What is the best course of treatment for a patient suspected of having altitude sickness?

Treatment of Altitude Sickness

For a patient with suspected altitude sickness, immediate descent to lower altitude is the single most effective treatment, combined with supplemental oxygen when available; pharmacologic therapy with dexamethasone for cerebral symptoms or nifedipine for pulmonary edema should be initiated if descent is delayed or impossible. 1, 2

Initial Assessment and Severity Classification

Rapidly determine the severity of altitude sickness to guide treatment intensity:

• Mild to moderate acute mountain sickness (AMS) presents with headache, apathy, reduced appetite, nausea, vomiting, and peripheral edema 3
• High-altitude cerebral edema (HACE) manifests as severe headache unrelieved by acetaminophen, ataxia, loss of movement coordination, mental deterioration, and progression to coma 4
• High-altitude pulmonary edema (HAPE) shows incapacitating fatigue, chest tightness, dyspnea progressing from exertion to rest, and cough that may produce pink frothy sputum 4

Primary Treatment Algorithm

For All Severity Levels:

• Stop further ascent immediately and rest at current altitude 1
• Administer supplemental oxygen if available to improve hypoxemia 3, 2

Mild to Moderate AMS:

• Acetazolamide 250 mg twice daily is effective for treatment 1, 4
• Symptomatic relief with acetaminophen for headache 4
• Hydration and rest at current altitude 1
• If symptoms persist or worsen after 24 hours, descend 3

Severe AMS/HACE (Life-Threatening):

• Immediate descent is mandatory - this is the definitive treatment 5, 6
• Dexamethasone in large doses intravenously as first-line pharmacologic therapy 5, 1
• Supplemental oxygen to maintain adequate saturation 2
• Portable hyperbaric chambers (Gamow bag) if descent is temporarily impossible 6
• Additional therapies may include diuretics (furosemide), hyperosmolar agents (mannitol, urea), and aggressive hydration 5
• Prognosis is excellent if descent and treatment start early, but permanent neurological damage occurs if the patient remains unconscious for prolonged periods before descent 5

HAPE (Life-Threatening):

• Immediate descent to lower altitude - this is the primary therapy 1, 6
• Nifedipine as the medication of choice for HAPE treatment 1, 2
• Supplemental oxygen administration 2
• Keep the patient warm and minimize exertion 4
• Portable hyperbaric therapy if descent is delayed 6

Critical Management Principles

The key distinction in treatment is that dexamethasone is specifically indicated for cerebral forms (HACE), while nifedipine is specifically indicated for pulmonary forms (HAPE). 3, 2

Common Pitfalls to Avoid:

• Delaying descent in severe cases - two deaths reported in the literature were associated with delayed evacuation 5
• Attempting to continue ascent with any symptoms present 1
• Using acetazolamide alone for severe HACE or HAPE - it is insufficient for life-threatening forms 4
• Inadequate hydration during treatment 1

When Descent is Impossible:

• Portable hyperbaric chambers provide temporary relief and facilitate eventual descent 6
• Aggressive pharmacologic therapy becomes essential 5
• Continuous monitoring for deterioration is mandatory 5

Special Considerations

• HAPE may occur with or without preceding AMS symptoms in approximately 20% of cases 4
• The pulmonary form results from exaggerated hypoxic pulmonary vasoconstriction, explaining nifedipine's effectiveness as a pulmonary vasodilator 4
• Cerebral edema in HACE appears to be vasogenic in nature with loss of cerebral autoregulation 4
• Most mild AMS cases resolve spontaneously within 1-2 days without further altitude gain 2