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Altitude prep and management

post #1 of 49
Thread Starter 
Many skiers come from lower altitudes to higher to enjoy the mountains. However, this can result in health challenges and less enjoyment as a result. So, one of the docs who frequents EpicSki has agreed to present on altitude management at the ESA. However, as I thought about it, I realized that it would be a greater help for ESA attendees (and others here!) to get some of the information prior to the event. So, I asked him if he'd be willing to post some of it here.

He has agreed, and has been working on the post for a while. So, this thread will shortly have one or more posts from our own dp on altitude issues and management. You'd be well-served to take it into account before your trip(s) this season!
post #2 of 49

Acclimatization to altitude and Acute Mountain Sickness (AMS)

a brief (well, maybe not so brief) guide for the worried flatlander

Many people who live at or near sea level have posted queries on the board regarding things like:
  • Am I going to get sick when I come up to Breckenridge?
  • The last time I was in Vail I had a splitting headache and vomited my guts out for 24 hours- is there anything I can do this time to keep from getting sick?
  • My brother in law said if I drink gingko tea I will not be sick- is this true?
  • Altitude sickness is a bunch of hooey- it only affects people climbing over 15,000ft (4700m). Don’t worry about it.
  • I have asthma (or heart disease, or emphysema, or morbid obesity, or hemorrhoids, or…) - do I need to worry when I come up to Jackson Hole?
  • I heard that if I have any alcohol up there it will have twice the effect as at sea level. Will I be able to finish a whole bottle of Jaegermeister in one sitting? Well Wear the Fox Hat think I am a wimp?
In this thread I will give an explanation of what acute mountain sickness (AMS) is, what the risks are, what you may be able to do to prevent it, and dispel some of the myths about it. I will also describe very briefly how one acclimates to altitude, and some facts about acclimatization and performance at altitude. There are some links to good web sites about altitude medicine at the end.

Who I am-
I came upon the EpicSki forums about 3½ years ago and have been hanging around ever since (far too much, according to my wife, who is probably right). I am a physician on the faculty at the University of Colorado School of Medicine, and have a long-standing interest in pulmonary physiology and altitude medicine.

What happens at altitude and why?
Altitude sickness doesn’t occur below 5000ft, and usually doesn’t develop until you ascent rapidly to more than 7500ft. The speed of ascent is important- going rapidly is much more likely to result in symptoms than ascending gradually.

At high altitude and low barometric pressure, there is less oxygen in the air (remember Boyle’s Law?), so each breath you take results in less oxygen being transferred into the blood by the lungs. (There is also some evidence that the lower barometric pressure itself as well as the low oxygen levels may play a role in AMS, too, but that is beyond the scope of this discussion.) With lower oxygen levels in the blood, there is less oxygen available to the tissues for metabolic needs. Thankfully, your body has some rather clever methods for dealing with this, otherwise we would all be stuck water skiing at sea level.

The first adaptation actually begins within minutes or hours of ascent- an increase in respiratory rate (more volume of air breathed each minute= more oxygen transferred to the blood each minute). This is why you feel short of breath. The magnitude and efficacy of this response is genetically predetermined for each individual. This reaches maximum response in about 4-7 days.

Your heart rate also increases within a day of ascent, pumping more blood (and therefore more oxygen) to the tissues. As other mechanisms kick in and you develop long-term acclimatization, your heart rate returns towards baseline.

It takes about a week for your body to begin to make more red blood cells to increase oxygen carrying capacity. By about 3-4 weeks, the increased red blood cell concentration in the blood has stabilized. Of course, you need enough iron in your diet for this to work. There is also a change in the ability of the red cells to pick up and off-load oxygen. This begins about 72 hours after ascent, and takes a few more days to fully kick in.

What is AMS?
Acute mountain sickness is a constellation of disorders caused by acute exposure to low pressure and low oxygen levels. It appears to be caused by swelling of the brain- a mild form of HACE (see below). Diagnosis (by the Lake Louise Criteria, which were formulated at the Hypoxia Symposium there a number of years ago) requires the presence of headache and one or more of the following:
  • GI symptoms (nausea, loss of appetite)
  • Fatigue or weakness
  • dizziness or lightheadedness
  • difficulty sleeping
A large study in Colorado found that 25% of people from low altitude ascending rapidly and sleeping at 8200ft (2500m) will develop AMS. These people may feel lousy for short while, but most of them will get better in a few days and not get sicker. About 1%, however, will develop more severe illness- high altitude cerebral edema (HACE, or brain swelling) or high altitude pulmonary edema (HAPE, or high blood pressure and fluid in the lungs). Both of these are life-threatening emergencies, and require immediate medical attention and descent if at all possible.

