographic opacities or hospital length of stay.96 Recommendation. Nifedipine should be used for HAPE treatment when descent is impossible or delayed and reliable access to supplemental oxygen or portable hyperbaric therapy is unavailable. Recommendation Grade: 1C

野外與登山醫學~~---39-- WMS 2019 update HAPE TREATMENT Beta-agonists 33

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Beta-agonists
Although there are reports of beta-agonist use in HAPE treatment97 and the risks of use are likely low, no data support a benefit from salmeterol or albuterol in patients experiencing HAPE. Recommendation. No recommendation can be made regarding beta-agonists for HAPE treatment due to lack of data.

野外與登山醫學~~---30--WMS 2019 update HAPE TREATMENT Portable hyperbaric chambers 30

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Portable hyperbaric chambers 攜帶式加壓艙
As for AMS and HACE, portable hyperbaric chambers can be used for HAPE treatment. They have not been systematically studied for this purpose, but their use for HAPE has been reported in the literature.94 Use of a portable hyperbaric chamber should not delay descent in situations where descent is feasible. Recommendation. When descent is infeasible or delayed or supplemental oxygen is unavailable, a portable hyperbaric chamber may be used to treat HAPE. Recommendation Grade: 1C

野外與登山醫學~~---29--WMS 2019 update HAPE TREATMENT Supplemental oxygen 29

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Supplemental oxygen
Oxygen delivered by nasal cannula or mask at flow rates sufficient to achieve an SpO2 >90% provides a suitable alternative to descent, particularly when patients can access healthcare facilities and be closely monitored.91e93 As noted earlier in the section on AMS/HACE treatment, providers should target an SpO2 of >90% rather than a particular FIO2. Short-term use in the form of visits to oxygen bars or use of over-the-counter oxygen canisters has no role in HAPE treatment. Recommendation. When available, supplemental oxygen sufficient achieve an SpO2 of >90% or to relieve symptoms should be used while waiting to initiate descent when descent is infeasible and during descent in severely ill patients. Recommendation Grade: 1A

野外與登山醫學----28--WMS 2019 update HAPE TREATMENT Descent 28

TREATMENT

Therapeutic options for HAPE include the following.

Descent

As with AMS and HACE, descent remains the single best treatment for HAPE. Individuals should try to descend at least 1000 m or until symptoms resolve. They should exert themselves as little as possible while descending (eg, travel without a pack or via motor vehicle, helicopter, or animal transportation) because exertion can further increase pulmonary artery pressure and exacerbate edema formation. Recommendation. Descent is indicated for individuals with HAPE. Recommendation Grade: 1A

野外與登山醫學----27--WMS 2019 update HAPE PREVENTION SUGGESTED APPROACH

SUGGESTED APPROACH TO HAPE PREVENTION
As noted earlier, because the rates of acclimatization and physiologic responses to high altitude vary considerably among individuals, the recommendations that follow, although generally effective, do not guarantee prevention in all high altitude travelers. A gradual ascent profile is the primary method for preventing HAPE; the recommendations provided for AMS and HACE prevention also apply to HAPE prevention. Pharmacologic prophylaxis should only be considered for individuals with a history of HAPE, especially multiple episodes. Nifedipine is the preferred drug in such situations; it should be started the day before ascent and continued either until descent is initiated or the individual has spent 4 d at the highest elevation, perhaps up to 7 d if the individual’s rate of ascent was faster than recommended. Note that these durations are longer than use of acetazolamide for AMS prevention. For individuals ascending to a high point and then descending toward the trailhead (eg, descending from the summit of Kilimanjaro), prophylactic medications should be stopped when descent is initiated. Further research is needed before tadalafil or dexamethasone can be recommended over nifedipine for prevention. Acetazolamide facilitates acclimatization in general but should not be relied upon as the sole preventive agent in known HAPE-susceptible individuals.

野外與登山醫學----26--WMS 2019 update HAPE PREVENTION Preacclimatization and staged ascent 26

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Preacclimatization and staged ascent
No study has examined whether preacclimatization strategies are useful for HAPE prevention. Staged ascent, with 7 d of residence at moderate altitude (~2200 m), has been found to blunt the hypoxia-induced increase in pulmonary artery pressure.48 However, uncertainty remains as to the magnitude and duration of moderate altitude exposure necessary to yield benefit, and no study has specifically investigated whether the strategy is of benefit in HAPE-susceptible individuals. Although the risks of preacclimatization and staged ascent are likely low, feasibility is a concern for many high altitude travelers. Because the optimal methods for preacclimatization and staged ascent have not been fully determined, the panel recommends consideration of these approaches but cannot endorse a particular protocol for implementation. Recommendation. When feasible, staged ascent and preacclimatization can be considered as a means for HAPE prevention. Recommendation Grade: 1C

野外與登山醫學----25-- WMS 2019 update HAPE PREVENTION Acetazolamide 25

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Acetazolamide
Because acetazolamide hastens acclimatization, it should be effective at preventing all forms of acute altitude illness. It has also been shown to blunt hypoxic pulmonary vasoconstriction, a key factor in HAPE pathophysiology, in animal models86e88 and in a single study in humans,89 but there are no data specifically supporting a role in HAPE prevention. Clinical observations suggest acetazolamide may prevent reentry HAPE,90 a disorder seen in individuals who reside at high altitude, travel to lower elevation, and then develop HAPE upon rapid return to their residence. Recommendation. Because of lack of data, no recommendation can be made regarding use of acetazolamide for HAPE prevention. Recommendation. Acetazolamide can be considered for prevention of reentry HAPE in people with a history of the disorder. Recommendation Grade: 1C

野外與登山醫學---24---WMS 2019 update HAPE PREVENTION Dexamethasone 24

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Dexamethasone
In the same study that assessed the role of tadalafil in HAPE prevention, dexamethasone (8 mg every 12 h) was also found to prevent HAPE in susceptible individuals.85 The mechanism for this effect is not clear, and there is very little clinical experience in using dexamethasone for this purpose. Further data are necessary before it can be recommended for HAPE prevention. Recommendation. Dexamethasone can be used for HAPE prevention in known susceptible individuals who are not candidates for nifedipine and tadalafil. Recommendation Grade: 1C

野外與登山醫學----23---WMS 2019 update HAPE PREVENTION Tadalafil 23

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Tadalafil
In a single, randomized placebo-controlled trial, 10 mg of tadalafil every 12 h was effective in preventing HAPE in susceptible individuals.85 The number of individuals in the study was small, and 2 developed incapacitating AMS. Clinical experience with tadalafil is lacking compared to nifedipine. As a result, further data are necessary before tadalafil can be recommended over nifedipine. Recommendation. Tadalafil can be used for HAPE prevention in known susceptible individuals who are not candidates for nifedipine. Recommendation Grade: 1C

野外與登山醫學----22---WMS 2019 update HAPE PREVENTION Salmeterol 22

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

Salmeterol
In a single randomized, placebo-controlled study, the longacting inhaled beta-agonist salmeterol decreased the incidence of HAPE by 50% in susceptible individuals.84 Very high doses (125 micrograms twice daily) that are often associated with side effects, including tremor and tachycardia, were used in the study. Clinical experience with salmeterol at high altitude is limited. Recommendation. Salmeterol is not recommended for HAPE prevention. Recommendation Grade: 2B.

