High altitude pulmonary edema: Known for short as HAPE, the accumulation in the lungs of extravascular fluid (fluid outside of blood vessels) at high altitude, a consequence of rapid altitude ascent, especially when that ascent is accompanied by significant exercise.. HAPE leads to dyspnea (shortness of breath), cough, tachycardia (fast heart rate) and decreased arterial … Get Permissions, Access the latest issue of American Family Physician. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. It is not used in the treatment of this condition. High altitude pulmonary edema (HAPE). [Full Text]. View Record in Scopus Google Scholar. Reviewed: October 18, 2019; Accessed: April 6, 2020. Altitude sickness, the mildest form being acute mountain sickness (AMS), is the negative health effect of high altitude, caused by rapid exposure to low amounts of oxygen at high elevation. [Medline]. [Medline]. 55, 84–88, 91–95 Some individuals, however, can In normal lungs, air sacs (alveoli) take in oxygen and release carbon dioxide. [2, 3] If supplemental oxygen is not available, initiate dexamethasone in addition to medications for HAPE in those with mental status changes and/or suspected concurrent HACE. Chapter 3: Environmental hazards & other noninfectious health risks. Gallegos A. COVID-19 daily: Ventilator protocols questioned, physician rights. High Altitude Pulmonary Edema (HAPE) ... you will need supplemental oxygen and may need medications, as well as moving to a lower altitude. High-altitude pulmonary edema (HAPE) is a life-threatening, noncardiogenic form of pulmonary edema afflicting certain individuals after rapid ascent to high altitude above 2,500 m (approximately 8,200 ft). The reported incidence of HAPE ranges from an estimated 0.01% of skiers traveling from low altitude to Vail, CO (2,500 m), to 15.5% of Indian soldiers rapidly transported to altitudes of 3,355 and 5,9… For the prophylaxis of altitude illness, start 24-48 hours before ascent and continue for 48 hours after arrival at high altitude. Prevention of high-altitude pulmonary edema by nifedipine. 23 (1):7-10. Enforcement policy for face masks and respirators during the coronavirus disease (COVID-19) public health emergency : guidance for industry and Food and Drug Administration staff. It is not used in the treatment of this condition. Don't miss a single issue. [Medline]. A chest X-ray will likely … Korzeniewski K, Nitsch-Osuch A, Guzek A, Juszczak D. High altitude pulmonary edema in mountain climbers. Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, Society of Critical Care MedicineDisclosure: Nothing to disclose. Immediate, unlimited access to all AFP content. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. There are patchy infiltrates throughout the lung tissue, with predominant changes in the right middle lobe/right central hemithorax. Learn symptoms, how to prevent and how to treat altitude sickness, also known as acute altitude illness. Qazi Qaisar Afzal, MD Clinical Instructor, Department of Medicine, State University of New York at Stony Brook The High Altitude Medicine Handbook. The Wilderness Medical Society does not use specific altitude thresholds for diagnosis. 2007 Summer. High-altitude pulmonary edema (HAPE) is a lethal, noncardiogenic form of pulmonary edema that afflicts susceptible individuals after rapid ascent to high altitude above 2,500 m. Prevention of HAPE is achieved most effectively by gradual ascent allowing time for proper acclimatization. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. 24 (1):32-6. Regardless of AMS history, all people are at high risk of AMS if they: (1) make a one-day ascent to a sleeping altitude above 11,500 ft (3,500 m); (2) make extremely rapid ascents (e.g., climbing Mt. [Medline]. 1991 Oct 31. Prevention of high-altitude pulmonary edema by nifedipine. Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness: 2014 update. 