以下使用民眾比較熟悉的 "丹木斯" 取代 "acetazolamide=乙醯胺基硫唑嘧錠"。
使用 "犀利士" 代替 "tadalafil"
201407281839
曾經罹患高海拔肺水腫 HAPE 如何預防再次發生
另一篇相關筆記 HAPE危險因子
2021-12-15 15:09 在uptodate 關於 HAPE 的危險因子, 另外寫了一篇筆記
高海拔肺水腫 HAPE 危險因子(連結在此)
2021-12-12 (另一篇HAPE介紹的筆記連結在此)
HAPE: 高海拔肺水腫
寒冷是否會增加HAPE機率. 答案是會.
uptodate 上面提到HAPE危險因子包括
1. 個體對低氧低壓的感受性
2. 到達的海拔高度
3. 上升到高海拔地區速率
4. 在高海拔停留時間
5. 男性較女性容易發生
6. 寒冷 (患者應注意保溫)
7. 有上呼吸道感染(感冒)
8. 激烈運動 (患者應限制不要做激烈活動)
9. 某些狀況或疾病會增加肺部血流量, 造成肺高壓, 增加肺部血管反應, 也容易誘發HAPE (甚至發生在海拔2500公尺以下). 這包括所有會造成肺動脈高壓的狀況, 先天性單側肺動脈缺失, 心臟內分流 intracardiac shunts, 例如心房中膈缺損或心室中膈缺損.
休息與保溫, 被放在HAPE治療裡面
高強度活動與冷刺激都會讓肺動脈壓力上升. 可能造成HAPE急性發作
因此. 治療HAPE患者, 限制患者運動量, 避免暴露在寒冷, 是治療HAPE的基本原則
因此, 罹患HAPE的人, 下降過程建議不要背負東西(輕裝或無裝),
臥床休息有沒有幫助, 目前不知道. 但曾有一篇秘魯研究報告說, 在海拔 3750 公尺, 36個輕度至中度 re-endry HAPE 患者, 單純臥床休息就幾乎快痊癒, 而使用氧氣加上臥床靜養, 效果更好. 之後的研究通常是臥床 + 給氧一起做.
在科羅拉多州的滑雪勝地, 通常不會要求在客房內使用氧氣治療的HAPE患者需嚴格臥床休息.
2018-10-29
首選還是緩慢上升 + 休息天. 藥物是不得已的選擇. 氧氣是很好的東西. 氧氣缺點是取得不易.
藥物首選是 nifedipine. 但沒有發生過HAPE的人並不需要預防性使用.
2017-06-06 EDIT
在 uptodate 裡面建議, 如果過去沒發生過 HAPE. 不需要吃預防 HAPE 藥物.
預防最好的方式是慢慢上升. 每一天睡眠/長時間休息海拔不要上升超過海拔 500 公尺.
再來根據登山/旅遊的風險程度選擇預防策略. 低危險性的不需要預防性用藥. 中度及高度危險性的考慮預防性用藥.
如果曾經罹患 HAPE, 首選藥物是緩慢釋放劑型的 nifedipine (常見商品 coracten. adalat). 不建議用速效型.
在 WMS 2014 操作指引建議. 犀利士/威而鋼資料不足. 不建議. salmaterol 不建議單獨使用於預防 HAPE.
丹木斯學理上有用. 但缺乏實證. 類固醇有文獻說有效. 但資料有限. 以上兩種都不建議單獨用於預防 HAPE
2014 WMW HAPE PREVENTION http://blog.xuite.net/ymmcc/twblog/540171169
https://www.uptodate.com/contents/high-altitude-illness-including-mountain-sickness-beyond-the-basics#H18
HAPE prevention — As with other high altitude illnesses, the best way to prevent HAPE is to ascend slowly. This is especially true if you have a previous history of HAPE. Preventive medicines are not usually recommended unless you have a history of HAPE and you must ascend quickly to altitudes above 8200 feet (2500 meters). Preventive medicines may include nifedipine (commonly used to treat high blood pressure), tadalafil, dexamethasone, or acetazolamide. (See "High altitude pulmonary edema".)
美國CDC 黃皮書 對於高海拔疾病的預防指引. 主要針對如何避免死亡以及脫困. 並非預防發生機率, 因為高海拔疾病的發生並非瞬間, 沒道理讓自己死於高海拔疾病, 除非受困於天氣, 地理環境, 導致無法降低高度. 避免死亡或嚴重後果, 有三個主要的原則
1. 了解高海拔疾病症狀, 當疾病出現, 早期辨識
2. 出現高海拔疾病症狀之後, 即使症狀再輕微, 不要上升到更高海拔去睡覺休息
3. 如果在相同海拔症狀惡化, 需下降.
https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/altitude-illness
PREVENTION OF SEVERE ALTITUDE ILLNESS OR DEATH
The main point of instructing travelers about altitude illness is not to eliminate the possibility, but to prevent death or evacuation due to altitude illness. Since the onset of symptoms and the clinical course are sufficiently slow and predictable, there is no reason for anyone to die from altitude illness, unless trapped by weather or geography in a situation in which descent is impossible. Three rules can prevent death or serious consequences from altitude illness:
Know the early symptoms of altitude illness, and be willing to acknowledge when they are present.
Never ascend to sleep at a higher altitude when experiencing symptoms of altitude illness, no matter how minor they seem.
Descend if the symptoms become worse while resting at the same altitude.
For trekking groups and expeditions going into remote high-altitude areas, where descent to a lower altitude could be problematic, a pressurization bag (such as the Gamow bag) can be beneficial. A foot pump produces an increased pressure of 2 lb/in2, mimicking a descent of 5,000–6,000 ft (1,500–1,800 m) depending on the starting altitude. The total packed weight of bag and pump is about 14 lb (6.5 kg).
2016-05-24 修改 .
為了方便山友閱讀, 以下使用山友比較熟悉的 "丹木斯" 取代 "acetazolamide=乙醯胺基硫唑嘧錠"。 使用 "犀利士" 代替 "tadalafil"
FROM UPTODATE 2015 JAN 06
過去在高海拔沒有發生疾病或肺高壓的人, 在高海拔發生肺水腫機率並不高, 不建議例行性預防 HAPE.
PREVENTION
Suggested approach to prophylaxis — Gradual ascent remains the primary method for preventing all forms of high altitude illness, including HAPE. For patients with no history of medical problems at high altitude or of pulmonary hypertension, the risk of HAPE is low and routine prophylaxis is not warranted.
如果本身有發生過 HAPE, 可給予藥物預防, 尤其是沒有充足的時間做高度適應的行程, 首選藥物是 Nifedipine. 使用方式是在上升到高海拔前一天開始吃藥. 在高海拔持續吃五天(如果沒待滿五天下降, 下降至低海拔 2500m 停用).
In individuals at high-risk, particularly those with a history of HAPE, pharmacologic prophylaxis may be prudent, especially when time does not allow for adequate acclimatization. Nifedipine is the drug of choice for prophylaxis against HAPE. It should be started the day prior to ascent if possible and continued for five days at altitude, or until descent below 2500 m is completed
類固醇和犀利士是否有效, 仍待進一步研究評估 . 有一篇 2006年研究, 比較犀利士和dexamethasone及安慰劑. 三組結果發現. 類固醇 dexamethasone 可以預防 HAPE 和 AMS http://blog.xuite.net/ymmcc/twblog/417180191
根據機轉及臨床經驗, 丹木斯 是預防 HAPE 合理的藥物, 但也缺乏更進一步研究
氣管擴張劑 salmeterol 在曾有高海拔肺水腫病史的高危險民眾, 可以作為 nifedipine 輔助療法.
