RESUMO
To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention, diagnosis, and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches for managing each form of acute altitude illness that incorporate these recommendations as well as recommendations on how to approach high altitude travel following COVID-19 infection. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in Wilderness & Environmental Medicine in 2010 and the subsequently updated WMS Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness published in 2014 and 2019.
Assuntos
Doença da Altitude , COVID-19 , Humanos , Doença da Altitude/diagnóstico , Doença da Altitude/prevenção & controle , Altitude , COVID-19/diagnóstico , COVID-19/prevenção & controle , Consenso , Sociedades Médicas , Teste para COVID-19RESUMO
Two randomized, placebo-controlled studies evaluated the pulmonary function safety of onabotulinumtoxinA (onabotA) for treatment of upper and/or lower limb spasticity. Patients with stable baseline respiratory status received one or two treatments with placebo, 240 U, or 360 U of onabotA. Pulmonary function tests, adverse events, and efficacy were measured at least every 6 weeks for 18 weeks (Study 1) or 30 weeks (Study 2). Study 1 enrolled 109 patients (n = 36-37/group) and Study 2 enrolled 155 patients (n = 48-54/group). Mean baseline forced vital capacity (FVC) was 76-78% of predicted per group in Study 1 and 71% of predicted per group in Study 2. In Study 1, change from baseline FVC values were significantly (p < 0.05) decreased vs. placebo at weeks 3 (240 U -57 mL vs. placebo +110 mL) and 12 (360 U -6 mL vs. +167 mL placebo). In Study 2, change from baseline FVC values were significantly decreased in the 360 U group vs. placebo at weeks 6 (-78 mL vs. +49 mL placebo), 13 (-60 mL vs. +119 mL placebo), 18 (-128 mL vs. +80 mL placebo), and 24 (-82 mL vs. +149 mL placebo). Individual pulmonary function-related adverse events were not correlated with PFT decreases. The most frequent pulmonary-related adverse events were nasopharyngitis (Study 1) and upper respiratory tract infection (Study 2). Ashworth scores were significantly improved at multiple time points in both studies. Injection of onabotA for spasticity in patients with decreased pulmonary function, at single and repeated doses of up to 360 U, was associated with small but statistically significant decreases in FVC or forced expiratory volume 1 s (FEV1) (>12% and 200 mL) that were subclinical and not correlated with any adverse clinical pulmonary events.
Assuntos
Inibidores da Liberação da Acetilcolina/uso terapêutico , Toxinas Botulínicas Tipo A/uso terapêutico , Extremidade Inferior/inervação , Pneumopatias/fisiopatologia , Pulmão/fisiopatologia , Espasticidade Muscular/tratamento farmacológico , Extremidade Superior/inervação , Inibidores da Liberação da Acetilcolina/efeitos adversos , Toxinas Botulínicas Tipo A/efeitos adversos , Método Duplo-Cego , Europa (Continente) , Feminino , Volume Expiratório Forçado , Humanos , Pulmão/efeitos dos fármacos , Pneumopatias/diagnóstico , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular/diagnóstico , Espasticidade Muscular/fisiopatologia , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Capacidade VitalRESUMO
To provide guidance to clinicians, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and a balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations. This is the 2019 update of the Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2014 Update.
Assuntos
Hipotermia/diagnóstico , Hipotermia/terapia , Padrões de Prática Médica , Medicina Selvagem/normas , Humanos , Hipotermia/fisiopatologia , Sociedades Médicas , Medicina Selvagem/métodosRESUMO
To provide guidance to clinicians about best preventive and therapeutic practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to prevention and management of each form of acute altitude illness that incorporate these recommendations. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in 2010 and subsequently updated as the WMS Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness in 2014.
Assuntos
Doença da Altitude/prevenção & controle , Edema Encefálico/prevenção & controle , Padrões de Prática Médica , Edema Pulmonar/prevenção & controle , Medicina Selvagem/normas , Doença da Altitude/terapia , Edema Encefálico/terapia , Humanos , Montanhismo , Edema Pulmonar/terapia , Sociedades MédicasRESUMO
Patients suffering from chronic mountain sickness (CMS) have excessive erythrocytosis. Low -level cobalt toxicity as a likely contributor has been demonstrated in some subjects. We performed a randomized, placebo controlled clinical trial in Cerro de Pasco, Peru (4380m), where 84 participants with a hematocrit (HCT) ≥65% and CMS score>6, were assigned to four treatment groups of placebo, acetazolamide (ACZ, which stimulates respiration), N-acetylcysteine (NAC, an antioxidant that chelates cobalt) and combination of ACZ and NAC for 6 weeks. The primary outcome was change in hematocrit and secondary outcomes were changes in PaO2, PaCO2, CMS score, and serum and urine cobalt concentrations. The mean (±SD) hematocrit, CMS score and serum cobalt concentrations were 69±4%, 9.8±2.4 and 0.24±0.15µg/l, respectively for the 66 participants. The ACZ arm had a relative reduction in HCT of 6.6% vs. 2.7% (p=0.048) and the CMS score fell by 34.9% vs. 14.8% (p=0.014) compared to placebo, while the reduction in PaCO2 was 10.5% vs. an increase of 0.6% (p=0.003), with a relative increase in PaO2 of 13.6% vs. 3.0%. NAC reduced CMS score compared to placebo (relative reduction of 34.0% vs. 14.8%, p=0.017), while changes in other parameters failed to reach statistical significance. The combination of ACZ and NAC was no better than ACZ alone. No changes in serum and urine cobalt concentrations were seen within any treatment arms. ACZ reduced polycythemia and CMS score, while NAC improved CMS score without significantly lowering hematocrit. Only a small proportion of subjects had cobalt toxicity, which may relate to the closing of contaminated water sources and several other environmental protection measures.