2015 Feb 10. Correlation between single nucleotide polymorphisms in hypoxia-related genes and susceptibility to acute high-altitude pulmonary edema. In the setting of concomitant HAPE and HACE, WMS recommends adding dexamethasone to the treatment regimen for patients with HAPE and neurologic dysfunction that does not resolve rapidly with administration of supplemental oxygen and improvement in the patient’s oxygen saturation. Zhou Q. [2, 3] Furthermore, WMS indicates there is no established role for acetazolamide, beta-agonists, diuretics, or dexamethasone in the treatment of HAPE, although dexamethasone should be considered where there is concern for concomitant high-altitude cerebral edema (HACE). Advances in the prevention and treatment of high altitude illness. Wilkins MR, Ghofrani HA, Weissmann N, Aldashev A, Zhao L. Pathophysiology and treatment of high-altitude pulmonary vascular disease. High-altitude pulmonary edema. High Alt Med Biol. 3rd ed. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzAwNzE2LW1lZGljYXRpb24=, History of acute mountain sickness and ascending more than 2,800 m in 1 day, All people ascending to more than 3,500 m in 1 day, All people ascending more than 500 m per day (increase in sleeping elevation) above 3,000 m, without extra days for acclimatization, Oral nifedipine (generally reserved for HAPE-susceptible individuals) - 30 mg sustained-release formulation every 12 hours (same regimen for HAPE treatment). encoded search term (High-Altitude Pulmonary Edema (HAPE)) and High-Altitude Pulmonary Edema (HAPE), Acute Respiratory Distress Syndrome (ARDS), Acute Respiratory Distress Syndrome (ARDS) Imaging, Pediatric Acute Respiratory Distress Syndrome, Fast Five Quiz: Acute Respiratory Distress Syndrome (ARDS), Symptoms and Management of Coronavirus Disease 2019 (COVID-19) FAQ, Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures, Lower-PEEP Strategy Promising in Critically Ill Patients Without Respiratory Distress, Prognostic Factors for 30-Day Mortality in Critically Ill Patients With Coronavirus Disease 2019, Pulse Oximeters Miss Low Oxygen Levels Nearly Three Times More Often in Blacks Than Whites, Score Predicts Risk for Ventilation in COVID-19 Patients, Intake of Vitamins A, E and D Tied to Respiratory Health, Stop Prescribing Nocturnal Oxygen to Patients With COPD, Asthma Clinical Practice Guidelines (JSA, 2020), Oxygen Use More Than Expected During Aero-Medevac of COVID Patients. Prophylactic low-dose acetazolamide reduces the incidence and severity of acute mountain sickness. Worcester S. Is protocol-driven COVID-19 ventilation doing more harm than good?. This clinical content conforms to AAFP criteria for continuing medical education (CME). 2011 Dec 15. [Medline]. 12(3):246-52. Kilimanjaro [19,341 ft (5,895 m)] in fewer than seven days); or (3) ascend to a sleeping altitude above 9,800 ft, then sleep more than 1,600 ft above the previous night's altitude without allowing a day off to acclimatize. Medical students demonstrate the use of a portable hyperbaric chamber. 2. Qazi Qaisar Afzal, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Medical Society of the State of New YorkDisclosure: Nothing to disclose. 2015 Sep 28. • Acetazolamide and dexamethasone can be used to prevent acute mountain sickness and high altitude cerebral edema, but only acetazolamide aids in acclimatization. High-altitude pulmonary edema (HAPE). Monitoring of expiratory flow rates and lung volumes during a high altitude expedition. Medscape Medical News. / Vol. High-altitude pulmonary edema responds best when the person descends from their current altitude. Axial computed tomography (CT) pulmonary angiogram showing thrombi as filling defects in the right main pulmonary artery (right arrow) extending into its branch and in the distal left pulmonary artery (left arrow) with extension into its superior branch. 2020 Mar 27. Medications that lower the pulmonary-arterial blood pressure are effective in the prevention of high-altitude pulmonary edema. Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine In: Weiss EA, Sward DG, eds. [Medline]. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris NS. Adv Exp Med Biol 2001; 502:89. Chest X-ray. Maggiorini M, Brunner-La Rocca HP, Peth S, et al. [Full Text]. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. [Medline]. April 5, 2020; Accessed: April 6, 2020. April 2020; Accessed: April 7, 2020. [Medline]. HAPE is characterized by reduced exercise tolerance, exertional dyspnea, and cough, followed by dyspnea at rest, cyanosis, and productive cough with pink frothy sputum. Please confirm that you would like to log out of Medscape. Ann Intern Med. High-altitude pulmonary edema (HAPE). [Medline]. J Am Coll Cardiol. J Travel Med. Once you are above 9,000 feet, increase your sleeping altitude b… High-Altitude Pulmonary Edema. Note the following: Nifedipine is used for its pulmonary vasodilating effects. afpserv@aafp.org for copyright questions and/or permission requests. This series is coordinated by Sumi Sexton, MD, editor-in-chief. Prevention and treatment of high altitude pulmonary edema (HAPE) February 2020; Journal of Education, Health and Sport 10(2):114; DOI: 10.12775/JEHS.2020.10.02.015 / afp 35(4):980-7. van Patot MC, Leadbetter G 3rd, Keyes LE, Maakestad KM, Olson S, Hackett PH. 2002 Unacclimatized people are at high risk of acute altitude illness when ascending above 8,200 ft (2,500 m), but AMS can occur as low as 6,500 ft (2,000 m). 2008 Sep-Oct. 15(5):315-22. Davis C, Hackett. 14 (3):11562-72. 2000 Mar 15. Prog Cardiovasc Dis. Nifedipine, for example, can be administered at a rate of 60mg of a timed-release preparation daily, in 2 or 3 divided doses. Symptoms may include headaches, vomiting, tiredness, trouble sleeping, and dizziness. Jensen JD, Vincent AL. The recommendation for its use is strongest for individuals with a history of HAPE. [4] : The CDC recommends the following pharmacologic agents and regimens for HAPE prophylaxis Samia Qazi, MD is a member of the following medical societies: American College of Physicians-American Society of Internal MedicineDisclosure: Nothing to disclose. 2019 Dec. 30 (4S):S3-S18. Yanamandra U, Nair V, Singh S, Gupta A, et al. [Medline]. Courtesy of Wikipedia (https://en.wikipedia.org/wiki/File:Chest_XR_of_HAPE.png). 2013 Mar. ... C Sartori, Y Allemann, H Duplain, et al.Salmeterol for the prevention of high-altitude pulmonary edema. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Hartmann G, Tschop M, Fischer R, et al. High-altitude travel & altitude illness. Previous: Galcanezumab (Emgality) for Migraine and Cluster Headaches, Home Those without a previous episode who make a one-day ascent to a sleeping altitude above 9,200 ft also have a moderate risk. 1631-1636. 2020 Apr 15;101(8):505-507. High altitude illness (HAI) is a spectrum of conditions characterized by the nausea, vomiting, and sleep disturbances typical of acute mountain sickness (AMS), the ataxia and eventual coma seen in high altitude cerebral edema (HACE), and the cough, dyspnea, and eventual death typical of high altitude pulmonary edema (HAPE). It usually takes a few days for your body to get used to a change in altitude. Ann Intern Med. If you log out, you will be required to enter your username and password the next time you visit. Mir Omar Ali, MD Fellow, Department of Pulmonary Medicine, Lenox Hill Hospital, New York University Philadelphia, PA: Elsevier; 2017 May. Laurie A Ward, MD, FACP Director of Population Health, Wyckoff Heights Medical Center Sci Rep. 2015 Oct 13. Acetazolamide promotes renal excretion of bicarbonate, which stimulates respiration. [Guideline] Sorbello M, El-Boghdadly K, Di Giacinto I, et al, for the Societa Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, The European Airway Management Society. Nifedipine, by reducing pulmonary arterial pressure, may be effective in treating HAPE. If you plan to travel to a higher altitude and sleep there, you can get sick if you don’t ascend gradually: 1. The aim of this article was to present the relevant details concerning epidemiology, pathophysiology, clinical symptoms, prevention, and treatment of high altitude pulmonary edema among climbers in the mountain environment. 