HIGH ALTITUDE MEDICINE & BIOLOGYVolume 9, Number 4, 2008© Mary Ann Liebert, Inc.DOI: 10.1089/ham.2008.1063

Letter to the Editor

Do We Have a Best Practice for Treating High AltitudePulmonary Edema?

Robert. O. Koch1 and Martin Burtscher2

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ANDREW LUKS reports in his nice review “Do we have abest practice for treating high altitude pulmonary

edema” that continuous positive airway pressure (CPAP)may be used to relieve dyspnea in patients suffering fromhigh altitude pulmonary edema (HAPE) (Luks, 2008). Hestates that the great disadvantage of CPAP is that it is notavailable in the field due to the lack of compressed air orpower sources. We support the importance of CPAP sincethere is much data underlining the advantage of positive air-way pressure in pulmonary edema as a hospital-based treat-ment (Vital et al., 2008).

We combined a CPAP helmet (Stamed, Italy), used for thelast few years in intensive care units, with a mechanicalhand-operated two liter double-action air pump (Wehncke,Germany). Arterial oxygen saturation could be increasedfrom 80.6 � 3.4% to 90.6 � 3.8% (p � 0.01, n � 14) when us-ing a positive end expiratory pressure (PEEP) ranging be-tween 10—15 cm H2O) in normobaric hypoxia (FiO2 12.9 �0.4%, corresponding to about 4300 m). Furthermore, arterialoxygen saturation could be enhanced (88.1 � 1.9% to 93.5 �3.0%; p � 0.01, n � 11) at real altitude (3150 m) after a 20-min application of the CPAP helmet (Koch et al., 2008).

1Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University Innsbruck, Austria.2Department of Sport Science, Medical Section, University of Innsbruck, Austria.

075

Time with CPAP [min]

n � 9altitude � 4400 m

*p � 0.0005

Oxy

gen

Sat

urat

ion

[%]

5 10 15 20

80

85

90

95

100

FIG. 1. A mountaineer using continuous positive airway pressure (CPAP) via the thin air rescue (TAR) helmet. In thiscase, CPAP improved SaO2 from 81.8 � 2.0% to 91.4 � 3.5%.

The CPAP-helmet pump combination, which we namedthin air rescue (TAR) helmet, was also used at high altitudeon Lenin Peak (7135 m) in Kyrgyzstan. Even under these ex-treme environmental conditions, CPAP was able to increasearterial oxygen saturation from 72.6 � 2.3% to 81.1 � 4.9%(p � 0.001, n � 8) at 5400 m. During this study, we were con-fronted with a 52-year-old male mountaineer who partici-pated in an expedition group and was suffering from an ad-vanced stage of HAPE on day 20 of his acclimatization. Hisarterial oxygen saturation (pulse oximeter) was 56% despitepre-treatment with nifedipine 40 mg and acetazolamid 500mg. We gave him dexamethasone 20 mg intravenously andstarted the treatment with the TAR helmet two times for 30minutes. After a few minutes breathing against a pressureof 15 cm H2O, the oxygen saturation improved to 74%. Dur-ing treatment, the patient’s symptoms improved constantlyand rales disappeared. Finally, he descended to the basecamp where he recovered completely.

These studies together with the case report display that CPAPcan be applied in the alpine environment and may be a valu-able tool to treat HAPE when rapid descent is not possible.

References

Luks A.M. (2008). Do we have a “best practice” for treating highaltitude pulmonary edema?. High Alt. Med. Biol. 9:111–114.

Vital FM, Saconato H, Ladeira MT, Sen A, Hawkes CA, SoaresB, Burns KE and Atallah AN. (2008). Non-invasive positivepressure ventilation (CPAP or bilevel NPPV) for cardiogenicpulmonary edema

Cochrane Database Syst Rev. 16:CD005351.Koch R., Punter E., Gatterer H., Flatz M., Faulhaber M.and

Burtscher M. (2008). Application of CPAP improves oxy-genation during normobaric and hypobaric hypoxia. WienerMedizinische Wochenschrift 158:156–159.

Koch R., Faulhaber M., Gatterer H. and Burtscher M. (2008). DerCPAP-Helm Eine alternative Behandlungsform von Höhen-erkrankungen? Flugmedizin Tropenmedizin Reisemedizin15:74–76.

Address correspondence to:Robert Koch, M.D.

Dept. of Gastroenterology & HepatologyMedical University Innsbruck

Anichstrasse 35A-6020 Innsbruck

Austria

E-mail: robert.koch@i-med.ac.at

Received August 11, 2008; accepted in final form August 14, 2008.

LETTER TO THE EDITOR344