Breathless: Altitude Sickness in Nepal

Man Traveler with backpack mountaineering Travel Lifestyle concept

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Man Traveler with backpack mountaineering Travel Lifestyle concept

Nepal offers some of the most sought-after trekking routes in the world, with thousands of Nepalese nationals and foreigners ascending into the clouds to the north every year. As the growing trend to conquer high altitudes and see some of the most breathtaking views available in Nepal increases, so will the influx of trekkers. These trekkers without proper experience and knowledge to keep themselves safe from the dangers of altitude sickness, poses a challenge for the medical teams working to keep them safe. With over 187,000 foreigners entering Nepal for trekking in 2018, the pressure to keep them safe continues to provide little to no breathing room for physicians in Nepal.
Altitude sickness is comprised of three different types of illness, with reversible Acute Mountain Sickness being the first form (AMS), followed by potentially fatal forms of illnesses known as High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE). AMS is a common form of altitude sickness and is prevalent in approximately 60-70 percent of travellers ascending to high altitude (>2,500 m), while HACE and HAPE are less common, affecting only 1-2 percent of travellers. The symptoms of AMS vary from individual to individual, with, mild to moderate symptoms including: difficulty sleeping; dizziness; fatigue; headache; loss of appetite; vomiting; shortness of breath; and, rapid pulse. Symptoms of HACE as well as HAPE are more severe and immediate medical attention should be found. They include: blue color to the skin (cyanosis); chest tightness or congestion; confusion; coughing up blood; decreased consciousness; gray or pale complexion; cannot walk in a straight line, or walk at all; and, fluid or swelling in the brain.
The pathophysiological mechanisms behind these conditions are not completely understood and the prevalence of them is highly variable among individuals and even more so amongst various ethnic populations. Moreover, depending on the individual, they may be able to acclimatize better or even be more resistant to altitude sickness in general. As altitude increases the partial pressure of oxygen in the atmosphere is reduced, this is known as hypobaric hypoxia. Once exposed to hypobaric hypoxia the human body begins to work to acclimatize itself in order to undergo changes to manage the reduction of oxygen pressure at high altitudes. These changes take the form of increased breathing rate and heart rate as well as kidneys produce more urine. These changes begin as soon as you begin to reach high altitudes and the human body takes days to fully reach acclimation through these mechanisms. In addition to these short term mechanisms, if the individual stays long term at high altitudes, the body will make more red blood cells in order to transport more oxygen.
On average there is three deaths out of every 100,000 trekkers that enter Nepal to climb the various trekking routes available. Therefore, it is crucial for trekkers to be cautious while attempting any climb that requires rapid ascents, as it is one of the main causes of AMS. It occurs when trekkers above 2500 meters attempt to exceed 300-500 meters of sleeping altitude per day. Additionally, when a rest day isn’t taken after ascending 1000-1200 meters during the climb, AMS may set in. Trekkers may further be effected by AMS when they become dehydrated, overexerted or are not properly protected from the cold and hyperthermia. Therefore it is recommended that climbers use rest days, don’t exceed 500 meters in sleeping altitude change in a day, stay hydrated, or take Acetazolamide (Diamox) 125 mg twice daily as a prophylaxis for altitude sickness.
Dr. Santosh Baniya a MDGP and Emergency Physician, DiMM; as well as a team member of the Mountain Medicine Society of Nepal and TUTH; is a leading physician working on altitude sickness in Nepal. He discussed the complications of combing the usage of alcohol while trekking, which he stated is a growing trend among Nepali nationals as well as foreigners. It has led to complications for medical teams in high altitudes to properly evaluate and treat trekkers. Another issue increasing the prevalence of altitude sickness is the direct flights to high altitude areas, as well as roads that are reaching high altitudes allowing for increased access by vehicles, in areas such as Manang. This has led to a relatively new illness here in Nepal known as Re-entry high altitude pulmonary edema. Although this is new to Nepal, it is a common phenomenon in South American Andes. The major complication from this comes from the lack of knowledge physicians and Nepalis have regarding it here in Nepal. The lack of knowledge, according to Dr. Santosh, is going to cause severe complications and difficulties to doctors here in Nepal. In which he has been conducting research on and calling for more doctors to do the same with indigenous communities in the Himalayans.
Re-entry high altitude pulmonary edema has become prevalent in the last couple years as Nepalis living in high altitudes for most of the year around Lake Tilcho (4,900 m) and Lake Gosaikunda (4,380 m) have been traveling to low elevations for short periods of time before returning to their homes at extreme altitudes. Resulting in an increased number of Nepalis contracting Re-entry high altitude pulmonary edema or other severe forms of altitude sickness like HACE and HAPE. There has also been severe cases which have led to the death of Nepalis. Dr. Santosh attributes this both to increased access to areas by motorbike and plane, as well as Nepalis miss-conception of being capable to travel to low and then extreme altitudes very quickly due to their genetics.
As both national and foreigner tourists trekking through Nepal increases, so does the risk of illness and the need for medical assistance. Nepal has well-established rescue and aid posts throughout the Annapurna and Everest region. Himalayan Rescue Association runs aid posts in Pherice (4,300 m) and Everest Base Camp (5,300 m) in the Everest region; and in Manang (3,500 m) in the Annapurna region. Additionally, the International Porters Protection Group runs a rescue post in Machhermo (4,410 m) and Gokyo (4,880 m). All of these posts are seasonal posts and ran by volunteer doctors from Nepal and abroad. Where each doctor works for two and a half months each season. In addition to immediate medical attention at the aid posts, trekkers in emergencies, have access to air-evac, which has become robust and more effective in the last few years according to Dr. Santosh. He stated, “Due to satellite phones and the use of credit cards in-leu of radios and advanced payment which was the norm before; countless lives have been saved”.
Significant strives have been made regarding altitude sickness in the world as well as here in Nepal. For example, genetic studies are beginning to be conducted in the Himalayas on the physiology of high altitude inhabitants. Which Dr. Santosh said stated being crucial research as they may be able to apply the findings to other branches of medicine like critical care and medical emergencies. The research being conducted and the need to protect trekkers are some of the leading factors to Dr. Santosh helping to organize the World Congress on Mountain Medicine in Nepal, in 2018. As one of the organizers he took great pride in being able to bring in professionals, as well as providing free registration to 80 Nepali and foreign medical students from around the world. Giving future researchers and doctors the chance to meet with experienced professionals in order to share knowledge and encouraging words from all corners of the world. Dr. Santosh said, “This was an incredible opportunity for us at Mountain Medicine as well as Nepali students in order to develop the pool of young experts we need to move forward”. Which he followed up by saying was the primary need for the field as well as the primary focus of Mountain Medicine.
Trekkers begun flooding Nepal in the 1960s and haven’t slowed down since. With Nepal presenting Visit Nepal 2020, its projected that the number of trekkers will skyrocket, and thus will the incidents of altitude sicknesses. No matter if you are a foreigner traversing the mountains for the beautiful scenery, or a lowlander Nepali with the Himalayas in your own backyard; no one is protected from the effects of low oxygen altitudes. Dr. Santosh cannot stress enough the importance of taking the necessary precautions needed to keep yourself safe, as well as being able to recognize the symptoms of altitude sickness while traveling into thin air.

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