high altitude headache (HAH) 高海拔頭痛
ibuprofen 可用於治療 HAH, 劑量每次 600mg, 八小時吃一次.
2023年10月14日 星期六
野外與登山醫學 WMS 2024 指引更新-AMS/HACE治療選擇
2023-10-15 11:37AM
這篇僅節錄AMS/HACE治療選擇這幾段. 選項包括下面八項(並不是說一定有效)
下降 Descent
氧氣治療 Supplemental Oxygen
加壓艙 Portable Hyperbaric Chambers
丹木斯 Acetazolamide (下面內容有兒童使用劑量建議)
類固醇 Dexamethasone
普拿疼 Acetaminophen
止痛消炎藥物 普服芬/布洛芬 Ibuprofen
持續性正壓呼吸器 Continuous positive airway pressure (CPAP)
下面是原文
Treatment
Potential therapeutic options for AMS and HACE include:
Potential therapeutic options for AMS and HACE include:
Descent
下降多少海拔才能治療 AMS/HACE, 通常是下降 300~ 1000 公尺海拔. 但下降多少高度才有效還是因人而異.
Descent remains the single best treatment for AMS and HACE. However, it is not necessary in all circumstances (discussed further below). Individuals should descend until symptoms resolve, unless terrain, weather, or injuries make descent impossible. Symptoms typically resolve following descent of 300 to 1000 m, but the required altitude decrease varies between persons. Individuals should not descend alone, particularly if they are suffering from HACE.
Recommendation
We recommend that descent is effective for any degree of AMS/HACE and is indicated for individuals with severe AMS or HACE. Strong recommendation, high-quality evidence.
下降多少海拔才能治療 AMS/HACE, 通常是下降 300~ 1000 公尺海拔. 但下降多少高度才有效還是因人而異.
Descent remains the single best treatment for AMS and HACE. However, it is not necessary in all circumstances (discussed further below). Individuals should descend until symptoms resolve, unless terrain, weather, or injuries make descent impossible. Symptoms typically resolve following descent of 300 to 1000 m, but the required altitude decrease varies between persons. Individuals should not descend alone, particularly if they are suffering from HACE.
Recommendation
We recommend that descent is effective for any degree of AMS/HACE and is indicated for individuals with severe AMS or HACE. Strong recommendation, high-quality evidence.
Supplemental Oxygen
使用氧氣治療, 將病患血氧濃度提升到超過 90% 即可. 低流量氧氣(每分鐘 1-2 公升)持續使用兩小時. 會比大流量氧氣使用幾分鐘更好. 因此不建議使用小型罐裝氧氣. 或短暫進入氧氣酒吧. 來預防 AMS
Oxygen delivered by a nasal cannula or mask at flow rates sufficient to relieve symptoms provides a suitable alternative to descent. An SpO2 (oxygen saturation measured by pulse oximetry) of >90% is usually adequate. The 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 indicated but not feasible or during descent in severely ill individuals. Supplemental oxygen should be administered to target an SpO2 of >90% rather than a specific fraction of inspired oxygen (FIO2). This is because the inspired oxygen fraction varies significantly between oxygen delivery systems, including nasal cannulas, simple facemasks, Venturi masks, or nonrebreather masks. Use of low-flow oxygen (1–2 L/min) for ≥2 h has much greater benefit than short bursts (several minutes) of large amounts of oxygen. Short visits to oxygen bars or use of over-the-counter oxygen cannisters has never been studied for AMS treatment and should not be relied on for this purpose.
Recommendation
We recommend that, when available, ongoing supplemental oxygen sufficient to raise SpO2 to >90% or relieve symptoms can be used while waiting to initiate descent or when descent is not practical. Strong recommendation, high-quality evidence.
使用氧氣治療, 將病患血氧濃度提升到超過 90% 即可. 低流量氧氣(每分鐘 1-2 公升)持續使用兩小時. 會比大流量氧氣使用幾分鐘更好. 因此不建議使用小型罐裝氧氣. 或短暫進入氧氣酒吧. 來預防 AMS
Oxygen delivered by a nasal cannula or mask at flow rates sufficient to relieve symptoms provides a suitable alternative to descent. An SpO2 (oxygen saturation measured by pulse oximetry) of >90% is usually adequate. The 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 indicated but not feasible or during descent in severely ill individuals. Supplemental oxygen should be administered to target an SpO2 of >90% rather than a specific fraction of inspired oxygen (FIO2). This is because the inspired oxygen fraction varies significantly between oxygen delivery systems, including nasal cannulas, simple facemasks, Venturi masks, or nonrebreather masks. Use of low-flow oxygen (1–2 L/min) for ≥2 h has much greater benefit than short bursts (several minutes) of large amounts of oxygen. Short visits to oxygen bars or use of over-the-counter oxygen cannisters has never been studied for AMS treatment and should not be relied on for this purpose.
Recommendation
We recommend that, when available, ongoing supplemental oxygen sufficient to raise SpO2 to >90% or relieve symptoms can be used while waiting to initiate descent or when descent is not practical. Strong recommendation, high-quality evidence.
Portable Hyperbaric Chambers
加壓艙能有效的治療高海拔疾病. 但需要有人持續監視患者. 但很難用在有幽閉空間恐懼症或嘔吐患者. 且患者離開加壓艙症狀可能會再發, 但以上種種情況並不代表不能使用加壓艙
以前的使用經驗發現, 病懨懨的患者經過加壓艙治療, 大多數都能緩解病情, 因此病患能自己照顧自己(脫離加壓艙), 能進行下降, 但不要因為想使用加壓艙, 反而耽誤最重要的治療"下降"
以前的使用經驗發現, 病懨懨的患者經過加壓艙治療, 大多數都能緩解病情, 因此病患能自己照顧自己(脫離加壓艙), 能進行下降, 但不要因為想使用加壓艙, 反而耽誤最重要的治療"下降"
Portable hyperbaric chambers are effective for treating severe altitude illness but require constant tending by care providers and are difficult to use with patients who are claustrophobic or vomiting. Symptoms may recur when individuals are removed from the chamber, but this should not preclude use of the chamber when indicated. In many cases, ill individuals may improve sufficiently to assist with their evacuation and descent once symptoms improve. Use of a portable hyperbaric chamber should not delay descent in situations where descent is required.
Recommendation
We recommend that, when available, portable hyperbaric chambers should be used for patients with severe AMS or HACE when descent is not feasible or must be delayed and supplemental oxygen is not available. Strong recommendation, moderate-quality evidence.
Recommendation
We recommend that, when available, portable hyperbaric chambers should be used for patients with severe AMS or HACE when descent is not feasible or must be delayed and supplemental oxygen is not available. Strong recommendation, moderate-quality evidence.
Acetazolamide
發生AMS的兒童使用丹木斯治療. 每次最大劑量 250mg. 每12小時吃一次.
發生AMS的兒童使用丹木斯治療. 每次最大劑量 250mg. 每12小時吃一次.
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 not known. 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
We recommend that acetazolamide be considered for treatment of AMS. Strong recommendation, low-quality evidence.
Recommendation
We recommend that acetazolamide be considered for treatment of AMS. Strong recommendation, low-quality evidence.
Dexamethasone
Dexamethasone is very effective for treating AMS.The medication does not facilitate acclimatization, so further ascent should be delayed until the patient is asymptomatic without 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 (intramuscular, IV, or oral administration), followed by 4 mg every 6 h until symptoms resolve. The pediatric dose is 0.15 mg·kg−1·dose−1 every 6 h.
Recommendation
We recommend that dexamethasone be considered for treatment of AMS. Strong recommendation, low-quality evidence.
Recommendation
We recommend that dexamethasone be administered for treatment of HACE. Strong recommendation, low-quality evidence.
Dexamethasone is very effective for treating AMS.The medication does not facilitate acclimatization, so further ascent should be delayed until the patient is asymptomatic without 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 (intramuscular, IV, or oral administration), followed by 4 mg every 6 h until symptoms resolve. The pediatric dose is 0.15 mg·kg−1·dose−1 every 6 h.
Recommendation
We recommend that dexamethasone be considered for treatment of AMS. Strong recommendation, low-quality evidence.
Recommendation
We recommend that dexamethasone be administered for treatment of HACE. Strong recommendation, low-quality evidence.
Acetaminophen
Acetaminophen has been shown to relieve headache at high altitude
106 but has not been shown to improve the full spectrum of AMS symptoms or effectively treat HACE.
Recommendation
We recommend that acetaminophen can be used to treat headache at high altitude. Strong recommendation, low-quality evidence.
Acetaminophen has been shown to relieve headache at high altitude
106 but has not been shown to improve the full spectrum of AMS symptoms or effectively treat HACE.
Recommendation
We recommend that acetaminophen can be used to treat headache at high altitude. Strong recommendation, low-quality evidence.
Ibuprofen
Ibuprofen has been shown to relieve headache at high altitude but has not been shown to improve the full spectrum of AMS symptoms or effectively treat HACE.
Ibuprofen has been shown to relieve headache at high altitude but has not been shown to improve the full spectrum of AMS symptoms or effectively treat HACE.
Recommendation
We recommend that ibuprofen can be used to treat headache at high altitude. Strong recommendation, low-quality evidence.
We recommend that ibuprofen can be used to treat headache at high altitude. Strong recommendation, low-quality evidence.
Continuous Positive Airway Pressure
Continuous positive airway pressure (CPAP) carries theoretical benefit in acute altitude illness by virtue of its ability to increase the arterial partial pressure of oxygen (PO2). This impact is not due to increases in barometric pressure, as application of 15 cm H2O of CPAP, for example, yields only an 11 mm Hg increase in barometric pressure. Instead, 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,
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
No recommendation can be made regarding use of CPAP for AMS treatment because of lack of data.
Continuous positive airway pressure (CPAP) carries theoretical benefit in acute altitude illness by virtue of its ability to increase the arterial partial pressure of oxygen (PO2). This impact is not due to increases in barometric pressure, as application of 15 cm H2O of CPAP, for example, yields only an 11 mm Hg increase in barometric pressure. Instead, 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,
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
No recommendation can be made regarding use of CPAP for AMS treatment because of lack of data.
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野外與登山醫學 - WHAT DEFINES HIGH ALTITUDE?
本來是想要查詢. 不同高度的大氣組成比例是否不變. 剛好看到這一篇. 就順手貼上來
答案: 大氣的氧氣組成比例. 從地面至100公里(10萬公尺)是不太變動的, 但微量氣體(例如二氧化碳)的變動會比較大.