野外與登山醫學----21---WMS 2019 update HAPE PREVENTION Nifedipine 21

Nifedipine
A single, randomized, placebo-controlled study83 and extensive clinical experience have established a role for nifedipine in HAPE prevention in susceptible individuals. The recommended dose is 30 mg of the extended-release preparation administered every 12 h. Hypotension was not noted in the study83 and is generally not a concern with the extended-release version of the medication but may occur in a limited number of individuals. Recommendation. Nifedipine is recommended for HAPE prevention in HAPE-susceptible people. Recommendation Grade: 1B

野外與登山醫學----20--WMS 2019 update HAPE PREVENTION Gradual ascent

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

High altitude pulmonary edema
Information on the epidemiology, clinical presentation, and pathophysiology of HAPE, the majority of which comes from studies in adults, is provided in extensive reviews.13,14,79,80 Although some of the prophylactic and therapeutic modalities are the same for HAPE as for AMS and HACE, important differences in the underlying pathophysiology mandate certain alternative prevention and treatment approaches.

PREVENTION Potential preventive measures for HAPE include the following.
Gradual ascent
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.17,81,82 Recommendation. Gradual ascent is recommended to prevent HAPE. Recommendation Grade: 1B

野外與登山醫學----19---WMS 2019 update AMS/HACE Treatment SUGGESTED APPROACH 19

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病

SUGGESTED APPROACH TO AMS/HACE TREATMENT 治療AMS/HACE的方法

做出高山病的診斷時, 要排除其他會造成相似症狀的疾病, 例如一氧化碳中毒, 脫水, 體力不支, 低血糖, 失溫, 低血鈉
罹患AMS的病患, 不管HACE輕重度如何, 都應該停止上升. 依照疾病嚴重度級所處環境, 考慮撤退,
單純罹患AMS的人, 可以在原地休息, 給予非鴉片類止痛藥(治療頭痛,嘔吐), 但要有人在一旁監護

Care should be taken to exclude disorders whose symptoms and signs resemble those seen with AMS and HACE, such as carbon monoxide poisoning, dehydration, exhaustion, hypoglycemia, hypothermia, and hyponatremia. Persons with AMS of any severity or HACE should cease ascending and may need to consider descent, depending on the severity of illness and the circumstances (Table 3). Patients with AMS can remain at their current altitude and use nonopioid analgesics for headache and antiemetics for nausea and vomiting. These individuals should be closely observed for signs of progression of altitude illness.

何時該下降?
1. AMS 症狀更惡化
2. 經適當治療之後 1-2 天仍有高海拔症狀
3. 丹木斯可加速高度適應, 對於輕微的AMS有些療效, 但將丹木斯做為預防性藥物可能更好
4. 類固醇

Descent should be initiated for AMS if symptoms worsen or fail to improve after 1 to 2 d of appropriate interventions.

Although acetazolamide facilitates acclimatization and is somewhat effective for treating mild illness, it is likely better for prevention than for treatment.

對於中度和重度AMS, 類固醇能提供較可靠的療效, 這些患者通常也應該下降

Dexamethasone is considered to be a more reliable treatment for moderate to severe AMS, which often also requires descent.

當AMS症狀改善後, 可再次上升, 症狀尚未完全改善前, 不可以再次爬升至先前罹患AMS的海拔,
Individuals with AMS may resume ascending once symptoms resolve. Further ascent or reascent to a previously attained altitude should never be undertaken if there are ongoing symptoms.

當AMS症狀改善後, 按照之前劑量繼續使用丹木斯,
After resolution of AMS, taking acetazolamide at preventive doses during reascent is prudent.

HACE與嚴重AMS區別在於是否有中樞神經系統症狀 , 包括在急速上升後出現運動失調, 神智混亂, 神智改變, HACE可發生在AMS之後, 也可能與 HAPE 同時發生,
HACE is differentiated from severe AMS by neurological signs 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.

罹患 HACE 的人到達醫院/診所之後, 應該給予類固醇及氧氣治療, 將血氧飽和度提升超過 90%,
Individuals developing HACE in locations with access to hospitals or specialized clinics should be started on dexamethasone and supplemental oxygen sufficient to achieve an SpO2 >90%.

在遠離醫療資源的偏遠地區, 如果懷疑已經罹患 HACE, 或AMS症狀惡化, 給予類固醇和丹木斯無法改善症狀時, 應開始下降
In remote areas away from medical resources, descent should be initiated in any suspected cases of HACE or if symptoms of AMS are worsening despite treatment with acetazolamide or dexamethasone.

若無法下撤, 應該使用氧氣或攜帶式高壓艙, 罹患HACE的人應該同時給予類固醇, 至於在 HACE 改善後是否能繼續未完成的旅遊行程或探險, 目前無系統性資料或個案報告. 謹慎起見, 應避免使用類似的方法再次上升, 若還是想繼續上升, 上升前最低條件, 病患需完全沒有症狀, 至少兩三天沒有服用類固醇,
If descent is not feasible, supplemental oxygen or a portable hyperbaric chamber should be used. Persons with HACE should also be started on dexamethasone. There are no systematic data or case reports about reascent during the same trip or expedition after resolution of HACE. The prudent course is to avoid reascent in this situation, but if it is to be attempted, at a minimum the individual should be asymptomatic and no longer taking dexamethasone for at least 2 to 3 d before reascent.

野外與登山醫學----17---WMS 2019 update AMS/HACE Treatment Acetaminophen/ Ibuprofen 17

Acetaminophen has been found to relieve headache at high altitude76 but has not been found to improve the full spectrum of AMS symptoms or effectively treat HACE. Recommendation. Acetaminophen can be used to treat headache at high altitude. Recommendation Grade: 1C.

