Thursday, September 30, 2010

Notes re Altitude Sickness

Definition of High Altitude
- High Altitude: 1500 - 3500 m (5000 - 11500 ft)
- Very High Altitude: 3500 - 5500 m (11500 - 18000 ft)
- Extreme Altitude: above 5500 m
The Body’s reaction to altitude
Certain normal physiologic changes occur in every person who goes to altitude:
- Hyperventilation (breathing faster, deeper, or both)
- Shortness of breath during exertion
- Changed breathing pattern at night
- Awakening frequently at night
- Increased urination

As one ascends through the atmosphere, every breath contains fewer and fewer molecules of oxygen. One must work harder to obtain oxygen, by breathing faster and deeper. This is particularly noticeable with exertion, such as walking uphill. Being out of breath with exertion is normal, as long as the sensation of shortness of breath resolves rapidly with rest. The increase in breathing is critical. It is therefore important to avoid anything that will decrease breathing, e.g. alcohol and certain drugs. Despite the increased breathing, attaining normal blood levels of oxygen is not possible at high altitude.

Cheyne stokes breathing
Persistent increased breathing results in reduction of carbon dioxide in the blood, a metabolic waste product that is removed by the lungs. The build-up of carbon dioxide in the blood is the key signal to the brain that it is time to breathe, so if it is low, the drive to breathe is blunted (the lack of oxygen is a much weaker signal, and acts as an ultimate safety valve). As long as you are awake it isn't much trouble to consciously breathe, but at night an odd breathing pattern develops due to a back-and-forth balancing act between these two respiratory triggers. Periodic breathing consists of cycles of normal breathing which gradually slows, breath-holding, and a brief recovery period of accelerated breathing.

This is not altitude sickness. The breath-holding may last up to 10-15 seconds. This is not altitude sickness. It may improve slightly with acclimatization, but does not usually resolve until descent. Periodic breathing can cause a lot of anxiety:
- In the person who wakes up during the breath-holding phase and knows he has stopped breathing.
- In the person who wakes up in the post-breath-holding hyperventilation (recovery) phase and thinks he's short of breath and has High Altitude Pulmonary Edema (HAPE).
- In the person who wakes up and realizes his neighbor has stopped breathing.
In the first two cases waiting a few moments will establish a normal breathing pattern. In the final case, the sleeping neighbour will eventually take a breath, though periodic breathing cycles will likely continue until he or she is awake. If periodic breathing symptoms are troublesome, a medication called acetazolamide may be helpful.

Dramatic changes take place in the body's chemistry and fluid balance during acclimatization. The osmotic center, which detects the "concentration" of the blood, gets reset so that the blood is more concentrated. This results in an altitude diuresis as the kidneys excrete more fluid. The reason for this reset is not understood, though it has the effect of increasing the hematocrit (concentration of red blood cells) and perhaps improving the blood's oxygen-carrying ability somewhat; it also counteracts the tendency for edema formation. It is normal at altitude to be urinating more than usual. If you are not, you may be dehydrated, or you may not be acclimatizing well.

Things to Avoid
Respiratory depression (the slowing down of breathing) can be caused by various medications, and may be a problem at altitude. The following medications can do this, and should never be used by someone who has symptoms of altitude illness:
- Alcohol
- Sleeping pills (acetazolamide is the sleeping tablet of choice at altitude)
- Narcotic pain medications in more than modest doses
Preventing Altitude Sickness
The key to avoiding altitude sickness is a gradual ascent that gives your body time to acclimatize (we are riding up, so ascent will be necessarily gradual). People acclimatize at different rates, so no absolute statements are possible, but in general, the following recommendations will keep most people from getting altitude sickness:
- If possible, you should spend at least one night at an intermediate elevation below 3000 meters.
- At altitudes above 3000 meters (10,000 feet), your sleeping elevation should not increase more than 300-500 meters (1000-1500 feet) per night.
- Every 1000 meters (3000 feet) you should spend a second night at the same elevation
As with all of this stuff, better too much information than not enough. It’s important to keep it in perspective, though. Whilst very few travellers explore the Eastern Plains of Nepal (lowlands); the routes near and around Kathmandu (higher altitude) are a well worn tourist trail visited by thousands of people every year.