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David Meier, MD, and Tinh-Hai Collet, MD, discuss the clinical examination for acute mountain sickness with David L. Simel, MD.
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David Meier, MD, and Tinh-Hai Collet, MD, discuss the clinical examination for acute mountain sickness with David L. Simel, MD.
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Segment:0 .
[ Music ] >> Hello, and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I'm David Simel, the Editor of the Rational Clinical Examination Series and Professor of Medicine at the Durham Veterans Affairs Healthcare System in Duke University.
You've been listening to Kate Jones and Jesse McQuarters perform Canon Adua [phonetic] by Gabriele. Why? Well, Jesse is our producer for JAMA Evidence podcast, and he and Kate got their double basses to 14,264 feet, or 4,348 meters, atop Mount Evans, Colorado, for this performance. And today, we are talking about high altitude illness. So I thought we would start with having Jesse join us to discuss his experience performing at altitude.
Welcome, Jesse. >> Thank you very much. >> I can't tell from the recording whether you were affected by the altitude, but I'm confident that you're performance wasn't the same as a performance at sea level. So tell us how you got to the summit of Mount Evans with your basses and what the performance was like. >> Well, thank you so much, David. I really appreciate the chance to talk about it because it was an amazing experience. Kate and I taught together at a music institute in Beaver Creek, Colorado, and the previous summer we had hiked to the summit of Mount Evans, one of the 14 areas in the front range of Colorado.
And we sort of were joking around, and we said we should bring our basses up here. I thought she was kidding until the next spring when she was like, okay, let's figure out what we're going to play. And of course, I couldn't turn down that opportunity, so about a month later, we found ourselves with our basses on our backs, a bunch of video equipment, hiking up the slopes of Mount Evans. And luckily there's a scenic byway that goes up a lot of the way, but at a certain point you are just climbing over rocks and going up switchbacks and really feeling the altitude.
>> So how long did it take you to get to the summit? >> You know, luckily, it wasn't too bad. It was just, I believe, a few hours. Obviously, having the basses on our backs slowed us down a little bit, but actually it was kind of nice because all of the people that were passing us by waited at the summit for us, and we slowly plotted our way up and climbing over the rocks and fought the wind and the altitude. When we got up there, we did this concert, and all the people we kind of knew from our trip up there and they were waiting, and they so kindly supported us.
And we had a great time. It was an amazing experience. >> Well, how did the altitude affect you? >> I think hiking at that altitude in general is tough. You definitely get lightheaded, you definitely sometimes get a little nauseous, you feel like you should drink a lot of water. And when you're doing physical exertion like carrying these large instruments up, you definitely feel that a lot more. So it definitely took some time as we got unpacked to just kind of settle in and gather our wits a little bit and then do this mental task, which usually you don't have to do at the summit, which is read music and play together and be musical and all that stuff that we really enjoy doing.
>> Did you have a headache at any time? >> Luckily, no headache. You know, we had been teaching at about 8,000 feet for the week prior, so we weren't quite acclimated to the summit, but we had been acclimated to a little bit of the altitude. So luckily not too much of a headache, but definitely some lightheadedness. >> Well, these are big instruments, and that's a big hike. Was your shortness of breath out of proportion to just the difficulty of the climb and carrying the instruments?
>> Yeah, it's a little tough to say because both hiking by yourself or maybe with just a backpack is tough as it is. I think having the instruments definitely made it harder. It definitely made it more physically exerting and we definitely felt the effects a lot more, but it also made it a lot more gratifying. >> Well, do you have any advice for other musicians who might now be inspired to perform at altitude? >> Well, I think the recommendations would be the same as if somebody was going to go hike. Drink lots of water, gets lots of rest the night before.
Sleep is super important. Take your time. And the beauty of it is you are at 14,000 feet, you're at the mountain summit, you have this amazing view, you're out in nature. So there's absolutely nothing wrong with just taking some time and listening to your body and enjoying the view. For musicians specifically, I would say take the opportunity to interact with people around you because people love music. They love music in context outside of the normal concert hall or where they normally hear it, and it's an opportunity to really connect with people.
>> Thanks, Jesse and Kate, for sharing your performance. Joining us to talk about high altitude illness from the Lausanne University in Lausanne, Switzerland, are Drs. David Meier of the Department of Cardiology -- >> Hello. It's a pleasure for me to be here. >> -- and Tinh-Hai Collet from the service of endocrinology, diabetes, and metabolism. >> Hello. Thank you for having me on this podcast. >> Thanks for joining us all the way from Switzerland. To help us understand the illness, tell us more about the common symptoms of acute mountain sickness.