Further study is needed to determine whether dexamethasone or phosphodiesterase 5 (PDE-5) inhibitors such as tadalafil are appropriate prophylactic medications. Based upon mechanism and clinical experience, acetazolamide is a reasonable medication for HAPE prophylaxis, but formal studies are lacking. Salmeterol should be considered an adjunct treatment to nifedipine in high-risk individuals with a clear history of recurrent HAPE.
Prophylactic medications — A summary of medications used for the prophylaxis and treatment of HAPE is provided (table 4). More thorough discussions of the drugs used for prophylaxis are found below.
Nifedipine — Nifedipine is the preferred drug for the prevention of HAPE, but is used only in high-risk individuals and only when acclimatization is not possible. Ideally, treatment is started 24 hours prior to ascent and continued for five days at the destination altitude. In higher risk scenarios, treatment may be continued for a longer period. We give 30 mg of the extended release formulation every 12 hours.
In a small randomized trial, 20 mg of a slow release formulation taken by mouth every eight hours while the participants performed a steep ascent prevented HAPE in 9 of 10 subjects with a history of repeated episodes documented by chest radiograph [38]. Seven of the 11 subjects given placebo developed radiographically-proven HAPE. Note that 20 mg extended release formulations are not available in the United States.
Dexamethasone — Further study is needed to determine whether dexamethasone is an appropriate medication for prophylaxis against HAPE. In one randomized trial of 29 individuals with a history of HAPE, none of the 10 participants given dexamethasone prophylaxis (8 mg every 12 hours) developed HAPE during a rapid ascent from 490 to 4559 m with an overnight stay [35]. Prophylaxis with dexamethasone has the added advantage of preventing AMS/HACE, whereas nifedipine and the PDE-5 inhibitors have no such effect.
Dexamethasone's mechanism of action remains unclear. It may involve upregulation of nitric oxide production and upregulation of alveolar epithelial membrane sodium channels and sodium-potassium ATPase [39].
Tadalafil and Sildenafil — The phosphodiesterase 5 (PDE-5) inhibitors sildenafil and tadalafil effectively prevented hypoxic pulmonary hypertension and the development of HAPE in small studies [40-43]. Optimal doses have not been established. Regimens for sildenafil have varied from a single dose of 50 or 100 mg just prior to exposure for acute ascent, to 40 mg three times a day for individuals who spend two to six days at altitude; we give 50 mg every eight hours. For tadalafil, 10 mg every 12 hours is the usual dose. These drugs are potentially safer than nifedipine because there is less risk of hypotension, but they are more expensive. Sildenafil has shorter dosing intervals because its half-life is four to five hours; tadalafil's half-life is 17 hours.
Beta agonist — Salmeterol prevented HAPE in 50 percent of subjects in one small study, and thus appears less effective than other agents [44]. However, it is safe and can be used in combination with acetazolamide or other medications. Salmeterol was chosen for prophylactic studies because of its relatively longer duration of action. Albuterol is less expensive and may be effective prophylaxis, but this has not been studied.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
http://tinyurl.com/l7kmpay
山友詢問
===============================================
我大約五年前爬奇萊連峰從屯原進松雪樓出，在第四天晚上急性高山肺水腫，當時的行程我沒有吃高山症預防用藥，發病後我大概休息一年才又開始接觸高山。 有在雪季待在玉山4-5天，也有嚐試爬其他的山，但最多只有四天就下山了，每次都有吃單木斯預防用藥。 我6/30開始南湖大山的行程，6/29晚上住獨立山，有吃半顆單木斯，6/30起每早晚各半顆，一直吃到7/2晚上。 我們6/30住新雲稜。7/1.2住南湖山屋。我在7/3凌晨兩點發現自己呼吸怪怪的，便馬上坐起來，之後就開始咳嗽有水，一開始吐出來的水是透明的，後 來變淡黃色，當時我很明確知道自己應該是高山肺水腫又發作了。我在兩點半左右吃了一顆劑量4mg的類固醇，吃了之後咳嗽頻率有減緩。三點左右伙伴幫我打電 話給消防隊，後來我在七點左右搭直升機下山就醫。 我在發病前一天狀況都算穩定，只是前一天的行程時間有點長。 我想請問我已經有服用預防用藥了是否還有其他更好的預防?記得有醫師說過類固醇+單木斯也可以一起服用當預防用藥。 另外我已經第二次發病了，我很了解我可能跟長程縱走無緣了，那如果是低於四天的行程我還能上山嗎？ 我也了解或許以後自己一天的行程不能太累。 還有~~我這樣有必要去醫院檢查我自己是否有心肺上的疾病呢？ 不好意思問了你那麼多~~ 還是你有建議的門診讓我可以去諮詢嗎?
回應：
1. 類固醇是可以用的。每天吃兩次 8mg dexamethasone 可以將HAPE發生率從 70% 降低至 10% 以下, 但目前預防HAPE的第一選擇仍是 nifedipine. 類固醇的研究不多. 不建議用為第一線預防藥物.
Small randomized trials involving persons with a history of high-altitude pulmonary edema have shown that the risk of recurrence can be reduced with the use of medications that lower the high pulmonary-artery pressure that is typical in susceptible persons. Nifedipine in a slow-release formulation at a dose of 30 mg twice perday, tadalafil (a phosphodiesterase-5 inhibitor) at a dose of 10 mg twice per day, and dexamethasone at a dose of 8 mg twice per day appear to be similarly effective in lowering pulmonary artery pressure and reducing the incidence of high-altitude pulmonary edema from approximately 70% to approximately 10% or less. Although it has not been compared directly with these agents, inhaled salmeterol, a long-acting β 2 -agonist, at a high dose of 5 puffs (125 μg) twice per day, appears to be less effective; in a placebo-controlled trial, it was associated with a reduction in the incidence of high-altitude pulmonary edema from 74% to 33%.
http://tinyurl.com/lo2jf9q
2. 預防AMS/HACE可以吃 acetazolamide, 預防HAPE以nifedipine為首選, dexamethasone用於無法服用 acetazolamide 的人。威而剛也可以預防高海拔肺水腫, 但威而鋼無法預防AMS或HACE。
另外，如果要長程縱走前兩個月，可以先到合歡山進行高度暴露，建議在三千公尺以上山區待滿四天，且要在三千公尺以上地區過夜，最合適的地點是松雪樓或滑雪山莊，白天再到北合歡山或西合歡山訓練。
威而剛的吃法是，進入3000公尺以上山區，每八小時吃50mg (也就是每八小時半顆)，吃到山上第四天。
3. 高海拔肺水腫（HAPE）是最容易復發，也是最危險、死亡率極高、進展最快的高山病。只要曾發生過高海拔肺水腫（HAPE）的病人要再次到高海拔地區，都建議要用藥物預防，且行前要做好完善的撤出計劃。
2014-10-27
使用類固醇 DEXAMETHASONE 預防 HAPE, 要提早一天使用, 如果已經上升到高海拔才吃會失效, 先前有些案例指出, 使用 DEXAMETHASONE 治療AMS 的病人, 仍會發生 HAPE. 如果要上升至海拔 3000 公尺以上, 五天以下的行程, 沒有禁忌症的情況, 預防性使用 DEXAMETHASONE 是安全可靠的.