下面是用google的中文翻譯的. 原文連結請點下面一行字
高海拔的定義是什麼？
對於生理學家來說，高海拔是從 5000 英尺左右開始的，在這個高度，身體能夠感知到氧氣水平的變化，並開始透過增加呼吸來做出反應。科羅拉多州的滑雪勝地的海拔範圍從 6 至 9,000 英尺到接近 13,000 英尺，其中 54 座山峰海拔超過 14,000 英尺。
為什麼空氣中的氧氣較少？
隨著海拔的升高，大氣中的壓力會降低。實際上，所有海拔高度的氧氣百分比都是相同的，即 21%；然而，隨著數字的增加，這個數字會變小，達到 21%。海平面的氣壓為 760 毫米汞柱，10,000 英尺處的氣壓為 534 毫米汞柱。呼吸特柳賴德(滑雪勝地.,海拔2667公尺) 的空氣相當於呼吸海平面含氧量只有 15%（而非 21%）的空氣。最終結果是，與海平面相比，特柳賴德空氣中的氧氣含量減少了 29%。在 14,000 英尺的高度，空氣中的氧氣含量比海平面低 43%。由於高海拔地區氣壓降低，您吸入肺部的空氣量中含有較少的氧分子。
生理變化
您的身體必須適應較低的氧氣水平，這個調節過程稱為適應。在適應過程中，您的身體會發生許多變化。您會注意到的第一件事就是您呼吸得更快更深，以吸入更多氧氣。因此，您可能會在前 2-3 天感到氣短，尤其是在進行體力活動時。運動時出現一些氣短是正常現象。心率也會增加，以向組織提供更多含氧血液，這在最初幾天可能會很明顯；之後，它會下降到更正常的水平。排尿增多是對身體酸鹼平衡變化的反應，有助於您適應環境；這通常在第二天就很明顯。有些人的手、腳和臉部會出現輕微腫脹，但並不嚴重。
睡眠障礙
在高海拔地區，睡眠困難很常見。低氧直接影響大腦的睡眠中樞。頻繁起床、睡眠淺和睡眠總時間少是主要問題，這些問題通常會在幾個晚上後適應環境後得到改善。然而，有些人儘管適應了環境，仍會出現睡眠困難。
什麼是睡眠期間的週期性呼吸？
這種會導致睡眠困難的情況經常發生，但與高原病無關。它是睡眠期間身體內部對呼吸控制進行鬥爭的結果。體內的氧氣感知器命令大腦增加呼吸，導致肺部排出二氧化碳。但體內的二氧化碳感測器會告訴大腦停止呼吸，因為二氧化碳濃度太低了。因此呼吸會停止大約 12 秒，直到氧氣感知器再次接管。結果是呼吸不規律，大約有 4 次大呼吸，然後就沒有呼吸。第一次大呼吸有時會讓人醒來，有一種呼吸困難或窒息的感覺。這種模式也可能持續一整天，但通常在夜間最令人不安，因為它經常多次吵醒人。雖然不舒服，但並不危險。睡前服用小劑量 Diamox®（62.5 或 125 毫克）即可輕鬆治療；這可以使呼吸順暢，改善睡眠並提高血氧水平。
我可以服用什麼來幫助我入睡？如果您因週期性呼吸而睡眠不好，Diamox®應該是改善睡眠的首選藥物。
一般應避免使用苯二氮平類藥物，如替馬西泮(Restoril®)、勞拉西泮(Ativan®)、地西泮(Valium®) 和阿普扎崙(Xanax®)，因為它們會降低呼吸動力，尤其是與酒精合用時。唑吡坦 (Ambien®) 和艾司佐匹克隆 (Lunesta®) 等安眠藥物在高海拔地區是安全的，似乎效果良好，不會影響呼吸動力。
有些人使用非處方助眠劑，例如 Tylenol PM®，其中含有 Benadryl®（一種抗組織胺）。抗組織胺尚未被證明會影響呼吸，可以安全服用。
如果您服用曲扎酮用於睡眠，沒有證據表明它會降低呼吸動力，並且在高海拔地區可能是安全的。
如果您患有阻塞性睡眠呼吸中止症 (OSA)，這可能會使您在高海拔地區的睡眠症狀惡化。如果您在睡眠時使用 CPAP（持續性正壓呼吸器），則應確保在高海拔地區使用它。
鍛鍊
由於工作肌肉可用的氧氣較少，因此在高海拔地區運動表現會下降。例如，在高海拔地區跑一英里的速度不可能像在低海拔地區一樣快。這適用於任何有氧運動，即任何持續超過兩分鐘的肌肉活動。此外，人們不能期望以與低海拔地區相同的強度進行比賽，並且必須相應地調整步伐。這意味著在高海拔地區跑步、騎自行車或步行要慢一些，並多休息和休息，以避免疲憊。對於那些追蹤最大攝氧量（身體表現的整體衡量標準）的人來說：從海拔 5000 英尺左右開始，每增加 1000 英尺，最大攝氧量就會下降 3%。
高海拔的定義是什麼？
對於生理學家來說，高海拔是從 5000 英尺左右開始的，在這個高度，身體能夠感知到氧氣水平的變化，並開始透過增加呼吸來做出反應。科羅拉多州的滑雪勝地的海拔範圍從 6 至 9,000 英尺到接近 13,000 英尺，其中 54 座山峰海拔超過 14,000 英尺。
為什麼空氣中的氧氣較少？
隨著海拔的升高，大氣中的壓力會降低。實際上，所有海拔高度的氧氣百分比都是相同的，即 21%；然而，隨著數字的增加，這個數字會變小，達到 21%。海平面的氣壓為 760 毫米汞柱，10,000 英尺處的氣壓為 534 毫米汞柱。呼吸特柳賴德(滑雪勝地.,海拔2667公尺) 的空氣相當於呼吸海平面含氧量只有 15%（而非 21%）的空氣。最終結果是，與海平面相比，特柳賴德空氣中的氧氣含量減少了 29%。在 14,000 英尺的高度，空氣中的氧氣含量比海平面低 43%。由於高海拔地區氣壓降低，您吸入肺部的空氣量中含有較少的氧分子。
生理變化
您的身體必須適應較低的氧氣水平，這個調節過程稱為適應。在適應過程中，您的身體會發生許多變化。您會注意到的第一件事就是您呼吸得更快更深，以吸入更多氧氣。因此，您可能會在前 2-3 天感到氣短，尤其是在進行體力活動時。運動時出現一些氣短是正常現象。心率也會增加，以向組織提供更多含氧血液，這在最初幾天可能會很明顯；之後，它會下降到更正常的水平。排尿增多是對身體酸鹼平衡變化的反應，有助於您適應環境；這通常在第二天就很明顯。有些人的手、腳和臉部會出現輕微腫脹，但並不嚴重。
睡眠障礙
在高海拔地區，睡眠困難很常見。低氧直接影響大腦的睡眠中樞。頻繁起床、睡眠淺和睡眠總時間少是主要問題，這些問題通常會在幾個晚上後適應環境後得到改善。然而，有些人儘管適應了環境，仍會出現睡眠困難。
什麼是睡眠期間的週期性呼吸？
這種會導致睡眠困難的情況經常發生，但與高原病無關。它是睡眠期間身體內部對呼吸控制進行鬥爭的結果。體內的氧氣感知器命令大腦增加呼吸，導致肺部排出二氧化碳。但體內的二氧化碳感測器會告訴大腦停止呼吸，因為二氧化碳濃度太低了。因此呼吸會停止大約 12 秒，直到氧氣感知器再次接管。結果是呼吸不規律，大約有 4 次大呼吸，然後就沒有呼吸。第一次大呼吸有時會讓人醒來，有一種呼吸困難或窒息的感覺。這種模式也可能持續一整天，但通常在夜間最令人不安，因為它經常多次吵醒人。雖然不舒服，但並不危險。睡前服用小劑量 Diamox®（62.5 或 125 毫克）即可輕鬆治療；這可以使呼吸順暢，改善睡眠並提高血氧水平。
我可以服用什麼來幫助我入睡？如果您因週期性呼吸而睡眠不好，Diamox®應該是改善睡眠的首選藥物。
一般應避免使用苯二氮平類藥物，如替馬西泮(Restoril®)、勞拉西泮(Ativan®)、地西泮(Valium®) 和阿普扎崙(Xanax®)，因為它們會降低呼吸動力，尤其是與酒精合用時。唑吡坦 (Ambien®) 和艾司佐匹克隆 (Lunesta®) 等安眠藥物在高海拔地區是安全的，似乎效果良好，不會影響呼吸動力。
有些人使用非處方助眠劑，例如 Tylenol PM®，其中含有 Benadryl®（一種抗組織胺）。抗組織胺尚未被證明會影響呼吸，可以安全服用。
如果您服用曲扎酮用於睡眠，沒有證據表明它會降低呼吸動力，並且在高海拔地區可能是安全的。
如果您患有阻塞性睡眠呼吸中止症 (OSA)，這可能會使您在高海拔地區的睡眠症狀惡化。如果您在睡眠時使用 CPAP（持續性正壓呼吸器），則應確保在高海拔地區使用它。
鍛鍊
由於工作肌肉可用的氧氣較少，因此在高海拔地區運動表現會下降。例如，在高海拔地區跑一英里的速度不可能像在低海拔地區一樣快。這適用於任何有氧運動，即任何持續超過兩分鐘的肌肉活動。此外，人們不能期望以與低海拔地區相同的強度進行比賽，並且必須相應地調整步伐。這意味著在高海拔地區跑步、騎自行車或步行要慢一些，並多休息和休息，以避免疲憊。對於那些追蹤最大攝氧量（身體表現的整體衡量標準）的人來說：從海拔 5000 英尺左右開始，每增加 1000 英尺，最大攝氧量就會下降 3%。
野外與登山醫學-高海拔肺水腫 HAPE 診斷 from uptodate/ CDC
2024-05-29
大多數受害者均可偵測到囉音。脈搏血氧儀可以幫助診斷； HAPE 患者的氧飽和度水準比相同海拔的健康人低至少 10 個百分點。 50%–70% 的氧飽和度值很常見。 HAPE 的鑑別診斷包括支氣管痙攣、心肌梗塞、肺炎和肺栓塞。
High-Altitude Pulmonary Edema
HAPE can occur by itself or in conjunction with AMS and HACE; incidence is roughly 1 per 10,000 skiers in Colorado, and ≤1 per 100 climbers at >14,000 ft (≈4,300 m).
Diagnosis
Early diagnosis is key; HAPE can be more rapidly fatal than HACE. Initial symptoms include chest congestion, cough, exaggerated dyspnea on exertion, and decreased exercise performance. If unrecognized and untreated, HAPE progresses to dyspnea at rest and frank respiratory distress, often with bloody sputum. This typical progression over 1–2 days is easily recognizable as HAPE, but the condition sometimes presents only as central nervous system dysfunction, with confusion and drowsiness.
Rales are detectable in most victims. Pulse oximetry can aid in making the diagnosis; oxygen saturation levels will be at least 10 points lower in HAPE patients than in healthy people at the same elevation. Oxygen saturation values of 50%–70% are common. The differential diagnosis for HAPE includes bronchospasm, myocardial infarction, pneumonia, and pulmonary embolism.
美國疾管局2024年黃皮書-關於高海拔疾病-HAPE的段落
(註. HAPE 和 HACE 死亡率到底哪個高?)
診斷
早期診斷是關鍵； HAPE 比 HACE 更容易致命。最初的症狀包括胸悶、咳嗽、運動時呼吸困難、運動能力下降。如果未被識別和治療，HAPE 會發展為休息時呼吸困難和明顯的呼吸窘迫，通常伴隨血痰。這種持續 1-2 天的典型進展很容易被識別為 HAPE，但這種情況有時僅表現為中樞神經系統功能障礙，伴隨意識模糊和嗜睡。
高海拔肺水腫
HAPE可以單獨發生，也可以與AMS和HACE同時發生；在科羅拉多州，發生率約為每 10,000 名滑雪者中 1 例，在 >14,000 英尺（約 4,300 m）處，每 100 名登山者中≤1 例。(註. HAPE 和 HACE 死亡率到底哪個高?)
診斷
早期診斷是關鍵； HAPE 比 HACE 更容易致命。最初的症狀包括胸悶、咳嗽、運動時呼吸困難、運動能力下降。如果未被識別和治療，HAPE 會發展為休息時呼吸困難和明顯的呼吸窘迫，通常伴隨血痰。這種持續 1-2 天的典型進展很容易被識別為 HAPE，但這種情況有時僅表現為中樞神經系統功能障礙，伴隨意識模糊和嗜睡。
大多數受害者均可偵測到囉音。脈搏血氧儀可以幫助診斷； HAPE 患者的氧飽和度水準比相同海拔的健康人低至少 10 個百分點。 50%–70% 的氧飽和度值很常見。 HAPE 的鑑別診斷包括支氣管痙攣、心肌梗塞、肺炎和肺栓塞。
High-Altitude Pulmonary Edema
HAPE can occur by itself or in conjunction with AMS and HACE; incidence is roughly 1 per 10,000 skiers in Colorado, and ≤1 per 100 climbers at >14,000 ft (≈4,300 m).
Diagnosis
Early diagnosis is key; HAPE can be more rapidly fatal than HACE. Initial symptoms include chest congestion, cough, exaggerated dyspnea on exertion, and decreased exercise performance. If unrecognized and untreated, HAPE progresses to dyspnea at rest and frank respiratory distress, often with bloody sputum. This typical progression over 1–2 days is easily recognizable as HAPE, but the condition sometimes presents only as central nervous system dysfunction, with confusion and drowsiness.
Rales are detectable in most victims. Pulse oximetry can aid in making the diagnosis; oxygen saturation levels will be at least 10 points lower in HAPE patients than in healthy people at the same elevation. Oxygen saturation values of 50%–70% are common. The differential diagnosis for HAPE includes bronchospasm, myocardial infarction, pneumonia, and pulmonary embolism.
2023-10-25 16:50
2012年台灣CDC高山症簡介有一張表格. 年代雖然久遠, 排版雖然有瑕疵. 但還是值得參考
(最後更新日期 2012/10/1)
The Lake Louise AMS Score Consensus Committee是定義 AMS 診斷標準. 而非 HACE/HAPE診斷標準.
2023-10-15 09:39AM
High-altitude pulmonary edema from uptodate
僅節錄診斷標準和影像檢查
1. HAPE 主要是臨床診斷(不需要抽血或影像檢查就可以診斷)
2. 通常發生在抵達高海拔 2-4 天出現(也有文獻說五天)
3. 症狀: 初期是乾咳. 呼吸急促. 運動時出現呼吸困難. 兒童的症狀可能會比成人更快出現
一兩天後開始出現咳嗽帶痰, 休息狀態仍呈現呼吸困難.
