1. Trauma Related High-Altitude Pulmonary Edema
Christine Ebert-Santos
Ebert Family Clinic - Frisco, Colorado
High-altitude pulmonary edema (HAPE) is caused by the abrupt change in barometric pressure with subsequent decrease in partial pressure of O2 that causes pulmonary hypertension leading to pulmonary edema and worsened hypoxemia.
Symptoms of HAPE include nonproductive cough, dyspnea on exertion, and reduced exercise tolerance. Clinical features are cyanosis, tachycardia, tachypnea and elevated body temperature, generally not exceeding 38.5C. Rales in one or both lungs strengthens diagnosis.
HAPE affects lowlanders ascending quickly to elevations above 2440m. Mountain residents are susceptible to reentry HAPE and may also develop HAPE without travel.1
Arriving at altitude with an underlying inflammatory process is known to increase susceptibility to HAPE.2 Victims of chest trauma with pulmonary contusions and/or rib fractures also fall into this category.
INTRODUCTION
Figure 1a: CXR displaced fractured ribs 5-8 on the right side laterally and posteriorly with no other cardiopulmonary abnormalities. PE showed HR 86, RR 27, BP 120/75, temp 97.7F, O2 sat 94 on 2 lpm. He was weaned to room air and discharged the next day.
Figure 1b: PE vitals showed HR 102, RR 22, temp 99.3F, BP 151/90 and O2 sat 49%. He was placed on high-flow oxygen at 15 lpm. Auscultation revealed B/L rales and tachypnea. Low lung volumes visualized in RLL. Patient was diagnosed with HAPE and transferred to lower altitude.
10/17/17 at 0615 & 1609m
10/18/17 at 2215 & 2800m
Victims of chest trauma with rib fractures and/or small pleural contusions are treated outpatient or with a brief hospitalization. At home, they will experience pain and dyspnea which will be ascribed to their injury. Pain medications may further depress ventilation.
Most patients and caregivers will not recognize hypoxia until it reaches critical levels. Hypoxia is aggravated by injury and reaction in the lungs at high altitude, predisposing them to fulminant HAPE.
A study performed on Swiss/Italian border located at 4559m showed that 50% of visitors to high altitude may have asymptomatic fluid accumulation in the lungs, consistent with occult edema. This usually resolves spontaneously even though subjects remain at high altitude.3
In our experience, patients at altitude can get edema that manifests as hypoxia, fatigue and cough.
Figure 3: follow-up x-ray showing small right pleural effusion, but patient was stable on room air.
DISCUSSION
11/3/18 at 2800m
CASE REPORT
35-year-old male was a victim of a pedestrian-vehicle accident. He had no loss of consciousness and was transported by ambulance to a hospital located at 1609m elevation.
After initial evaluation (Figure 1a), admission, and stabilization the patient was discharged home at 2800m the next day on room air with O2 saturation in the 90s. Within a few hours, he developed increasing shortness of breath with difficulty walking across the room. He initiated oxygen at home at 2-5 lpm before getting a pulse oximeter reading of 77%. He denied change in his level of pain. His family drove him to the local hospital where his O2 sat was 49% (Figure 1b).
He was stabilized in the ED locally (2800m) and then transferred to lower elevation. A CT was performed and he was admitted to ICU at 1609m and weaned from 15 lpm O2 to 5 lpm over 8 hours.
HAPE is a rapidly evolving and potentially fatal complication of hypoxia at altitude.
Although recognized as a disease of visitors, mountain residents are also at risk. Awareness of the potential for this complication in victims of chest trauma returning to altitude is key in early detection and recognition and potentially even prevention of HAPE.
Access to home pulse oximetry and oxygen can be life-saving, as it was in this case. It can also lead to a diagnosis of hypoxia before symptoms become more severe and progress to imaging showing obvious infiltrates.
CONCLUSION
Figure 2a (LEFT): CT of the chest revealed a small right pleural effusion as well as small pulmonary contusions in the lateral right lobe adjacent to rib fracture. Near complete atelectasis of the RLL and pleural effusion. Figure 2b (RIGHT): right pleural effusion evacuated s/p chest tube placement.
10/18/17 at 1609m
10/24/17 at 1609m
10/20-22
10/23/17
10/25/17
10/26/17
10/27/17
Monitoring of the patient’s progress with imaging showing increasing lung fluid volumes
Chest tube placed
CT scan shows “continued subsegmental atelectasis” with improvement from last image
Chest tube removed after initial output of 240cc
Resolution of the fluid and reexpansion of the right lung base. Patient discharged
REFERENCE/ACKNOWLEDGEMENTS/ DISCLOSURE
(1) Ebert-Santos, C. (2017). High-Altitude Pulmonary Edema in Mountain Community Residents. High Altitude Medicine & Biology Vol 18, Number 3, 2017.
(2) Durmowicz AG, Noordewier E, Nicholas R, and Reeves JT. (1997). Inflammatory processes may predispose children to high-altitude pulmonary edema. J Pediatr 130:
(3)Cremona G, Asnaghi R, Baderna P, Brunetto A, Brutsaert T, Cavallaro C, et al. Pulmonary extravascular fluid accumulation in recreational climbers: A prospective study. Lancet 2002;359:303‐9.
This research was funded by Ebert Family Clinic. No competing financial interests exist. This case study was performed with the help of PA students Sierra Miller and Andrea King. Poster prepared by Katie Newton PA-S.