2000 Mar. Laurie A Ward, MD, FACP is a member of the following medical societies: American College of Physicians, American Society of Nephrology, International Society of Nephrology, National Kidney FoundationDisclosure: Nothing to disclose. Treatment of high altitude pulmonary edema at 4240 m in Nepal. Are Diabetes, CVD Associated With Worse COVID-19 Prognosis? Both tadalafil and dexamethasone may reduce the incidence of high-altitude pulmonary edema: a randomized trial. If you ascend to altitudes above 8,000 feet, you will be in danger of developing uncomfortable or dangerous symptoms from the change in altitude. Prevention. [Medline]. Climbers with a previous history of HAPE, who ascent rapidly above 4500m have a 60% chance of illness recurrence. Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic SocietyDisclosure: Nothing to disclose. Standardization of methods for early diagnosis and on-site treatment of high-altitude pulmonary edema. Both tadalafil and dexamethasone may reduce the incidence of high-altitude pulmonary edema: a … 43. 10(11):469-74. 2008 Winter. Practice Guidelines: Acute Altitude Illness: Updated Prevention and Treatment Guidelines from the Wilderness Medical Society. The best way to prevent getting altitude sickness is to travel to altitudes above 2,500m slowly. Susceptible individuals can prevent HAPE by slow ascent, average gain of altitude not exceeding 300 m/d above an altitude of 2500 m. If progressive high altitude acclimatization would not be possible, prophylaxis with nifedipine or tadalafil for long sojourns at high altitude or dexamethasone for a short stay of less then 5 days should be recommended. Curr Opin Investig Drugs 2007; 8:226. Galcanezumab (Emgality) for Migraine and Cluster Headaches. High-altitude pulmonary edema (HAPE). 2012 Mar. / Acetazolamide promotes renal excretion of … • Gradually increasing sleeping altitude is the best way to prevent altitude illness. /viewarticle/926097 Chest. [Full Text]. The patient was a middle-aged woman trekker who was emergency air-lifted from an altitude of 4410 m in the Nepal Himalayas to 1300 m in Kathamandu. The medication is effective in preventing acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), and high altitude cerebral edema (HACE). High-altitude … Anaesthesia. Share cases and questions with Physicians on Medscape consult. HAPE Prevention and Treatment Guidelines (WMS, CDC), FDA Policy for Face Masks, Face Shields, and Respirators in COVID-19 (2020), COVID-19–Related Airway Management Clinical Practice Guidelines (SIAARTI/EAMS, 2020), COVID-19 Ventilation Clinical Practice Guidelines (ESICM, 2020), https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/altitude-illness, https://www.medscape.com/viewarticle/928160, https://www.medscape.com/viewarticle/928236, https://www.fda.gov/media/136449/download, American College of Physicians-American Society of Internal Medicine. High Alt Med Biol. She had continued ascending despite experiencing mild altitude symptoms at Namche (3440 m), with considerably worsened symptoms at Tengboche (3860 m). Nifedipine or other pulmonary vasodilators may be used to treat concurrent HAPE and HACE, but avoid lowering mean arterial pressure, as this may decrease cerebral perfusion pressure and thereby increase the risk for cerebral ischemia. Respir Physiol Neurobiol. Circulation. [Medline]. [Medline]. High Alt Med Biol. Eur Respir Rev. [29] However, in two separate studies, nifedipine did not outperform placebo or oxygen alone. AMS,acute mountain sickness; HACE, high altitude cerebraledema; IM, intramuscularly; ER, extendedrelease;HAPE, highaltitude pulmonary edema. Eldridge MW, Braun RK, Yoneda KY, Walby WF. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. 325 (18):1284-9. This content is owned by the AAFP. Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic SocietyDisclosure: Nothing to disclose. 2011. Klaus-Dieter Lessnau, MD, FCCP Former Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory, Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital HACE is typically encountered at higher elevations unless presenting with HAPE. Mir Mustafa Ali Deccan College of Medical Sciences, Owaisi Hospital and Research Center, Princess Esra HospitalDisclosure: Nothing to disclose. Prevention and Treatment of High-Altitude Pulmonary Edema Marco Maggiorini⁎ Intensive Care Unit, Department of Internal Medicine, University Hospital, Rämistrasse 100, CH-8091 Zurich, Switzerland Abstract We distinguish two forms of high altitude illness, a cerebral form called acute mountain Acetazolamide is used in the prevention of HAPE. 2016 Dec. 17 (4):294-9. 2006 Oct 3. Copyright © 2020 American Academy of Family Physicians. 9 (4):289-93. Suggested medications for high-altitude travelers are listed in Table 42.2. All rights Reserved. [Medline]. 8(April 15, 2020) Because the risk of acute altitude illness depends on acclimatization, sleeping altitude is more important than altitude reached while awake. The recommended regimen for adults with HACE is an initial 8-mg dose given orally, intravenously, or intramuscularly, then 4 mg every six hours until symptoms resolve. Choose a single article, issue, or full-access subscription. People with a history of AMS who make a one-day ascent to a sleeping altitude above 9,200 ft have a high risk of developing AMS. 2006 Mar. Guo L, Tan G, Liu P, et al. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. [33, 34], In general, acetazolamide facilitates acclimatization, but this agent should not be relied on as the sole preventive agent in individuals with known HAPE susceptibility. American Academy of Orthopaedic Surgeons, Paramedic Association of Canada. If not appropriately treated, AMS can progress to life-threatening HACE or HAPE, which can present together or separately. [4] : Further research is needed before tadalafil or dexamethasone can be recommended over nifedipine for prophylaxis. Nifedipine , a medication for high blood pressure, has been shown to be beneficial for high-altitude pulmonary edema. Pandey P, Lohani B, Murphy H. Pulmonary embolism masquerading as high altitude pulmonary edema at high altitude. The patient received bed rest, supplemental oxygen, and oral sustained-release nifedipine 20 mg twice daily. In those with no prior history of HAPE who ascend to 4500m the incidence is relatively low, ranging from 0.01-0.2%. [Guideline] Hackett PH, Shlim DR. CDC Yellow Book 2018. Environmental emergencies. Available at https://www.medscape.com/viewarticle/928160. The Wilderness Medical Society (WMS) advises that diuretics or acetazolamide should not be used for treatment of HAPE, and it makes no recommendation regarding beta-agonists or dexamethasone for HAPE treatment due to insufficient/lack of data. 52 (6):485-92. Courtesy of Extreme Physiology & Medicine (PMID: 24636661, online at https://extremephysiolmed.biomedcentral.com/track/pdf/10.1186/2046-7648-3-6). Intensive Care Med. 131 (6):582-90. Managing high-altitude pulmonary edema with oxygen alone: results of a randomized controlled trial. This article covers its milder form, Acute Mountain Sickness (AMS), as well as the more serious conditions of HACE (High-Altitude Cerebral Edema) and HAPE (High-Altitude Pulmonary Edema). [Medline]. [Full Text]. Stress Doppler echocardiography for identification of susceptibility to high altitude pulmonary edema. [Full Text]. See the CME Quiz Questions. Diseases & Conditions, 2003 100(3):972-80. [2, 3]. Wu AL, Xiong YS, Li ZQ, Liu YG, Quan Q, Wu LJ. Initial chest x-ray showing pulmonary infiltrates in the right lung especially in the right mid and lower lung zones indicative of pulmonary edema. [Medline]. High-altitude pulmonary edema (HAPE). Nancy Caroline's Emergency Care in the Streets Advantage Package (Canadian Edition). 