Recently, at the Hypoxia Symposium in Lake Louise 2009, we presented the result of a follow-up study in HAPE-susceptible persons testing the effect of dexamethasone early vs late prophylaxis. We found that dexamethasone taken 1 day prior to ascent (early) prevented HAPE but not if taken after the first night at 4559 m (late). These results confirm that dexamethasone taken 1 day prior to ascent is effective for HAPE prophylaxis, but not if started after the first night at high altitude. This is in line with previous case reports indicating that HAPE may develop despite treatment of AMS with dexamethasone. 50,51 In both studies, during the observation period of 3 and 5 days respectively, AMS score was significantly lower in the dexamethasone than in the placebo group, the blood glucose levels and systemic blood pressure being not different between groups. 27 Thus, for individuals susceptible to HAPE who plan to be exposed to an altitude above 3000 m for less then 5 days, in the absence of contraindications, a prophylaxis with dexamethasone appears highly attractive and safe, particularly if the use of a calcium antagonist or a hosphodiesterase 5 inhibitor is contraindicated. 52 However, before general recommendation can be given, particularly for those mountaineers planning a prolonged exposure to high altitude, further studies are needed to determinate the minimaleffective dose anditssafetyprofileinthe setting of trek or expedition.
http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.p
2010 瑞士 蘇黎世大學醫院. 內科部. 加護病房. Marco Maggiorini 醫師(大陸的醫學期刊稱其為教授) 寫的
這篇文章有圖片. 說明類固醇及其他藥物對於高海拔肺水腫 HAPE 的作用機轉
http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.pdf?fbclid=IwAR23BeSkDA_WUHtwf0IU_nGgHSCzpWYyx8JsXQhWGRY0M6NxdffDwweWBvw
在這篇文章有圖片說明機轉http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.pdf威而鋼/犀利士 增加肺循環中的一氧化氮NO, 造成肺血管張力下降(阻力下降, 壓力下降), 因此減少肺部微血管壓力及體液漏出至組織間隙和肺泡類固醇增加肺循環 NO 使得肺血管張力下降, 減少缺氧引起的神經賀爾蒙活化, 減少肺微血管通透性, 改善缺氧引起的肺泡水分清除下降氣管擴張劑藉由刺激 ENaC 增加肺泡水分清除Fig 1. Action mechanisms of the different drugs used for prevention and treatment of high altitude pulmonary edema. Phosphodiesterase 5-inhibitors such as sildenafil and tadalafil increase nitricoxide availability in the pulmonary circulation leading to a decrease in pulmonary vascular tone; hence,pulmonary capillary pressure and fluid leakage in to the interstitial and alveolar space. Corticosteroids increase nitric oxide availability in the pulmonary circulation leading to a decrease in pulmonary vascular tone, decrease hypoxia associated neurohumoral activation and pulmonary capillary permeability, and enhance hypoxia-associated decrease in alveolar water clearance. β2 agonists enhance alveolar water clearance by stimulating ENaC.(補充, 根據自己臨床經驗, 心因性肺水腫使用氣管擴張劑通常沒有效果, 很多病患反而使用擴張劑會一直感覺到呼吸更困難, 除非病患同同時合併肺水腫及慢性呼吸道阻塞疾病, 才會考慮使用氣管擴張劑作為治療)
Yumin Lai 關於HAPE的危險性如王醫師所言，不過我認為用直升機運出來的社會成本太高，不建議這位山友再冒險去爬相近高度的山
羅OO 目前有一些假說，正常生理在hypoxia環境下hepcidin會下降，EPO會被釋放，這個平衡如果被打破可能是HAPE的成因，如果體內處於發炎狀態hepcidin會上升，類固醇則可能透過消炎來逆轉這個過程。我是前年聽人家報告的，現在一時也找不到相關的文獻。
羅OO 樓主的問題可以參考這篇高海拔肺水腫復發的研究，我覺得比較值得注意就是不論初次或是復發的HAPE幾乎都是上升到9000feet以上48小時內發病，所以初期的高度適應非常重要，依照台灣爬山的特性低於四天的行程高度適應通常都很鳥，還是轉戰中級山吧
======================================================================
使用類固醇 DEXAMETHASONE 預防 HAPE, 要提早一天使用
如果已經上升到高海拔才吃會失效,
先前有些個案報告發現, 在使用 DEXAMETHASONE 治療AMS 的病人, 仍會發生 HAPE.
如果要上升至海拔 3000 公尺以上, 五天以下的行程, 沒有禁忌症的情況, 預防性使用 DEXAMETHASONE 是安全可靠的.
Recently, at the Hypoxia Symposium in Lake Louise 2009, we presented the result of a follow-up study in HAPE-susceptible persons testing the effect of dexamethasone early vs late prophylaxis. We found that dexamethasone taken 1 day prior to ascent (early) prevented HAPE but not if taken after the first night at 4559 m (late). These results confirm that dexamethasone taken 1 day prior to ascent is effective for HAPE prophylaxis, but not if started after the first night at high altitude. This is in line with previous case reports indicating that HAPE may develop despite treatment of AMS with dexamethasone. 50,51 In both studies, during the observation period of 3 and 5 days respectively, AMS score was significantly lower in the dexamethasone than in the placebo group, the blood glucose levels and systemic blood pressure being not different between groups. 27 Thus, for individuals susceptible to HAPE who plan to be exposed to an altitude above 3000 m for less then 5 days, in the absence of contraindications, a prophylaxis with dexamethasone appears highly attractive and safe, particularly if the use of a calcium antagonist or a hosphodiesterase 5 inhibitor is contraindicated. 52 However, before general recommendation can be given, particularly for those mountaineers planning a prolonged exposure to high altitude, further studies are needed to determinate the minimaleffective dose anditssafetyprofileinthe setting of trek or expedition.
2021-12-15 15:09 在uptodate 關於 HAPE 的危險因子, 另外寫了一篇筆記
高海拔肺水腫 HAPE 危險因子(連結在此)
2021-12-12 (另一篇HAPE介紹的筆記連結在此)
HAPE: 高海拔肺水腫
寒冷是否會增加HAPE機率. 答案是會.
uptodate 上面提到HAPE危險因子包括
1. 個體對低氧低壓的感受性
2. 到達的海拔高度
3. 上升到高海拔地區速率
4. 在高海拔停留時間
5. 男性較女性容易發生
6. 寒冷 (患者應注意保溫)
7. 有上呼吸道感染(感冒)
8. 激烈運動 (患者應限制不要做激烈活動)
9. 某些狀況或疾病會增加肺部血流量, 造成肺高壓, 增加肺部血管反應, 也容易誘發HAPE (甚至發生在海拔2500公尺以下). 這包括所有會造成肺動脈高壓的狀況, 先天性單側肺動脈缺失, 心臟內分流 intracardiac shunts, 例如心房中膈缺損或心室中膈缺損.
