Healthcare Provider Information
on Prevention and Treatment of Altitude Illness

Advice to give patients traveling to altitude

Drink an extra liter to liter and a half of water when coming to altitude. If possible, spend a night at intermediate altitude (Denver, Montrose, Durango, or Ridgway) before coming to above 9000 ft to sleep. Limit strenuous activity on the first 1-2 days at altitude. Avoid alcohol for the first 1-2 days at altitude. Caffeine is okay at altitude. Consider medical prophylaxis if patient has a history of prior AMS or HAPE or is coming directly to high altitude from below 4000 ft without spending a night in between. There are a few medical conditions that might require prophylactic use of medications or oxygen while at altitude. Please feel free to contact the Institute for Altitude Medicine for advice on this issue.

Prophylaxis of Acute Mountain Sickness

Diamox (acetazolamide) 125 mg by mouth twice daily (Peds 3-5 mg/kg/day divided by mouth twice daily) 1 day prior to ascent, then continued for 2 days at maximum sleeping altitude, (drug of choice) or
Decadron (dexamethasone) 4-8 mg by mouth twice daily 1 day prior to ascent, then continued for 2 days at maximum sleeping altitude, or
Ginkgo Biloba 100 mg (over the counter) by mouth twice daily started 3-5 days prior to ascent then continued for 2-3 days at maximum sleeping altitude (Recommended if your patient wishes to try a nonprescription alternative; not as effective as Diamox.)

Prophylaxis of High Altitude Pulmonary Edema

Cialis (tadalafil) 10 mg by mouth twice daily starting day before ascent, then continued for 2-4 days at maximum sleeping altitude, or
Viagra (sildenafil) 20 mg by mouth twice daily starting the day before ascent then continued for 2-4 days at maximum sleeping altitude, or
Nifedipine XR 30 mg by mouth twice daily starting day before ascent, then continued for 2-4 days at maximum sleeping altitude , or
Decadron (dexamethasone) 8 mg by mouth twice daily 1 day prior to ascent, then continued for 2-4 days at maximum sleeping altitude (Do not take for more than 5-7 days continuously), or
Diamox (acetazolamide) 125 mg by mouth twice daily starting the day before ascent then continued for 2-4 days at maximum sleeping altitude: this is our recommendation, prevents both AMS and HAPE.
Salmeterol 5 puffs twice daily starting day before ascent, then continued for 2-4 days at maximum sleeping altitude.

Diagnosis of Acute Mountain Sickness

History of recent ascent (within 24 hrs) to altitude with a headache is the basic clinical diagnosis. For research purposes a Lake Louise Score of 3 or higher meets the diagnosis for AMS. Please see the AMS worksheet to aid in field diagnosis and serial evaluations of the patient with AMS. In the clinical setting, high altitude headache associated with AMS should resolve within 10-15 minutes of oxygen. Consider other diagnoses if headache does not improve with oxygen therapy.

Treatment of Acute Mountain Sickness

Supplemental oxygen 2 liters per minute in medical setting until symptoms improved. AMS headache typically resolves within 10-15 minutes of supplemental oxygen. If headache has not resolved with oxygen, consider other diagnoses for headache. If symptoms resolve patient may be discharged home on supplemental oxygen 2 liters per minute on a portable oxygen device and/or an oxygen concentrator for 24 hours, or
Tylenol 650 mg to 1 gm by mouth every 6 hours as needed until symptoms improve (for those with mild symptoms), or
Motrin 400-600 mg by mouth every 6 hours as needed until symptoms improve (for those with mild symptoms), or
Diamox 125 mg by mouth twice daily (Peds 3-5 mg/kg/day divided by mouth twice daily) for 2 days, or
Decadron 4-8mg by mouth twice daily for 1-2 days, or
No medications (just rest) if mild symptoms (Reserve this option for mild symptoms only or those patients who prefer not to take medications at all.)

