I was asked by PM to respond. Thanks.

First, one of my favorite quotes from one of the greats in the mountaineering literature:

One man acclimatises quickly, another slowly...The whole process appears to be analogous to sea-sickness about which predictions are impossible.
Eric Shipton, Upon That Mountain page 376

Going beyond that, please see the High Altitude Tutorial at http://www.ismmed.org/np_altitude_tutorial.htm#HAPE


Is the original question on this thread still whether or not to treat HAPE with Dex or other steroids?


To answer some specific questions about HAPE and HACE as life-threatening complications of AMS, here are some thoughts from my knowledge as a physician and specifically a high altitude medical team member who has seen and helped with these problems on the mountain. Maybe some time I can post my little study "Brains and Video Games at High Altitude." Harvey


Primary option for treatment is descent, descent, descent. First option should be descent, depending of course on situation, weather, ambulatory status, etc. Then there is oxygen by bottle vs. pressurized air by Gamow bag. These two are Greater Ranges stuff.

Diamox is sometimes thrown in the mix but is mainly used to accelerate acclimatization especially early on, whereas Dex (or another steroid) is used for complications HACE, HAPE and is far more powerful.

Since HAPE and HACE often overlap in the same patient (especially if they have HACE) and since steroids are beneficial in both (more so in HACE than HAPE), then I personally would treat a patient ill with either of those problems with Dex and not quibble about the potential of overtreating or risking side effects. On the mountain, sometimes you just gotta shotgun it, and get down as quickly as possible. Otherwise you might be dead soon. Real soon. The risk of death from either HAPE or HACE is extraordinarily high. I've seen that. Why wait for it to worsen? (in just hours). Treat it hard, treat it now. Of course going down is often enough by itself, but what if you are no longer walking, night falls, or your rescuer breaks a leg? HAPE and HACE are rare at moderate altitudes like the Sierras, but with a susceptible individual, and bad conditions like nasty weather, high work load, other illness or injury, dehydration, etc, the risk level increases. It happens occasionally on Rainier and Whitney, as described recently at http://www.whitneyportalstore.com/forum/...age=2#Post76972

Inhaled steroids: They help stabilize lung linings for "reactive airways" like cold-induced asthma or some benefit for HAPE. Sometimes it is not clear what the hacking, coughing climber actually has at 18,000 feet where everyone else is also coughing. Inhaled steroids have less systemic (whole body) effect and since for HAPE or HACE you need to hit it hard, then we use big dose parenteral (injected) or oral route. (On the ill fated 1996 Everest disaster, prepackaged injectable dex was used .... just forget sterile technique, uncover the needle and shoot right through the down suit.)

Nifedipine: Cardiac/bp med. It had some greater popularity for a while in the past since it acts as a pulmonary artery vasodilator. Used preventatively (in selected persons such as those with prior HAPE episode) , it helps treat the rise in pressure in the lung vessels that occurs more in some folks than others at high altitude, this being a risk factor for HAPE. Also was used acutely to treat that pressure response once HAPE was suspected. Not as widely accepted now. When I stopped at the medical clinic in Khumbu in 2000 we had disagreements then on its benefit. (I know that my HAPE-susceptible climbing partner did far better on Aconcagua with it than without it on Denali, but that's just one person). Usually administered orally. Under the tongue, it can drop blood pressure. Best to leave this to medical team.

Viagra has also been used as a pulmonary artery dilator drug (rather than its customary use) although I don't know its current status in the high altitude field.

Have I personally advised/helped/evacuated family, friends, or team clients with AMS/HAPE/HACE/death/all - yes
Have I ever personally had AMS ? a few times at 10-14,000 ft
Have I ever use Diamox for acclimatization? Sometimes
Does the literature and my experience support Diamox for AMS--yes.
Have I ever had such massively bad headache that I worried about HACE ? yes, at 19,000 ft and stopped.
Do I carry emergency dex or prednisone (steroids)?

Hope this helps some.