Assuntos
Acetazolamida/uso terapêutico , Acetilcisteína/uso terapêutico , Doença da Altitude/tratamento farmacológico , Inibidores da Anidrase Carbônica/uso terapêutico , Sequestradores de Radicais Livres/uso terapêutico , Adulto , Doença da Altitude/sangue , Doença da Altitude/urina , Análise de Variância , Gasometria , Distribuição de Qui-Quadrado , Doença Crônica , Cobalto/sangue , Cobalto/urina , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Hematócrito/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Peru , Estudos Prospectivos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.
Assuntos
Doença da Altitude/prevenção & controle , Atletas , Exame Físico/métodos , Medicina Esportiva/métodos , Esportes , Meio Selvagem , Altitude , Doença da Altitude/epidemiologia , Doença da Altitude/fisiopatologia , Meio Ambiente , Humanos , Relações Médico-Paciente , Medição de Risco , Fatores de RiscoRESUMO
High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.
Assuntos
Doença da Altitude/prevenção & controle , Atletas , Montanhismo , Exame Físico , Medicina Selvagem , Humanos , Exame Físico/métodos , Medição de Risco , SegurançaRESUMO
To provide guidance to clinicians about best practices, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations about their role in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to prevention and management of each disorder that incorporate these recommendations. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in Wilderness & Environmental Medicine 2010;21(2):146-155.
Assuntos
Doença da Altitude/prevenção & controle , Edema Encefálico/prevenção & controle , Padrões de Prática Médica , Edema Pulmonar/prevenção & controle , Medicina Selvagem , Doença da Altitude/terapia , Edema Encefálico/terapia , Humanos , Montanhismo , Edema Pulmonar/terapia , Sociedades Médicas , Medicina Selvagem/normasRESUMO
To provide guidance to clinicians, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations. This is an updated version of the original Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia published in Wilderness & Environmental Medicine 2014;25(4):425-445.
Assuntos
Hipotermia/diagnóstico , Hipotermia/terapia , Padrões de Prática Médica , Medicina Selvagem/métodos , Humanos , Hipotermia/fisiopatologia , Montanhismo , Sociedades Médicas , Medicina Selvagem/normasRESUMO
To provide guidance to clinicians, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations.
Assuntos
Hipotermia/diagnóstico , Hipotermia/terapia , Medicina Selvagem/métodos , Acidentes , Assistência Ambulatorial/métodos , Avalanche , Temperatura Corporal , Medicina de Emergência/métodos , Prática Clínica Baseada em Evidências , Hipotermia/fisiopatologia , Padrões de Prática Médica , Trabalho de Resgate/métodos , Índice de Gravidade de Doença , Estremecimento , Sociedades MédicasAssuntos
Doença da Altitude/prevenção & controle , Montanhismo , Substâncias para Melhoria do Desempenho/administração & dosagem , Medicina Selvagem/ética , Acetazolamida/uso terapêutico , Doença da Altitude/terapia , Dexametasona/uso terapêutico , Humanos , Montanhismo/ética , Nifedipino/uso terapêutico , Oxigênio/administração & dosagem , Oxigenoterapia/ética , Oxigenoterapia/métodosRESUMO
More than 140 million people live permanently at high altitude (>2400 m) under hypoxic conditions that challenge basic physiology. Here we present a short historical review of the populating of these regions and of evidence for genetic adaptations and environmental factors (such as exposure to cobalt) that may influence the phenotypic responses. We also review some of the common renal physiologic responses focusing on clinical manifestations. The frequent presentation of systemic hypertension and microalbuminuria with relatively preserved GFR coupled with the presence of polycythemia and hyperuricemia suggests a new clinical syndrome we term high altitude renal syndrome (HARS). ACE inhibitors appear effective at reducing proteinuria and lowering hemoglobin levels in these patients.