身體檢查主要異常: 心跳加速. 呼吸急促, 發燒(體溫 38度C), 肺部溼囉音
特定海拔的氧氣濃度低於預期值. 給予氧氣治療和休息會迅速改善.
4. 影像檢查可以幫助確診(但非必要)(包括x光,超音波,斷層等等)
HAPE 影像檢查與肺炎不同之處, HAPE影像看起來很嚴重, 但病患可能症狀沒有預期的那麼嚴重, 吸氧氣之後會迅速改善.
相反的. 一般肺炎患者, 如果x光片看到嚴重異常, 往往代表是病患病情比較嚴重, 病患會病懨懨的. 經過氧氣及其他治療, 通常無法快速改善. 常常會需要插管使用呼吸器.
google中文翻譯
診斷
HAPE 通常根據病史和檢查結果進行臨床診斷。最初的症狀通常在到達高海拔後兩到四天開始出現，包括輕微的乾咳、用力時呼吸急促以及上坡困難。兒童的症狀可能發展得更快。一到兩天后，咳嗽通常會變得有痰。從勞力性呼吸困難到休息時呼吸困難的早期進展是一個主要特徵。主要檢查結果包括心跳過速、呼吸急促、低燒（高達 38°C）和肺部濕囉音。在給定海拔高度下的氧飽和度低於預期。補充氧氣和休息治療可以使病情迅速改善。影像學檢查的特徵性發現（如果有且有指示）有助於確診。
DIAGNOSIS
HAPE is typically diagnosed clinically on the basis of the history and examination findings. The initial symptoms typically begin two to four days after arrival at high altitude and include a subtle nonproductive cough, shortness of breath on exertion, and difficulty walking uphill. Symptoms can develop more precipitously in children. Over one to two days, the cough often becomes productive. Early progression from dyspnea with exertion to dyspnea at rest is a cardinal feature. Prominent examination findings include tachycardia, tachypnea, low-grade fever (up to 38°C), and pulmonary crackles. Oxygen saturation is lower than expected for a given altitude. Treatment with supplemental oxygen and rest can lead to rapid improvement. Characteristic findings on imaging studies, when available and indicated, help to confirm the diagnosis.
google 中文翻譯
影像學研究
X 光平片、電腦斷層掃描和超音波心動圖 — 與急性高山症和高原腦水腫 (HACE) 一樣，HAPE 的診斷是基於病史和身體檢查。然而，胸部X光檢查是有用的，可以顯示特徵性的斑塊狀肺泡浸潤，主要是在右半胸中部，隨著疾病的進展，這些浸潤變得更加融合和雙側（圖1 ）。然而，在某些情況下，浸潤可能會從左肺開始[ 16 ]。很少見，水腫完全是單側的，即使很嚴重，這表明肺動脈發育不全或阻塞[ 17 ]。
儘管 HAPE 的放射學表現可能與感染性浸潤相似，但我們經常發現放射照片上的廣泛浸潤與患者的臨床狀態之間存在顯著差異。HAPE 患者的病情通常並不像根據 X 光檢查結果所預期的那樣嚴重，並且透過氧氣治療穩步改善。相較之下，因肺炎而出現類似胸部X光的患者通常病情危重，通常需要氣管插管和使用呼吸器機械通氣。
胸部電腦斷層掃描 (CT) 雖然很少顯示，但顯示出斑狀小葉磨玻璃樣外觀和實性混濁，反映了不均勻的肺泡充盈（圖 2 ）。心臟超音波顯示肺動脈壓力增加，有時會出現右心功能障礙和矛盾的室間隔運動[ 1,2 ]。
IMAGING STUDIES from uptodate
Plain radiograph, computed tomography, and echocardiography — As with acute mountain sickness and high-altitude cerebral edema (HACE), the diagnosis of HAPE is based upon the history and physical examination. However, chest radiography is useful and reveals characteristic patchy alveolar infiltrates, predominantly in the right central hemithorax, which become more confluent and bilateral as the illness progresses (image 1). However, in some cases, the infiltrates may start in the left lung [16]. Rarely, the edema is entirely unilateral even when severe, which suggests a pulmonary artery agenesis or obstruction [17].
Although the radiographic appearance of HAPE may mimic that of infectious infiltrates, we often find a significant discrepancy between the extensive infiltrates on radiograph and the patient's clinical status. The patient with HAPE often does not appear as severely ill as one would expect based on the radiograph findings and steadily improves with oxygen therapy. In contrast, a patient with a comparable chest radiograph due to pneumonia typically appears critically ill and often requires tracheal intubation and mechanical ventilation.
Computed tomography (CT) of the chest, while rarely indicated, reveals a patchy lobular ground-glass appearance and consolidative opacities, reflecting heterogeneous alveolar filling (image 2). Echocardiography reveals increased pulmonary artery pressure and sometimes right heart dysfunction and paradoxical septal motion [1,2].
另一篇參考資料 High Altitude Pulmonary Edema
Jacob D. Jensen; Andrew L. Vincent. Last Update: July 17, 2023.
節錄其中一段. 評估
裡面提到了. HAPE臨床診斷包括至少兩種症狀或主訴. 理學檢查(PE 身體檢查)有兩項異常. 而x光檢查會有以下異常發現: 肺葉浸潤. 中膈腔及心臟大小通常正常.
超音波可以看到 B lines
心電圖可能呈現 RAD或缺血變化
在X光出現浸潤的患者. 給予補充氧氣治療能快速緩解症狀. 是HAPE的病理性特徵
(其他原因引起的肺水腫通常不會這麼戲劇性改善)
(臨床診斷是指不需要照x光的情況. 根據病患症狀與身體檢查發現作診斷)
(需抽血或做影像檢查或做其他檢驗才能診斷的. 稱為實驗室診斷. 例如急性心肌梗塞的診斷)
下面是google中文翻譯.
評估
HAPE 的臨床診斷將包括以下至少兩種症狀或主訴：胸悶或疼痛、咳嗽、休息時呼吸困難以及運動耐受性下降。它還會有以下兩項檢查結果：中樞性紫紺、囉音/喘息、心跳過速和呼吸急促。如果有的話，CXR 可能顯示斑狀肺泡浸潤，縱膈/心臟大小正常，超音波可能顯示與肺水腫一致的 B 光。心電圖可能顯示電軸右偏和/或缺血的跡象。對於 CXR 上有浸潤的患者，透過補充氧氣快速糾正臨床狀態和 SpO2 是 HAPE 的特徵。即使可用，實驗室的效用也有限，臨床醫生應始終考慮伴隨的 AMS 和/或 HACE。
Evaluation
HAPE's clinical diagnosis would include at least two of the following symptoms or complaints: chest tightness or pain, cough, dyspnea at rest, and decreased exercise tolerance. It also would have two of the following exam findings: central cyanosis, rales/wheezes, tachycardia, and tachypnea. If available, CXR may show patchy alveolar infiltrates with normal-sized mediastinum/heart, and ultrasound may show B-lines consistent with pulmonary edema. ECG may show signs of right axis deviation and/or ischemia. In a patient with infiltrates on CXR, rapid correction of clinical status and SpO2 with supplemental oxygen is pathognomonic of HAPE. Even if available, labs are of limited utility, and the clinician should always consider concomitant AMS and/or HACE.
(最後更新日期 2012/10/1)
The Lake Louise AMS Score Consensus Committee是定義 AMS 診斷標準. 而非 HACE/HAPE診斷標準.
2023-10-15 09:39AM
High-altitude pulmonary edema from uptodate
僅節錄診斷標準和影像檢查
1. HAPE 主要是臨床診斷(不需要抽血或影像檢查就可以診斷)
2. 通常發生在抵達高海拔 2-4 天出現(也有文獻說五天)
3. 症狀: 初期是乾咳. 呼吸急促. 運動時出現呼吸困難. 兒童的症狀可能會比成人更快出現
一兩天後開始出現咳嗽帶痰, 休息狀態仍呈現呼吸困難.
身體檢查主要異常: 心跳加速. 呼吸急促, 發燒(體溫 38度C), 肺部溼囉音
特定海拔的氧氣濃度低於預期值. 給予氧氣治療和休息會迅速改善.
4. 影像檢查可以幫助確診(但非必要)(包括x光,超音波,斷層等等)
HAPE 影像檢查與肺炎不同之處, HAPE影像看起來很嚴重, 但病患可能症狀沒有預期的那麼嚴重, 吸氧氣之後會迅速改善.
相反的. 一般肺炎患者, 如果x光片看到嚴重異常, 往往代表是病患病情比較嚴重, 病患會病懨懨的. 經過氧氣及其他治療, 通常無法快速改善. 常常會需要插管使用呼吸器.
google中文翻譯
診斷
HAPE 通常根據病史和檢查結果進行臨床診斷。最初的症狀通常在到達高海拔後兩到四天開始出現，包括輕微的乾咳、用力時呼吸急促以及上坡困難。兒童的症狀可能發展得更快。一到兩天后，咳嗽通常會變得有痰。從勞力性呼吸困難到休息時呼吸困難的早期進展是一個主要特徵。主要檢查結果包括心跳過速、呼吸急促、低燒（高達 38°C）和肺部濕囉音。在給定海拔高度下的氧飽和度低於預期。補充氧氣和休息治療可以使病情迅速改善。影像學檢查的特徵性發現（如果有且有指示）有助於確診。
DIAGNOSIS
HAPE is typically diagnosed clinically on the basis of the history and examination findings. The initial symptoms typically begin two to four days after arrival at high altitude and include a subtle nonproductive cough, shortness of breath on exertion, and difficulty walking uphill. Symptoms can develop more precipitously in children. Over one to two days, the cough often becomes productive. Early progression from dyspnea with exertion to dyspnea at rest is a cardinal feature. Prominent examination findings include tachycardia, tachypnea, low-grade fever (up to 38°C), and pulmonary crackles. Oxygen saturation is lower than expected for a given altitude. Treatment with supplemental oxygen and rest can lead to rapid improvement. Characteristic findings on imaging studies, when available and indicated, help to confirm the diagnosis.
google 中文翻譯
影像學研究
X 光平片、電腦斷層掃描和超音波心動圖 — 與急性高山症和高原腦水腫 (HACE) 一樣，HAPE 的診斷是基於病史和身體檢查。然而，胸部X光檢查是有用的，可以顯示特徵性的斑塊狀肺泡浸潤，主要是在右半胸中部，隨著疾病的進展，這些浸潤變得更加融合和雙側（圖1 ）。然而，在某些情況下，浸潤可能會從左肺開始[ 16 ]。很少見，水腫完全是單側的，即使很嚴重，這表明肺動脈發育不全或阻塞[ 17 ]。
儘管 HAPE 的放射學表現可能與感染性浸潤相似，但我們經常發現放射照片上的廣泛浸潤與患者的臨床狀態之間存在顯著差異。HAPE 患者的病情通常並不像根據 X 光檢查結果所預期的那樣嚴重，並且透過氧氣治療穩步改善。相較之下，因肺炎而出現類似胸部X光的患者通常病情危重，通常需要氣管插管和使用呼吸器機械通氣。
胸部電腦斷層掃描 (CT) 雖然很少顯示，但顯示出斑狀小葉磨玻璃樣外觀和實性混濁，反映了不均勻的肺泡充盈（圖 2 ）。心臟超音波顯示肺動脈壓力增加，有時會出現右心功能障礙和矛盾的室間隔運動[ 1,2 ]。
IMAGING STUDIES from uptodate
Plain radiograph, computed tomography, and echocardiography — As with acute mountain sickness and high-altitude cerebral edema (HACE), the diagnosis of HAPE is based upon the history and physical examination. However, chest radiography is useful and reveals characteristic patchy alveolar infiltrates, predominantly in the right central hemithorax, which become more confluent and bilateral as the illness progresses (image 1). However, in some cases, the infiltrates may start in the left lung [16]. Rarely, the edema is entirely unilateral even when severe, which suggests a pulmonary artery agenesis or obstruction [17].
Although the radiographic appearance of HAPE may mimic that of infectious infiltrates, we often find a significant discrepancy between the extensive infiltrates on radiograph and the patient's clinical status. The patient with HAPE often does not appear as severely ill as one would expect based on the radiograph findings and steadily improves with oxygen therapy. In contrast, a patient with a comparable chest radiograph due to pneumonia typically appears critically ill and often requires tracheal intubation and mechanical ventilation.