Ibuprofen

Ibuprofen has been found to relieve headache at high altitude76 but has not been shown to improve the full spectrum of AMS symptoms or effectively treat HACE. Recommendation. Ibuprofen can be used to treat headache at high altitude. Recommendation Grade: 1C.

野外與登山醫學----18---WMS 2019 update AMS/HACE Treatment Continuous positive airway pressure 18

Continuous positive airway pressure

Rather than affecting barometric pressure, CPAP works by increasing transmural pressure across alveolar walls, thereby increasing alveolar volume and improving ventilation-perfusion matching and gas exchange. Two reports have demonstrated the feasibility of administering CPAP to treat AMS,77,78 but this has not been studied in a systematic manner. Logistical challenges to use in field settings include access to power and the weight and bulk of these systems. Recommendation. Because of lack of data, no recommendation can be made regarding use of CPAP for AMS treatment.

野外與登山醫學----15---WMS 2019 update AMS/HACE Treatment Acetazolamide 15

Acetazolamide Only 1 study has examined acetazolamide for AMS treatment. The dose studied was 250 mg every 12 h; whether a lower dose might suffice is unknown.72 No studies have assessed AMS treatment with acetazolamide in pediatric patients, but anecdotal reports suggest it has utility. The pediatric treatment dose is 2.5 mg$kg-1$dose-1 every 12 h up to a maximum of 250 mg$dose-1. Recommendation. Acetazolamide should be considered for treatment of AMS. Recommendation Grade: 1C

野外與登山醫學----16--- WMS 2019 update AMS/HACE Treatment Dexamethasone 16

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病

Dexamethasone Dexamethasone is very effective for treating AMS.73e75 The medication does not facilitate acclimatization, so further ascent should be delayed until the patient is asymptomatic while off the medication. Although systematic studies have not been conducted, extensive clinical experience supports using dexamethasone in patients with HACE. It is administered as an 8 mg dose (intramuscularly, IV, or orally) followed by 4 mg every 6 h until symptoms resolve. The pediatric dose is 0.15 mg$kg-1$dose-1 every 6 h.27 Recommendation. Dexamethasone should be considered for treatment of AMS. Recommendation Grade 1B. Recommendation. Dexamethasone should be administered to patients with HACE. Recommendation Grade: 1B

野外與登山醫學----14---WMS 2019 update AMS/HACE Treatment Portable hyperbaric chambers 14

Portable hyperbaric chambers Portable hyperbaric chambers are effective for treating severe altitude illness69,70 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,71 but this should not preclude use of the chamber when indicated. In many cases, ill individuals may improve sufficiently to enable them to assist in their evacuation and descend once symptoms improve. Use of a portable hyperbaric chamber should not delay descent in situations where descent is required. Recommendation. When available, portable hyperbaric chambers should be used for patients with severe AMS or HACE when descent is infeasible or delayed and supplemental oxygen is not available. Recommendation Grade: 1B

野外與登山醫學----13---WMS 2019 update AMS/HACE Treatment Supplemental oxygen 13

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病

Supplemental oxygen
Oxygen delivered by nasal cannula or mask at flow rates sufficient to relieve symptoms provides a suitable alternative to descent. A peripheral capillary oxygen saturation (SpO2) >90% is usually adequate. Use of oxygen is not required in all circumstances and is generally reserved for mountain clinics and hospitals where supply is abundant. It should also be used when descent is recommended but not feasible or during descent in severely ill individuals. The inspired oxygen fraction will vary significantly between oxygen delivery systems, including nasal cannula, simple facemasks, Venturi masks, or non-rebreather masks. In addition, because of interindividual variability in inspiratory flow rates and minute ventilation, the inspired fractional concentration of oxygen (FIO2) can vary significantly between patients for any given common oxygen delivery system, with the exception of high flow systems. For this reason, supplemental oxygen should be administered to target an SpO2 of >90% rather than a specific FIO2. Oxygen supply may be limited at remote high altitude clinics or on expeditions, necessitating judicious use. Short-term oxygen use in the form of visits to oxygen bars or use of over-the-counter oxygen canisters has not been studied for AMS treatment and should not be relied on for this purpose.

Recommendation. When available, ongoing supplemental oxygen sufficient to raise SpO2 to >90% or to relieve symptoms can be used while waiting to initiate descent or when descent is not practical. Recommendation Grade: 1A

野外與登山醫學----12---WMS 2019 update AMS/HACE Treatment Descent 12

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病

TREATMENT Potential therapeutic options for AMS and HACE include the following.

Descent
Descent remains the single best treatment for AMS and HACE, but it is not necessary in all circumstances (discussed further later in the text). Individuals should descend until symptoms resolve unless terrain, weather, or injuries make descent impossible. Symptoms typically resolve after descent of 300 to 1000 m, but the required decrease in altitude varies among individuals. Individuals should not descend alone, particularly if they are experiencing HACE. Recommendation. Descent is effective for any degree of AMS/HACE and is indicated for individuals with severe AMS, AMS that fails to resolve with other measures, or HACE. Recommendation Grade: 1A

野外與登山醫學----11--WMS 2019 update AMS/HACE prevention suggested approach 11

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病

SUGGESTED APPROACH TO AMS/HACE PREVENTION 預防AMS/HACE 建議策略
個人之間高度適應的速率, 高海拔生理反應差異很大. 臨床醫師要認知到, 通常有效的預防方式也無法完全避免 AMS/HACE, 這些策略僅是風險狀況的其中一種功能.
Because the rates of acclimatization and physiologic responses to high altitude vary considerably between individuals, clinicians must recognize that the recommendations that follow, although generally effective, do 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 2).