Assuntos
Adaptação Fisiológica/genética , Adaptação Fisiológica/fisiologia , Doença da Altitude , Atitude , Nefropatias , Doença da Altitude/epidemiologia , Doença da Altitude/genética , Doença da Altitude/fisiopatologia , Humanos , Nefropatias/epidemiologia , Nefropatias/genética , Nefropatias/fisiopatologia , PrevalênciaRESUMO
OBJECTIVE: To explore the association of end-title partial pressure (Petco(2)) and oxygen saturation (Spo(2)) with the development of AMS in travelers rapidly ascending to Cusco, Peru (3326 m). METHODS: Using the 715 TIDAL WAVE Sp handheld, portable capnometer/oximeter, we measured Spo(2) and Petco(2) in 175 subjects upon ascent to Cusco, Peru (3326 m) from Lima (sea level) (a mean time of 3.9 hours.) Symptoms of AMS were recorded at the same initial time on arrival to altitude and 24 hours later using the Environmental Symptoms Questionnaire (ESQ). RESULTS: This study showed that no subjects with the lowest Petco(2) of 23 to 30 mm Hg had AMS (P <.044). The data also demonstrate that subjects with a higher Petco(2) (36-40 mm Hg) and lower Sao(2) (72%-86%) have a higher incidence of AMS. CONCLUSION: The most important finding of this study is that Petco(2) upon ascent was found to have a more significant effect than Spo(2) on a subject's ultimate ESQ score. This study demonstrates that those individuals with a brisk ventilatory response upon ascent to moderate altitude, as measured by Petco(2), did not develop AMS, whereas a blunted ventilatory response, as reflected in the highest Petco(2), was related to the subsequent development of AMS.
Assuntos
Doença da Altitude/fisiopatologia , Dióxido de Carbono/análise , Hipóxia/fisiopatologia , Montanhismo , Oxigênio/sangue , Doença Aguda , Adulto , Doença da Altitude/sangue , Pressão Atmosférica , Temperatura Baixa , Feminino , Humanos , Hipóxia/sangue , Masculino , Oximetria , Peru , Testes de Função Respiratória , Volume de Ventilação PulmonarRESUMO
To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.
Assuntos
Doença da Altitude/prevenção & controle , Doença da Altitude/terapia , Montanhismo , Medicina Selvagem/normas , Acetazolamida/uso terapêutico , Doença Aguda , Albuterol/análogos & derivados , Albuterol/uso terapêutico , Edema Encefálico/prevenção & controle , Edema Encefálico/terapia , Carbolinas/uso terapêutico , Dexametasona/uso terapêutico , Humanos , Nifedipino/uso terapêutico , Piperazinas/uso terapêutico , Edema Pulmonar/prevenção & controle , Edema Pulmonar/terapia , Purinas/uso terapêutico , Xinafoato de Salmeterol , Citrato de Sildenafila , Sociedades , Sulfonas/uso terapêutico , TadalafilaRESUMO
High-altitude illnesses have profound consequences on the health of many unsuspecting and otherwise healthy individuals who sojourn to high altitude for recreation and work. The clinical manifestations of high-altitude illnesses are secondary to the extravasation of fluid from the intravascular to extravascular space, especially in the brain and lungs. The most common of these illnesses, which can present as low as 2,000 m, is acute mountain sickness, which is usually self-limited but can progress to the more severe and potentially fatal entities of high-altitude cerebral edema and high-altitude pulmonary edema. This article will briefly review normal adaptation to high altitude and then more extensive reviews of the clinical presentations, prevention, and treatments of these potentially fatal conditions. Research on the mechanisms of these conditions will also be reviewed. A better understanding of these disorders by practitioners will lead to improved prevention and rational treatment for the increasing number of people visiting high-altitude areas around the globe. There will not be space for writing about high-altitude residents, medical conditions in low-altitude residents going to high altitude, or training for athletes at high altitude. These topics deserve another article.
Assuntos
Doença da Altitude/etiologia , Doença da Altitude/terapia , Aclimatação , Doença da Altitude/diagnóstico , Edema Encefálico/diagnóstico , Edema Encefálico/etiologia , Edema Encefálico/terapia , Humanos , Edema Pulmonar/diagnóstico , Edema Pulmonar/etiologia , Edema Pulmonar/terapiaRESUMO
Very little information is known about patients with chronic obstructive pulmonary disease who travel to high altitude for work or pleasure. Even less is known about the outcomes at high altitude for patients with severe bullous lung disease. We present the case of a 54-yr-old man with vanishing lung syndrome, an idiopathic form of severe bullous emphysema, who has made repeated trips to altitudes as high as 3400 m, where he has engaged in physical activity, such as downhill skiing. We consider the issues of adequacy of oxygenation and the risks of barotrauma in patients with obstructive lung disease traveling to high altitude, and we also consider factors, such as improved air-flow limitation, maintenance of adequate ventilation-perfusion matching, and underlying physical fitness, which may affect our patient's ability to tolerate physical activity in this environment. The case demonstrates that the presence of severe lung disease does not necessarily preclude travel to and moderate activity at high altitude. Such travel may, in fact, be safe as long as the patient has undergone appropriate pretravel evaluation, and we provide recommendations regarding such evaluation in patients with chronic obstructive pulmonary disease.