Computed tomography (CT) of the chest, while rarely indicated, reveals a patchy lobular ground-glass appearance and consolidative opacities, reflecting heterogeneous alveolar filling (image 2). Echocardiography reveals increased pulmonary artery pressure and sometimes right heart dysfunction and paradoxical septal motion [1,2].
另一篇參考資料 High Altitude Pulmonary Edema
Jacob D. Jensen; Andrew L. Vincent. Last Update: July 17, 2023.
節錄其中一段. 評估
裡面提到了. HAPE臨床診斷包括至少兩種症狀或主訴. 理學檢查(PE 身體檢查)有兩項異常. 而x光檢查會有以下異常發現: 肺葉浸潤. 中膈腔及心臟大小通常正常.
超音波可以看到 B lines
心電圖可能呈現 RAD或缺血變化
在X光出現浸潤的患者. 給予補充氧氣治療能快速緩解症狀. 是HAPE的病理性特徵
(其他原因引起的肺水腫通常不會這麼戲劇性改善)
(臨床診斷是指不需要照x光的情況. 根據病患症狀與身體檢查發現作診斷)
(需抽血或做影像檢查或做其他檢驗才能診斷的. 稱為實驗室診斷. 例如急性心肌梗塞的診斷)
下面是google中文翻譯.
評估
HAPE 的臨床診斷將包括以下至少兩種症狀或主訴：胸悶或疼痛、咳嗽、休息時呼吸困難以及運動耐受性下降。它還會有以下兩項檢查結果：中樞性紫紺、囉音/喘息、心跳過速和呼吸急促。如果有的話，CXR 可能顯示斑狀肺泡浸潤，縱膈/心臟大小正常，超音波可能顯示與肺水腫一致的 B 光。心電圖可能顯示電軸右偏和/或缺血的跡象。對於 CXR 上有浸潤的患者，透過補充氧氣快速糾正臨床狀態和 SpO2 是 HAPE 的特徵。即使可用，實驗室的效用也有限，臨床醫生應始終考慮伴隨的 AMS 和/或 HACE。
Evaluation
HAPE's clinical diagnosis would include at least two of the following symptoms or complaints: chest tightness or pain, cough, dyspnea at rest, and decreased exercise tolerance. It also would have two of the following exam findings: central cyanosis, rales/wheezes, tachycardia, and tachypnea. If available, CXR may show patchy alveolar infiltrates with normal-sized mediastinum/heart, and ultrasound may show B-lines consistent with pulmonary edema. ECG may show signs of right axis deviation and/or ischemia. In a patient with infiltrates on CXR, rapid correction of clinical status and SpO2 with supplemental oxygen is pathognomonic of HAPE. Even if available, labs are of limited utility, and the clinician should always consider concomitant AMS and/or HACE.
野外與登山醫學-Objective criteria for diagnosing high altitude pulmonary edema in acclimatized patients at altitudes between 2700 m and 3500 m
這篇是印度武裝部隊期刊的文章. 中文的部分先使用google翻譯.
Objective criteria for diagnosing high altitude pulmonary edema in acclimatized patients at altitudes between 2700 m and 3500 m
回到實際面. 每100個病人. 有17 個會被誤診. 這項參數你要不要賭一把.
Objective criteria for diagnosing high altitude pulmonary edema in acclimatized patients at altitudes between 2700 m and 3500 m
摘要(下面這段是我寫的)
1. 研究對象是在 2700-3500公尺的印度士兵.
2. 發病時間 2-3 天 (2.8 ± 2.2) (0.6~~5天)
1. 研究對象是在 2700-3500公尺的印度士兵.
2. 發病時間 2-3 天 (2.8 ± 2.2) (0.6~~5天)
3. 當血氧濃度高於該海拔正常值. 仍有可能發生高海拔肺水腫
4. 敏感度= 符合設定條件時, 能診斷出高海拔肺水腫的機率
特異性=不符合設定條件時, 真的沒生病的機率
4. 敏感度= 符合設定條件時, 能診斷出高海拔肺水腫的機率
特異性=不符合設定條件時, 真的沒生病的機率
心率超過每分鐘 95 次 (bpm)-- 敏感度0.66 特異性0.83
呼吸頻率超過每分鐘 21 次-- 敏感度0.82 特異性0.94
SPO2 低於 86%-- 敏感度0.95 特異性0.93
舉例. 現在有個遊客. 當他出現類似高海拔反應的症狀時, 心跳是每分鐘85次(低於我們設定的數值 95 bpm). 那麼有 83% 的機率. 他不是高海拔疾病(這裡指高海拔肺水腫).
回到實際面. 每100個病人. 有17 個會被誤診. 這項參數你要不要賭一把.
在臨床醫師的觀點. 當一個非常可能致死的疾病出現. 我會希望能將所有可能的病例都找出來. 這個稱為敏感度. 但敏感度越高的指標. 往往會伴隨沒事卻被判定生病的機率上升. 心率超過 95 bpm 並不是很理想的數值.
臨床醫師最喜歡的參數. 是敏感度和特異性都很高的. 在這篇研究, 血氧濃度是不錯的參數
(但過去有其他研究證實, 血氧濃度沒這麼好的鑑別診斷力. 或許可能是研究樣本差異造成. 例如種族. 性別, 年齡. 當地氣候條件等等 )
(下面是google翻譯的)
背景
用於診斷高原疾病的標準主要基於西方文獻。本研究旨在為海拔 2700 m 至 3500 m 之間的印度士兵制定客觀、簡單且可靠的高原肺水腫 (HAPE) 診斷標準。
方法
對235例2700~3500m海拔高度HAPE患者的臨床資料進行分析。採用受試者工作特徵（ROC）曲線分析來選擇適合週邊醫療機構HAPE診斷的簡單臨床參數。定義了 HAPE 診斷的臨界值及其可靠性。
結果
HAPE 發生在到達海拔 2700 m 至 3500 m 之間後 2.8 ± 2.2 天。呼吸困難、咳嗽、胸部不適和頭痛是最常見的症狀。 89% 的患者發現脈搏血氧飽和度 (SPO2) 值低於該海拔的正常值。臨床參數的 ROC 分析確定，在該海拔高度呼吸環境空氣時，心率超過每分鐘 95 次 (bpm)、呼吸頻率超過每分鐘 21 次、SPO2 低於 86%，作為 HAPE 的診斷。這些臨界值的敏感度和特異性分別為 0.66、0.83 和 0.82 以及 0.94、0.95 和 0.93。
結論
在抵達海拔 2700 公尺之間的頭 5 天內，主訴呼吸困難、咳嗽、胸部不適或頭痛的個體心率超過 95 bpm，呼吸頻率超過每分鐘 21 次，SPO2 低於呼吸室內空氣的 86% 3500 m 高度提示HAPE。
關鍵字：高山症、肺水腫、ROC 曲線
簡介
高海拔 (HA) 醫學和生理學仍然與印度武裝部隊高度相關。大量非 HA 本土部隊在平均海平面以上 9000 英尺的海拔地區服役。 HA環境中氧分壓低、溫度低、大氣濕度低、紫外線輻射強度大，對人體的生理功能提出了挑戰。透過實驗室和現場研究更了解這些生理反應，使得過去十年中高山症 (HAI) 的發生率急劇下降。
眾所周知，有些人比其他人更容易感染 HAI，因此，只要部隊在 HA 環境中生活和工作，HAI 就會繼續發生，儘管發病率較低。1病人和醫療機構之間的第一個接觸點通常是團醫務官 (RMO)，這些病人的管理取決於他的判斷和能力。由於HAI 的診斷通常在偏遠地區進行，無法使用實驗室和影像設施，因此某些基於現場的診斷標準，例如路易斯湖(LL) 共識標準，已被描述用於急性高山症(AMS) 的現場診斷，高原肺水腫（HAPE）和高原腦水腫（HACE）。2
HAI 的現有現場診斷標準主要是根據從發生 HAI 的登山者和遊客收集的西方數據得出的。這個人口可能無法與印度士兵人口相比，因此需要研究這些標準的普遍性。此外，LL 標準（例如心動過速和呼吸急促）是非特異性的，並且不會在給定海拔下為這些參數指定截止值。在給定海拔高度上提供更客觀的 HAPE 診斷標準將是有益的，特別是對於偏遠醫療機構的輔助醫務人員。本研究旨在檢驗 LL 共識標準在印度士兵診斷 HAPE 中的適用性，並提出對於給定海拔可能更具體的診斷標準。
材料與方法
對位於平均海平面以上 3350 公尺的醫管局研究實驗室的 HAI 資料庫進行了分析。選擇資料庫中可用的 HAPE 病例的臨床記錄進行分析。以下 HAPE 病例納入分析：
a.發生海拔高度在2700公尺至3500公尺之間。
b. 由受過訓練的醫生確認的 HAPE 診斷。
c.「完整」的記錄（包含上升情況的詳細資訊、症狀的發作以及在前往醫療機構就診時記錄的臨床檢查體徵）。
以下記錄未包含在分析中：
a.懷疑HAPE診斷但未確診的。
b.記錄不完整。
c. 在接受醫療專業人員檢查之前有接受藥物/吸氧史記錄的患者。
依上述標準，共納入235例HAPE病例進行分析。
醫管局研究實驗室提供的 235 名健康士兵在 3350 公尺海拔的適應醫療數據也經過分析，以確定在海拔約 3000 公尺的頭 6 天內的心率、呼吸頻率和脈搏血氧飽和度值。該中心每天記錄抵達 HA 的前 6 天內的這些參數。該資料庫包含1000多名健康士兵的資料。根據研究組HAPE發生的平均天數，選擇健康士兵相應天的適應醫學數據進行分析。採樣是使用 Microsoft Excel 中的「隨機」函數完成的。這些數據作為健康對照。由於研究組和對照組由混合士兵組成，因此假設這些群體在種族組成上具有可比性。沒有進行詳細的配對。
使用非配對 t 檢定比較 HAPE 病例和對照組的心率、呼吸頻率和 SPO2 值的統計顯著性差異，然後進行受試者工作特徵 (ROC) 曲線分析。3這樣做是為了確定這些易於測量的臨床參數中的哪些可以作為 2700 m 至 3500 m 之間發生的 HAPE 的良好診斷標準。此識別是使用記錄的每個參數的曲線下面積 (AUC) 值來完成的。3 , 4然後確定 ROC 曲線上的最佳操作點，以建議診斷 2700 m 至 3500 m 之間發生的 HAPE 的截止值。 ROC 分析中的最佳操作點是給定資料獲得最高可能靈敏度和特異性的點。與這一點相對應的臨床參數值是作為所研究的臨床病症的診斷標準提出的截止值的邏輯選擇。
將現有的 HAPE 診斷 LL 標準應用於 HAPE 病例，並計算該群組的 LL 標準的敏感性、特異性、陽性和陰性預測值。由於 LL 標準提到心動過速和呼吸急促是 HAPE 患者的兩種體徵，但沒有指定相同的數值，因此使用心率大於 100 次/分鐘 (bpm) 和呼吸頻率大於 20 次呼吸/分鐘來診斷分別定義心跳過速和呼吸急促，這是臨床上的常態。使用從 ROC 分析獲得的 HR、RR 和 SPO2 的截止值進行類似的計算。對所獲得的兩組數據進行分析，以比較現有和提議的印度士兵 HAPE 診斷臨界值的性能。
結果
HAPE 症狀平均出現時間為到達海拔 2700 m 至 3500 m 後 2.8 ± 2.2 天。 HAPE患者在診斷時報告的各種臨床症狀的頻率如表1所示。呼吸困難、頭痛和咳嗽是最常見的症狀。最不常見的症狀是疲勞。表 2顯示了 HAPE 患者向醫療機構報告時的臨床檢查結果以及在 HA 第三天進行的健康適應對照的結果。與同等海拔的健康適應士兵相比，HAPE 患者的心率和呼吸頻率明顯較高，而 SPO2 值較低。 HAPE患者的心率、呼吸頻率及SPO2值的頻率分佈分別如圖1、圖2、圖3所示。大多數 HAPE 患者的 SPO2 值低於該海拔的預期，其中 48.9% 在診斷時患有心動過速（HR > 100 bpm）（表 3）。
圖 1
235 名 HAPE 患者的心率值頻率分佈顯示，只有 48.9% 的患者心率超過 100 bpm。
圖2
235例HAPE患者呼吸頻率值的頻率分佈。
圖3
235例HAPE患者SPO2值頻率分佈。
表 1HAPE 患者的臨床症狀（依出現頻率排列）。
臨床症狀 ---- 患者人數（患者百分比）
呼吸困難 202 (79.5%)
頭痛 183 (72%)
咳嗽 155 (61%)
胸部不適 99 (39%)
咳痰 31 (12.2%)
失眠 20 (7.9%)
疲勞 11 ( 4.3 ) %)
表 2
HAPE 患者初次診斷時的臨床檢查結果。顯示健康對照中第三天在 HA 中記錄的相同參數的相應值以進行比較。
參數HAPE 患者(n = 235)[平均值 ± 標準差] 健康對照組(n = 235)[平均值 ± 標準差]
心率（次/分鐘） 100.6 ± 17.8 88.5.1 ± 8.3*
呼吸頻率（呼吸/分鐘) 26.1 ± 5.5 16.1 ± 3.0*
收縮壓 (mmHg) 124.8 ± 15.6 126.7 ± 11.5
舒張壓(mmHg) 81.2 ± 10.7 79.2 ± 11.8
SPO2 – 室內呼吸*p < 0.001（未配對t 檢定）。
表 3
235 名 HAPE 患者的心率、呼吸頻率和脈搏血氧飽和度結果分析。臨床參數 患者百分比 心率 > 100 次/分鐘 48.9% SPO2 < 88% 呼吸環境空氣 89%呼吸頻率 > 20次呼吸/分鐘 83% ROC 曲線以及 HR、RR 和 SPO2 的 AUC 如圖 1所示。5。所有三個參數均具有較高的 AUC，範圍從 HR 的 0.86 到 SPO2 的 0.88。每條曲線上的最佳操作點對應於 HR >95 bpm、RR >21 每分鐘和 SPO2 <86%。這些臨界值的敏感度、特異度、陽性及陰性預測值如表4、表5、表6所示。這些建議的臨界值與現有心搏過速(HR > 100 bpm) 和呼吸急促(RR > 20 每分鐘) 標準在海拔2700 m 至3350 m 之間診斷HAPE 的敏感性和特異性的比較如下表所示：
表 7 .