Other common problems at altitude
Dehydration- the air is dryer up here (due to the lower barometric pressure) and you breathe faster, so you lose a lot of body water in your breath. You also pee more when you ascend (high altitude diuresis), so there are several sources of body water loss that must be accounted for. Drink a lot! Drink more than you think you need, but also make sure that you have adequate salt and potassium in your diet.
The sun is strong up here- and the atmosphere is thinner, so there is less filtering of UV which can cause both sunburn and snow blindness - don’t underestimate this! Wear sunscreen even when it is cloudy, and wear sunglasses or goggles with UV protection.

Myths and truths about altitude:
  • If you are in great shape you will acclimate better.
Not true- fitness does not alter the incidence of AMS at all. Fitness does, however, improve athletic performance at altitude (just like it does at sea level!). You should not expect, however, that you will be able to achieve the same level of performance until you acclimate- your tissues don’t have as much oxygen available. I certainly highly recommend getting in the best shape you can so you can ski better, be less sore and less fatigued, etc., but it will not alter your risk of AMS.
  • You are a victim of your genes- if you have the right genes, you will acclimate well, otherwise…well, maybe surfing is the sport for you.
Only partly true- there is a genetic component to the ability to acclimate effectively and quickly. But most people can acclimate; it is just harder and takes more time for some.
  • People born up there are different, and those of us born in flatland will never measure up.
Partly true, again- people born at altitude may always have some edge. The reasons for this are not clear, but there are plenty of people born at or near sea level that do pretty well at altitude anyway. Ed Viesturs, who has climbed all 8000m peaks without supplemental oxygen, was born in the Midwest. So was Tom Hornbein, the first person to climb the West Ridge of Everest. The list of high altitude climbers from flatland is pretty long.
  • Alcohol has increased effect up here- you get drunk much easier at altitude.
Not true- good news or bad news, depending on your perspective (you can drink as much as you do at home, but it’s not cheaper to get drunk). There is evidence, however, that alcohol intake may slow your adaptation to altitude, and it is a diuretic (it makes you pee), so it can increase the risk of dehydration, which is a problem at altitude. Alcohol also decreases your breathing rate and respiratory responses, thereby blunting one of the most critical early mechanisms of adaptation. It is probably wise to limit alcohol intake for the first few days at altitude.
  • I got sick before; am I doomed to be sick every time I go above 7000ft?
Well, maybe- this one is hard to answer. There are some people who are just more likely to have altitude sickness, and are slower to acclimate. Some of this risk is genetically determined- there are good adapters and poor adapters. One time may not mean anything more than bad luck, but if it is a repeated problem every time you ascend, you are a candidate for prophylaxis (see below).
  • My head is killing me- is this AMS?
Possibly. It is wise to consider it AMS until you prove it is not. Dehydration is the other big cause of headache at altitude. If you rehydrate well, and the headache goes away, it was probably not AMS. If not, you probably have AMS.
  • I just can’t sleep well up here- should I try a sleeping pill?
NO!! The reason that you don’t sleep well is because of an abnormality in your breathing that occurs at altitude called Cheynes-Stokes respiration- alternating periods of deep and shallow breathing. This interferes you’re your ability to fall into a deep sleep, and during the shallow periods you may even wake completely feeling short of breath. The best treatment for this is Diamox (see below). Using drugs that can decrease respiration can make you sicker.
  • I am a smoker- is this a problem?
Well of course it’s a problem! Smoking is really, really bad for you (did you expect me to say anything else?). But it has a number of particularly bad effects at altitude. Smokers have increased levels of carbon monoxide in their blood, which interferes with the function of red blood cells to carry oxygen. Nicotine constricts your blood vessels, so you will have less blood flow to your extremities. Even if you think you do fine at altitude while smoking, you will do better if you don’t.
  • Don’t drink caffeine.
Not true- there isn’t any relationship between caffeine intake and either AMS or impaired acclimatization. However, caffeine is a diuretic, and if you drink caffeine you must be more watchful of your fluid intake to compensate for what you pee out.
  • Drink lots of fluids and you will not get AMS.
Not really- it IS important to drink more than usual at altitude because you get dehydrated easily. But that is not the same as AMS, and the relationship between the two is far from direct. You can get quite sick at altitude from dehydration, but if you feel better after rehydrating, your headache was probably not AMS.

