6-40
medical attention for cough or frothy, pink or bloody sputum or gurgling sounds in your chest or throat when
breathing.
Follow-up Actions
Return evaluation: Evaluate individuals who survive for neurologic deficits that might affect their performance
of military duties. Individuals who have had one episode of HACE are at increased risk of future episodes and
should be referred for possible medical profile to restrict exposure to altitudes greater than 8,000 feet.
Evacuation/Consultation Criteria: Evacuate all patients with HACE to higher echelon of medical care,
preferably to hospital facility. CT scan or MRI imaging of the brain may show cerebral edema. If not
evacuated rapidly, even patients who survive may have prolonged or permanent neurologic damage.
*NOTES: Portable hyperbaric chambers (e.g., Gamow bag, CERTEC bag, Hyperlite chamber, Portable
Altitude Chamber [PAC]) are not normally available in the military medical supply inventory. They are available
in the civilian sector in the USA and many European countries. These lightweight, highly portable cloth
chambers are extremely useful in treating altitude illnesses (including AMS). When deploying rapidly to high
altitude terrain, consider procuring such a chamber. Given that the incidence of altitude illness diminishes
greatly after acclimatization to altitude (7-10 days), the portable chamber could be stored (or discarded) after
that time.
High Altitude Illnesses: High Altitude Pulmonary Edema
COL Paul Rock, MC, USA & LTC Brian Campbell, MC, USAIntroduction: High Altitude Pulmonary Edema (HAPE) is a potentially fatal accumulation of fluid (edema)
in the lungs that occurs in people from low altitude (less than 5000 ft) who ascend rapidly to high altitudes
(usually greater than 9000 ft) and remain there for several days. It is caused by the decreased amount of
oxygen available in the low-pressure atmosphere at high altitude (see Aerospace Medicine: Hypoxia). It often
begins after the first or second night spent at high altitude and is most common during first week. Young
men who do heavy physical exertion upon arrival at high altitude are very susceptible. Although not common
(usually less than 10% of persons going to altitudes above 12,000 ft), once HAPE develops, it can be rapidly
fatal (6-12 hours) if not treated. Half of individuals with HAPE will also have symptoms of acute mountain
sickness (AMS) (see Acute Mountain Sickness section), and some may develop high altitude cerebral edema
(HACE) (see High Altitude Cerebral Edema section), which can also be fatal.
Subjective: Symptoms
Early: shortness of breath, dry cough, dyspnea on exertion; later: dyspnea at rest, symptoms of AMS
(headache, nausea and vomiting, decreased appetite and fatigue), clear and watery sputum; still later: frothy,
blood-streaked or pink sputum; feel or hear ‘gurgling’ in chest with breathing.
Focused History: Do you have difficulty breathing or a cough? Are you coughing up frothy, pink or bloody
sputum? (typical symptoms) When did symptoms begin? (typically after exercise or after sleeping during first
week at altitude) Did you have these symptoms or any illness before going to altitude? (rule out preexisting
condition) How is your coordination? Have you been stumbling or falling? Are you seeing or hearing
unexpected or unusual things (hallucinations)? (suggest coexisting HACE) Have you had fever and chills?
Have you coughed up thick, greenish or yellow-colored sputum? (suggest bronchopneumonia) Do you have
any pain or swelling in your legs? Does your chest hurt when you breathe? (typical of possible deep
venous blood clot in legs with subsequent blood clot in lungs) Have you ever had asthma or hay fever in
the past? (rule out asthma)
Objective: Signs
Using Basic Tools: Early signs: Tachypnea and tachycardia during physical activity (compared to compan-
ions at same altitude), dry cough, crackling sounds (rales) in lungs (mid-lung area); progressive signs:
tachypnea and tachycardia at rest (compared to unaffected companions); ‘gurgling’ breath sounds; excessive
(compared to companions at same altitude) bluish color of lips, fingernail bed, tip of nose and ears (cyanosis);
cough productive of frothy and/or pink, blood streaked sputum; low-grade fever. Late signs: coma, respiratory