Patient education: High-altitude illness (including mountain sickness) (Beyond the Basics)

INTRODUCTION — 

Ascending to or being at a new high altitude may cause high-altitude illness (HAI). HAI includes acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). HAI is caused by lower oxygen levels in the air and thus the blood. Travel to high altitude may also exacerbate certain pre-existing medical conditions. While 8000 feet (2500 meters) is considered the usual threshold altitude for HAI, some persons are more sensitive to lower oxygen levels and may become ill at 5000 to 7000 feet (1500 to 2100 meters).

It is generally possible to prevent HAI by ascending slowly and allowing your body to adjust gradually. Serious complications can be avoided by monitoring early signs and symptoms of high-altitude illness and responding promptly.

This article will review the prevention and treatment of high-altitude illness. More detailed information is available by subscription. (See 'Professional level information' below.)

RISK FACTORS — 

It is impossible to know if you will get sick when traveling to a high altitude. Being physically fit does not lower your chances of developing a high-altitude illness. However, certain groups are at increased risk, including people who:

●Have a prior history of high-altitude illness

●Overexert themselves before adjusting to the change in altitude

●Ascend rapidly (eg, within one day) from low elevation to sleeping altitudes above 9000 feet (2750 m)

●Ascend rapidly (>1640 ft [500 m] in sleeping altitude, when already above 9000 feet [2750 m])

●Have a medical problem that affects breathing

PREPARING TO TRAVEL — 

If you will be sleeping at altitudes above 8000 feet (2400 m) and have concerns about developing altitude sickness due to previous episodes or other risk factors, you should schedule an appointment with a knowledgeable health care provider. During this visit, discuss your travel plans, the availability of medical care at your destination, and the potential need for medications to prevent and/or treat high-altitude illness. Methods for reducing risk and treating altitude sickness are discussed in greater detail below. (See 'AMS prevention' below and 'AMS treatment' below.)

Traveling with medical conditions — People with certain medical conditions need to take special precautions when traveling at high altitudes:

●If you have diabetes and check your blood sugar, be aware that blood glucose meters can provide inaccurate results at high altitudes. Consult the manufacturer of the meter for recommendations regarding high altitude readings.

●If you have angina or have had a heart attack in the past, consult your doctor to ensure it is safe to travel to high altitudes. If you experience chest pain, shortness of breath, or dizziness while traveling, seek medical help immediately.

●Asthma does not worsen at high altitudes, but cold-induced bronchospasm should be considered in low-temperature environments at high altitude.

●If you use oxygen due to lung disease, you will require a higher oxygen flow rate at high altitude. Even if you don't need oxygen for your lung disease at home, you might need it at high altitude. Consult your doctor before traveling. You may want to bring a pulse oximeter to monitor your blood oxygen levels. (See "Patient education: Supplemental oxygen on commercial airlines (Beyond the Basics)".)

●If you have sickle cell disease, you will likely need oxygen if you travel above 7000 feet (2100 m). If you have sickle cell trait (some people are unaware they have it), altitude-related complications (eg, spleen injury) can occur even at altitudes below 9000 feet (2700 m), although this is uncommon.

●If you have lung disease, such as COPD, cystic fibrosis, pneumonia, pulmonary hypertension, or sleep apnea, you should check with your doctor prior to travel to high altitude.

●If you have high blood pressure, be aware that traveling to high altitudes could raise or sometimes lower your blood pressure; at times, your BP medication may need adjustment. Discuss this with your doctor.

●If you are pregnant, traveling to sleeping altitudes of 8000 to 9000 feet is not risky for a normal pregnancy. However, if you have any pregnancy complications or if you are a smoker, discuss altitude travel with your doctor.

ACUTE MOUNTAIN SICKNESS — 

Acute mountain sickness (AMS) is the most common of the altitude illnesses; it occurs in approximately 40 to 50 percent of people who live at a low altitude and travel to sleep at an altitude above 10,000 feet (3000 m), and in approximately 25 percent of those sleeping above 8000 feet (2400 m). Some people can develop AMS as low as 6500 feet (2000 m).

Symptoms typically occur within 6 to 12 hours after arriving at altitudes above 8000 feet (2400 m). They can begin as soon as one hour or as long as 24 hours after arrival. AMS does not develop after acclimatizing to a specific altitude for three or more days.

AMS prevention

Ascend slowly — Ascending slowly is the best way to avoid AMS. Experts recommend the following:

●If you live below 5000 feet (1500 m), avoid ascending rapidly. On the first night, avoid sleeping above 9000 feet (2750 m).

●If you plan to travel above 9800 feet (3000 m), do not increase your sleeping altitude by more than 1600 feet (500 m) per day as you ascend. Plan a rest day for every 3300 feet (1000 m) you gain. On this rest day, avoid over-exerting yourself.