休息與保溫, 被放在HAPE治療裡面
高強度活動與冷刺激都會讓肺動脈壓力上升. 可能造成HAPE急性發作
因此. 治療HAPE患者, 限制患者運動量, 避免暴露在寒冷, 是治療HAPE的基本原則
因此, 罹患HAPE的人, 下降過程建議不要背負東西(輕裝或無裝),
臥床休息有沒有幫助, 目前不知道. 但曾有一篇秘魯研究報告說, 在海拔 3750 公尺, 36個輕度至中度 re-endry HAPE 患者, 單純臥床休息就幾乎快痊癒, 而使用氧氣加上臥床靜養, 效果更好. 之後的研究通常是臥床 + 給氧一起做.
在科羅拉多州的滑雪勝地, 通常不會要求在客房內使用氧氣治療的HAPE患者需嚴格臥床休息.
2018-10-29
首選還是緩慢上升 + 休息天. 藥物是不得已的選擇. 氧氣是很好的東西. 氧氣缺點是取得不易.
藥物首選是 nifedipine. 但沒有發生過HAPE的人並不需要預防性使用.
2017-06-06 EDIT
在 uptodate 裡面建議, 如果過去沒發生過 HAPE. 不需要吃預防 HAPE 藥物.
預防最好的方式是慢慢上升. 每一天睡眠/長時間休息海拔不要上升超過海拔 500 公尺.
再來根據登山/旅遊的風險程度選擇預防策略. 低危險性的不需要預防性用藥. 中度及高度危險性的考慮預防性用藥.
如果曾經罹患 HAPE, 首選藥物是緩慢釋放劑型的 nifedipine (常見商品 coracten. adalat). 不建議用速效型.
在 WMS 2014 操作指引建議. 犀利士/威而鋼資料不足. 不建議. salmaterol 不建議單獨使用於預防 HAPE.
丹木斯學理上有用. 但缺乏實證. 類固醇有文獻說有效. 但資料有限. 以上兩種都不建議單獨用於預防 HAPE
2014 WMW HAPE PREVENTION http://blog.xuite.net/ymmcc/twblog/540171169
https://www.uptodate.com/contents/high-altitude-illness-including-mountain-sickness-beyond-the-basics#H18
HAPE prevention — As with other high altitude illnesses, the best way to prevent HAPE is to ascend slowly. This is especially true if you have a previous history of HAPE. Preventive medicines are not usually recommended unless you have a history of HAPE and you must ascend quickly to altitudes above 8200 feet (2500 meters). Preventive medicines may include nifedipine (commonly used to treat high blood pressure), tadalafil, dexamethasone, or acetazolamide. (See "High altitude pulmonary edema".)
美國CDC 黃皮書 對於高海拔疾病的預防指引. 主要針對如何避免死亡以及脫困. 並非預防發生機率, 因為高海拔疾病的發生並非瞬間, 沒道理讓自己死於高海拔疾病, 除非受困於天氣, 地理環境, 導致無法降低高度. 避免死亡或嚴重後果, 有三個主要的原則
1. 了解高海拔疾病症狀, 當疾病出現, 早期辨識
2. 出現高海拔疾病症狀之後, 即使症狀再輕微, 不要上升到更高海拔去睡覺休息
3. 如果在相同海拔症狀惡化, 需下降.
https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/altitude-illness
PREVENTION OF SEVERE ALTITUDE ILLNESS OR DEATH
The main point of instructing travelers about altitude illness is not to eliminate the possibility, but to prevent death or evacuation due to altitude illness. Since the onset of symptoms and the clinical course are sufficiently slow and predictable, there is no reason for anyone to die from altitude illness, unless trapped by weather or geography in a situation in which descent is impossible. Three rules can prevent death or serious consequences from altitude illness:
Know the early symptoms of altitude illness, and be willing to acknowledge when they are present.
Never ascend to sleep at a higher altitude when experiencing symptoms of altitude illness, no matter how minor they seem.
Descend if the symptoms become worse while resting at the same altitude.
For trekking groups and expeditions going into remote high-altitude areas, where descent to a lower altitude could be problematic, a pressurization bag (such as the Gamow bag) can be beneficial. A foot pump produces an increased pressure of 2 lb/in2, mimicking a descent of 5,000–6,000 ft (1,500–1,800 m) depending on the starting altitude. The total packed weight of bag and pump is about 14 lb (6.5 kg).
2016-05-24 修改 .
為了方便山友閱讀, 以下使用山友比較熟悉的 "丹木斯" 取代 "acetazolamide=乙醯胺基硫唑嘧錠"。 使用 "犀利士" 代替 "tadalafil"
FROM UPTODATE 2015 JAN 06
過去在高海拔沒有發生疾病或肺高壓的人, 在高海拔發生肺水腫機率並不高, 不建議例行性預防 HAPE.
PREVENTION
Suggested approach to prophylaxis — Gradual ascent remains the primary method for preventing all forms of high altitude illness, including HAPE. For patients with no history of medical problems at high altitude or of pulmonary hypertension, the risk of HAPE is low and routine prophylaxis is not warranted.
如果本身有發生過 HAPE, 可給予藥物預防, 尤其是沒有充足的時間做高度適應的行程, 首選藥物是 Nifedipine. 使用方式是在上升到高海拔前一天開始吃藥. 在高海拔持續吃五天(如果沒待滿五天下降, 下降至低海拔 2500m 停用).
In individuals at high-risk, particularly those with a history of HAPE, pharmacologic prophylaxis may be prudent, especially when time does not allow for adequate acclimatization. Nifedipine is the drug of choice for prophylaxis against HAPE. It should be started the day prior to ascent if possible and continued for five days at altitude, or until descent below 2500 m is completed
類固醇和犀利士是否有效, 仍待進一步研究評估 . 有一篇 2006年研究, 比較犀利士和dexamethasone及安慰劑. 三組結果發現. 類固醇 dexamethasone 可以預防 HAPE 和 AMS http://blog.xuite.net/ymmcc/twblog/417180191
根據機轉及臨床經驗, 丹木斯 是預防 HAPE 合理的藥物, 但也缺乏更進一步研究
氣管擴張劑 salmeterol 在曾有高海拔肺水腫病史的高危險民眾, 可以作為 nifedipine 輔助療法.
Further study is needed to determine whether dexamethasone or phosphodiesterase 5 (PDE-5) inhibitors such as tadalafil are appropriate prophylactic medications. Based upon mechanism and clinical experience, acetazolamide is a reasonable medication for HAPE prophylaxis, but formal studies are lacking. Salmeterol should be considered an adjunct treatment to nifedipine in high-risk individuals with a clear history of recurrent HAPE.
Prophylactic medications — A summary of medications used for the prophylaxis and treatment of HAPE is provided (table 4). More thorough discussions of the drugs used for prophylaxis are found below.
Nifedipine — Nifedipine is the preferred drug for the prevention of HAPE, but is used only in high-risk individuals and only when acclimatization is not possible. Ideally, treatment is started 24 hours prior to ascent and continued for five days at the destination altitude. In higher risk scenarios, treatment may be continued for a longer period. We give 30 mg of the extended release formulation every 12 hours.