1. 第一個原則是確保逐漸上升至目標海拔, 旅行者可選擇在中海拔地區住一晚.
The first priority should be ensuring gradual ascent to the target elevation. Travelers can lower their risk by sleeping 1 night at an intermediate altitude. For example, sea-level residents traveling to Colorado resort areas over 2800 m can spend 1 night in Denver (1600 m). It should be recognized that a large number of people will travel directly by car or plane to commonly visited mountain high altitude locations, often located between 2500 and 3000 m, and may be unable to ascend gradually because of various logistical factors. In such situations, pharmacologic prophylaxis can be considered. Such individuals should also take care to slow the rate of further ascent beyond the altitude achieved at the start of their visit. With travel above 3000 m, individuals should not increase their sleeping elevation by more than 500 m$d-1 and should include a rest day (ie, no ascent to higher sleeping elevation) every 3 to 4 d. The increase in sleeping elevation should be less than 500 m for any given day of a trip. In many areas, terrain and other logistical factors prevent strict adherence to this approach and mandate larger gains in sleeping elevation over a single day. In such cases, acclimatization days should be strongly considered before and/or after these large gains in elevation and elsewhere in the itinerary to ensuredat the very least and as an approximation of properly controlled ascentdthat the overall ascent rate averaged over the entire trip (ie, total elevation gain divided by the number of days of ascent during the trip) is below the 500 m$d-1threshold.
Prophylactic medications are not necessary in low-risk situations but should be considered in addition to gradual ascent for use in moderate- to high-risk situations (Table 2). Acetazolamide is the preferred medication; dexamethasone may be used as an alternative in individuals with a history of intolerance of or allergic reaction to acetazolamide. In rare circumstances (eg, military or rescue teams that must ascend rapidly to and perform physical work at >3500 m), consideration can be given to concurrent use of acetazolamide and dexamethasone. This strategy should be avoided except in these particular or other emergency circumstances that mandate very rapid ascent. Acetazolamide and dexamethasone should be started the day before ascent but still have beneficial effects if started on 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 d at the highest altitude. Individuals ascending faster than the recommended ascent rates may consider continuing preventive medication for 2 to 4 d after arrival at the target altitude, but there are no data to support this approach. For individuals ascending to a high point and then descending toward the trailhead (eg, descending from the summit of Mt. Kilimanjaro), in the absence of AMS/HACE symptoms, preventive medications should be stopped when descent is initiated.

野外與登山醫學----10---WMS 2019 update AMS/HACE prevention others 10

安地斯山的旅客有咀嚼可可葉, 喝可可茶. 及其他可可製品, 以預防AMS的傳統, 這些預防高海拔疾病的方式到底有多大功效, 目前尚缺乏適當的研究, 因此不建議用這種方式代替已經有實證研究的預防方式.
Chewed coca leaves, coca tea, and other coca-derived products are commonly recommended for travelers in the Andes mountains for AMS prevention. Their utility in prevention of altitude illness has not been properly studied, so they should not be substituted for other established preventive measures described in these guidelines.

其他預防方式也被廣泛研究, 包括抗氧化劑, 鐵, 膳食硝酸鹽, 白三烯受體阻斷劑, 磷酸二酯酶抑制劑, 水楊酸, 保鉀利尿劑 spironolactone. 英明格(註) 都被拿來試驗是否可以預防AMS, 但以上全部直到目前並無證據支持可以預防 AMS

Multiple studies have sought to determine whether other agents, including antioxidants,58 iron,59 dietary nitrates,60 leukotriene receptor blockers,61,62 phosphodiesterase inhibitors,63 salicylic acid,64 spironolactone,65 and sumatriptan can prevent AMS, but the current state of evidence does not support their use.

強迫喝水, 過量喝水, 從來都不能預防高海拔疾病, 且可能造成低血鈉. 低血鈉與AMS症狀又有點相似.

“Forced” or “over” hydration has never been found to prevent altitude illness and might increase the risk of hyponatremia; however, maintenance of adequate hydration is important because symptoms of dehydration can mimic those of AMS.

夜間呼氣正壓可藉由一次使用的鼻夾達成, 對於預防AMS並無效果, 且這種方式可能造成遠端缺血,

Nocturnal expiratory positive airway pressure (EPAP) administered via a single-use nasal strip during sleep is not effective for AMS prophylaxis,67 nor is a regimen of remote ischemic preconditioning.68

雖然沒有研究檢視短期使用氧氣, 例如去氧氣吧台, 或使用小型氧氣瓶, 這些設備的容量僅 2-10 公升, 且使用時間很短暫, 不太可能預防AMS/HACE.

No studies have examined short-term oxygen use in the form of either visits to oxygen bars or over-the-counter oxygen delivery systems by which individuals inhale oxygenenriched gas from a small prefilled canister. Due to the small volume of gas (2 to 10 L/canister) and short duration of administration, these interventions are unlikely to be of benefit and, as a result, have no role in AMS/HACE prevention. Other over-the-counter products, such as powdered drink mixes, also lack any evidence of benefit.

註: sumatriptan 是一種選擇性血清張力素(serotonin)催動劑, 商品名︰英明格

野外與登山醫學----09-Acute altitude illness WMS 2019 update AMS/HACE prevention Hypoxic tents 9

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病

文章太長. 把最下面結論貼上來
建議: 低氧帳經過長期規則恰當的暴露周數後, 如果睡眠品質不受影響, 可用於加速高度適應, 預防AMS,
Recommendation. Hypoxic tents can be used for facilitating acclimatization and preventing AMS, provided sufficiently long exposures can be undertaken regularly over an appropriate number of weeks and other factors, such as sleep quality, are not compromised.

Recommendation Grade: 2B

低氧帳 Hypoxic tents

在計畫去高海拔前, 目前有很多商品可以提供個人在低氧環境睡覺或運動, 目前僅有一個安慰劑對照實驗, 評估這種方法是否有效. 這項實驗顯示在模擬高海拔環境睡覺的人, 相較於正常氣壓, AMS 發生率降低 . 但這個系統技術上的難關, 導致參加研究的人無法接收完整的低氧劑量. 雖然這項系統已經商業化, 廣泛使用於登山家及高海拔地區參賽的運動員, 但沒有任何資料證明能提高登頂的成功率, 或改善體能

Commercial products are available that allow individuals to sleep or exercise in hypoxic conditions for the purpose of facilitating acclimatization before a trip to high altitude. Only 1 placebo-controlled study has examined their utility.57 Although this study demonstrated a lower incidence of AMS in persons who slept in simulated high altitude conditions compared to normoxia, technical difficulties with the system resulted in a substantial number of study participants not receiving the intended hypoxic dose. Although the systems are marketed to be of benefit and anecdotal reports suggest they are widely used by climbers and other athletes competing at high altitude, there are no data indicating increased likelihood of summit success or improved physical performance.

就像上面提到的高度適應方式, 藉由這套系統能累積的效益, 需要長時間暴露於低氧 (每天8小時以上) 持續數周, 短期漸歇性暴露於低氧, 包括運動訓練, 可能無助益
As with the preacclimatization approaches previously described, any benefit that may accrue 積累 from these systems is more likely with long hypoxic exposures (>8 h per day) for at least several weeks before planned high altitude travel. Short and/or infrequent exposures, including exercise training, are likely of no benefit.