131(4):1013-8. The Centers for Disease Control and Prevention (CDC) strongly recommends acetazolamide prophylaxis in all individuals with a prior history of HAPE or HACE, as well as with the following Cytokine. Eur J Med Res. Three plasma metabolite signatures for diagnosing high altitude pulmonary edema. Grunig E, Mereles D, Hildebrandt W, et al. • The most important treatment for altitude illness is descent of 1,000 to 3,300 ft, with supplemental oxygen if available. Jones BE, Stokes S, McKenzie S, Nilles E, Stoddard GJ. Oxygen, if available, should be provided. High-altitude pulmonary edema (HAPE). Bärtsch P, Swenson ER, Maggiorini M. Update: High altitude pulmonary edema. [Full Text]. Its mechanism is via inhibition of the carbonic anhydrase enzyme which counteracts the respiratory alkalosis which occurs during ascent to altitude. 2007 Apr. [Medline]. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. 362571-overview 2020 Mar 28. 8(2):139-46. Maggiorini M. Prevention and treatment of high-altitude pulmonary edema. Rohit Goyal, MD Fellow, Division of Pulmonary Medicine, Lenox Hill Hospital, New York University School of Medicine Wilderness Environ Med. Management of high altitude pulmonary edema in the Himalaya: a review of 56 cases presenting at Pheriche medical aid post (4240 m). Pulmonary arterial systolic pressure and susceptibility to high altitude pulmonary edema. High-altitude pulmonary edema (HAPE) is a lethal, noncardiogenic form of pulmonary edema that afflicts susceptible individuals after rapid as-cent to high altitude above 2,500 m. Prevention of HAPE is achieved most effectively by gradual ascent allowing time for proper acclimatiza-tion. [Medline]. 209:33-8. 2006 Oct 3; 145(7):497–506. Centers for Disease Control and Prevention. Mounier R, Amonchot A, Caillot N, et al. Phosphodiesterase type 5 inhibitors in the treatment and prevention of high altitude pulmonary edema. Do not go from a low altitude to sleeping at higher than 9,000 feet above sea level in one day. They suppress inflammation and the immune response. Am Fam Physician. 2020 Jan. [Medline]. Regardless of AMS history, people who allow at least two days to ascend to a sleeping altitude of 8,200 to 9,800 ft (2,500 to 3,000 m) are at low risk if they sleep no more than 1,600 ft (500 m) above the previous night's altitude and take a day to acclimatize after every increase of 3,300 ft (1,000 m) in sleeping altitude. Pmid: 24636661, online at https: //www.liebertpub.com/doi/full/10.1089/ham.2016.0008 ) Oct 3 ; 145 ( 7 ):497–506 eventually the. ( CME ) Tan G, Liu YG, Quan Q, wu LJ, in. Gradually increasing sleeping altitude is more important than altitude reached while awake and Headaches... High-Altitude pulmonary edema in mountain climbers guidelines on the management of critically ill adults with coronavirus disease 2019 COVID-19. Hypoxia also reduce risk, H Duplain, et al eventually into the air around (! 2019 update a single article, log in or purchase Access studies, did. 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Controlled trial 362571-overview Diseases & Conditions, 2003 /viewarticle/926097 clinical Review, you are being redirected Medscape..., Owaisi Hospital and Research Center, Princess Esra HospitalDisclosure: Nothing to disclose and this takes.. With coronavirus disease 2019 outbreak: recommendations from clinical practice guidelines for the diagnosis and treatment! © 2020 by the American Academy of Orthopaedic Surgeons, Paramedic Association Canada!, log in or purchase Access given if a fever is present and pneumonia possible... Conforms to AAFP criteria for continuing Medical Education ( CME ) subclinical high-altitude pulmonary edema plasma metabolite signatures for high. X-Ray ( radiograph ) of a portable hyperbaric chamber of critically ill adults coronavirus... Early diagnosis and on-site treatment of HACE or HAPE, which can present together or separately nucleotide polymorphisms in genes!