Is there anything I can do to enhance acclimatization?
  • The first, best, and most obvious thing is graded ascent. If you can, come up slowly- spend a night in Denver or Salt Lake City before going up to the resort. This, of course, is not always practical, but may be an option for some.
  • Limit exertion on the first day out.
  • Don’t smoke!
  • There is some evidence that a high carbohydrate diet beginning about 3 days before ascent may speed acclimatization.
  • Climb high, sleep low. This old climber’s maxim makes a lot of sense, especially since sleep disordered breathing is a common manifestation of AMS, and AMS is often worse during sleep. If you are prone to AMS, you may feel better at a resort with a lower base elevation.
  • Avoid alcohol for the first few days.
If you have had consistent, repeated problems with altitude sickness, you may be a candidate for prophylactic (preventive) therapy. You should discuss this with your doctor. There is one medication proven to help acclimate to altitude and one that is controversial.
The proven one is acetazolamide (Diamox). It works mostly by mimicking and enhancing the body’s respiratory adaptive mechanisms, and should be started a day in advance of ascent. It can also reduce the symptoms of AMS once it develops, but should not be relied upon for treating anything more than mild disease- particularly sleep disturbances. It has several mildly unpleasant potential side effects- it causes tingling in the lips, hands and feet, and makes carbonated beverages taste bad. It is a diuretic, so you need to increase fluid intake. It is about 75% effective at preventing AMS during rapid ascent. It cannot be used by people with true sulfa drug allergies.
Gingko biloba is an herbal preparation that has been shown in some studies- but not in others- to reduce the incidence of AMS by about 50%. It has not been shown to be effective for treating AMS once it has developed. The jury is still out on this, because of the conflicting data in the literature, although it may be effective in some circumstances for some people, and may be worth a try. The dose is 120mg twice a day starting 5 days before ascent. One problem is that herbal preparations are not regulated by the FDA, so standardization of what you are actually getting from brand to brand is virtually non-existent.

Good web sites for more information:
http://www.ismmed.org/ -International Society for Mountain Medicine. An excellent tutorial for the layman on AMS is available here (click on Mountain Medicine Information Center), as well as links to journals, abstracts and other scientific information.
http://www.high-altitude-medicine.com/ - excellent site by Thomas Dietz, MD, although it has not been recently updated, and a few of the links are broken
http://www.uchsc.edu/ccamp/ -shameless plug for some of the interesting things that we do here at the CO Center for Altitude Medicine and Physiology

© 2006, D.M. Polaner
post #3 of 49
Thread Starter 
Thanks, dp!

For those of us who live above 5000 feet but below 7500, how does the approach change, if at all?
post #4 of 49
Excellent Thread!

My first trip was to Winterpark, which is pretty high, & I developed the headaches every night.
Headaches were the only symptoms I had. When I returned home, I talked to my MD & he prescribed Diamox. He also recommended testing the effects of the Diamox a few weeks before we left for our trip.

It's a good thing I did. The side affects were worse than the headaches.

The next season I started using Ginko, & though I am still somewhat sceptical, I have experienced no headaches in the last three seasons on the mountain.

Thanks dp for the thread.
post #5 of 49
Thread Starter 
dp, can headaches also come from the dehydration?
post #6 of 49
ssh- you're welcome! Thanks to you for facilitating this. If you live at, say, 5500ft, you will have much less trouble with ascent, but you still are at greater risk for illness, and will be less acclimated than someone from Leadville (12,000ft) or even someone from 7500ft. The likelihood is that you will not notice much, and certainly less at Snowbird (base elevation 7800ft, summit 11,000ft) than at Breckenridge (base 9800ft, summit 12,998ft). The key is in how much you ascend above your usual place of habitation (and if you have a past history of episodes of AMS). So for us, we are going up only 3000ft; for a NY'er, it is 8500ft. In the summer, when I climb 14'ers every chance I get, I do nothing special for acclimatization, however I know of Denverites who have had AMS on the 14'ers- since it is an ascent of 9000 vertical feet in a day, this is not surprising.