除了系統的費用及運轉時所需電力, 個人會面對睡眠不佳的風險, 經過長時間睡眠不佳. 在競賽的時候表現可能更差.
In addition to the cost of the systems and power needed to run them, individuals face the risk of poor sleep, which over a long period of time could have deleterious effects on performance during an expedition.

建議: 低氧帳經過長期規則恰當的暴露周數後, 如果睡眠品質不受影響, 可用於加速高度適應, 預防AMS,
Recommendation. Hypoxic tents can be used for facilitating acclimatization and preventing AMS, provided sufficiently long exposures can be undertaken regularly over an appropriate number of weeks and other factors, such as sleep quality, are not compromised.

Recommendation Grade: 2B

野外與登山醫學--08--Acute altitude illness WMS 2019 update AMS/HACE prevention Staged ascent and preacclimatization 8

Staged ascent and preacclimatization 分段上升及高度適應

在爬到最高海拔前, 第六天至第七天, 停留於海拔 2200~3000 公尺, 可減少AMS 風險, 增加通氣量及氧和, 也可弱化肺動脈對於接下來高海拔 (4300 公尺) 的反應.

Two studies showed that spending 6 to 7 d at moderate altitude (~2200 to 3000 m) before proceeding to higher altitude (referred to as “staged ascent”) decreases the risk of AMS, improves ventilation and oxygenation, and blunts the pulmonary artery pressure response after subsequent ascent to 4300 m.16,48

有些遊客在前往高海拔前, 會先至海拔 2500-3000 公尺的高山旅館短時間停留. 海拔上升 1500 公尺的短暫停留以預防接下來更高海拔的AMS機率, 從生理角度看起來似乎還蠻合理的.
Many travelers to high altitude visit mountain resorts at more moderate elevations between 2500 and 3000 m. The value of short stays at intermediate elevations of ~1500 m for decreasing the risk of AMS during such ascents makes sense from a physiologic standpoint.

這種高度適應的策略並沒有人做過隨機研究, 雖然之前有研究顯示, 在海拔 1600 公尺處住一晚, 接下來前往海拔 1920-2950 公尺的地區, 可降低AMS機率.
However, this approach has not been studied in a randomized fashion, aside from 1 cross-sectional study finding a decreased risk of AMS in travelers who spent 1 night at 1600 m before ascent to resort communities between 1920 and 2950 m.5

很多研究評估, 在數天至數周內, 反覆暴露於低壓或常壓低氧環境, 這種方式稱為高度適應, 其結果並不一致, 有些研究說可以降低AMS發生率或是嚴重度, 其他的研究卻顯示無效.
A larger number of studies examining the effects of repeated exposures to hypobaric or normobaric hypoxia in the days and week preceding high altitude travel (referred to as “preacclimatization”) showed mixed results, with some studies finding benefit in terms of decreased AMS incidence or severity49e51 and others showing no effect.52e55

在解讀這些高度適應研究時, 最大的困難是各自的低氧協議不同. 也不是每個研究都有證據顯示, 在這樣的低氧對於生理帶來哪些與高度適應符合的變化,.
A significant challenge in interpreting the literature on preacclimatization is the variability among the hypoxic exposure protocols used, as well as the fact that not all studies include evidence that their protocols induced physiologic responses consistent with acclimatization.

不管是分段上升或是高度適應, 對於多數高海拔的旅客都是很難做到的,
一般說來, 短時間 15-60 分鐘暴露於低氧, 或是在爬升前, 花幾次幾小時的時間暴露於低氧, 對於高度適應可能無用. 長時間(每天8小時, 連續七天) 暴露於低氧, 對於高度適應比較可能有幫助.

Implementation of either staged ascent or preacclimatization may be logistically difficult for many high altitude travelers. In general, short-term exposures (eg, 15 to 60 min of exposure to hypoxia, or a few hours of hypoxia a few times before ascent) are unlikely to aid acclimatization, whereas longer exposures (eg, >8 h daily for >7 d) are more likely to yield benefit.

低壓低氧相較於常壓低氧, 更能有效加速高度適應, 預防AMS. 但目前對於高度適應和分段上升最好的操作方式, 並沒有被徹底檢驗過, 因此專家會議建議, 可考慮這些方式, 但不贊同哪一種協議
Hypobaric hypoxia is more effective than normobaric hypoxia in facilitating preacclimatization and preventing AMS.56 Because the optimal methods for preacclimatization and staged ascent have not been fully determined, the panel recommends consideration of these approaches but does not endorse a particular protocol.

建議: 如果情況許可, 可考慮使用分段上升及高度適應, 來預防 AMS
Recommendation. When feasible, staged ascent and preacclimatization can be considered as a means for AMS prevention.
Recommendation Grade: 1C

野外與登山醫學----07-Acute altitude illness WMS 2019 update AMS/HACE prevention Acetaminophen 7

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病
Acetaminophen 乙醯胺酚, 下面用比較多人知道的"普拿疼"代替

Acetaminophen 普拿疼

acetaminophen 通常劑量是 500 mg. 但一天吃的總量沒超過 4000mg 都還算安全
分析的對象是在海拔 4370 公尺至海拔 4940 公尺這一段的健行者, 給予普拿疼每次 1000mg, 一天三次, 對於預防AMS效果與 ibuprofen 相近
但這篇研究並沒有安慰劑對照組, 研究團隊採用過去未接受治療的健行者的發生率作為比較, 並與之前的研究, 採用相同的上升速率.
依照這些研究報告, 不建議使用普拿疼做為預防AMS的藥物,
A single study demonstrated that acetaminophen 1000 mg 3 times daily was as effective as ibuprofen at preventing AMS in trekkers travelling between 4370 and 4940 m in elevation.45 Rather than including a placebo arm, the study attempted to establish the benefit of acetaminophen by comparing the incidence rates in the study with those of untreated trekkers from prior studies that used the same ascent profile. Based on these data, acetaminophen is not recommended for use as a preventive agent over acetazolamide or dexamethasone. Recommendation. Acetaminophen should not be used for AMS prevention. Recommendation Grade: 1C

野外與登山醫學---06-Acute altitude illness WMS 2019 update AMS/HACE prevention Ibuprofen 6 (done)

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病
NSAID 非類固醇消炎止痛藥
Ibuprofen 布洛芬/芬必得/普羅芬是一種常使用的非類固醇消炎止痛藥, 有兩篇研究顯示每天服用三次 600 mg 布洛芬(一天總量 1800mg)有預防AMS效果 (台灣常見的劑型是 400 mg, 例如 purfen). 第三篇較小規模的研究顯示沒有預防效果.
另一篇研究雖然說有效, 但該研究並無設計對照組, 而是採用該地區以往的AMS發生率作參照

