Altitude sickness

Acute altitude sickness occurs when an individual who is accustomed to low altitudes rapidly climbs to high altitude. Altitude sickness is a potentially lethal complication of climbing to altitudes above 8,000 feet.

Three main syndromes of altitude illness may affect travellers: acute mountain sickness, high altitude cerebral oedema (HACO), and high altitude pulmonary oedema (HAPO)

• risk of dying from altitude related illnesses is low, at least for tourists. For trekkers to Nepal the death rate from all causes was 0.014% and from altitude illness 0.0036%
• soldiers posted to altitude had an altitude related death rate of 0.16%

Clinical features of mild altitude sickness are (1):

• headache
• loss of appetite
• nausea
• fatigue
• dizziness
• insomnia
• extremity oedema
• dyspnoea
• palpitations

There is an increased mortality in patients with acute altitude sickness.

Definitions of altitude and associated physiological changes

Intermediate altitude (1500-2500 metres)

• physiological changes detectable
• arterial oxygen saturation >90%
• altitude illness possible but rare

High altitude (2500-3500 metres)

• altitude illness common with rapid ascent
• very high altitude (3500-5800 metres)
• altitude illness common
• arterial oxygen saturation <90%
• marked hypoxaemia during exercise

Extreme altitude (>5800 metres)

• marked hypoxaemia at rest
• progressive deterioration, despite maximal acclimatisation
• permanent survival cannot be maintained

Treatment of altitude related illness is to stop further ascent and, if symptoms are severe or getting worse, to descend

• oxygen, drugs, and other treatments for altitude illness should be viewed as adjuncts to aid descent

Prevention of acute mountain sickness (AMS) (3)

• acetazolamide can be used for preventing AMS according to the National Travel and Health Network Centre and Fit For Travel recommendations (not licensed for this this indication)
• acetazolamide prevents AMS by mimicking the body naturally adjusting to a change in environment
• a Cochrane review demonstrated acetazolamide reduced the risk of AMS vs placebo by a factor of 0.47 (n=2,301, 16 studies). Acetazolamide was administered one to five days prior to ascent with doses of up to 500mg/day to adults at risk of AMS
• overall, evidence for the use of the medicines listed below to prevent AMS is inconclusive and for some, side effects are a concern:
  • aspirin
  • dexamethasone
    • Using dexamethasone has been suggested by some organisations to help prevent AMS. However, the Cochrane review (n=176) assessing four parallel studies comparing dexamethasone with placebo found dexamethasone does not prevent AMS at any dose and does not aid acclimatisation.
  • ibuprofen
  • iron supplements
  • magnesium citrate
  • spironolactone
  • sumatriptan

Reference:

• 1. Pulse (2002), 62 (31), 36.
• 2. Barry PW, Pollard AJ. Altitude illness. BMJ 2003;326:915-919
• 3 NHS Specialist Pharmacy Service (April 2022). Using medicines for preventing acute mountain sickness