For other symptoms of altitude illness, consider adding any of the following:

Zofran (ondansetron) 4-8 mg oral dissolve tablets every 6 hours as needed for nausea/vomiting (preferred as there are less side effects)

Compazine (prochlorperazine) 10 mg by mouth or 20 mg suppository per rectum every 3-4 hours for nausea and vomiting (if not responding to Zofran)

Phenergan (promethazine) 12.5-25 mg by mouth or 25 mg suppository per rectum every 4-6 hours as needed (if not responding to Zofran or Compazine)

Treatment of Periodic Breathing

Diamox (acetazolamide) 62.5 mg by mouth before bedtime

For other sleep disturbances at altitude:

Ambien (zolpidem) 5-10 mg by mouth before bedtime as needed for sleep
Ambien CR (controlled release) 12.5 mg by mouth before bedtime as needed for sleep
Lunesta (eszopiclone) 1-3 mg by mouth before bedtime as needed for sleep

Advice to give patients: Adequate hydration, avoid alcohol and sedatives such as benzodiazepines. Rest and avoid strenuous activity. Gradual return to activity after symptoms resolved. Advise prophylaxis for next trip to altitude.

Diagnosis of High Altitude Pulmonary Edema

Development of symptoms within 2-4 days after arrival to altitude.
Symptoms; shortness of breath at rest or increasing with exertion, increasing fatigue, cough, chest congestion, or dizziness.
Clinical findings; hypoxia at rest or with exertion, crackles or rales on lung exam, tachypnea, tachycardia AND infiltrate on chest x-ray. The HAPE Severity Score may be useful in determining severity and in serial evaluations.

Treatment of High Altitude Pulmonary Edema

Supplemental oxygen: Hi-flow oxygen in an emergency setting for 1-2 hours. Assess if the patient is able to maintain SaO2 -> 90%* on 2-4 liters per minute. If unable to maintain SaO2 > 90%* continue O2 in ED or admit until able to maintain SaO2 -> 90%* on 2-4 liters per minute. Once able to maintain SaO2 -> 90% *on 2-4 liters per minute and no other contraindications patient may be discharged home with oxygen at 2-4 liters per minute continuously with portable oxygen or an oxygen concentrator and rest with light activity only. Re-check patient every 24 hours until their room air ambulatory SaO2 > 90%*. Once room air ambulatory SaO2 on RA > 90%* for 24 hrs, allow gradual return to activity, consider gradual return to more vigorous activity (eg, hiking, skiing) 48 hrs after RA ambulatory sat > 90%*.

Oxygen therapy is sufficient to treat HAPE, no medication is necessary if oxygen is available. However, if oxygen is not available, you may consider giving medical therapy with the following:

Cialis (tadalafil) 10 mg by mouth every 12 hours until down to lower altitude
Viagra (sildenafil) 20 mg by mouth every 12 hours until down to lower altitude
Nifedipine 10 mg by mouth, then 30mg XR every 12-24 until down to lower altitude
Albuterol metered dose inhaler with spacer 2-4 puffs every 4 hours for 2 days

Advice post treatment for HAPE patients: Same as for AMS, except strongly emphasize need for slow ascent, limiting activity for first few days at altitude and medication prophylaxis. If plans for travel to higher elevations, particularly in remote settings, must emphasize significant risks involved, extreme caution with ascent, need for prophylaxis and education regarding signs/symptoms/dangers of HAPE.

*SaO2% of 90% is the average target value for altitudes of 8,000-9000 feet.

For a thorough altitude illness treatment and medication review please read Hackett PH, Roach RC, High Altitude Illness. New England Journal of Medicine, 2001. 345(2). p 107-114.

*Phosphodiesterase-5 Inhibitors such as Cialis and Viagra are quite effective in preventing HAPE and may have potential in treatment of HAPE. They also have fewer side effects of hypotension and tachycardia than nifedipine and are becoming the preferred choice of high altitude specialists.

*Decadron (dexamethasone) for prevention of HAPE is a new concept. It has been shown very effective in one study. General recommendations are not to take it for more than 3 consecutive days.

Healthcare Provider Information on Prevention and Treatment of Altitude Illness