Two trials demonstrated that ibuprofen (600 mg 3 times daily) is more effective than placebo at preventing AMS,42,43 while a third, smaller study showed no benefit.44 Another study claimed to show benefit, but the trial did not include a placebo arm and instead compared the incidence of AMS with ibuprofen with historically reported rates from the region in which the study was conducted.45

目前並無布洛芬與類固醇的療效比較, 有兩篇研究比較布洛芬與丹木斯的差異, 第一篇說, 兩組的高海拔頭痛與AMS發生率相近, 兩篇都顯示, 相較於安慰劑, 布洛芬有預防AMS效果.
Although no studies have compared ibuprofen with dexamethasone, 2 studies have compared ibuprofen with acetazolamide. The first found an equal incidence of high altitude headache and AMS in the acetazolamide and ibuprofen groups, with both showing significant protection compared to placebo.46

一篇更近期的研究顯示, 布洛芬預防AMS效果比丹木斯差,
A more recent trial failed to show that ibuprofen was noninferior to acetazolamide (ie, ibuprofen is inferior to acetazolamide for AMS prophylaxis).47

上面提到的這些研究, 服藥時間較短, 大約 24-48 小時, 因此常時間服用布洛芬, 效益與安全性是否大於副作用, 仍屬未知, 需要更多研究比較丹木斯, 類固醇, 布洛芬的差異. 對於布洛芬是否可用於預防AMS, 目前無法給出明確建議
建議: 對於不想吃(或有禁忌)丹木斯或類固醇的人, 可以服用布洛芬預防AMS, 證據等及 2B

The aforementioned trials all used the medication for a short duration (~24 to 48 h). As a result, efficacy and safety (eg, the risk of gastrointestinal bleeding or renal dysfunction) over longer periods of use at high altitude remain unclear. For these reasons, as well as more extensive clinical experience with acetazolamide and dexamethasone, ibuprofen cannot be recommended over these medications for AMS prevention for rapid ascent. Recommendation. Ibuprofen can be used for AMS prevention in persons who do not wish to take acetazolamide or dexamethasone or have allergies or intolerance to these medications. Recommendation Grade: 2B.

野外與登山醫學----05-Acute altitude illness WMS 2019 update AMS/HACE prevention Ginkgo biloba 5 (done)

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update
統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
acute altitude illness 急性高海拔疾病

Ginkgo biloba 銀杏萃取物, 有兩篇研究顯示銀杏有預防AMS功效, 但也有其他研究顯示無效, 結果差異或許與銀杏產品的來源及組成有關, 懷孕婦女應避免使用銀杏, 服用抗凝血劑的患者也需小心(可能會增加出血風險),. 對於預防AMS而言, 應該優先考慮使用丹木斯, 不建議使用銀杏萃取物作為預防AMS的方式, 證據等級1C

Although 2 trials demonstrated a benefit of Ginkgo in AMS prevention,35,36 2 other negative trials have also been published.37,38 This discrepancy may result from differences in the source and composition of the Ginkgo products.39 Ginkgo should be avoided in pregnant women40 and used with caution in people taking anticoagulants.41 Acetazolamide is considered far superior for AMS prevention. Recommendation. Ginkgo biloba should not be used for AMS prevention. Recommendation Grade: 1C

野外與登山醫學----03-04-WMS 2019 acute altitude illness update 3 Dexamethasone 類固醇 ~ ~4 Inhaled budesonide 吸入性類固醇

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update

統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病
Acetazolamide 乙醯唑胺, 乙醯偶氮胺, 為方便閱讀記憶, 統一翻譯為丹木斯
Dexamethasone 地塞米松, 一種人工合成的類固醇(腎上腺皮質激素/皮質類固醇), 底下翻譯用類固醇代替 (類固醇還有很多其他不同種類, 藥效及作用時間不太相同)
Inhaled budesonide 一種吸入性類固醇, 布地奈德（Budesonide），常見商品名 Pulmicort，類固醇(腎上腺皮質激素/皮質類固醇), 下面使用吸入性類固醇代替 budesonide

AMS及HACE

Acute mountain sickness and high altitude cerebral edema

有幾篇回顧性文獻提供AMS和HACE的成因, 臨床表現, 病理生理學. 在臨床觀點, HACE可視為是非常嚴重的AMS, 因此這兩個疾病的預防及治療方式可同時討論,

Information on the epidemiology, clinical presentation, and pathophysiology of AMS and HACE is provided in several extensive reviews. From a clinical standpoint, HACE represents an extremely severe form of AMS; therefore, preventive and treatment measures for the 2 disorders can be addressed simultaneously.

預防AMS及HACE的方式有下列數種 (依序翻譯)

PREVENTION Measures considered for prevention of AMS and HACE include the following.

1. Gradual ascent 緩慢爬升 建議用以預防AMS及HACE(及HAPE)

2. Acetazolamide 丹木斯
若罹患AMS/HACE為中度或高度風險, 強烈建議使用丹木斯預防
兒童也可以使用丹木斯預防AMS/HACE

3. Dexamethasone 類固醇 罹患AMS為中度或高度風險時, 類固醇可做為丹木斯替代藥物, 證據等級1A
兒童不建議使用類固醇預防AMS/HACE

4. Inhaled budesonide 吸入性類固醇 不建議用吸入性類固醇預防AMS, 證據等級 1C

5. Ginkgo biloba 銀杏萃取物
Although 2 trials demonstrated a benefit of Ginkgo in AMS prevention,35,36 2 other negative trials have also been published.37,38 This discrepancy may result from differences in the source and composition of the Ginkgo products.39 Ginkgo should be avoided in pregnant women40 and used with caution in people taking anticoagulants.41 Acetazolamide is considered far superior for AMS prevention.