●Climb high and sleep low. Hike to a higher altitude during the day and return to a lower elevation for sleeping at night. This practice will help you adjust to the altitude.

●If you plan to ski, hike, or climb, avoid overexerting yourself during the first few days at altitude. It's very important to pace yourself. Limit your use of alcohol and sleeping pills, particularly as you adjust to the altitude in the initial two days.

●Staying or hiking at elevations above 4900 feet (1500 m) in the weeks leading up to your ascent may help you ascend more quickly.

●If you regularly consume caffeine (coffee, tea, soda), do not stop before or during your trip. Caffeine is safe at high altitudes, and abruptly ceasing its intake can lead to symptoms similar to AMS.

These suggestions are particularly important if you have had AMS or another high-altitude illness previously.

Consider taking a preventive medicine — Preventive treatment with a medicine may be recommended if you have had high-altitude illness previously or if you must ascend quickly. (See 'AMS treatment' below.)

If you have had high-altitude illness before, you may be able to avoid taking preventive medicines by ascending slowly. If you require medication, you will need a prescription for these treatments.

●Prevention typically involves a medication called acetazolamide (brand name: Diamox), which you begin taking the day before your ascent and continue for 48 hours or until you reach the highest point of your trip. Acetazolamide accelerates the acclimatization process.

Acetazolamide can temporarily make carbonated drinks taste unpleasant. Other side effects can include urinating more frequently, numbness or tingling in the hands or feet, nausea, drowsiness, or blurry vision. Acetazolamide is not recommended during pregnancy.

Acetazolamide is a sulfa medicine, but many people with an allergy to sulfa antibiotics can take acetazolamide without a problem. If you have had anaphylaxis or Stevens-Johnson syndrome from a sulfa drug, you should avoid acetazolamide. If you are unsure, talk to your doctor or nurse before traveling. (See "Sulfonamide hypersensitivity", section on 'Cross-reactivity'.)

●Dexamethasone is a steroid that may be recommended as preventive treatment if you are allergic to acetazolamide or do not tolerate it.

●Taking aspirin or ibuprofen can help prevent the headache that often occurs with AMS. If you will be ascending quickly, you can start taking aspirin or ibuprofen before you ascend. Otherwise, take it only if you develop a headache.

AMS symptoms — The symptoms of AMS are similar to a hangover, and include:

●Headache

●Feeling tired

●Lightheadedness or dizziness

●Lack of appetite

●Difficulty staying asleep (waking frequently)

●Nausea, sometimes with vomiting

These symptoms can range from mild to severe. AMS symptoms are often the worst after the first night but typically improve within one day if you do not ascend to a higher altitude. However, symptoms may return as you travel higher. In some cases, symptoms can persist for days, even if you do not climb higher.

If you develop signs of AMS, you should NOT go higher until your symptoms have resolved (usually within 24 hours). You should rest and avoid drinking alcohol and taking sedatives or sleeping pills as you recover.

This may mean that you and your fellow travelers will be delayed or unable to go as high or as far as you had hoped. However, moving higher while you have symptoms of AMS can lead to serious complications.

AMS treatment — AMS treatment includes rest and descent and may also involve medications to relieve symptoms. You should refrain from exercising or ascending until your symptoms have resolved. Additionally, be aware of when you need to seek help. (See 'When to seek help' below.)

●Headache – You can take over-the-counter medications for headaches, such as aspirin, acetaminophen (brand name: Tylenol), or ibuprofen (sample brand names: Advil, Motrin).

●Nausea or vomiting – If you have nausea or vomiting, a prescription medicine like ondansetron (brand name: Zofran) may be helpful, if it is available.

●Descent – If your symptoms do not improve or worsen over 24 to 48 hours, descend to an altitude at which you feel better. Most people feel better after descending 1600 to 3300 feet (500 to 1000 m).

●Oxygen – If needed, treatment with supplemental oxygen via tank or concentrator can reduce the symptoms of AMS. You can use oxygen for a period of time (eg, one hour), only when you have symptoms, or while sleeping, which is especially helpful. Small handheld canisters of oxygen that provide only a few breaths of oxygen are unlikely to provide sustained relief. Home oxygen companies are present in most high-altitude resort areas, and your doctor should be able to call in a prescription for oxygen.

●Acetazolamide – Acetazolamide is a prescription medication that treats and prevents AMS.

●Dexamethasone – Dexamethasone is a steroid that also treats and prevents AMS, but is usually reserved for treatment. You can take dexamethasone with acetazolamide, if needed. Dexamethasone increases blood sugar levels in people with diabetes.