In a small randomized trial, 20 mg of a slow release formulation taken by mouth every eight hours while the participants performed a steep ascent prevented HAPE in 9 of 10 subjects with a history of repeated episodes documented by chest radiograph [38]. Seven of the 11 subjects given placebo developed radiographically-proven HAPE. Note that 20 mg extended release formulations are not available in the United States.
Dexamethasone — Further study is needed to determine whether dexamethasone is an appropriate medication for prophylaxis against HAPE. In one randomized trial of 29 individuals with a history of HAPE, none of the 10 participants given dexamethasone prophylaxis (8 mg every 12 hours) developed HAPE during a rapid ascent from 490 to 4559 m with an overnight stay [35]. Prophylaxis with dexamethasone has the added advantage of preventing AMS/HACE, whereas nifedipine and the PDE-5 inhibitors have no such effect.
http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.pdf
在一篇 2006 年的研究發現. DEXAMETHASONE 類固醇可以預防 HAPE 和 AMS. http://blog.xuite.net/ymmcc/twblog/417180191
http://www.mjafi.net/article/S0377-1237(02)80082-X/
想請問那短期使用（預防性投藥、肺水腫發病時吃）dexamethasone 這類類固醇會有什麼嚴重副作用嗎？
答: 短期使用，副作用幾乎可以忽略
在 uptodate 裡面建議, 如果過去沒發生過 HAPE. 不需要吃預防 HAPE 藥物.
預防最好的方式是慢慢上升. 每一天睡眠/長時間休息海拔不要上升超過海拔 500 公尺.
再來根據登山/旅遊的風險程度選擇預防策略. 低危險性的不需要預防性用藥. 中度及高度危險性的考慮預防性用藥.
如果曾經罹患 HAPE, 首選藥物是緩慢釋放劑型的 nifedipine (常見商品 coracten. adalat). 不建議用速效型.
在 WMS 2014 操作指引建議. 犀利士/威而鋼資料不足. 不建議. salmaterol 不建議單獨使用於預防 HAPE.
丹木斯學理上有用. 但缺乏實證. 類固醇有文獻說有效. 但資料有限. 以上兩種都不建議單獨用於預防 HAPE
2014 WMW HAPE PREVENTION http://blog.xuite.net/ymmcc/twblog/540171169
https://www.uptodate.com/contents/high-altitude-illness-including-mountain-sickness-beyond-the-basics#H18
HAPE prevention — As with other high altitude illnesses, the best way to prevent HAPE is to ascend slowly. This is especially true if you have a previous history of HAPE. Preventive medicines are not usually recommended unless you have a history of HAPE and you must ascend quickly to altitudes above 8200 feet (2500 meters). Preventive medicines may include nifedipine (commonly used to treat high blood pressure), tadalafil, dexamethasone, or acetazolamide. (See "High altitude pulmonary edema".)
美國CDC 黃皮書 對於高海拔疾病的預防指引. 主要針對如何避免死亡以及脫困. 並非預防發生機率, 因為高海拔疾病的發生並非瞬間, 沒道理讓自己死於高海拔疾病, 除非受困於天氣, 地理環境, 導致無法降低高度. 避免死亡或嚴重後果, 有三個主要的原則
1. 了解高海拔疾病症狀, 當疾病出現, 早期辨識
2. 出現高海拔疾病症狀之後, 即使症狀再輕微, 不要上升到更高海拔去睡覺休息
3. 如果在相同海拔症狀惡化, 需下降.
https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/altitude-illness
PREVENTION OF SEVERE ALTITUDE ILLNESS OR DEATH
The main point of instructing travelers about altitude illness is not to eliminate the possibility, but to prevent death or evacuation due to altitude illness. Since the onset of symptoms and the clinical course are sufficiently slow and predictable, there is no reason for anyone to die from altitude illness, unless trapped by weather or geography in a situation in which descent is impossible. Three rules can prevent death or serious consequences from altitude illness:
Know the early symptoms of altitude illness, and be willing to acknowledge when they are present.
Never ascend to sleep at a higher altitude when experiencing symptoms of altitude illness, no matter how minor they seem.
Descend if the symptoms become worse while resting at the same altitude.
For trekking groups and expeditions going into remote high-altitude areas, where descent to a lower altitude could be problematic, a pressurization bag (such as the Gamow bag) can be beneficial. A foot pump produces an increased pressure of 2 lb/in2, mimicking a descent of 5,000–6,000 ft (1,500–1,800 m) depending on the starting altitude. The total packed weight of bag and pump is about 14 lb (6.5 kg).
2016-05-24 修改 .
為了方便山友閱讀, 以下使用山友比較熟悉的 "丹木斯" 取代 "acetazolamide=乙醯胺基硫唑嘧錠"。 使用 "犀利士" 代替 "tadalafil"
FROM UPTODATE 2015 JAN 06
過去在高海拔沒有發生疾病或肺高壓的人, 在高海拔發生肺水腫機率並不高, 不建議例行性預防 HAPE.
PREVENTION
Suggested approach to prophylaxis — Gradual ascent remains the primary method for preventing all forms of high altitude illness, including HAPE. For patients with no history of medical problems at high altitude or of pulmonary hypertension, the risk of HAPE is low and routine prophylaxis is not warranted.
如果本身有發生過 HAPE, 可給予藥物預防, 尤其是沒有充足的時間做高度適應的行程, 首選藥物是 Nifedipine. 使用方式是在上升到高海拔前一天開始吃藥. 在高海拔持續吃五天(如果沒待滿五天下降, 下降至低海拔 2500m 停用).
In individuals at high-risk, particularly those with a history of HAPE, pharmacologic prophylaxis may be prudent, especially when time does not allow for adequate acclimatization. Nifedipine is the drug of choice for prophylaxis against HAPE. It should be started the day prior to ascent if possible and continued for five days at altitude, or until descent below 2500 m is completed
類固醇和犀利士是否有效, 仍待進一步研究評估 . 有一篇 2006年研究, 比較犀利士和dexamethasone及安慰劑. 三組結果發現. 類固醇 dexamethasone 可以預防 HAPE 和 AMS http://blog.xuite.net/ymmcc/twblog/417180191
根據機轉及臨床經驗, 丹木斯 是預防 HAPE 合理的藥物, 但也缺乏更進一步研究
氣管擴張劑 salmeterol 在曾有高海拔肺水腫病史的高危險民眾, 可以作為 nifedipine 輔助療法.
Further study is needed to determine whether dexamethasone or phosphodiesterase 5 (PDE-5) inhibitors such as tadalafil are appropriate prophylactic medications. Based upon mechanism and clinical experience, acetazolamide is a reasonable medication for HAPE prophylaxis, but formal studies are lacking. Salmeterol should be considered an adjunct treatment to nifedipine in high-risk individuals with a clear history of recurrent HAPE.
Prophylactic medications — A summary of medications used for the prophylaxis and treatment of HAPE is provided (table 4). More thorough discussions of the drugs used for prophylaxis are found below.
Nifedipine — Nifedipine is the preferred drug for the prevention of HAPE, but is used only in high-risk individuals and only when acclimatization is not possible. Ideally, treatment is started 24 hours prior to ascent and continued for five days at the destination altitude. In higher risk scenarios, treatment may be continued for a longer period. We give 30 mg of the extended release formulation every 12 hours.
