野外與登山醫學- 高海拔肺水腫HAPE診斷- from uptodate

相關筆記

1. 高海拔肺水腫HAPE診斷-from StatPearls-High Altitude Pulmonary Edema(Archived)2017

2. 高海拔肺水腫HAPE診斷-from CDC

2025-08-05 15:01

筆記

1. HAPE 通常發生在抵達高海拔之後 2-4 天

2. 乾咳, 咳痰, 咳血痰, 極度疲憊, 運動時呼吸困難 DOE , 上坡困難

    靜止時呼吸困難, 端坐呼吸

3. 有些個案會發燒(通常低於38度C)

4. 血氧濃度低於預期值 10%

5. 聽診可聽到肺部有泡泡聲(濕囉音)

下面中文使用google 翻譯

平均肺動脈壓升高（超過 35 至 40 mmHg）似乎是高海拔肺水腫 (HAPE) 的起始因素, 另一個必要因素是血管收縮不均, 某些節段性和亞節段性毛細血管床由於血管收縮相對較弱，會不成比例地暴露於升高的平均肺動脈壓所導致的微血管壓力升高（>20 mmHg）。這種血管收縮不均和局部過度灌注會導致肺泡-毛細血管屏障功能障礙和斑狀肺水腫 [ 6 ]。

(收縮明顯的區域. 血流入的少. 因肺動脈高壓引起的滲漏較少. 收縮較弱的區域. 血流進去的多. 局部肺水腫較嚴重. 但隨著時間過去. 原本收縮較弱肺水腫較嚴重區域. 局部水腫會導致該部位缺氧更嚴重. 同時肺泡被水灌滿之後也無法容納更多滲出液. 能進入的血流也會逐漸減少. 血流開始流向肺水腫較輕微的區域. 直到整個肺部都淪陷. 無法提供足夠的氧氣到腦部及全身. 腦部缺氧後會造成昏迷. 心臟缺氧之後會逐漸停止跳動. 患者死亡)

(血管收縮比較大的區域, 流入的血流會減少. 局部微血管壓力上升幅度相對較小. 因此血漿滲漏到肺泡的現象會先從血管收縮比較少的區域先開始. )

隨著肺泡毛細血管屏障破壞的進展，高分子量蛋白質、細胞和液體滲漏到肺泡腔。最終，基底內皮細胞和上皮細胞膜遭到破壞，導致肺泡出血。

HAPE 的一個顯著特徵是，隨著海拔下降或簡單地給予氧氣，由於肺血管阻力和肺動脈壓力立即下降，這個過程可以迅速逆轉。 

High mean pulmonary artery pressure, over 35 to 40 mmHg, appears to be the initiating event. However, while elevated pulmonary artery pressure is essential for HAPE, it is insufficient. The other necessary factor is uneven vasoconstriction. Specific segmental and subsegmental capillary beds with relatively less vasoconstriction are disproportionately exposed to elevated microvascular pressures (>20 mmHg) from the elevated mean pulmonary artery pressure. This uneven vasoconstriction and regional overperfusion result in failure of the alveolar-capillary barrier and patchy pulmonary edema [6].

As disruption of the alveolar-capillary barrier progresses, high molecular weight proteins, cells, and fluid leak into the alveolar space. Eventually, basement endothelial and epithelial cell membranes are disrupted, leading to alveolar hemorrhage.

A striking feature of HAPE is the rapid reversibility of this process with descent or simply the administration of oxygen, due to the immediate drop in pulmonary vascular resistance and pulmonary artery pressure.

高海拔肺水腫通常根據病史和檢查結果進行臨床診斷。

初始症狀通常在到達高海拔地區後兩到四天出現，包括輕微乾咳、運動時氣短和上坡行走困難。兒童的症狀可能更為突然。

一到兩天後，咳嗽常常轉為咳痰。

早期從運動時呼吸困難進展為靜止時呼吸困難是一個主要特徵。

重要的身體檢查發現包括心跳過速、呼吸急促、低燒（最高 38°C）和肺部濕囉音。

血氧飽和度通常比特定海拔的預期值低至少 10 個點。

吸氧和休息治療可使病情迅速好轉。

若能照胸部x光. 更有助於確診(但在野外很難做影像檢查)

(**有可能是兒童生理代償較好, 在輕度肺水腫沒有明顯症狀, 到更嚴重的程度才被觀察到異常)

(以前老師教的, 兒童血管彈性好. 在休克初期, 血管能大幅度收縮維持血壓, 到了更嚴重休克才出現突然血壓驟降. 這時候往往很難救. 不知道是不是類似情況)

DIAGNOSIS
HAPE is typically diagnosed clinically based on the history and examination findings. The initial symptoms typically begin two to four days after arrival at high altitude, including 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 usually at least 10 points lower than expected for a given altitude. Treatment with supplemental oxygen and rest can lead to rapid improvement. When available, characteristic findings on imaging studies help confirm the diagnosis.