Rayl1964- I am glad that you have had good results from gingko. You are right that the side effects from Diamox can be very troublesome, although with the low dose regimen (125mg bid instead of 250 bid) they are less severe and less common. For lightweights (people under 55 or 60kg), I have heard some people recommend even half of that (62.5mg bid) with good results. One of the studies that found positive results with gingko was from the altitude medicine group here at CU, and I think that the design of the study was very good. I am inclined to believe their results.
post #7 of 49
Headaches can definitely come from dehydration (it is perhaps the most common symptom of all from dehydration), and I strongly recommend that if you develop a headache, you drink a lot and see if it goes away. If it does, you have the diagnosis, since rehydration will not help an AMS headache.
post #8 of 49


try diamox if you have had a previous problem, starting at home. or you can sleep in one of those nifty simulators that some elite tri-athletes use
post #9 of 49


It's a good sign to see this thread on EpicSki as it is not only necessary but serious. I have a lot of experience with changing altitude and believe it is the most serious thing to consider when taking a ski trip.
post #10 of 49
Excellent and comprehensive post dp. Thank you.

Can you briefly comment on the following about asthma and altitude:
Do asthmatics have any increased vulnerability to AMS?
Outside of AMS issues, what is likelihood that a ski trip to Rocky Mtn altitudes will trigger respiratory symptoms in flatlander asthmatics?
Believe you mentioned in an earlier post, forgive me if misstated, that some people with asthma might actually receive respiratory/pulmonary benefits by locating to higher altitudes due to less particulate resistance in their bronchial tubes? Can you elaborate if true?
post #11 of 49

A BIG thanks DP and SSH

Coming from sea level it always takes a couple of days to get use to altitude. Will follow suggestions, don't want to ruin my first trip up this year!
post #12 of 49
Great thread!

I always thought that sleeping at higher elevations while skiing would improve the adjusting body.

I'm now going to stay & sleep at the lower elevations (SLC or Sandy and not at the resort, for example). Getting a good nights sleep will certainly improve the on-slope activities.


post #13 of 49
Great thread! Thanks for initiating the discussion, Steve.

Here's a question I have to add to the thread: What are the general effects on the body for those of us that sleep at a moderate altidude (approx 5700) and work above 9000 ft? Thanks.
post #14 of 49
Well done David(Dp) & Steve(ssh) and thanks for taking the time

I've never really had any issues with altitude, but I know many others do.

The only problem with the thread is now I have to quit smoking, drinking AND learn how to ski
post #15 of 49
thanks DP

I forwarded to my friend in Boston who will be out here on the 10th.

BTW -- I used 125mg of Diamox and it worked well ... I don't drink fizzy drinks for the most part, so that didn't bother me ... I did get some tingling in toes and soles of feet when exerting -- but I slept like a baby!

post #16 of 49
ssh & dp,

Thanks for this excellent thread!

As a sea-leveller who is also going to have to cope with a 7 hour time difference and a 20 hour journey to cope with on top of the altitude, it's useful to know what's an old wives tale and what is actually likely to have any effect.

I have used Diamox before, but might try ginko this time - what does bid mean?

One other thing please - do you continue this medication (either Diaomox or ginko) for the entire duration of your stay at altitude, or can you cut it out after teh first few days?


10 days and counting!!!
post #17 of 49
Excellent and informative thread, dp.

As I recall, one other medication that has been demonstrated to be effective in both the prevention and treatment of AMS is dexamethasone; it's an option for those that are sulfa-allergic, and it appears to be at least as effective as acetoazolamide in preventing AMS.