圖 4
心率 (HR) 和呼吸頻率 (RR) 的 ROC 曲線顯示 HR 和 RR 的曲線下面積分別為 0.86 和 0.87。
圖 5
脈搏血氧飽和度值 (SPO2) 的 ROC 曲線顯示曲線下面積為 0.88。
表 4
所選心率臨界值的特異性、敏感性、陽性和陰性預測值計算。
HAPE 患者對照心率 > 95/分鐘 156 13
心率 < 95/分鐘 79 222
靈敏度 = 156/(156 + 79) = 0.66；特異性 = 222/(13 + 222) = 0.94；陽性預測值=156/(156+13)=0.92；陰性預測值 = 222/(79 + 222) = 0.74。
表 5 所選呼吸頻率截止值的特異性、敏感度、陽性和陰性預測值計算。
HAPE 患者對照呼吸頻率 > 21/分鐘 194 12
呼吸頻率 < 21/分鐘 41 223
靈敏度 = 194/(194 + 41) = 0.83；特異性=223/(12+223)=0.95；陽性預測值=194/(194+12)=0.94；陰性預測值 = 223/(41 + 223) = 0.84。
表 6
所選脈搏血氧飽和度值 (SPO2) 截止值的特異性、靈敏度、陽性和陰性預測值計算。
HAPE 患者對照組 SPO2 < 86% 193 16
SPO2 > 86% 42 219
靈敏度 = 193/(193 + 42) = 0.82；特異性 = 219/(16 + 219) = 0.93；陽性預測值=193/(193+16)=0.92；陰性預測值 = 219/(42 + 219) = 0.83。
表 7 現有 LL 標準和建議的臨界值以及診斷 2700-3500 m 發生的 HAPE 的心率、呼吸頻率和 SPO2 的敏感性和特異性的比較。
心率 (bpm) 呼吸頻率 (呼吸/分鐘)SPO2 (%)
建議 >95 現有 >100 建議 >21 現有 >20 建議 <86% 現有 無靈敏度 0.66 0.49 0.83 0.83 0.82
(59.9–72.0) (78. 87.8) (77.0–86.9)
特異性 0.94 1.0 0.95 0.83 0.93
(90.9–97.0) (92.2–97.7) (89.7–96.2)
陽性預測值 a 0.92 1.0 5.95–909. 0)
(88.5 –95.4)
陰性預測值值 a 0.74 0.66 0.84 0.83 0.83
(68.3–79.6) (79.3–88.6) (78.1–87.8)
心率大於100 bpm 且呼吸頻率已大於被呼吸/分鐘來定義「心跳過速」和現有 LL 標準為「呼吸急促」。括號中的數值表示 95% 的置信限。
a 對於給定研究族群中明顯的疾病盛行率有效。
轉至：
討論
據了解，HAPE 的症狀會在高原地區的最初幾天內出現。5研究族群在 2700-3500 m 海拔高度發生 HAPE 的平均時間為 2.8 ± 2.2 天。強調這一事實是因為，在沒有近期海拔升高史或沒有可能的誘發因素（例如嚴重不習慣的運動或呼吸道感染）的情況下，必須謹慎對待提示 HAPE 的症狀。
本研究中患者報告的症狀值得關注。雖然呼吸困難、胸部不適和咳嗽症狀是 HAPE 的眾所周知的特徵，但很大一部分患者 (72%) 也被發現抱怨頭痛。頭痛是一種非特異性症狀，在醫管局出現頭痛可能是由多種因素造成的，包括脫水、睡眠不足、旅途疲勞以及急性高山症並存等。有趣的是，在其他報告中也有報告 HAPE 患者抱怨頭痛。6 , 7儘管根據目前的了解，HAPE 的病理生理學無法解釋頭痛的發生，但這種症狀與 HAPE 的頻繁關聯可能值得在 HAPE 診斷標準中考慮該症狀。
有趣的是，我們的患者沒有疲勞作為主要症狀，因為根據路易斯湖標準，疲勞/虛弱/運動能力下降是 HAPE 的重要診斷症狀。2 , 8只有 4.3% 的患者報告了這種症狀。一個可能的原因可能是，與沉迷於高海拔冒險運動的登山者、徒步旅行者和遊客相比，士兵在高海拔的最初幾天並沒有進行大量的體力活動。因此，一般久坐的士兵可能不會注意到疲勞是 HAPE 的早期和突出症狀。
在我們的研究中，並非所有 HAPE 患者都會出現心搏過速（定義為心率超過 100 bpm）。只有 48.9% 的患者心率超過 100 bpm，這表明超過一半 (51.1%) 在海拔 2700-3500 m 發生 HAPE 的患者可能不會表現出心動過速。眾所周知，心率增加的幅度與上升的高度和疾病的嚴重程度成正比。9 , 10研究族群心率較低可能有多種原因。其中可能包括所討論的海拔高度（2700-3500 m），與其他一些 HAPE 報告相比，該海拔較低，這些患者的病情不太嚴重，可能是早期診斷病情的結果，相對久坐的性質士兵在醫管局進行的活動的適應情況以及士兵由於身體狀況可能較低的靜止心率。與 >100 bpm 的值相比，提出的心率大於 95 bpm 的標準似乎對診斷 HAPE 具有更好的敏感性（0.66 與 0.49），同時保留了高特異性（0.94）。
眾所周知，HAPE 患者的呼吸頻率較高。這些比率應該要多高才能診斷出 HAPE？使用呼吸急速的傳統定義，即呼吸頻率大於每分鐘20次，此參數診斷HAPE的敏感度和特異度為0.83。然而，選擇 21 次呼吸/分鐘的值將特異性提高到 0.95，同時保持靈敏度 0.83。
儘管 HA 的脈搏血氧測定法有其局限性，且其本身可能無法用作診斷參數，但如果謹慎執行，透過脈搏血氧測定法獲得的資訊可以補充整體臨床情況。在目前的一系列患者中，85% 的患者 SPO2 值低於 88%，這是健康個體在 3000 m 處呼吸室內空氣的預期 SPO2 值。脈搏血氧飽和度可能有助於監測 HAPE 患者的病情進展和治療效果。
HR、RR 和 SPO2 的 ROC 分析表明，這三個參數都非常適合作為 HAPE 的診斷參數，因為它們的曲線下面積範圍為 0.86 至 0.88。 0.8 到 0.9 之間的區域表示測試良好，0.9 到 1.0 之間的區域表示優。4在三個參數中，SPO2 似乎是最佳參數，因為它具有最高的 AUC (0.88)。 ROC 分析建議的這三個參數的截止值顯示出非常令人鼓舞的特異性和敏感性水平，可用作診斷 2700 m 至 3500 m 之間發生的 HAPE 的參數。
診斷測試的陽性和陰性預測值受疾病盛行率的影響。隨著人群中疾病盛行率的增加，對該族群應用測試標準會產生更高的陽性預測值和更低的陰性預測值。由於文獻中所報告的HAPE 真實盛行率各不相同，且不同族群之間可能有所不同，因此在解釋本研究中提出的數值時應牢記這一事實，並且如果疾病盛行率與本研究中的盛行率不同，該值也會改變。
儘管盡了最大努力來防止 HAPE 的發生，但 HAPE 的許多人確實發生了這種情況。因此，及時診斷病情至關重要，以防止病情惡化和可能的死亡。診斷 HAPE 的標準必須可靠、客觀，並且易於偏遠地區外圍醫療機構的非醫務人員和輔助醫務人員使用。雖然 LL 標準已被全球接受用於 HAPE 的臨床診斷，但它們相當通用，且不針對海拔高度。因此，建議在最近到達2700-3500 m的環境中，如果個體出現呼吸困難、咳嗽、胸部不適和頭痛症狀，且HR、RR和SPO2值如上所述，則很可能是患有以下疾病的患者： HAPE 並應進行相應的管理（表 8）。與診斷 HAPE 的現有 LL 標準相比，本研究提出的標準顯示出更好的特異性，且不影響敏感性。
表 8
現有路易斯湖 HAPE 診斷標準與本研究提出的標準的比較。
現有標準（路易斯湖）
提議的標準
最近登上高海拔地區的歷史 過去 5 天內到達高海拔地區 (2700–3500 m) 的歷史 出現
以下任何兩種症狀 症狀
• 休息時呼吸困難
• 呼吸困難
• 咳嗽
• 咳嗽
• 虛弱或運動能力下降 • 胸部不適
• 胸悶或充血 • 頭痛
出現以下任兩種徵象 徵象
• 至少一側肺野出現爆裂聲或喘息音 • 心跳 > 95 次/分鐘
• 中樞性發紺 • 呼吸頻率 > 21 次/分鐘
• 心跳過速 • SPO2 < 86%
• 呼吸急促
局限性
本研究基於臨床記錄的回顧性分析，並受到其中所含資訊的限制。假設記錄中的臨床病史和發現結果是準確的。本研究建議的 HAPE 診斷臨床標準需要透過前瞻性地將其應用於 HAPE 診斷和治療的病例並記錄這些標準的適用性來進行驗證。一旦經過驗證，這些標準可以建議用於海拔 2700 m 至 3500 m 之間的 HAPE 現場診斷。
Abstract
Material and methods
The HAI database of a HA Research Laboratory located at 3350 m above mean sea level was analysed. Clinical records of cases of HAPE available in the database were selected for analysis. The following cases of HAPE were included for analysis:
Background
The criteria used for diagnosing high altitude illnesses are largely based on Western literature. This study was undertaken to define objective, simple and reliable diagnostic criteria for high altitude pulmonary edema (HAPE) in Indian soldiers at altitudes between 2700 m and 3500 m.
Methods
Clinical data of 235 cases of HAPE that occurred between 2700 m and 3500 m were analysed. Receiver operator characteristic (ROC) curve analysis was used to select simple clinical parameters suitable for the diagnosis of HAPE at peripheral medical facilities. Cut-off values and their reliability for the diagnosis of HAPE were defined.
Results
HAPE occurred 2.8 ± 2.2 days after arrival at altitudes between 2700 m and 3500 m. Breathlessness, cough, chest discomfort and headache were the commonest symptoms. Low pulse oximetry (SPO2) values than normal for this altitude were seen in 89% of patients. ROC analysis of clinical parameters identified a heart rate more than 95 beats per minute (bpm), respiratory rate more than 21 per minute and SPO2 less than 86% while breathing ambient air at this altitude as diagnostic of HAPE. The sensitivity and specificity of these cut-offs was 0.66, 0.83 and 0.82 and 0.94, 0.95 and 0.93 respectively.
Conclusion
A heart rate of more than 95 bpm, respiratory rate more than 21 per minute and SPO2 less than 86% breathing room air in individuals complaining of breathlessness, cough, chest discomfort or headache within the first 5 days of arrival at altitudes between 2700 m and 3500 m is highly suggestive of HAPE.
