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Christine Ebert-Santos, M.D., M.P.S Ebert Family Clinic, Frisco, CO, USA Background on HAPE Background on HAPE Methods Resul
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Document DEVICE REPORTebert-family-clinic-hape-mountain-childrenHigh Altitude Pulmonary Edema in Mountain Children with No Recent Travel Christine Ebert-Santos, M.D., M.P.S Ebert Family Clinic, Frisco, CO, USA Background on HAPE High altitude pulmonary edema (HAPE) is a type of noncardiogenic pulmonary edema seen at higher altitudes generally above 2,500m to 3,000m and is usually associated with travel.1 Pediatric patients present with increased respiratory distress and tend to be afebrile, with temperatures no higher than 38.3C.2,3,4 There is an increased incidence of HAPE with underlying infections causing inflammation including upper respiratory infections, otitis media, and streptococcal pharyngitis.5 Objective/Rationale In our clinic and hospital that is located in Frisco, CO (elevation 2,800m above sea level), we frequently see resident pediatric patients without recent travel presenting with respiratory tract infections and severe hypoxia with symptoms compatible with HAPE. Many of these children are diagnosed with pneumonia but have rapid and dramatic recovery with just high flow oxygen, without antibiotics. HAPE described in previous publications involve visitors to high altitude. In 1985, Fasules and colleagues published cases of HAPE in high altitude residents with no recent travel as well high altitude residents who developed HAPE after return from a lower elevation.6 The diagnoses was made on the basis of cardiac catheterization done in Leadville at 3,080 m. In our study, we identified three distinct types of HAPE: Classic, Reentry, and Resident. Methods Medical records of 52 patients with suspected HAPE seen in 2015 at Ebert Family Clinic in Frisco, CO were reviewed Patients studied lived in elevations between 2,440m to 3,500m Medical records were accessed through the electronic medical record system, EPIC, which was used at both clinic and hospital. Key findings documented for this study were clinical symptoms, vital signs, images including chest x-rays, residency status, and number of days since arrival to higher elevation. Results Age Gen Primary der 14 M Fever, URI 5 M Fever, cough, vomiting 6 F Fever, cough, otitis media 6 M Fever, cough, rales, otitis media 2 M URI , wheezing, pale, otitis media 5 M Fever, cough, sore throat 8 M Fever, cough, sore throat, wheezing 4 M Fever, cough 5 M Fever, cough, sore throat, rales 14 F Fever, cough, sore throat 5 M Fever, sore throat, wheezing, rales 4 M Fever, cough, vomiting, rales 2 F Cough, rales 5 M Fever, cough, otitis media 6 M Fever, cough, wheezing, abdominal pain, otitis media 4 M Cough, rales 8 M Cough, URI , rales 5 M Cough, otitis media 3 F Fever, cough 4 M Cough, rales 4 M Fever, cough, sore throat, URI , otitis media 3 M Cough, sore throat, URI , wheezing 5 M Cough, URI , wheezing 15 F Fever, cough, wheezing 5 M Fever, cough (Flu +), rhonchi 8 M Fever, cough, URI 6 M URI , wheezing 4 F Fever, cough, URI , wheezing 22mo F Fever, cough ,URI 5 M Fever, cough 7 M Fever, URI , rhonchi, wheezing, otitis media 10 M Fever, cough, crackles, otitis media 7 M Fever, cough, vomiting, abdominal pain, rales, grunting 3 F Fever, cough, abdominal pain, crackles 16mo F Cough, vomiting, URI , rales 3 M URI , rales 6 F Fever, cough abdominal pain 6 M Fever, cough, URI , rales, otitis media 12 F Fever, cough 20mo M Fever, cough, URI , rales 12mo F Fever, cough, URI 3 F Cough 3 M Cough, URI 2 M Cough Temp (C) 37.7 37.4 37.2 37.8 36.6 38.4 37.1 38.4 38.1 38.5 36.7 38.5 37.8 38.2 38.4 37.6 37.6 37.8 36.2 39.6 37.5 37.0 37.8 37.4 37.0 36.8 37.0 36.7 37.1 37.6 38.4 36.8 37.2 37.0 37.4 37.4 37.7 37.8 37.8 36.7 37.4 37.1 37.7 37.3 O2 Sat Resident 85 O* 86 O 86 O 86 O 87 O 88 O 88 O 87 O 84 O 94 O 84 O 84 O 85 O 88 O 85 O Duration Prior episode since arrival to high altitude Within past None 24 hours 4 days None - None - None - RSV, Flu (within 1 mo) - RSV, Flu - None - X1 - None - None - X1 6 days X2 - None - None - X1 86 O 24 hours None 90 O - None 87 O - None 84 O - None 72 X** 3 days None 82 O - None 84 O - None 87 O - X2 84 O - None 84 O - None 85 O - None 86 O - X2 84 O - X1 86 O 48 hrs None 85 O - None 86 O - None 86 O - None 82 O - None 85 O - None 73 x 24 hrs None 83 O - None 82 O - None 85 O - None 85 O - None 86 O - None 82 O 24 hours None 82 O 2 wks None 82 O - None 89 O - None Table of HAPE patients ages 12 months to 15 years of 2015. Clinic draws from five county area above 2500 meters with populations of 5000-29000 Patients seen in 2015: 1637 with 4230 total visits. *O indicates that the patient is a resident of an high altitude region. **X indicates that the patient is a visitor to high altitude region. Day 1 Day 2 Example: 10 year old male patient with suspected case of HAPE Result Summary Diagnosis Classic HAPE Reentry HAPE Resident HAPE Asthma attack Pneumonia Outcome (N=52) 2 (4%) 7 (13%) 35 (67%) 2 (4%) 6 (12%) Conclusion · 3 different categories of high altitude pulmonary edema can be recognized based on the etiology indicated by the patient's residency/travel history; Classic, Reentry, Resident. · 72% of pediatric patients with clinical features consistent with HAPE were found to have Resident HAPE at our clinic (elevation 2,800m) · Clinical diagnosis by experienced providers can avoid misdiagnosis, unnecessary antibiotics, and prevent episodes of both resident and reentry HAPE in pediatric patients. References 1. Bartsch P, et al. Physiological aspects of high-altitude pulmonary edema. J Appl Physiol (1985). 2005 Mar;98(3):1101-10. 2. Duster MC and Derlet MN. High-altitude illness in children. Pediatr Ann. 2009 Apr;38(4):218-23. 3. Yaron M, et al. Evaluation of diagnostic criteria and incidence of acute mountain sickness in preverbal children. Wilderness Environ Med. 2002 Spring;13(1):21-6. 4. Pollard AJ, et al. Children at high altitude: an international consensus statement by an ad hoc committee of the International Society for Mountain Medicine, March 12, 2001. High Alt Med Biol. 2001 Fall;2(3):389-403. 5. Durmowicz AG, et al. Inflammatory processes may predispose children to high-altitude pulmonary edema. J Pediatr. 1997 May;130(5):838-40. 6. Fasules JW, Wiggins JW, Wolfe RR. Increased lung vasoreactivity in children from Leadville, Colorado, after recovery from high-altitude pulmonary edema. Circulation. 1985 Nov;72(5):957- 62.aMicrosoft Office PowerPoint 2007