In a small randomized trial, 20 mg of a slow release formulation taken by mouth every eight hours while the participants performed a steep ascent prevented HAPE in 9 of 10 subjects with a history of repeated episodes documented by chest radiograph [38]. Seven of the 11 subjects given placebo developed radiographically-proven HAPE. Note that 20 mg extended release formulations are not available in the United States.
Dexamethasone — Further study is needed to determine whether dexamethasone is an appropriate medication for prophylaxis against HAPE. In one randomized trial of 29 individuals with a history of HAPE, none of the 10 participants given dexamethasone prophylaxis (8 mg every 12 hours) developed HAPE during a rapid ascent from 490 to 4559 m with an overnight stay [35]. Prophylaxis with dexamethasone has the added advantage of preventing AMS/HACE, whereas nifedipine and the PDE-5 inhibitors have no such effect.
Dexamethasone's mechanism of action remains unclear. It may involve upregulation of nitric oxide production and upregulation of alveolar epithelial membrane sodium channels and sodium-potassium ATPase [39].
Tadalafil and Sildenafil — The phosphodiesterase 5 (PDE-5) inhibitors sildenafil and tadalafil effectively prevented hypoxic pulmonary hypertension and the development of HAPE in small studies [40-43]. Optimal doses have not been established. Regimens for sildenafil have varied from a single dose of 50 or 100 mg just prior to exposure for acute ascent, to 40 mg three times a day for individuals who spend two to six days at altitude; we give 50 mg every eight hours. For tadalafil, 10 mg every 12 hours is the usual dose. These drugs are potentially safer than nifedipine because there is less risk of hypotension, but they are more expensive. Sildenafil has shorter dosing intervals because its half-life is four to five hours; tadalafil's half-life is 17 hours.
Beta agonist — Salmeterol prevented HAPE in 50 percent of subjects in one small study, and thus appears less effective than other agents [44]. However, it is safe and can be used in combination with acetazolamide or other medications. Salmeterol was chosen for prophylactic studies because of its relatively longer duration of action. Albuterol is less expensive and may be effective prophylaxis, but this has not been studied.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
http://tinyurl.com/l7kmpay
山友詢問
===============================================
我大約五年前爬奇萊連峰從屯原進松雪樓出，在第四天晚上急性高山肺水腫，當時的行程我沒有吃高山症預防用藥，發病後我大概休息一年才又開始接觸高山。 有在雪季待在玉山4-5天，也有嚐試爬其他的山，但最多只有四天就下山了，每次都有吃單木斯預防用藥。 我6/30開始南湖大山的行程，6/29晚上住獨立山，有吃半顆單木斯，6/30起每早晚各半顆，一直吃到7/2晚上。 我們6/30住新雲稜。7/1.2住南湖山屋。我在7/3凌晨兩點發現自己呼吸怪怪的，便馬上坐起來，之後就開始咳嗽有水，一開始吐出來的水是透明的，後 來變淡黃色，當時我很明確知道自己應該是高山肺水腫又發作了。我在兩點半左右吃了一顆劑量4mg的類固醇，吃了之後咳嗽頻率有減緩。三點左右伙伴幫我打電 話給消防隊，後來我在七點左右搭直升機下山就醫。 我在發病前一天狀況都算穩定，只是前一天的行程時間有點長。 我想請問我已經有服用預防用藥了是否還有其他更好的預防?記得有醫師說過類固醇+單木斯也可以一起服用當預防用藥。 另外我已經第二次發病了，我很了解我可能跟長程縱走無緣了，那如果是低於四天的行程我還能上山嗎？ 我也了解或許以後自己一天的行程不能太累。 還有~~我這樣有必要去醫院檢查我自己是否有心肺上的疾病呢？ 不好意思問了你那麼多~~ 還是你有建議的門診讓我可以去諮詢嗎?
回應：
1. 類固醇是可以用的。每天吃兩次 8mg dexamethasone 可以將HAPE發生率從 70% 降低至 10% 以下, 但目前預防HAPE的第一選擇仍是 nifedipine. 類固醇的研究不多. 不建議用為第一線預防藥物.
Small randomized trials involving persons with a history of high-altitude pulmonary edema have shown that the risk of recurrence can be reduced with the use of medications that lower the high pulmonary-artery pressure that is typical in susceptible persons. Nifedipine in a slow-release formulation at a dose of 30 mg twice perday, tadalafil (a phosphodiesterase-5 inhibitor) at a dose of 10 mg twice per day, and dexamethasone at a dose of 8 mg twice per day appear to be similarly effective in lowering pulmonary artery pressure and reducing the incidence of high-altitude pulmonary edema from approximately 70% to approximately 10% or less. Although it has not been compared directly with these agents, inhaled salmeterol, a long-acting β 2 -agonist, at a high dose of 5 puffs (125 μg) twice per day, appears to be less effective; in a placebo-controlled trial, it was associated with a reduction in the incidence of high-altitude pulmonary edema from 74% to 33%.
http://tinyurl.com/lo2jf9q
2. 預防AMS/HACE可以吃 acetazolamide, 預防HAPE以nifedipine為首選, dexamethasone用於無法服用 acetazolamide 的人。威而剛也可以預防高海拔肺水腫, 但威而鋼無法預防AMS或HACE。
另外，如果要長程縱走前兩個月，可以先到合歡山進行高度暴露，建議在三千公尺以上山區待滿四天，且要在三千公尺以上地區過夜，最合適的地點是松雪樓或滑雪山莊，白天再到北合歡山或西合歡山訓練。
威而剛的吃法是，進入3000公尺以上山區，每八小時吃50mg (也就是每八小時半顆)，吃到山上第四天。
3. 高海拔肺水腫（HAPE）是最容易復發，也是最危險、死亡率極高、進展最快的高山病。只要曾發生過高海拔肺水腫（HAPE）的病人要再次到高海拔地區，都建議要用藥物預防，且行前要做好完善的撤出計劃。
2014-10-27
使用類固醇 DEXAMETHASONE 預防 HAPE, 要提早一天使用, 如果已經上升到高海拔才吃會失效, 先前有些案例指出, 使用 DEXAMETHASONE 治療AMS 的病人, 仍會發生 HAPE. 如果要上升至海拔 3000 公尺以上, 五天以下的行程, 沒有禁忌症的情況, 預防性使用 DEXAMETHASONE 是安全可靠的.
