Case 1:- 5 year old child with High Altitude Pulmonary Edema (HAPE).

Summary – Apparently well 5 years old child went to high altitude ( Leh ) by flight .Within 8-10 hrs of landing at high altitude child developed breathing difficulty.Over next few hours she developed frank pulmonary edema and CXR showed bilateral extensive fluffy infiltrates in both lung fields. In view of respiratory failure ( saturation 50 %) child was intubated and was started on mechanical ventilation. The child was shifted to our hospital in air ambulance. At the time of admission in our PICU, child was critically sick , requiring very high pressure settings . Hemodynamically she was in unstable condition with poor perfusion , cold peripheries & low urine output. She was given fluid resuscitation with focus on major therapeutic end points. Central venous line ( 5 Fr Double lumen) and Arterial line were inserted by Paediatric Intensivist. Since the basic pathophysiology of HAPE revolves around hypoxic pulmonary vasoconstriction which precedes edema formation , bedside echocardiography was done which provided crucial information on PA pressures that was not apparent on clinical assessment. Lung protective ventilation strategies were employed. Continuous monitoring of intra-arterial BP , CVP , end tidal CO2 , pulse oximetry ,urine output , lactate, blood gas etc was also done. Combination of vasoactive agents and drugs like Sildenafil, Nifedipine were titrated according to these hemodynamic parameters. Gradually her lung compliance improved, peak pressures got normalized, peripheral perfusion and urine output improved and child was extubated after 6 days .

Learning points — Recreational activities have increased in recent past and each year many thousands of lowland children travel to high altitude. HAPE is a potentially life threatening condition and pediatricians should be aware that this entity do exist.We should know regarding the risk factors for HAPE in children ( in this case it was tonsillopharyngitis, & rapid ascent !!). Guidelines are available and they should be provided to parents who want to take their children to altitudes above 2500 m.