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Ospedale di Cava de’ Tirreni, Tirreni, Italy Ospedale Silvestrini, Perugia, Italy
Correspondence to: Giuseppe Fiorenzano, MD, FCCP, Fisiopatologia Respiratoria, Via Santoriello, 2, 84013 Cava De’ Tirreni, Italy; e-mail: gxfiore{at}tiscali.it
To the Editor:
We read with great interest the article by Gabry et al (January 2003)1 about high-altitude pulmonary edema (HAPE) in the French Alps and would like to add some considerations based on our experience in the Italian Alps.2 In the Sondalo Hospital (approximately 1,000 m above sea level), located near Stelvio Pass (2,760 m), we observed 10 cases of radiologically proven HAPE between 1989 and 1995 (1 or 2 cases per year). The lower incidence of HAPE may be explained by the fact that Stelvio Pass is closed during the winter season. The ski area of Stelvio (range, 2,760 to 3,500 m) is used only during the summer for training athletes or ski school. The population at risk is probably much less than in the article by Gabry et al.1 In our opinion, HAPE is probably underestimated, because we cannot exclude that patients with mild cases of HAPE recovered with return to low altitude, without being hospitalized. The recent article by Cremona et al3 also suggests an underestimation of mild HAPE. What is surprising in the French study is the low sleeping altitude of these subjects, as, in our experience, the sleeping altitude appeared very important. Indeed, all subjects except one slept at least 1 night at an altitude ranging from 2,760 to 3,100 m. The other subject slept at 1,800 m, exercising at > 3,000 m. Most subjects have had previous experience of ski and physical activity at altitudes > 3,000 m without problems during daytime excursions. Regarding the predisposing factors, one of our patients had a right pulmonary artery hypoplasia.4 Another patient had two episodes of HAPE in 2 different years, suggesting an individual predisposition. Two of the subjects came from Scandinavian countries (Finland and Sweden), and all were young (14 to 40 years old) male subjects in good physical condition. The article by Gabry et al1 underlines the need for epidemiologic studies about HAPE. In the older series,5 HAPE was reported together with acute mountain sickness and high-altitude cerebral edema. Probably this is a confusing factor, because in the article by Honigman et al6 and in our epidemiologic study at Stelvio Pass,7 acute mountain sickness was more frequent in women than in men, while HAPE appears to be more frequent in male patients. The retrospectivity of the French study is a limitation about the possible individual predisposition; some articles suggest that vascular reactivity8 or ion transport,9 possibly by genetic differences, may play a role. In conclusion, the study of Gabry et al1 strongly suggests the need for further investigations about HAPE epidemiology and pathogenetic mechanisms.
References
Hôpital Nord and Marseille School of Medicine, Marseille, France
Correspondence to: Claude Martin, MD, FCCP, Hôpital Nord, 13915 Marseille Cedex 20, France; e-mail: cmartin{at}ap-hm.fr
To the Editor:
We were very interested in reading the comments of Dr. Fiorenzano et al on our study.1
As discussed in our study, we agree with the fact that the incidence of high-altitude pulmonary edema (HAPE) is certainly underestimated, one reason being that some patients return at lower altitude and recover without consulting a physician. We read with interest that in the Italian experience, patients slept at higher altitudes than in the French experience. Whether or not this difference in the sleeping altitude has some consequence on the incidence of HAPE remains to be determined by further studies. We also noticed a difference in the two populations of patients. Most subjects seemed to have previous experience of ski and physical activity at high altitude (
3,000 m) in the Italian series. In our case series, most patients had no specific physical training and started physical activities the same day or the day after their arrival at the ski resorts. In any case, these discrepancies between different experiences from different countries emphasize the need for more epidemiologic studies on HAPE.
References
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