Recently, at the Hypoxia Symposium in Lake Louise 2009, we presented the result of a follow-up study in HAPE-susceptible persons testing the effect of dexamethasone early vs late prophylaxis. We found that dexamethasone taken 1 day prior to ascent (early) prevented HAPE but not if taken after the first night at 4559 m (late). These results confirm that dexamethasone taken 1 day prior to ascent is effective for HAPE prophylaxis, but not if started after the first night at high altitude. This is in line with previous case reports indicating that HAPE may develop despite treatment of AMS with dexamethasone. 50,51 In both studies, during the observation period of 3 and 5 days respectively, AMS score was significantly lower in the dexamethasone than in the placebo group, the blood glucose levels and systemic blood pressure being not different between groups. 27 Thus, for individuals susceptible to HAPE who plan to be exposed to an altitude above 3000 m for less then 5 days, in the absence of contraindications, a prophylaxis with dexamethasone appears highly attractive and safe, particularly if the use of a calcium antagonist or a hosphodiesterase 5 inhibitor is contraindicated. 52 However, before general recommendation can be given, particularly for those mountaineers planning a prolonged exposure to high altitude, further studies are needed to determinate the minimaleffective dose anditssafetyprofileinthe setting of trek or expedition.
http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.p
2010 瑞士 蘇黎世大學醫院. 內科部. 加護病房. Marco Maggiorini 醫師(大陸的醫學期刊稱其為教授) 寫的
這篇文章有圖片. 說明類固醇及其他藥物對於高海拔肺水腫 HAPE 的作用機轉
http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.pdf?fbclid=IwAR23BeSkDA_WUHtwf0IU_nGgHSCzpWYyx8JsXQhWGRY0M6NxdffDwweWBvw
在這篇文章有圖片說明機轉http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.pdf威而鋼/犀利士 增加肺循環中的一氧化氮NO, 造成肺血管張力下降(阻力下降, 壓力下降), 因此減少肺部微血管壓力及體液漏出至組織間隙和肺泡類固醇增加肺循環 NO 使得肺血管張力下降, 減少缺氧引起的神經賀爾蒙活化, 減少肺微血管通透性, 改善缺氧引起的肺泡水分清除下降氣管擴張劑藉由刺激 ENaC 增加肺泡水分清除Fig 1. Action mechanisms of the different drugs used for prevention and treatment of high altitude pulmonary edema. Phosphodiesterase 5-inhibitors such as sildenafil and tadalafil increase nitricoxide availability in the pulmonary circulation leading to a decrease in pulmonary vascular tone; hence,pulmonary capillary pressure and fluid leakage in to the interstitial and alveolar space. Corticosteroids increase nitric oxide availability in the pulmonary circulation leading to a decrease in pulmonary vascular tone, decrease hypoxia associated neurohumoral activation and pulmonary capillary permeability, and enhance hypoxia-associated decrease in alveolar water clearance. β2 agonists enhance alveolar water clearance by stimulating ENaC.(補充, 根據自己臨床經驗, 心因性肺水腫使用氣管擴張劑通常沒有效果, 很多病患反而使用擴張劑會一直感覺到呼吸更困難, 除非病患同同時合併肺水腫及慢性呼吸道阻塞疾病, 才會考慮使用氣管擴張劑作為治療)
Yumin Lai 關於HAPE的危險性如王醫師所言，不過我認為用直升機運出來的社會成本太高，不建議這位山友再冒險去爬相近高度的山
羅OO 目前有一些假說，正常生理在hypoxia環境下hepcidin會下降，EPO會被釋放，這個平衡如果被打破可能是HAPE的成因，如果體內處於發炎狀態hepcidin會上升，類固醇則可能透過消炎來逆轉這個過程。我是前年聽人家報告的，現在一時也找不到相關的文獻。
羅OO 樓主的問題可以參考這篇高海拔肺水腫復發的研究，我覺得比較值得注意就是不論初次或是復發的HAPE幾乎都是上升到9000feet以上48小時內發病，所以初期的高度適應非常重要，依照台灣爬山的特性低於四天的行程高度適應通常都很鳥，還是轉戰中級山吧
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使用類固醇 DEXAMETHASONE 預防 HAPE, 要提早一天使用
如果已經上升到高海拔才吃會失效,
先前有些個案報告發現, 在使用 DEXAMETHASONE 治療AMS 的病人, 仍會發生 HAPE.
如果要上升至海拔 3000 公尺以上, 五天以下的行程, 沒有禁忌症的情況, 預防性使用 DEXAMETHASONE 是安全可靠的.
Recently, at the Hypoxia Symposium in Lake Louise 2009, we presented the result of a follow-up study in HAPE-susceptible persons testing the effect of dexamethasone early vs late prophylaxis. We found that dexamethasone taken 1 day prior to ascent (early) prevented HAPE but not if taken after the first night at 4559 m (late). These results confirm that dexamethasone taken 1 day prior to ascent is effective for HAPE prophylaxis, but not if started after the first night at high altitude. This is in line with previous case reports indicating that HAPE may develop despite treatment of AMS with dexamethasone. 50,51 In both studies, during the observation period of 3 and 5 days respectively, AMS score was significantly lower in the dexamethasone than in the placebo group, the blood glucose levels and systemic blood pressure being not different between groups. 27 Thus, for individuals susceptible to HAPE who plan to be exposed to an altitude above 3000 m for less then 5 days, in the absence of contraindications, a prophylaxis with dexamethasone appears highly attractive and safe, particularly if the use of a calcium antagonist or a hosphodiesterase 5 inhibitor is contraindicated. 52 However, before general recommendation can be given, particularly for those mountaineers planning a prolonged exposure to high altitude, further studies are needed to determinate the minimaleffective dose anditssafetyprofileinthe setting of trek or expedition.
2021-12-15 15:09 在uptodate 關於 HAPE 的危險因子, 另外寫了一篇筆記
高海拔肺水腫 HAPE 危險因子(連結在此)
2021-12-12 (另一篇HAPE介紹的筆記連結在此)
HAPE: 高海拔肺水腫
寒冷是否會增加HAPE機率. 答案是會.
uptodate 上面提到HAPE危險因子包括
1. 個體對低氧低壓的感受性
2. 到達的海拔高度
3. 上升到高海拔地區速率
4. 在高海拔停留時間
5. 男性較女性容易發生
6. 寒冷 (患者應注意保溫)
7. 有上呼吸道感染(感冒)
8. 激烈運動 (患者應限制不要做激烈活動)
9. 某些狀況或疾病會增加肺部血流量, 造成肺高壓, 增加肺部血管反應, 也容易誘發HAPE (甚至發生在海拔2500公尺以下). 這包括所有會造成肺動脈高壓的狀況, 先天性單側肺動脈缺失, 心臟內分流 intracardiac shunts, 例如心房中膈缺損或心室中膈缺損.
休息與保溫, 被放在HAPE治療裡面
高強度活動與冷刺激都會讓肺動脈壓力上升. 可能造成HAPE急性發作
因此. 治療HAPE患者, 限制患者運動量, 避免暴露在寒冷, 是治療HAPE的基本原則
因此, 罹患HAPE的人, 下降過程建議不要背負東西(輕裝或無裝),
臥床休息有沒有幫助, 目前不知道. 但曾有一篇秘魯研究報告說, 在海拔 3750 公尺, 36個輕度至中度 re-endry HAPE 患者, 單純臥床休息就幾乎快痊癒, 而使用氧氣加上臥床靜養, 效果更好. 之後的研究通常是臥床 + 給氧一起做.
在科羅拉多州的滑雪勝地, 通常不會要求在客房內使用氧氣治療的HAPE患者需嚴格臥床休息.
2018-10-29
首選還是緩慢上升 + 休息天. 藥物是不得已的選擇. 氧氣是很好的東西. 氧氣缺點是取得不易.
藥物首選是 nifedipine. 但沒有發生過HAPE的人並不需要預防性使用.
2017-06-06 EDIT
在 uptodate 裡面建議, 如果過去沒發生過 HAPE. 不需要吃預防 HAPE 藥物.
預防最好的方式是慢慢上升. 每一天睡眠/長時間休息海拔不要上升超過海拔 500 公尺.