Keywords: Altitude sickness, Pulmonary edema, ROC curve
Introduction
High altitude (HA) medicine and physiology remains highly relevant to the Indian Armed Forces. A large number of troops, not native to HA, serve at altitudes greater than 9000 ft above mean sea level. The HA environment, with its low partial pressure of oxygen, low temperature, low atmospheric humidity and high levels of ultraviolet radiation challenges human physiological function. A better understanding of these physiological responses through both laboratory-based and field studies has resulted in a dramatic reduction in the incidence of high altitude illnesses (HAIs) over the last decade.
It is an accepted fact that some individuals are susceptible to HAI more than others, and hence, HAI would continue to occur, although with a lower incidence, as long as troops live and work in the HA environment.1 The first point of contact between patients and medical facilities is usually the regimental medical officer (RMO), upon whose judgement and competence, the management of these patients depends. Since the diagnosis of HAI is often at remote locations without access to laboratory and imaging facilities, certain field-based diagnostic criteria, like the Lake Louise (LL) Consensus Criteria, have been described for the field diagnosis of acute mountain sickness (AMS), high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).2
Existing field-based diagnostic criteria for HAI have largely been arrived at from Western data gathered from mountaineers and tourists who develop HAI. This population may not be comparable with the Indian soldier population and hence the generalisability of these criteria requires study. Additionally, the LL criteria, such as tachycardia and tachypnoea, are non-specific and do not ascribe cut-off values for these parameters at a given altitude. The availability of more objective criteria for diagnosing HAPE at a given altitude would be beneficial, especially for paramedical staff at remote medical facilities. The present study was undertaken to examine the applicability of the LL Consensus Criteria for the diagnosis of HAPE in the Indian soldier and to suggest diagnostic criteria which could be more specific for a given altitude.
The criteria used for diagnosing high altitude illnesses are largely based on Western literature. This study was undertaken to define objective, simple and reliable diagnostic criteria for high altitude pulmonary edema (HAPE) in Indian soldiers at altitudes between 2700 m and 3500 m.
Methods
Clinical data of 235 cases of HAPE that occurred between 2700 m and 3500 m were analysed. Receiver operator characteristic (ROC) curve analysis was used to select simple clinical parameters suitable for the diagnosis of HAPE at peripheral medical facilities. Cut-off values and their reliability for the diagnosis of HAPE were defined.
Results
HAPE occurred 2.8 ± 2.2 days after arrival at altitudes between 2700 m and 3500 m. Breathlessness, cough, chest discomfort and headache were the commonest symptoms. Low pulse oximetry (SPO2) values than normal for this altitude were seen in 89% of patients. ROC analysis of clinical parameters identified a heart rate more than 95 beats per minute (bpm), respiratory rate more than 21 per minute and SPO2 less than 86% while breathing ambient air at this altitude as diagnostic of HAPE. The sensitivity and specificity of these cut-offs was 0.66, 0.83 and 0.82 and 0.94, 0.95 and 0.93 respectively.
Conclusion
A heart rate of more than 95 bpm, respiratory rate more than 21 per minute and SPO2 less than 86% breathing room air in individuals complaining of breathlessness, cough, chest discomfort or headache within the first 5 days of arrival at altitudes between 2700 m and 3500 m is highly suggestive of HAPE.
Keywords: Altitude sickness, Pulmonary edema, ROC curve
Introduction
High altitude (HA) medicine and physiology remains highly relevant to the Indian Armed Forces. A large number of troops, not native to HA, serve at altitudes greater than 9000 ft above mean sea level. The HA environment, with its low partial pressure of oxygen, low temperature, low atmospheric humidity and high levels of ultraviolet radiation challenges human physiological function. A better understanding of these physiological responses through both laboratory-based and field studies has resulted in a dramatic reduction in the incidence of high altitude illnesses (HAIs) over the last decade.
It is an accepted fact that some individuals are susceptible to HAI more than others, and hence, HAI would continue to occur, although with a lower incidence, as long as troops live and work in the HA environment.1 The first point of contact between patients and medical facilities is usually the regimental medical officer (RMO), upon whose judgement and competence, the management of these patients depends. Since the diagnosis of HAI is often at remote locations without access to laboratory and imaging facilities, certain field-based diagnostic criteria, like the Lake Louise (LL) Consensus Criteria, have been described for the field diagnosis of acute mountain sickness (AMS), high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).2
Existing field-based diagnostic criteria for HAI have largely been arrived at from Western data gathered from mountaineers and tourists who develop HAI. This population may not be comparable with the Indian soldier population and hence the generalisability of these criteria requires study. Additionally, the LL criteria, such as tachycardia and tachypnoea, are non-specific and do not ascribe cut-off values for these parameters at a given altitude. The availability of more objective criteria for diagnosing HAPE at a given altitude would be beneficial, especially for paramedical staff at remote medical facilities. The present study was undertaken to examine the applicability of the LL Consensus Criteria for the diagnosis of HAPE in the Indian soldier and to suggest diagnostic criteria which could be more specific for a given altitude.
Material and methods
The HAI database of a HA Research Laboratory located at 3350 m above mean sea level was analysed. Clinical records of cases of HAPE available in the database were selected for analysis. The following cases of HAPE were included for analysis:
a.Altitude of occurrence between 2700 m and 3500 m.
b.Diagnosis of HAPE confirmed by a trained physician.
c.Records that were ‘complete’ (containing details of ascent profile, onset of symptoms and documented signs on clinical examination at the time of presenting to a medical facility).
The following records were not included in the analysis:
b.Diagnosis of HAPE confirmed by a trained physician.
c.Records that were ‘complete’ (containing details of ascent profile, onset of symptoms and documented signs on clinical examination at the time of presenting to a medical facility).
The following records were not included in the analysis:
a.Where the diagnosis of HAPE was suspected but not confirmed.
b.Incomplete records.
c.Patients with documented history of having being administered drugs/oxygen prior to being examined by a medical professional.
Based on the above criteria, a total of 235 cases of HAPE were included for the analysis.
The acclimatisation medical data of 235 healthy soldiers at 3350 m, available with the HA Research Laboratory, was also analysed to determine values of heart rate, respiratory rate and pulse oximetry values during the first 6 days at an altitude of approximately 3000 m. A daily record of these parameters over the first 6 days of arrival at HA is maintained by the centre. This database contains data of more than 1000 healthy soldiers. Based on the mean day of occurrence of HAPE in the study group, acclimatisation medical data of the healthy soldiers for the corresponding day were chosen for analysis. The sampling was done using the ‘Random’ function in Microsoft Excel. These data served as healthy controls. Since the study and control group comprised a mixed soldier population, it was assumed that the groups were comparable in ethnic composition. A detailed matching for the same was not carried out.
The heart rate, respiratory rate and SPO2 values of HAPE cases and controls were compared for statistically significant differences using an unpaired t-test and then subjected to a receiver operator characteristic (ROC) curve analysis.3 This was done to identify which of these easily measurable clinical parameters would serve as good diagnostic criteria for HAPE occurring between 2700 m and 3500 m. This identification was done using the area under the curve (AUC) value for each of the parameter recorded.3, 4 The best operating point on the ROC curve was then identified to suggest cut-off values for diagnosing HAPE occurring between 2700 m and 3500 m. The best operating point in an ROC analysis is that point where the highest possible sensitivity and specificity are obtained for the given data. The value of a clinical parameter corresponding to this point is the logical choice for a cut-off value proposed as criteria for diagnosis of the clinical condition being studied.
The existing LL criteria for diagnosis of HAPE were applied to the HAPE cases and the sensitivity, specificity, positive and negative predicted values of the LL criteria calculated for this cohort. Since the LL criteria mention tachycardia and tachypnoea as two signs in patients with HAPE but do not specify values for the same, a heart rate of greater than 100 beats per minute (bpm) and a respiratory rate greater than 20 breaths/min were used to define tachycardia and tachypnoea respectively, as is the norm in clinical practice. A similar calculation was done using the cut-off values of HR, RR and SPO2 obtained from the ROC analysis. The two sets of data obtained were analysed to compare the performance of the existing and proposed cut-off values for the diagnosis of HAPE in the Indian soldier.
b.Incomplete records.
c.Patients with documented history of having being administered drugs/oxygen prior to being examined by a medical professional.
Based on the above criteria, a total of 235 cases of HAPE were included for the analysis.
The acclimatisation medical data of 235 healthy soldiers at 3350 m, available with the HA Research Laboratory, was also analysed to determine values of heart rate, respiratory rate and pulse oximetry values during the first 6 days at an altitude of approximately 3000 m. A daily record of these parameters over the first 6 days of arrival at HA is maintained by the centre. This database contains data of more than 1000 healthy soldiers. Based on the mean day of occurrence of HAPE in the study group, acclimatisation medical data of the healthy soldiers for the corresponding day were chosen for analysis. The sampling was done using the ‘Random’ function in Microsoft Excel. These data served as healthy controls. Since the study and control group comprised a mixed soldier population, it was assumed that the groups were comparable in ethnic composition. A detailed matching for the same was not carried out.
The heart rate, respiratory rate and SPO2 values of HAPE cases and controls were compared for statistically significant differences using an unpaired t-test and then subjected to a receiver operator characteristic (ROC) curve analysis.3 This was done to identify which of these easily measurable clinical parameters would serve as good diagnostic criteria for HAPE occurring between 2700 m and 3500 m. This identification was done using the area under the curve (AUC) value for each of the parameter recorded.3, 4 The best operating point on the ROC curve was then identified to suggest cut-off values for diagnosing HAPE occurring between 2700 m and 3500 m. The best operating point in an ROC analysis is that point where the highest possible sensitivity and specificity are obtained for the given data. The value of a clinical parameter corresponding to this point is the logical choice for a cut-off value proposed as criteria for diagnosis of the clinical condition being studied.
The existing LL criteria for diagnosis of HAPE were applied to the HAPE cases and the sensitivity, specificity, positive and negative predicted values of the LL criteria calculated for this cohort. Since the LL criteria mention tachycardia and tachypnoea as two signs in patients with HAPE but do not specify values for the same, a heart rate of greater than 100 beats per minute (bpm) and a respiratory rate greater than 20 breaths/min were used to define tachycardia and tachypnoea respectively, as is the norm in clinical practice. A similar calculation was done using the cut-off values of HR, RR and SPO2 obtained from the ROC analysis. The two sets of data obtained were analysed to compare the performance of the existing and proposed cut-off values for the diagnosis of HAPE in the Indian soldier.
Results
The mean time of onset of symptoms of HAPE was 2.8 ± 2.2 days after arrival at altitudes between 2700 m and 3500 m. The frequency of various clinical symptoms reported by HAPE patients at the time of diagnosis is shown in Table 1. Breathlessness, headache and cough were the commonest symptoms. The least common symptom was fatigue. The findings on clinical examination in patients of HAPE at the time of reporting to a medical facility and in the healthy acclimatising controls on day three at HA are shown in Table 2. Patients of HAPE had significantly higher heart rates and respiratory rates and lower SPO2 values compared to healthy acclimatising soldiers at a comparable altitude. A frequency distribution of heart rate, respiratory rate and SPO2 values in patients of HAPE is shown in Fig. 1, Fig. 2, Fig. 3 respectively. Majority of HAPE patients had SPO2 values lower than expected at that altitude and 48.9% of them had tachycardia (HR > 100 bpm) at the time of being diagnosed (Table 3).
Fig. 1
Frequency distribution of heart rate values in 235 patients of HAPE showing that only 48.9% of patients had heart rates more than 100 bpm.
Fig. 2
Frequency distribution of respiratory rate values in 235 patients of HAPE.
Fig. 3
Frequency distribution of SPO2 values in 235 patients of HAPE.
Table 1
Clinical symptoms in patients of HAPE in order of frequency.
Clinical symptomNumber of patients (% of patients)Breathlessness 202 (79.5%)
Headache 183 (72%)
Cough 155 (61%)
Chest discomfort 99 (39%)
Expectoration 31 (12.2%)
Insomnia 20 (7.9%)
Fatigue 11 (4.3%)
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Table 2
Findings on clinical examination in patients of HAPE at the time of initial diagnosis. Corresponding values of the same parameters in healthy controls, recorded on the third day in HA, are shown for comparison.
ParameterHAPE patients
(n = 235)
[Mean ± std dev]Healthy controls
(n = 235)
[Mean ± std dev]Heart rate (beats/min) 100.6 ± 17.8 88.5.1 ± 8.3*
Respiratory rate (breaths/min) 26.1 ± 5.5 16.1 ± 3.0*
Systolic blood pressure (mmHg) 124.8 ± 15.6 126.7 ± 11.5
Diastolic blood pressure (mmHg) 81.2 ± 10.7 79.2 ± 11.8
SPO2 – breathing room air (%) 72.2 ± 12.9 88.5 ± 2.2*
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*p < 0.001 (unpaired t-test).