Recommendation.
Ginkgo biloba should not be used for AMS prevention.
Recommendation Grade: 1C

Ibuprofen

Two trials demonstrated that ibuprofen (600 mg 3 times daily) is more effective than placebo at preventing AMS,42,43 while a third, smaller study showed no benefit.44 Another study claimed to show benefit, but the trial did not include a placebo arm and instead compared the incidence of AMS with ibuprofen with historically reported rates from the region in which the study was conducted.45 Although no studies have compared ibuprofen with dexamethasone, 2 studies have compared ibuprofen with acetazolamide. The first found an equal incidence of high altitude headache and AMS in the acetazolamide and ibuprofen groups, with both showing significant protection compared to placebo.46 A more recent trial failed to show that ibuprofen was noninferior to acetazolamide (ie, ibuprofen is inferior to acetazolamide for AMS prophylaxis).47 The aforementioned trials all used the medication for a short duration (~24 to 48 h). As a result, efficacy and safety (eg, the risk of gastrointestinal bleeding or renal dysfunction) over longer periods of use at high altitude remain unclear. For these reasons, as well as more extensive clinical experience with acetazolamide and dexamethasone, ibuprofen cannot be recommended over these medications for AMS prevention for rapid ascent.

Recommendation.
Ibuprofen can be used for AMS prevention in persons who do not wish to take acetazolamide or dexamethasone or have allergies or intolerance to these medications.
Recommendation Grade: 2B.

Acetaminophen
A single study demonstrated that acetaminophen 1000 mg 3 times daily was as effective as ibuprofen at preventing AMS in trekkers travelling between 4370 and 4940 m in elevation.45 Rather than including a placebo arm, the study attempted to establish the benefit of acetaminophen by comparing the incidence rates in the study with those of untreated trekkers from prior studies that used the same ascent profile. Based on these data, acetaminophen is not recommended for use as a preventive agent over acetazolamide or dexamethasone.

Recommendation.
Acetaminophen should not be used for AMS prevention.
Recommendation Grade: 1C

Staged ascent and preacclimatization
Two studies showed that spending 6 to 7 d at moderate altitude (~2200 to 3000 m) before proceeding to higher altitude (referred to as “staged ascent”) decreases the risk of AMS, improves ventilation and oxygenation, and blunts the pulmonary artery pressure response after subsequent ascent to 4300 m.16,48 Many travelers to high altitude visit mountain resorts at more moderate elevations between 2500 and 3000 m. The value of short stays at intermediate elevations of ~1500 m for decreasing the risk of AMS during such ascents makes sense from a physiologic standpoint. However, this approach has not been studied in a randomized fashion, aside from 1 cross-sectional study finding a decreased risk of AMS in travelers who spent 1 night at 1600 m before ascent to resort communities between 1920 and 2950 m.5 A larger number of studies examining the effects of repeated exposures to hypobaric or normobaric hypoxia in the days and week preceding high altitude travel (referred to as “preacclimatization”) showed mixed results, with some studies finding benefit in terms of decreased AMS incidence or severity49e51 and others showing no effect.52e55 A significant challenge in interpreting the literature on preacclimatization is the variability among the hypoxic exposure protocols used, as well as the fact that not all studies include evidence that their protocols induced physiologic responses consistent with acclimatization. Implementation of either staged ascent or preacclimatization may be logistically difficult for many high altitude travelers. In general, short-term exposures (eg, 15 to 60 min of exposure to hypoxia, or a few hours of hypoxia a few times before ascent) are unlikely to aid acclimatization, whereas longer exposures (eg, >8 h daily for >7 d) are more likely to yield benefit. Hypobaric hypoxia is more effective than normobaric hypoxia in facilitating preacclimatization and preventing AMS.56 Because the optimal methods for preacclimatization and staged ascent have not been fully determined, the panel recommends consideration of these approaches but does not endorse a particular protocol.

Recommendation.
When feasible, staged ascent and preacclimatization can be considered as a means for AMS prevention.
Recommendation Grade: 1C

Hypoxic tents
Commercial products are available that allow individuals to sleep or exercise in hypoxic conditions for the purpose of facilitating acclimatization before a trip to high altitude. Only 1 placebo-controlled study has examined their utility.57 Although this study demonstrated a lower incidence of AMS in persons who slept in simulated high altitude conditions compared to normoxia, technical difficulties with the system resulted in a substantial number of study participants not receiving the intended hypoxic dose. Although the systems are marketed to be of benefit and anecdotal reports suggest they are widely used by climbers and other athletes competing at high altitude, there are no data indicating increased likelihood of summit success or improved physical performance. As with the preacclimatization approaches previously described, any benefit that may accrue from these systems is more likely with long hypoxic exposures (>8 h per day) for at least several weeks before planned high altitude travel. Short and/or infrequent exposures, including exercise training, are likely of no benefit. In addition to the cost of the systems and power needed to run them, individuals face the risk of poor sleep, which over a long period of time could have deleterious effects on performance during an expedition.

Recommendation.
Hypoxic tents can be used for facilitating acclimatization and preventing AMS, provided sufficiently long exposures can be undertaken regularly over an appropriate number of weeks and other factors, such as sleep quality, are not compromised.
Recommendation Grade: 2B

Other options
Chewed coca leaves, coca tea, and other coca-derived products are commonly recommended for travelers in the Andes mountains for AMS prevention. Their utility in prevention of altitude illness has not been properly studied, so they should not be substituted for other established preventive measures described in these guidelines.

Multiple studies have sought to determine whether other agents, including antioxidants,58 iron,59 dietary nitrates,60 leukotriene receptor blockers,61,62 phosphodiesterase inhibitors,63 salicylic acid,64 spironolactone,65 and sumatriptan66 can prevent AMS, but the current state of evidence does not support their use.

“Forced” or “over” hydration has never been found to prevent altitude illness and might increase the risk of hyponatremia; however, maintenance of adequate hydration is important because symptoms of dehydration can mimic those of AMS.

Nocturnal expiratory positive airway pressure (EPAP) administered via a single-use nasal strip during sleep is not effective for AMS prophylaxis,67 nor is a regimen of remote ischemic preconditioning.68

No studies have examined short-term oxygen use in the form of either visits to oxygen bars or over-the-counter oxygen delivery systems by which individuals inhale oxygenenriched gas from a small prefilled canister. Due to the small volume of gas (2 to 10 L/canister) and short duration of administration, these interventions are unlikely to be of benefit and, as a result, have no role in AMS/HACE prevention. Other over-the-counter products, such as powdered drink mixes, also lack any evidence of benefit.

2020年4月26日星期日

野外與登山醫學----01-02--WMS 2019 acute altitude illness update part 1~2

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update

統一名詞翻譯
AMS 急性高山病
HACE 高海拔腦水腫
HAPE 高海拔肺水腫
acute altitude illness 急性高海拔疾病

簡介及高海拔定義
Introduction 簡介
到海拔 2500 公尺以上地區旅遊, 可能會罹患一種或多種高海拔疾病, 急性高山病AMS, 高海拔肺水腫 HAPE, 高海拔腦水腫 HAPE. 在高海拔地區或探險隊工作的醫師, 可能會遇到一些高海拔疾病的個案, 因此需要熟悉預防性處方以及治療方案.