>> So one of the most frequently reported symptoms of acute mountain sickness is clearly headache. And then you have lot of gastrointestinal symptoms including a patient with poor appetite, nausea, vomiting, and even diarrhea. There are also some neurological symptoms such as dizziness or lightheadedness, and some more, I would say, nonspecific symptoms such as general fatigue or weakness.
>> So can you tell us what the incidence is of acute mountain sickness among travelers at high altitude? >> So it is a difficult number to give, and that's exactly why we started this meta-analysis and the systematic review for that. The most important determinant of AMS, or acute mountain sickness, is the absolute altitude which is reached by the travelers. So high altitude is usually defined as going above 2,500 meters, or approximately 8,200 feet of altitude.
And then in our pooled analysis we showed that the increase of AMS, acute mountain sickness, prevalence increased by 13%, one three, for each 1,000 meters or approximately 3,300 feet. This means that if you reach an altitude of 3,500 meters or approximately 11,500 feet, you would have a prevalence of acute mountain sickness of around 30%. And if you reach 5,000 meters, or approximately 16,400 feet, you would have about a 50% prevalence of acute mountain sickness.
I am completely aware that I haven't answered directly to your question because you asked about incidence, and that's even more difficult to answer to because we don't have big epidemiological studies. So it's hard to tell the incidence of acute mountain sickness. >> Having just traveled to Peru myself where coca tea and leaves are offered as you get off the plane, are there any supplements or modifiable behaviors that change the probability of developing acute mountain sickness?
>> Regarding modifiable behaviors, I would say that one of the most important is the ascend speed. It is well recognized that speed ascend faster than 500 meters per day, which would be around 1,300 feet per day, can as much as quadruple the risk of acute mountain sickness. And the slower ascent is really lowering the risk of AMS. Another thing that might lower the risk of AMS is the use of prophylactic medication, mainly acetazolamide.
And regarding coca leaves, it's effectively very frequently consumed at altitude, especially in South America, and there are even some reports suggesting that it's more frequently consumed than acetazolamide. However, to my knowledge, there is no solid scientific literature regarding the possible benefits of coca on acute mountain sickness symptoms. I think there is even one observational study from 2012, which reported a higher rate of acute mountain sickness in trials using coca.
So I think we cannot say that it's useful. Regarding supplements, there have also been some studies on antioxidants, ginkgo biloba, magnesium. None of these studies have shown benefits. So I would say that the only drug that has been consistently shown to reduce the rate of AMS is acetazolamide. >> Well, from my experience, the coca tea tasted nice, but I couldn't tell that it did anything for me.
[laughter] So how can travelers assess companions or themselves for actual acute mountain sickness? >> It's actually a very interesting question from the epidemiology standpoint, and that's more my background than my role in this analysis. So if you look at methodology, we quite often talk about self-administered versus self-reported use of instruments. So in this context it's very interesting because you're trying to use an instrument at especially high altitude where you don't have much more than the pen and paper methods.
So it is actually very challenging to test and validate. So to go back to your question, it's actually hard to tell whether the instrument was actually self-administered or self-reported to a fellow companion in most of the studies. So, so far the diagnosis essentially relies on symptoms assessed usually by the hiker or sometimes the companions rather than specific signs like we learn in medical school. And then the practical approach is to consider when a patient develops suggestive symptoms at high altitude.
And then the way we approach it as conditions is if you have any symptoms that were listed before, you have to consider it as an acute mountain sickness unless proven otherwise or unless you have a specific diagnosis that was already known for the traveler. The other thing, which is very interesting from the methodology point of view here is that because the traveler may be suffering from acute mountain sickness, his or her judgment might be impaired. So it's even more difficult to assess for ourselves whether we have symptoms that are compatible with acute mountain sickness.
So I think there is a very good place for fellow travelers assessing this, but it's actually difficult. In this review, we actually identified seven main clinical scores or instruments. Then we had a hard time finding comparative data, so studies that compared head-to-head different scores next to each other. And that is what we tried in this meta-analysis. >> Well, you mentioned that you found several different scoring systems.
I'm familiar with the Lake Louise questionnaire score, but you found other scores too. Can you tell us how the components of those scores are similar or different? What symptoms do they tend to track? >> You're right. The Lake Louise questionnaire score is the generally accepted gold standard for mountain sickness evaluation. And as I said in the introduction, the main components of these scores are headache, gastrointestinal symptoms, neurological symptoms, and fatigue.
