SHORTNESS OF BREATH IN AN ULTRAMARATHON RUNNER AT 12,600 FT

Transcription

1 SHORTNESS OF BREATH IN AN ULTRAMARATHON RUNNER AT 12,600 FT Morteza Khodaee, MD, MPH, FACSM, FAAFP Associate Professor University of Colorado SOM June 25, 2014

2 DISCLOSURE STATEMENT Nothing to Declare

3 CASE HISTORY A 43 year-old male runner was found sitting down dyspneic close to Hope pass during Leadville 100 race in Colorado. He was brought to the Hope Pass aid station by search and rescue. He had increased SOB and developed a dry cough during the previous 5-mile ascent, near the highest elevation of the race.

4 LEADVILLE 100 LT 100 is a high-altitude ultramarathon in Leadville, Colorado. The course ranges in altitude from 2804m to 3840m The majority is on forest trails with some mountain roads. Race start at 4 am on the 3 rd Saturday in August Cut off time is 30 hours Hope pass 3840m

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6 He flew from his home town, San Antonio, Texas, to Denver 2 days earlier. SOB began at the 50-mile and progressively worsened over the past 5 miles. SOB is exacerbated by physical activity and relieved by rest. He denied fevers, chills, and sick contacts. This is his first LT 100 attempt, but he has completed few 100-mile races before. He has never experienced these symptoms before despite many trips to high altitude. His past medical, family, and social histories are unremarkable, and he takes no medications. HPI

7 PHYSICAL EXAM He was evaluated at the aid station and appeared alert, but in mild distress. He was dyspneic and using accessory muscles to breathe. Unable to speak in complete sentences with periodic episodes of coughing and grunting. He was afebrile and normotensive, but tachycardic (110 BPM) and hypoxic with an oxygen saturation of 61%. His lung examination was significant for diffuse rales.

8 San Antonio Denver Mt. Everest Columbine Mine

9 DIFFERENTIAL DIAGNOSIS Exercise induced bronchospasm High altitude pulmonary edema Atypical pneumonia Pulmonary embolism Pneumothorax CAD

10 He was placed on O2 and was given Albuterol inhaler Transferred to the nearby road by an ATV Then transferred to the local ED Felt better with O2 and rest in the meantime MANAGEMENT

11 LOCAL ED He looked better after arrival at the local ED (3,110m; 10,200ft) He was still dyspneic with periodic episodes of coughing. He was afebrile and normotensive, heart rate came down to 96 BPM. His pulse Ox was 90% on 3 lit O2. His lung examination was unchanged with significant diffuse rales.

12 RADIOGRAPHY

13 DDX Condition Atypical pneumonia Pulmonary embolism HAPE Exercise induced bronchospasm Pneumothorax Characteristics Fever, productive cough; unilateral or bilateral heterogeneous, patchy, reticular, segmental, peribronchial opacifications on CXR Acute onset of cough, dyspnea, tachycardia, tachypnea, pleuretic chest pain, and hypoxia; CXR is usually normal, but a wedge-shaped opacity of the lung tissue may be present Caused by rapid ascent to high altitude above 2,500m; cough, dyspnea, hypoxia; dense bilateral patchy opacities in variable locations Cough, dyspnea, and wheezing triggered by exercise; CXR is usually normal Acute onset of dyspnea, pleuretic chest pain, diminished breath sounds; CXR may reveal displacement of visceral pleura and absence of pulmonary markings

14 FINAL DIAGNOSIS High altitude pulmonary edema (HAPE)

15 MANAGEMENT AND FOLLOW UP He was discharged on portable O2 same night He was prescribed Nifedipine SR 20 mg tid He was transported to lower elevation in Denver by his family the same night Upon follow up by phone his symptoms improved and he was able to fly back to San Antonio with a portable O2. His symptoms completely resolved 5 days later.

16 HIGH ALTITUDE ILLNESS Altitude illness occurs at elevations above 2,500 m (8,200 ft) Risk factors: rapid ascent poor acclimatization (e.g., no recent exposure to elevation >1,200 m) physical exertion at altitude young age history of prior altitude illness

17 HAPE not always related to AMS, may occur without signs of AMS incidence 0.1-5% often manifests at night (typically the second night of ascent) progresses rapidly, lethal within hours may lead to development of HACE

18 ALTITUDE ILLNESS Condition Symptoms and Signs Prophylaxis Treatment AMS Headache, anorexia, nausea, vomiting, dizziness, fatigue, difficulty sleeping Slow ascent, acetazolamide, ibuprofen Descent, acetazolamide, dexamethasone, supplemental oxygen HAPE HACE Dyspnea at rest, tachycardia at rest, wet cough, tachycardia, dyspnea on mild exertion, rales, wheezing Altered mental status or ataxia in a person with AMS or HAPE Slow ascent, nifedipine Slow ascent, acetazolamide only for severe cases when descent is not feasible Descent, supplemental oxygen, nifedipine, phosphodiesterase-5 inhibitors (e.g., sildenafil); portable hyperbaric chambers Descent, dexamethasone, acetazolamide, supplemental oxygen, portable hyperbaric chambers Hoffman MD et al. Medical services at ultra-endurance foot races in remote environments: medical issues and consensus guidelines. Sports Med (Published online ahead of print).

19 HAPE MANAGEMENT Pennardt A. High-altitude pulmonary edema: diagnosis, prevention, and treatment. Curr Sports Med Rep Mar-Apr;12(2):115-9.

20 TAKE HOME MESSAGE In runners with respiratory symptoms at altitude >2,000m, HAPE should be considered as a possible diagnosis Asthma and other respiratory conditions are risk factors for HAPE, so runners can have both If respiratory symptoms and signs do not improve with Albuterol, the diagnosis is HAPE until proven otherwise Mainstay of treatment is supplemental O2 and immediate descend

21 REFERENCES Pennardt A. High-altitude pulmonary edema: diagnosis, prevention, and treatment. Curr Sports Med Rep Mar-Apr;12(2): Eide RP 3rd, Asplund CA. Altitude illness: update on prevention and treatment. Curr Sports Med Rep May-Jun;11(3): Hoffman MD, Pasternak A, Rogers I, Khodaee M, Hill JC, Townes DA, Volker Scheer B, Krabak BJ, Basset P, Lipman GS. Medical services at ultra-endurance foot races in remote environments: medical issues and consensus guidelines. Sports Med (Published online ahead of print). Khodaee M, Ansari M. Common ultramarathon injuries and illnesses: race day management. Curr Sports Med Rep 2012 Nov-Dec;11(6): Luks AM, McIntosh SE, Grissom CK, Auerbach PS, Rodway GW, Schoene RB, Zafren K, Hackett PH; Wilderness Medical Society. Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness. Wilderness Environ Med Jun;21(2):

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