Table 3
Analysis of heart rate, respiratory rate, and pulse oximetry findings in 235 HAPE patients.
Clinical parameterPercentage of patientsHeart rate > 100/min 48.9%
SPO2 < 88% breathing ambient air 89%
Respiratory rate > 20 breaths/min 83%
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ROC curves and the AUCs for HR, RR and SPO2 are shown in Fig. 4, Fig. 5. All the three parameters were found to have a high AUC ranging from 0.86 for HR to 0.88 for SPO2. The best operating point on each curve corresponded to HR of >95 bpm, RR of >21 per minute and SPO2 of <86%. The sensitivity, specificity, positive and negative predictive values of these cut-off values are as shown in Table 4, Table 5, Table 6. A comparison of the sensitivity and specificity of these proposed cut-off values and the existing criteria of tachycardia (HR > 100 bpm) and tachypnoea (RR > 20 per min) for diagnosing HAPE at altitudes between 2700 m and 3350 m is as shown in Table 7.
Fig. 4
ROC curve for heart rate (HR) and respiratory rate (RR) showing areas under the curve of 0.86 and 0.87 for HR and RR respectively.
Fig. 5
ROC curve for pulse oximetry values (SPO2) showing an area under the curve of 0.88.
Table 4
Specificity, sensitivity, positive, and negative predictive value calculation for selected cut-off value of heart rate.
HAPE patientsControlsHeart rate > 95/min 156 13
Heart rate < 95/min 79 222
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Sensitivity = 156/(156 + 79) = 0.66; specificity = 222/(13 + 222) = 0.94; positive predictive value = 156/(156 + 13) = 0.92; negative predictive value = 222/(79 + 222) = 0.74.
Table 5
Specificity, sensitivity, positive, and negative predictive value calculation for selected cut-off value of respiratory rate.
HAPE patientsControlsRespiratory rate > 21/min 194 12
Respiratory rate < 21/min 41 223
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Sensitivity = 194/(194 + 41) = 0.83; specificity = 223/(12 + 223) = 0.95; positive predictive value = 194/(194 + 12) = 0.94; negative predictive value = 223/(41 + 223) = 0.84.
Table 6
Specificity, sensitivity, positive, and negative predictive value calculation for selected cut-off value of pulse oximetry values (SPO2).
HAPE patientsControlsSPO2 < 86% 193 16
SPO2 > 86% 42 219
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Sensitivity = 193/(193 + 42) = 0.82; specificity = 219/(16 + 219) = 0.93; positive predictive value = 193/(193 + 16) = 0.92; negative predictive value = 219/(42 + 219) = 0.83.
Table 7
A comparison of the sensitivity and specificity of existing LL criteria and proposed cut-off values and of heart rate, respiratory rate, and SPO2 for diagnosing HAPE occurring at 2700–3500 m.
Heart rate (bpm)Respiratory rate (breaths/min)SPO2 (%)
Proposed >95Existing >100Proposed >21Existing >20Proposed <86%Existing nilSensitivity 0.66 0.49 0.83 0.83 0.82
(59.9–72.0) (78.1–87.8) (77.0–86.9)
Specificity 0.94 1.0 0.95 0.83 0.93
(90.9–97.0) (92.2–97.7) (89.7–96.2)
Positive predictive valuea 0.92 1.0 0.94 0.83 0.92
(88.5–95.4) (90.9–97.0) (88.5–95.4)
Negative predictive valuea 0.74 0.66 0.84 0.83 0.83
(68.3–79.6) (79.3–88.6) (78.1–87.8)
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A heart rate of greater than 100 bpm and a respiratory rate of greater than 20 breaths/min have been used to define ‘tachycardia’ and ‘tachypnoea’ for the existing LL criteria. Values in brackets indicate 95% confidence limits.
aValid for a disease prevalence as evident in the given study population.
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Discussion
The symptoms of HAPE are known to develop within the first few days at altitude.5 The mean time of occurrence of HAPE at 2700–3500 m in the study population was 2.8 ± 2.2 days. This fact is emphasised since symptoms suggestive of HAPE, in the absence of a history of recent gain in altitude or a possible precipitating factor such as severe unaccustomed exercise or respiratory infection, must be viewed with caution.
The symptoms reported by patients in the present study merit attention. While symptoms of breathlessness, chest discomfort and cough are well-known features of HAPE, a large percentage of patients (72%) were also found to complain of headache. Headache is a non-specific symptom and its occurrence at HA could be the result of a number of factors ranging from dehydration, lack of sleep and tiredness of travel to co-existence of acute mountain sickness. Interestingly, patients of HAPE have been reported to complain of headache in other reports as well.6, 7 Though the pathophysiology of HAPE, as per current understanding, cannot explain the occurrence of headache, the frequent association of this symptom with HAPE might merit consideration of the symptom in the criteria for diagnosis of HAPE.
The absence of fatigue as a major symptom in our patients is interesting since fatigue/weakness/decreased exercise performance is an important diagnostic symptom of HAPE as per the Lake Louise criteria.2, 8 Only 4.3% of our patients reported this symptom. A possible reason could be that soldiers do not undertake significant physical activity during the initial days at altitude as compared to mountaineers, trekkers and tourists indulging in adventure sport at altitude. The average sedentary soldier may not, therefore, notice fatigue as an early and prominent symptom of HAPE.
Not all patients of HAPE in our study showed tachycardia as defined by a heart rate of more than 100 bpm. Only 48.9% of patients had a heart rate of more than 100 bpm, suggesting that more than half of the patients (51.1%) developing HAPE at altitudes of 2700–3500 m may not manifest tachycardia. The magnitude of increase in heart rate is known to be proportional to the altitude of ascent and the severity of illness.9, 10 The lower heart rates in the study population could be due to a number of reasons. Possible among these are the altitude in question (2700–3500 m), which is lower compared to some of the other reports of HAPE, a less severe illness in these patients, possibly the result of the condition being diagnosed early, the relatively sedentary nature of activities performed at HA by acclimatising soldiers and a possible lower resting heart rates in soldiers due to their physical conditioning. The proposed criterion of a heart rate greater than 95 bpm appears to have better sensitivity for diagnosis of HAPE compared to a value of >100 bpm (0.66 vs 0.49), while retaining a high specificity (0.94).
Patients of HAPE are known to have high respiratory rates. How high should these rates be to suggest a diagnosis of HAPE? Using the conventional definition of tachyapnea, i.e. a respiratory rate greater than 20 per minute, the sensitivity and specificity of this parameter for diagnosing HAPE are found to be 0.83. However, selecting a value of 21 breaths/min improved the specificity to 0.95 while maintaining a sensitivity of 0.83.
Though pulse oximetry at HA has its limitations and may not by itself serve as a diagnostic parameter, the information obtained via pulse oximetry, if carried out with due caution, may supplement the overall clinical picture. In the present series of patients, 85% of the patients had SPO2 values below 88%, which is the expected SPO2 value in healthy individuals breathing room air at 3000 m. Pulse oximetry may have utility in monitoring the progress of the condition and efficacy of treatment in HAPE patients.
The ROC analysis of HR, RR and SPO2 revealed that each of the three parameters is very good as diagnostic parameters for HAPE since their areas under the curve range from 0.86 to 0.88. Areas between 0.8 and 0.9 indicate good tests and between 0.9 and 1.0, excellent.4 Of the three parameters, SPO2 appears the best parameter since it had the highest AUC (0.88). The cut-off values suggested from the ROC analysis for these three parameters show very encouraging levels of specificity and sensitivity for their use as parameters for diagnosing HAPE occurring between 2700 m and 3500 m.
Positive and negative predictive values of a diagnostic test are influenced by the prevalence of the disease. As disease prevalence increases in a population, application of the test criteria to that population yields higher positive predictive values and lower negative predictive values. Since the true prevalence of HAPE has been variably reported in literature and may differ among population groups, the values presented in this study should be interpreted keeping this fact in mind and would change, should the disease prevalence be different from that of the present study.
Despite best attempts to prevent its occurrence, HAPE does occur in a number of individuals at HA. A prompt diagnosis of the condition is thus essential, to prevent worsening of the condition and possible fatality. The criteria for diagnosing HAPE need to be reliable, objective, yet simple to use in remote locations by non-medical and para-medical personnel at peripheral medical facilities. While the LL criteria are accepted globally for the clinical diagnosis of HAPE, they are fairly general and not altitude specific. It is therefore suggested that in the setting of recent arrival at 2700–3500 m, an individual with symptoms of breathlessness, cough, chest discomfort and headache, with values of HR, RR and SPO2 as discussed above, is likely to be a patient with HAPE and should be managed accordingly (Table 8). The criteria suggested by this study show better specificity, without compromising the sensitivity, as compared to the existing LL criteria for diagnosing HAPE.
Table 8
A comparison of the existing Lake Louise criteria for diagnosis of HAPE and the proposed criteria of the present study.
Existing criteria (Lake Louise)
The mean time of onset of symptoms of HAPE was 2.8 ± 2.2 days after arrival at altitudes between 2700 m and 3500 m. The frequency of various clinical symptoms reported by HAPE patients at the time of diagnosis is shown in Table 1. Breathlessness, headache and cough were the commonest symptoms. The least common symptom was fatigue. The findings on clinical examination in patients of HAPE at the time of reporting to a medical facility and in the healthy acclimatising controls on day three at HA are shown in Table 2. Patients of HAPE had significantly higher heart rates and respiratory rates and lower SPO2 values compared to healthy acclimatising soldiers at a comparable altitude. A frequency distribution of heart rate, respiratory rate and SPO2 values in patients of HAPE is shown in Fig. 1, Fig. 2, Fig. 3 respectively. Majority of HAPE patients had SPO2 values lower than expected at that altitude and 48.9% of them had tachycardia (HR > 100 bpm) at the time of being diagnosed (Table 3).
Fig. 1
Frequency distribution of heart rate values in 235 patients of HAPE showing that only 48.9% of patients had heart rates more than 100 bpm.
Fig. 2
Frequency distribution of respiratory rate values in 235 patients of HAPE.
Fig. 3
Frequency distribution of SPO2 values in 235 patients of HAPE.
Table 1
Clinical symptoms in patients of HAPE in order of frequency.
Clinical symptomNumber of patients (% of patients)Breathlessness 202 (79.5%)
Headache 183 (72%)
Cough 155 (61%)
Chest discomfort 99 (39%)
Expectoration 31 (12.2%)
Insomnia 20 (7.9%)
Fatigue 11 (4.3%)
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Table 2
Findings on clinical examination in patients of HAPE at the time of initial diagnosis. Corresponding values of the same parameters in healthy controls, recorded on the third day in HA, are shown for comparison.
ParameterHAPE patients
(n = 235)
[Mean ± std dev]Healthy controls
(n = 235)
[Mean ± std dev]Heart rate (beats/min) 100.6 ± 17.8 88.5.1 ± 8.3*
Respiratory rate (breaths/min) 26.1 ± 5.5 16.1 ± 3.0*
Systolic blood pressure (mmHg) 124.8 ± 15.6 126.7 ± 11.5
Diastolic blood pressure (mmHg) 81.2 ± 10.7 79.2 ± 11.8
SPO2 – breathing room air (%) 72.2 ± 12.9 88.5 ± 2.2*
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*p < 0.001 (unpaired t-test).
Table 3
Analysis of heart rate, respiratory rate, and pulse oximetry findings in 235 HAPE patients.
Clinical parameterPercentage of patientsHeart rate > 100/min 48.9%
SPO2 < 88% breathing ambient air 89%
Respiratory rate > 20 breaths/min 83%
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ROC curves and the AUCs for HR, RR and SPO2 are shown in Fig. 4, Fig. 5. All the three parameters were found to have a high AUC ranging from 0.86 for HR to 0.88 for SPO2. The best operating point on each curve corresponded to HR of >95 bpm, RR of >21 per minute and SPO2 of <86%. The sensitivity, specificity, positive and negative predictive values of these cut-off values are as shown in Table 4, Table 5, Table 6. A comparison of the sensitivity and specificity of these proposed cut-off values and the existing criteria of tachycardia (HR > 100 bpm) and tachypnoea (RR > 20 per min) for diagnosing HAPE at altitudes between 2700 m and 3350 m is as shown in Table 7.