When to seek help — AMS symptoms should improve as you adjust to the altitude, usually within 24 to 48 hours. If your symptoms worsen at any point, you should descend or seek help.

HIGH-ALTITUDE CEREBRAL EDEMA — 

High-altitude cerebral edema (HACE) is a rare, life-threatening severe form of acute mountain sickness (AMS). It occurs due to leaky capillaries in the brain, leading to fluid accumulation and swelling.

HACE prevention — HACE can be prevented with the measures discussed above. (See 'AMS prevention' above.)

HACE symptoms — HACE usually occurs within one to three days after traveling above 9800 feet (3000 m). Symptoms may include:

●Severe exhaustion or weakness

●Drowsiness, confusion, or irritability

●Difficulty walking straight

●Acting drunk

HACE treatment — HACE is a medical emergency, and you should immediately descend to a lower altitude. Waiting to descend can be disastrous; symptoms can worsen quickly, and you may not be able to walk. Delaying descent increases the risk of life-threatening complications or even death.

Besides descent, other HACE treatments include:

●Supplemental oxygen – If available, it should be provided during descent or as a temporary measure until descent is possible. Oxygen can be used inside a hyperbaric chamber.

●Portable hyperbaric chamber – Treatment in a portable hyperbaric chamber (with or without supplemental oxygen) can be lifesaving until descent is possible. (See 'Portable hyperbaric chamber' below.)

●Dexamethasone – This is an important medicine to have on hand if you plan to sleep above 9800 feet (3000 m). Take it immediately if you develop signs of HACE, with the recommended dose being 8 to 10 mg by mouth. Take 4 mg every six hours thereafter until you have descended. Take dexamethasone before entering a hyperbaric chamber.

Portable hyperbaric chamber — Portable hyperbaric chambers are inflatable pressure bags used in remote settings to treat people with HACE when immediate descent is not feasible. You are zipped into the chamber, and the device is inflated with a foot pump (picture 1).

When inflated, the air pressure inside the chamber is more like the air you breathe at lower altitudes. This increases the amount of oxygen in your blood, relieving symptoms of high-altitude illness quickly. You can remain in the chamber for several hours.

HIGH-ALTITUDE PULMONARY EDEMA — 

High-altitude pulmonary edema (HAPE) is a potentially fatal condition in which lung capillaries leak and fluid accumulates in the lungs. HAPE is uncommon but can occur in people who rapidly ascend to altitudes above 8200 feet (2500 m).

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 m). Preventive medicines may include nifedipine (commonly used to treat high blood pressure), tadalafil, dexamethasone, or acetazolamide. (See "High-altitude pulmonary edema".)

HAPE symptoms — Symptoms of HAPE include cough (often with pink, frothy sputum), breathlessness with activity and at rest, and difficulty walking uphill. These symptoms usually begin two to four days after arriving at altitude. You may or may not experience acute mountain sickness (AMS). (See 'AMS symptoms' above.)

Symptoms can worsen, and you may feel more short of breath, even while resting. You may also begin to cough up pink, frothy sputum (spit).

HAPE treatment — HAPE is a medical emergency. You should seek medical care or descend as soon as possible if you develop symptoms. Waiting to descend can be disastrous; symptoms can worsen quickly, and you may not be able to walk. Waiting also increases the risk of developing life-threatening complications or even death. (See "High-altitude pulmonary edema".)

Besides descent, other HAPE treatments include:

●Supplemental oxygen – This is the most effective treatment and should be started immediately. It should be continued until symptoms resolve. Oxygen may be lifesaving if descent is not possible. In areas with medical care, oxygen and observation are often sufficient, and descent may not be necessary.

●Portable hyperbaric chamber – Treatment in a portable hyperbaric chamber may serve as a temporary measure until descent is feasible. You can utilize oxygen inside a hyperbaric chamber. (See 'Portable hyperbaric chamber' above.)

●Nifedipine or other medicines may be helpful if oxygen is unavailable and descent is impossible.

●Stay warm and avoid cold temperatures.

●Rest; this includes not carrying a pack while descending.

WHERE TO GET MORE INFORMATION — 

Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces 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.

Patient education: High-altitude illness (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Supplemental oxygen on commercial airlines (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up to date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute mountain sickness and high-altitude cerebral edema
Approach to patients with heart disease who wish to travel by air or to high altitude
High-altitude illness: Physiology, risk factors, and general prevention
High-altitude pulmonary edema
Sulfonamide hypersensitivity

The following organizations also provide reliable health information:

●United States Center for Disease Control and Prevention

(wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/altitude-illness)

●International Society for Mountain Medicine

(www.ismmed.org)

●Institute for Altitude Medicine

(www.altitudemedicine.org)

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