And these groups of symptoms are generally well represented in the other instruments. The difference may be with some other scores as the Hackett's clinical score or the Chinese score is that they also include some questions about respiratory symptoms, which are not found in the Lake Louise questionnaire score. It's also important to note that the original version of the Lake Louise questionnaire score includes fatigue symptoms but also trouble sleeping symptoms.
Right after we published this review, a panel of experts had a meeting in 2018 to discuss about a new definition of acute mountain sickness. And they decided that trouble sleeping and fatigue had to be taken out of the Lake Louise questionnaire score. And this is for two main reasons, or maybe three. First, everybody has trouble sleeping when traveling, so it's difficult to know if it's really due to acute mountain sickness or if it's the travel. Second, it's also to facilitate comparison between studies because many of the studies don't have altitude, only done on a day [inaudible] without sleeping.
So it makes it difficult to compare studies with people sleeping and studies without people sleeping. The third reason is that there are some studies that look at the correlation between sleep and other symptoms of acute mountain sickness. And it looks like the correlation was not very good, that the other symptoms were changing together while sleep seems to be independent. >> Well, this has been a fun discussion about acute mountain sickness. What else would you like to tell our listeners who are both clinicians and future travelers about the clinical examination for acute mountain sickness?
>> So in fact it has been a fun project. It took us some time to go through the whole literature, but as clinicians ourselves, we see several patients who like to go to high altitudes, even more so because we are based in Switzerland, so we're never far from mountains. Some of them are quite high. So we feel that it's very important to educate our patients about these symptoms for themselves or their fellow travelers. >> And maybe one simple message is that at altitude, in case of symptoms compatible with acute mountain sickness, you should think of acute mountain sickness first.
However, it's important, especially for the clinicians, to keep in mind that travelers at high altitude might develop non-altitude-related symptoms, that it's important to keep a differential diagnosis in mind. When acute mountain sickness is suspected, travelers should be very cautious before continuing ascension. And finally, I would say that the ultimate diagnosis is made when symptoms resolve, when altitude is lost, even if it has never been used as a reference in any study.
>> Well, thank you for this discussion today. More information about this topic is available in the Rational Clinical Examination and on our website, JAMAevidence.com, where you can listen to our entire roster of podcasts. I'm David Simel, and I'll be back with you soon for another edition of JAMAevidence. [ Music ] [ Applause ]
Segment:0 .
[ Music ] >> Hello, and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I'm David Simel, the Editor of the Rational Clinical Examination Series and Professor of Medicine at the Durham Veterans Affairs Healthcare System in Duke University.
You've been listening to Kate Jones and Jesse McQuarters perform Canon Adua [phonetic] by Gabriele. Why? Well, Jesse is our producer for JAMA Evidence podcast, and he and Kate got their double basses to 14,264 feet, or 4,348 meters, atop Mount Evans, Colorado, for this performance. And today, we are talking about high altitude illness. So I thought we would start with having Jesse join us to discuss his experience performing at altitude.
Welcome, Jesse. >> Thank you very much. >> I can't tell from the recording whether you were affected by the altitude, but I'm confident that you're performance wasn't the same as a performance at sea level. So tell us how you got to the summit of Mount Evans with your basses and what the performance was like. >> Well, thank you so much, David. I really appreciate the chance to talk about it because it was an amazing experience. Kate and I taught together at a music institute in Beaver Creek, Colorado, and the previous summer we had hiked to the summit of Mount Evans, one of the 14 areas in the front range of Colorado.
And we sort of were joking around, and we said we should bring our basses up here. I thought she was kidding until the next spring when she was like, okay, let's figure out what we're going to play. And of course, I couldn't turn down that opportunity, so about a month later, we found ourselves with our basses on our backs, a bunch of video equipment, hiking up the slopes of Mount Evans. And luckily there's a scenic byway that goes up a lot of the way, but at a certain point you are just climbing over rocks and going up switchbacks and really feeling the altitude.
>> So how long did it take you to get to the summit? >> You know, luckily, it wasn't too bad. It was just, I believe, a few hours. Obviously, having the basses on our backs slowed us down a little bit, but actually it was kind of nice because all of the people that were passing us by waited at the summit for us, and we slowly plotted our way up and climbing over the rocks and fought the wind and the altitude. When we got up there, we did this concert, and all the people we kind of knew from our trip up there and they were waiting, and they so kindly supported us.