Fig. 4
ROC curve for heart rate (HR) and respiratory rate (RR) showing areas under the curve of 0.86 and 0.87 for HR and RR respectively.
Fig. 5
ROC curve for pulse oximetry values (SPO2) showing an area under the curve of 0.88.
Table 4
Specificity, sensitivity, positive, and negative predictive value calculation for selected cut-off value of heart rate.
HAPE patientsControlsHeart rate > 95/min 156 13
Heart rate < 95/min 79 222
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Sensitivity = 156/(156 + 79) = 0.66; specificity = 222/(13 + 222) = 0.94; positive predictive value = 156/(156 + 13) = 0.92; negative predictive value = 222/(79 + 222) = 0.74.
Table 5
Specificity, sensitivity, positive, and negative predictive value calculation for selected cut-off value of respiratory rate.
HAPE patientsControlsRespiratory rate > 21/min 194 12
Respiratory rate < 21/min 41 223
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Sensitivity = 194/(194 + 41) = 0.83; specificity = 223/(12 + 223) = 0.95; positive predictive value = 194/(194 + 12) = 0.94; negative predictive value = 223/(41 + 223) = 0.84.
Table 6
Specificity, sensitivity, positive, and negative predictive value calculation for selected cut-off value of pulse oximetry values (SPO2).
HAPE patientsControlsSPO2 < 86% 193 16
SPO2 > 86% 42 219
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Sensitivity = 193/(193 + 42) = 0.82; specificity = 219/(16 + 219) = 0.93; positive predictive value = 193/(193 + 16) = 0.92; negative predictive value = 219/(42 + 219) = 0.83.
Table 7
A comparison of the sensitivity and specificity of existing LL criteria and proposed cut-off values and of heart rate, respiratory rate, and SPO2 for diagnosing HAPE occurring at 2700–3500 m.
Heart rate (bpm)Respiratory rate (breaths/min)SPO2 (%)
Proposed >95Existing >100Proposed >21Existing >20Proposed <86%Existing nilSensitivity 0.66 0.49 0.83 0.83 0.82
(59.9–72.0) (78.1–87.8) (77.0–86.9)
Specificity 0.94 1.0 0.95 0.83 0.93
(90.9–97.0) (92.2–97.7) (89.7–96.2)
Positive predictive valuea 0.92 1.0 0.94 0.83 0.92
(88.5–95.4) (90.9–97.0) (88.5–95.4)
Negative predictive valuea 0.74 0.66 0.84 0.83 0.83
(68.3–79.6) (79.3–88.6) (78.1–87.8)
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A heart rate of greater than 100 bpm and a respiratory rate of greater than 20 breaths/min have been used to define ‘tachycardia’ and ‘tachypnoea’ for the existing LL criteria. Values in brackets indicate 95% confidence limits.
aValid for a disease prevalence as evident in the given study population.
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Discussion
The symptoms of HAPE are known to develop within the first few days at altitude.5 The mean time of occurrence of HAPE at 2700–3500 m in the study population was 2.8 ± 2.2 days. This fact is emphasised since symptoms suggestive of HAPE, in the absence of a history of recent gain in altitude or a possible precipitating factor such as severe unaccustomed exercise or respiratory infection, must be viewed with caution.
The symptoms reported by patients in the present study merit attention. While symptoms of breathlessness, chest discomfort and cough are well-known features of HAPE, a large percentage of patients (72%) were also found to complain of headache. Headache is a non-specific symptom and its occurrence at HA could be the result of a number of factors ranging from dehydration, lack of sleep and tiredness of travel to co-existence of acute mountain sickness. Interestingly, patients of HAPE have been reported to complain of headache in other reports as well.6, 7 Though the pathophysiology of HAPE, as per current understanding, cannot explain the occurrence of headache, the frequent association of this symptom with HAPE might merit consideration of the symptom in the criteria for diagnosis of HAPE.
The absence of fatigue as a major symptom in our patients is interesting since fatigue/weakness/decreased exercise performance is an important diagnostic symptom of HAPE as per the Lake Louise criteria.2, 8 Only 4.3% of our patients reported this symptom. A possible reason could be that soldiers do not undertake significant physical activity during the initial days at altitude as compared to mountaineers, trekkers and tourists indulging in adventure sport at altitude. The average sedentary soldier may not, therefore, notice fatigue as an early and prominent symptom of HAPE.
Not all patients of HAPE in our study showed tachycardia as defined by a heart rate of more than 100 bpm. Only 48.9% of patients had a heart rate of more than 100 bpm, suggesting that more than half of the patients (51.1%) developing HAPE at altitudes of 2700–3500 m may not manifest tachycardia. The magnitude of increase in heart rate is known to be proportional to the altitude of ascent and the severity of illness.9, 10 The lower heart rates in the study population could be due to a number of reasons. Possible among these are the altitude in question (2700–3500 m), which is lower compared to some of the other reports of HAPE, a less severe illness in these patients, possibly the result of the condition being diagnosed early, the relatively sedentary nature of activities performed at HA by acclimatising soldiers and a possible lower resting heart rates in soldiers due to their physical conditioning. The proposed criterion of a heart rate greater than 95 bpm appears to have better sensitivity for diagnosis of HAPE compared to a value of >100 bpm (0.66 vs 0.49), while retaining a high specificity (0.94).
Patients of HAPE are known to have high respiratory rates. How high should these rates be to suggest a diagnosis of HAPE? Using the conventional definition of tachyapnea, i.e. a respiratory rate greater than 20 per minute, the sensitivity and specificity of this parameter for diagnosing HAPE are found to be 0.83. However, selecting a value of 21 breaths/min improved the specificity to 0.95 while maintaining a sensitivity of 0.83.
Though pulse oximetry at HA has its limitations and may not by itself serve as a diagnostic parameter, the information obtained via pulse oximetry, if carried out with due caution, may supplement the overall clinical picture. In the present series of patients, 85% of the patients had SPO2 values below 88%, which is the expected SPO2 value in healthy individuals breathing room air at 3000 m. Pulse oximetry may have utility in monitoring the progress of the condition and efficacy of treatment in HAPE patients.
The ROC analysis of HR, RR and SPO2 revealed that each of the three parameters is very good as diagnostic parameters for HAPE since their areas under the curve range from 0.86 to 0.88. Areas between 0.8 and 0.9 indicate good tests and between 0.9 and 1.0, excellent.4 Of the three parameters, SPO2 appears the best parameter since it had the highest AUC (0.88). The cut-off values suggested from the ROC analysis for these three parameters show very encouraging levels of specificity and sensitivity for their use as parameters for diagnosing HAPE occurring between 2700 m and 3500 m.
Positive and negative predictive values of a diagnostic test are influenced by the prevalence of the disease. As disease prevalence increases in a population, application of the test criteria to that population yields higher positive predictive values and lower negative predictive values. Since the true prevalence of HAPE has been variably reported in literature and may differ among population groups, the values presented in this study should be interpreted keeping this fact in mind and would change, should the disease prevalence be different from that of the present study.
Despite best attempts to prevent its occurrence, HAPE does occur in a number of individuals at HA. A prompt diagnosis of the condition is thus essential, to prevent worsening of the condition and possible fatality. The criteria for diagnosing HAPE need to be reliable, objective, yet simple to use in remote locations by non-medical and para-medical personnel at peripheral medical facilities. While the LL criteria are accepted globally for the clinical diagnosis of HAPE, they are fairly general and not altitude specific. It is therefore suggested that in the setting of recent arrival at 2700–3500 m, an individual with symptoms of breathlessness, cough, chest discomfort and headache, with values of HR, RR and SPO2 as discussed above, is likely to be a patient with HAPE and should be managed accordingly (Table 8). The criteria suggested by this study show better specificity, without compromising the sensitivity, as compared to the existing LL criteria for diagnosing HAPE.
Table 8
A comparison of the existing Lake Louise criteria for diagnosis of HAPE and the proposed criteria of the present study.
Existing criteria (Lake Louise)
Proposed criteria
History of recent ascent to high altitude History of arrival at high altitude (2700–3500 m) within last 5 days
Any two of the following symptoms Symptoms
• Dyspnoea at rest
Any two of the following symptoms Symptoms
• Dyspnoea at rest
• Breathlessness
• Cough
• Cough
• Cough
• Weakness or decreased exercise performance • Chest discomfort
• Chest tightness or congestion • Headache
• Chest tightness or congestion • Headache
Any two of the following signs Signs
• Crackles or wheeze in at least one lung field • Heart rate > 95 beats/min
• Central cyanosis • Respiratory rate > 21/min
• Tachycardia • SPO2 < 86%
• Tachypnoea
• Crackles or wheeze in at least one lung field • Heart rate > 95 beats/min
• Central cyanosis • Respiratory rate > 21/min
• Tachycardia • SPO2 < 86%
• Tachypnoea
Limitations
This study is based on the retrospective analysis of clinical records and limited by the information contained therein. It is assumed that the documentation of the clinical history and findings in the records are accurate. The clinical criteria suggested for the diagnosis of HAPE by this study need to be validated by applying them prospectively to cases of HAPE being diagnosed and managed at HA and documenting the applicability of these criteria. Once validated, these criteria can be suggested for the field diagnosis of HAPE at altitude between 2700 m and 3500 m.
This study is based on the retrospective analysis of clinical records and limited by the information contained therein. It is assumed that the documentation of the clinical history and findings in the records are accurate. The clinical criteria suggested for the diagnosis of HAPE by this study need to be validated by applying them prospectively to cases of HAPE being diagnosed and managed at HA and documenting the applicability of these criteria. Once validated, these criteria can be suggested for the field diagnosis of HAPE at altitude between 2700 m and 3500 m.
2023-10-15 野外及登山醫學上課內容
後記: 結果只講了高海拔疾病. 外傷部分講了一點點.
請上課學員加入這個FB社團: 野外與登山醫學
1. 高海拔疾病
2. 基本外傷處置: 止血固定包紮搬運
3. 熱急症: 中暑
4. 凍傷/失溫/壕溝足/雪盲/皮膚龜裂
5. 燒燙傷
6. 動物傷害. 蜂螫/蟲咬/硬蜱/蛇咬傷/恙蟲病/隱翅蟲灼傷/其他
7. 全身嚴重過敏反應 anaphylaxis 辨識及處置
8. 溺水
9. 海洋生物毒性反應
疾病的動畫模擬
1. 氣胸動畫1
氣胸動畫 2
胸腔負壓可以用引流瓶的水柱呈現(壓力大約是負 4-8公分水柱) (氣球與空瓶演示)
張力性氣胸使用14號靜脈留置針減壓
手術造成的皮下氣腫使用空針減壓(接上裝水的針筒可見氣泡冒出) (針十病患)
使用真實動物肺臟演示張力性氣胸 (真的肺臟)
使用空針減壓治療狗的氣胸 (真的狗)
開放性氣胸動畫
真實手術錄影-胸腔鏡-置入通氣管 pigtail 之後肺部膨脹恢復
1. 氣胸動畫1
氣胸動畫 2
胸腔負壓可以用引流瓶的水柱呈現(壓力大約是負 4-8公分水柱) (氣球與空瓶演示)
張力性氣胸使用14號靜脈留置針減壓
手術造成的皮下氣腫使用空針減壓(接上裝水的針筒可見氣泡冒出) (針十病患)
使用真實動物肺臟演示張力性氣胸 (真的肺臟)
使用空針減壓治療狗的氣胸 (真的狗)
開放性氣胸動畫
真實手術錄影-胸腔鏡-置入通氣管 pigtail 之後肺部膨脹恢復
2. 肺水腫
這段影片演示體液循環與水腫關係 Capillary Exchange and Edema, Animation
3. 全身性嚴重過敏反應
過敏原-肥大細胞Ige-組織胺-蕁麻疹-搔癢-血管性浮腫-氣管痙孿-低血壓-心跳過慢(影片3分21秒.從33秒開始)
註: 下面這段是google搜尋到的
肥大細胞（mast cell），發育源於骨髓CD34+前體細胞，是連接神經系統和免疫系統的橋梁，因為靠近周圍神經末梢而很早就可以感受神經纖維的活動。 肥大細胞激活後，可以釋放炎症因子並募集免疫細胞。
註: 下面這段是google搜尋到的
肥大細胞（mast cell），發育源於骨髓CD34+前體細胞，是連接神經系統和免疫系統的橋梁，因為靠近周圍神經末梢而很早就可以感受神經纖維的活動。 肥大細胞激活後，可以釋放炎症因子並募集免疫細胞。
4. 蛇咬傷
台中榮總毒物科製作的手冊(毛主任說可以分享)
台中榮總毒物科製作的手冊(毛主任說可以分享)
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