再來根據登山/旅遊的風險程度選擇預防策略. 低危險性的不需要預防性用藥. 中度及高度危險性的考慮預防性用藥.
如果曾經罹患 HAPE, 首選藥物是緩慢釋放劑型的 nifedipine (常見商品 coracten. adalat). 不建議用速效型.
在 WMS 2014 操作指引建議. 犀利士/威而鋼資料不足. 不建議. salmaterol 不建議單獨使用於預防 HAPE.
丹木斯學理上有用. 但缺乏實證. 類固醇有文獻說有效. 但資料有限. 以上兩種都不建議單獨用於預防 HAPE
2014 WMW HAPE PREVENTION http://blog.xuite.net/ymmcc/twblog/540171169
https://www.uptodate.com/contents/high-altitude-illness-including-mountain-sickness-beyond-the-basics#H18
HAPE prevention — As with other high altitude illnesses, the best way to prevent HAPE is to ascend slowly. This is especially true if you have a previous history of HAPE. Preventive medicines are not usually recommended unless you have a history of HAPE and you must ascend quickly to altitudes above 8200 feet (2500 meters). Preventive medicines may include nifedipine (commonly used to treat high blood pressure), tadalafil, dexamethasone, or acetazolamide. (See "High altitude pulmonary edema".)
美國CDC 黃皮書 對於高海拔疾病的預防指引. 主要針對如何避免死亡以及脫困. 並非預防發生機率, 因為高海拔疾病的發生並非瞬間, 沒道理讓自己死於高海拔疾病, 除非受困於天氣, 地理環境, 導致無法降低高度. 避免死亡或嚴重後果, 有三個主要的原則
1. 了解高海拔疾病症狀, 當疾病出現, 早期辨識
2. 出現高海拔疾病症狀之後, 即使症狀再輕微, 不要上升到更高海拔去睡覺休息
3. 如果在相同海拔症狀惡化, 需下降.
https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/altitude-illness
PREVENTION OF SEVERE ALTITUDE ILLNESS OR DEATH
The main point of instructing travelers about altitude illness is not to eliminate the possibility, but to prevent death or evacuation due to altitude illness. Since the onset of symptoms and the clinical course are sufficiently slow and predictable, there is no reason for anyone to die from altitude illness, unless trapped by weather or geography in a situation in which descent is impossible. Three rules can prevent death or serious consequences from altitude illness:
Know the early symptoms of altitude illness, and be willing to acknowledge when they are present.
Never ascend to sleep at a higher altitude when experiencing symptoms of altitude illness, no matter how minor they seem.
Descend if the symptoms become worse while resting at the same altitude.
For trekking groups and expeditions going into remote high-altitude areas, where descent to a lower altitude could be problematic, a pressurization bag (such as the Gamow bag) can be beneficial. A foot pump produces an increased pressure of 2 lb/in2, mimicking a descent of 5,000–6,000 ft (1,500–1,800 m) depending on the starting altitude. The total packed weight of bag and pump is about 14 lb (6.5 kg).
2016-05-24 修改 .
為了方便山友閱讀, 以下使用山友比較熟悉的 "丹木斯" 取代 "acetazolamide=乙醯胺基硫唑嘧錠"。 使用 "犀利士" 代替 "tadalafil"
FROM UPTODATE 2015 JAN 06
過去在高海拔沒有發生疾病或肺高壓的人, 在高海拔發生肺水腫機率並不高, 不建議例行性預防 HAPE.
PREVENTION
Suggested approach to prophylaxis — Gradual ascent remains the primary method for preventing all forms of high altitude illness, including HAPE. For patients with no history of medical problems at high altitude or of pulmonary hypertension, the risk of HAPE is low and routine prophylaxis is not warranted.
如果本身有發生過 HAPE, 可給予藥物預防, 尤其是沒有充足的時間做高度適應的行程, 首選藥物是 Nifedipine. 使用方式是在上升到高海拔前一天開始吃藥. 在高海拔持續吃五天(如果沒待滿五天下降, 下降至低海拔 2500m 停用).
In individuals at high-risk, particularly those with a history of HAPE, pharmacologic prophylaxis may be prudent, especially when time does not allow for adequate acclimatization. Nifedipine is the drug of choice for prophylaxis against HAPE. It should be started the day prior to ascent if possible and continued for five days at altitude, or until descent below 2500 m is completed
類固醇和犀利士是否有效, 仍待進一步研究評估 . 有一篇 2006年研究, 比較犀利士和dexamethasone及安慰劑. 三組結果發現. 類固醇 dexamethasone 可以預防 HAPE 和 AMS http://blog.xuite.net/ymmcc/twblog/417180191
根據機轉及臨床經驗, 丹木斯 是預防 HAPE 合理的藥物, 但也缺乏更進一步研究
氣管擴張劑 salmeterol 在曾有高海拔肺水腫病史的高危險民眾, 可以作為 nifedipine 輔助療法.
Further study is needed to determine whether dexamethasone or phosphodiesterase 5 (PDE-5) inhibitors such as tadalafil are appropriate prophylactic medications. Based upon mechanism and clinical experience, acetazolamide is a reasonable medication for HAPE prophylaxis, but formal studies are lacking. Salmeterol should be considered an adjunct treatment to nifedipine in high-risk individuals with a clear history of recurrent HAPE.
Prophylactic medications — A summary of medications used for the prophylaxis and treatment of HAPE is provided (table 4). More thorough discussions of the drugs used for prophylaxis are found below.
Nifedipine — Nifedipine is the preferred drug for the prevention of HAPE, but is used only in high-risk individuals and only when acclimatization is not possible. Ideally, treatment is started 24 hours prior to ascent and continued for five days at the destination altitude. In higher risk scenarios, treatment may be continued for a longer period. We give 30 mg of the extended release formulation every 12 hours.
In a small randomized trial, 20 mg of a slow release formulation taken by mouth every eight hours while the participants performed a steep ascent prevented HAPE in 9 of 10 subjects with a history of repeated episodes documented by chest radiograph [38]. Seven of the 11 subjects given placebo developed radiographically-proven HAPE. Note that 20 mg extended release formulations are not available in the United States.
Dexamethasone — Further study is needed to determine whether dexamethasone is an appropriate medication for prophylaxis against HAPE. In one randomized trial of 29 individuals with a history of HAPE, none of the 10 participants given dexamethasone prophylaxis (8 mg every 12 hours) developed HAPE during a rapid ascent from 490 to 4559 m with an overnight stay [35]. Prophylaxis with dexamethasone has the added advantage of preventing AMS/HACE, whereas nifedipine and the PDE-5 inhibitors have no such effect.
http://www.dr-kowalski.ch/wp-content/uploads/2012/06/H%C3%B6henlungen%C3%B6dem.pdf
在一篇 2006 年的研究發現. DEXAMETHASONE 類固醇可以預防 HAPE 和 AMS. http://blog.xuite.net/ymmcc/twblog/417180191
http://www.mjafi.net/article/S0377-1237(02)80082-X/
想請問那短期使用（預防性投藥、肺水腫發病時吃）dexamethasone 這類類固醇會有什麼嚴重副作用嗎？
答: 短期使用，副作用幾乎可以忽略
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