And we had a great time. It was an amazing experience. >> Well, how did the altitude affect you? >> I think hiking at that altitude in general is tough. You definitely get lightheaded, you definitely sometimes get a little nauseous, you feel like you should drink a lot of water. And when you're doing physical exertion like carrying these large instruments up, you definitely feel that a lot more. So it definitely took some time as we got unpacked to just kind of settle in and gather our wits a little bit and then do this mental task, which usually you don't have to do at the summit, which is read music and play together and be musical and all that stuff that we really enjoy doing.
>> Did you have a headache at any time? >> Luckily, no headache. You know, we had been teaching at about 8,000 feet for the week prior, so we weren't quite acclimated to the summit, but we had been acclimated to a little bit of the altitude. So luckily not too much of a headache, but definitely some lightheadedness. >> Well, these are big instruments, and that's a big hike. Was your shortness of breath out of proportion to just the difficulty of the climb and carrying the instruments?
>> Yeah, it's a little tough to say because both hiking by yourself or maybe with just a backpack is tough as it is. I think having the instruments definitely made it harder. It definitely made it more physically exerting and we definitely felt the effects a lot more, but it also made it a lot more gratifying. >> Well, do you have any advice for other musicians who might now be inspired to perform at altitude? >> Well, I think the recommendations would be the same as if somebody was going to go hike. Drink lots of water, gets lots of rest the night before.
Sleep is super important. Take your time. And the beauty of it is you are at 14,000 feet, you're at the mountain summit, you have this amazing view, you're out in nature. So there's absolutely nothing wrong with just taking some time and listening to your body and enjoying the view. For musicians specifically, I would say take the opportunity to interact with people around you because people love music. They love music in context outside of the normal concert hall or where they normally hear it, and it's an opportunity to really connect with people.
>> Thanks, Jesse and Kate, for sharing your performance. Joining us to talk about high altitude illness from the Lausanne University in Lausanne, Switzerland, are Drs. David Meier of the Department of Cardiology -- >> Hello. It's a pleasure for me to be here. >> -- and Tinh-Hai Collet from the service of endocrinology, diabetes, and metabolism. >> Hello. Thank you for having me on this podcast. >> Thanks for joining us all the way from Switzerland. To help us understand the illness, tell us more about the common symptoms of acute mountain sickness.
>> So one of the most frequently reported symptoms of acute mountain sickness is clearly headache. And then you have lot of gastrointestinal symptoms including a patient with poor appetite, nausea, vomiting, and even diarrhea. There are also some neurological symptoms such as dizziness or lightheadedness, and some more, I would say, nonspecific symptoms such as general fatigue or weakness.
>> So can you tell us what the incidence is of acute mountain sickness among travelers at high altitude? >> So it is a difficult number to give, and that's exactly why we started this meta-analysis and the systematic review for that. The most important determinant of AMS, or acute mountain sickness, is the absolute altitude which is reached by the travelers. So high altitude is usually defined as going above 2,500 meters, or approximately 8,200 feet of altitude.
And then in our pooled analysis we showed that the increase of AMS, acute mountain sickness, prevalence increased by 13%, one three, for each 1,000 meters or approximately 3,300 feet. This means that if you reach an altitude of 3,500 meters or approximately 11,500 feet, you would have a prevalence of acute mountain sickness of around 30%. And if you reach 5,000 meters, or approximately 16,400 feet, you would have about a 50% prevalence of acute mountain sickness.
I am completely aware that I haven't answered directly to your question because you asked about incidence, and that's even more difficult to answer to because we don't have big epidemiological studies. So it's hard to tell the incidence of acute mountain sickness. >> Having just traveled to Peru myself where coca tea and leaves are offered as you get off the plane, are there any supplements or modifiable behaviors that change the probability of developing acute mountain sickness?
>> Regarding modifiable behaviors, I would say that one of the most important is the ascend speed. It is well recognized that speed ascend faster than 500 meters per day, which would be around 1,300 feet per day, can as much as quadruple the risk of acute mountain sickness. And the slower ascent is really lowering the risk of AMS. Another thing that might lower the risk of AMS is the use of prophylactic medication, mainly acetazolamide.
And regarding coca leaves, it's effectively very frequently consumed at altitude, especially in South America, and there are even some reports suggesting that it's more frequently consumed than acetazolamide. However, to my knowledge, there is no solid scientific literature regarding the possible benefits of coca on acute mountain sickness symptoms. I think there is even one observational study from 2012, which reported a higher rate of acute mountain sickness in trials using coca.
