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.
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.
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.
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