c. Symptoms of AMS can mask early pulmonary difficulties. Symptoms of HAPE include:

• Progressive dry coughing with frothy white or pink sputum (this is usually a later sign) and then coughing up of blood.

• Cyanosis—a blue color to the face, hands, and feet.

• An increased ill feeling, labored breathing, dizziness, fainting, repeated clearing of the throat, and development of a cough.

• Respiratory difficulty, which may be sudden, accompanied by choking and rapid deterioration.

• Progressive shortness of breath, rapid heartbeat (pulse 120 to 160), and coughing (out of contrast to others who arrived at the same time to that altitude).

• Crackling, cellophane-like noises (rales) in the lungs caused by fluid buildup (a stethoscope is usually needed to hear them).

• Unconsciousness, if left untreated. Bubbles form in the nose and mouth, and death results.

d. HAPE is prevented by good nutrition, hydration, and gradual ascent to altitude (no more than 1,000 to 2,000 feet per day to an area of sleep). A rest day, with no gain in altitude or heavy physical exertion, is planned for every 3,000 feet of altitude gained. If a soldier develops symptoms despite precautions, immediate descent is mandatory where he receives prompt treatment, rest, warmth, and oxygen. He is quickly evacuated to lower altitudes as a litter patient. A descent of 300 meters may help; manual descent is not delayed to await air evacuation. If untreated, HAPE may become irreversible and cause death. Cases that are recognized early and treated promptly may expect to recover with no aftereffects. Soldiers who have had previous attacks of HAPE are prone to second attacks.

e. Treatment of HAPE includes:

• Immediate descent (2,000 to 3,000 feet minimum) if possible; if not, then treatment in a monoplace hyperbaric chamber.

• Rest (litter evacuation)

• Supplemental oxygen if available.

• Morphine for the systemic vasodilatation and reduction of preload. This should be carefully considered due to the respiratory depressive properties of the drug.

• Furosemide (Lasix), which is a diuretic, given orally can also be effective.

• The use of mannitol should not be considered due to the fact that it crystallizes at low temperatures. Since almost all high-altitude environments are cold, using mannitol could be fatal.

• Nifidipine (Procardia), which inhibits calcium ion flux across cardiac and smooth muscle cells, decreasing contractility and oxygen demand. It may also dilate coronary arteries and arterioles.

• Diphenhydramine (Benadryl), which can help alleviate the histamine response that increases mucosal secretions.

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