So I think we cannot say that it's useful. Regarding supplements, there have also been some studies on antioxidants, ginkgo biloba, magnesium. None of these studies have shown benefits. So I would say that the only drug that has been consistently shown to reduce the rate of AMS is acetazolamide. >> Well, from my experience, the coca tea tasted nice, but I couldn't tell that it did anything for me.
[laughter] So how can travelers assess companions or themselves for actual acute mountain sickness? >> It's actually a very interesting question from the epidemiology standpoint, and that's more my background than my role in this analysis. So if you look at methodology, we quite often talk about self-administered versus self-reported use of instruments. So in this context it's very interesting because you're trying to use an instrument at especially high altitude where you don't have much more than the pen and paper methods.
So it is actually very challenging to test and validate. So to go back to your question, it's actually hard to tell whether the instrument was actually self-administered or self-reported to a fellow companion in most of the studies. So, so far the diagnosis essentially relies on symptoms assessed usually by the hiker or sometimes the companions rather than specific signs like we learn in medical school. And then the practical approach is to consider when a patient develops suggestive symptoms at high altitude.
And then the way we approach it as conditions is if you have any symptoms that were listed before, you have to consider it as an acute mountain sickness unless proven otherwise or unless you have a specific diagnosis that was already known for the traveler. The other thing, which is very interesting from the methodology point of view here is that because the traveler may be suffering from acute mountain sickness, his or her judgment might be impaired. So it's even more difficult to assess for ourselves whether we have symptoms that are compatible with acute mountain sickness.
So I think there is a very good place for fellow travelers assessing this, but it's actually difficult. In this review, we actually identified seven main clinical scores or instruments. Then we had a hard time finding comparative data, so studies that compared head-to-head different scores next to each other. And that is what we tried in this meta-analysis. >> Well, you mentioned that you found several different scoring systems.
I'm familiar with the Lake Louise questionnaire score, but you found other scores too. Can you tell us how the components of those scores are similar or different? What symptoms do they tend to track? >> You're right. The Lake Louise questionnaire score is the generally accepted gold standard for mountain sickness evaluation. And as I said in the introduction, the main components of these scores are headache, gastrointestinal symptoms, neurological symptoms, and fatigue.
And these groups of symptoms are generally well represented in the other instruments. The difference may be with some other scores as the Hackett's clinical score or the Chinese score is that they also include some questions about respiratory symptoms, which are not found in the Lake Louise questionnaire score. It's also important to note that the original version of the Lake Louise questionnaire score includes fatigue symptoms but also trouble sleeping symptoms.
Right after we published this review, a panel of experts had a meeting in 2018 to discuss about a new definition of acute mountain sickness. And they decided that trouble sleeping and fatigue had to be taken out of the Lake Louise questionnaire score. And this is for two main reasons, or maybe three. First, everybody has trouble sleeping when traveling, so it's difficult to know if it's really due to acute mountain sickness or if it's the travel. Second, it's also to facilitate comparison between studies because many of the studies don't have altitude, only done on a day [inaudible] without sleeping.
So it makes it difficult to compare studies with people sleeping and studies without people sleeping. The third reason is that there are some studies that look at the correlation between sleep and other symptoms of acute mountain sickness. And it looks like the correlation was not very good, that the other symptoms were changing together while sleep seems to be independent. >> Well, this has been a fun discussion about acute mountain sickness. What else would you like to tell our listeners who are both clinicians and future travelers about the clinical examination for acute mountain sickness?
>> So in fact it has been a fun project. It took us some time to go through the whole literature, but as clinicians ourselves, we see several patients who like to go to high altitudes, even more so because we are based in Switzerland, so we're never far from mountains. Some of them are quite high. So we feel that it's very important to educate our patients about these symptoms for themselves or their fellow travelers. >> And maybe one simple message is that at altitude, in case of symptoms compatible with acute mountain sickness, you should think of acute mountain sickness first.
However, it's important, especially for the clinicians, to keep in mind that travelers at high altitude might develop non-altitude-related symptoms, that it's important to keep a differential diagnosis in mind. When acute mountain sickness is suspected, travelers should be very cautious before continuing ascension. And finally, I would say that the ultimate diagnosis is made when symptoms resolve, when altitude is lost, even if it has never been used as a reference in any study.
>> Well, thank you for this discussion today. More information about this topic is available in the Rational Clinical Examination and on our website, JAMAevidence.com, where you can listen to our entire roster of podcasts. I'm David Simel, and I'll be back with you soon for another edition of JAMAevidence. [ Music ] [ Applause ]
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