WMS 召開專家會議, 發展實證醫學為基礎的指引, 以預防或治療高海拔疾病, 提出每一種疾病的預防或治療方式. 根據現有的證據以及利弊考量, 將各種建議分級, 這些建議適用於所有到高海拔活動的旅客, 不管是工作, 休閒, 健行, 滑雪, 或登山.

Travel to elevations above 2500 m is associated with risk of developing 1 or more forms of acute altitude illness: acute mountain sickness (AMS), high altitude cerebral edema (HACE), and 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, clinicians working at facilities in high altitude regions or as members of expeditions traveling to such areas can expect to see persons who are experiencing these illnesses and must be familiar with prophylactic regimens and proper treatment protocols. To provide guidance to clinicians and disseminate knowledge about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute altitude illness. Preventive and therapeutic modalities are presented and recommendations made for each form of acute altitude illness. Recommendations are graded based on the quality of supporting evidence and consideration of benefits and risks/burdens associated with each modality. These recommendations are intended to apply to all travelers to high altitude, whether they are traveling to high altitude for work, recreation, or various activities including hiking, skiing, trekking, and mountaineering.

Defining the threshold for “high altitude” and when to apply these guidelines
高海拔定義, 何時可使用此指引

無法適應高海拔的人, 到達海拔 2500 公尺以上, 有罹患高海拔疾病的風險, 但以前的研究及臨床經驗顯示, 體質敏感的人, 在海拔 2000 公尺以上就有可能罹患 AMS, 甚至HAPE. HACE雖然多數都是在更高的海拔發生, 但也曾有案例在海拔 2500公尺發生 HACE 合併 HAPE.
我們很難界定到底多高的海拔可能發生高海拔疾病, 因為高海拔疾病中, 最常見的 AMS 的症狀並不具特異性, 甚至在幾個研究中, 研究對象在不提升海拔的狀況也符合AMS診斷, 因此在一些分析AMS發生率的研究中, 少許的海拔提升, 就會有一些研究對象被歸類到AMS患者, 而引起其症狀的原因可能不是高海拔, 這種情況會造成AMS發生率被高估,

Unacclimatized individuals are at risk of high altitude illness when ascending to altitudes above 2500 m. Prior studies and extensive clinical experience, however, suggest that susceptible individuals can develop AMS, and potentially HAPE, at elevations as low as 2000 m. HACE is typically encountered at higher elevations but has also been reported at around 2500 m in patients with concurrent HAPE.7 Part of the difficulty in defining a specific threshold at which altitude illness can develop is the fact that the symptoms and signs of AMS, the most common form of altitude illness, are nonspecific, as demonstrated in several studies in which participants met criteria for the diagnosis of AMS despite no gain in altitude. As a result, studies assessing AMS incidence at modest 不大的 elevations may label individuals as having altitude illness when, in fact, symptoms are related to some other process, thereby falsely elevating the reported incidence of AMS at that elevation.

因為無法界定一個明確的海拔高度, 專家會議建議預防或治療高海拔疾病時, 不要完全依據海拔高度, 考慮預防策略時, 要根據每個人在以往高海拔地區旅遊的表現. 海拔爬升速率, 高度適應的時間天數

Recognizing the difficulty in defining a clear threshold, the expert panel recommends an approach to preventing and treating acute altitude illness that does not depend strictly on the altitude to which an individual is traveling. Preventive measures should be considered based on the altitude to which the individual is traveling and also account for factors such as history of performance at high altitude, rate of ascent, and availability of acclimatization days (described in greater detail later).

不要以海拔 2500 公尺以下, 來排除 AMS, HAPE, HACE 診斷. 還需要考慮是否有相符的臨床症狀, 謹慎的排除其他成因, 例如嚴重脫水, 低血鈉, 肺炎, 一氧化碳中毒, 低血糖等等.

Diagnoses of AMS, HAPE, or HACE should not be excluded based on the fact that an ill individual is below 2500 m. These diagnoses should be strongly considered in the presence of compatible clinical features, with careful attempts to exclude other entities such as severe dehydration, hyponatremia, pneumonia, carbon monoxide poisoning, and hypoglycemia.

Acute altitude illness WMS 2019 update AMS/HACE prevention Gradual ascent 1

漸進爬升, 每天爬升的海拔不要太快(通常指睡眠海拔), 對於預防高海拔疾病非常有效. 但以往對於這方面的研究, 通常是回溯性研究(缺點是無法要求實驗組與對照組的身體特質一致性), 只有兩篇是前瞻性研究 (先訂出收案條件以及想評估的項目, 再挑選合適的個案), 睡眠海拔比行進間曾爬升的最高海拔影響更大, 舉例, 第一天從海拔 2500公尺出發, 中間曾經爬升到海拔 3200 公尺, 之後下降到海拔 2900 公尺的營地睡覺, 爬升的海拔要用 2900-2500 公尺來計算, 一天爬升的海拔是 400 公尺,

漸進爬升是指每天睡眠海拔不要增加太多, 建議以此預防急性高山病 AMS 及高海拔腦水腫 HACE.

Gradual ascent
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 2 recent prospective studies,15,16 this strategy has largely been evaluated retrospectively.17 In planning the rate of ascent, the altitude at which someone sleeps is considered more important than the altitude reached during waking hours.

Recommendation. Gradual ascent, defined as a slow increase in sleeping elevation, is recommended for AMS and HACE prevention. A specific approach is described further later in the text. Recommendation Grade: 1

2020年4月14日星期二

糖尿病合併慢性腎病何時考慮作腎臟切片

若病人有以下症狀，建議施行腎臟切片，以排除其他造成腎病變之原因：

( 一 ) 未合併糖尿病視網膜病變；

( 二 ) 腎絲球過濾率快速下降；

( 三 ) 快速增加之蛋白尿或合併腎病症候群；

( 四 ) 頑固型高血壓；

( 五 ) 多重尿液檢驗異常，如合併小便之紅血球 / 白血球或其柱狀體；

( 六 ) 合併系統性疾病之全身表現

( 七 ) 腎絲球過濾率在使用 ACEi/ARB 後三個月內下降 >30%

糖尿病腎病變惡化危險因子

年齡

糖尿病病史

性別

腎絲球過濾率

血清肌酸酐

尿液白蛋白 - 肌酸酐比值

收縮血壓

糖化血色素

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