There is also some evidence that the combination of both acetoazolamide and
dexamethasone may be more effective than either agent alone; combination therapy might be an option for high-risk individuals ( ie, those that have a prior history of AMS) to consider.
post #18 of 49
I'll try and cover a few of the questions in this one post:

Asthma: there is not a straightforward answer to this. The density of air at altitude is lower than at sea level, which is a significant benifit to someone with asthma. Think of squeezing ketchup vs water from a bottle- the less dense fluid (and gasses follow the physics of fluids in this case) flows easier, therefore gas flow, especially through narrowed tubes, flows more easily. However, there are also some factors which can be problems for some asthmatics- cold, dry air and exertion. Not all asthmatics have problems with these provocative factors. If you do, use a beta agonist (albuterol, for example) or an inhaled steroid before going out to ski.

bid: means twice a day (an abbreviation from the Latin). Sorry for the medical jargon- bad habit!

duration of therapy: You can probably stop either diamox or gingko about 2-3 days at your final altitude. If symptoms occur you can always restart.

living at 5000ft and working at 9000ft: Most likely you will have no problems whatsoever, especially if you do this on a regular basis. There is some evidence in the exercise physiology literature that this may be the best means of effective training of all. Think about what the high altitude climbers do in the Himalaya or Karakoram. They make frequent forays up to higher altitude, and then return to base camp or advanced base camp for sleep or recovery periods. That way when they begin their summit push they have acclimated to extreme altitude and minimized the ill effects of long periods at extreme altitude.

dexamethasone (Decadron): Dr. Rick is correct that dexamethasone can be used as prophylaxis for AMS, and also can be used for treating HACE (brain swelling) when a patient cannot be evacuated to lower elevation. However, it is probably not the best first line choice of drug for AMS prophylaxis. (I heard Peter Hackett discuss this once, and if I am not mistaken he has written about it in one of his review articles). The concern is that while diamox actually speeds acclimatization due to its effects on acid base status and diuresis, dexamethasone works by essentially masking or reducing the symptoms, and has no effect on acclimatization itself. The possibility that AMS may develop when the drug is stopped, therefore, is significantly greater with dexamethasone. In situations where rapid ascent is critical for an unacclimated individual (like an emergency rescue at very high or extreme altitude), the combination therapy is probably the best choice.
post #19 of 49
Originally Posted by jgiddyup
Well done David(Dp) & Steve(ssh) and thanks for taking the time

I've never really had any issues with altitude, but I know many others do.

The only problem with the thread is now I have to quit smoking, drinking AND learn how to ski
What jgiddyup said, GRACIAS!

Somewhere in the forums I read about taking Advil a few days prior, no booze first few days, and lotsa liquids. Works for us! Or are we just lucky not to be affected by altitude?
post #20 of 49

Just for the record, I skied my legs off for 8 days straight and should have been in better shape before I arrived, but 120mg of gingko biloba twice a day and plenty of fluids (but easy on the alcohol) seemed to work - at least it didn't make me ill :-)

Just thought you'd like to hear it "straight from the horse's mouth" so to speak. The only problem I did have was the dryness of the atmosphere. My nose bunged up something shocking every night, disturbing my sleep. An "over the counter" decongestant of some sort may be a worthwhile precaution.

I had a blast over the last week - a big than you to all the bears who were in contact with me during my trip - you made all the difference, really.

Thank You!

post #21 of 49

What about Ginseng?


Thanks for the great information.

I am heading to Break for a week soon and started taking ginseng a few weeks ago. I have read that it helps improve the bloods ability to carry oxygen. Any truth to it?
post #22 of 49
The exact mechanism of gingko's action is not clear. As I mentioned above, it has been shown in some studies to prevent or reduce the incidence of AMS with rapid ascent, although other studies have not shown benefit. Cardweg- glad to hear that it worked for you. I still have problems at times with the dry air during sleep- I think that a humidifier will work better than decongestants, which might make you feel even drier. KCMcleary- you probably need to start it only 3-5 days before ascent. 120mg twice a day. Hope it works for you.
post #23 of 49
Anyone looking for online info or the product itself, use the spelling ginkgo. Pedantry aside I'll add my thanks for this terrific info.

In a few weeks' time I'll report back on a micro test that starts on Feb 1: two couples, similar ages, from sea level and in mid-summer at home, are flying across the Pacific and going straight on up to Winter Park. One couple has been taking ginkgo biloba, echinacea and a multi-vitamin and mineral supplement in advance; they other pair are going unaugmented... stay tuned for the gory details :
post #24 of 49

dp and ssh - Thank You

Guys, great thread and needed for us right coasters.

Even though I live at the heady altitude of 700 feet: I still have "hit the wall' when going out to Summit County to ski. I generally arrange my schedule to allow at least two nights in Denver. I hit the museums and other great places in the area. Then I head up to altitude. I seem to have less problems than those people that rush straight out from the Denver Airport.

I still find myself running out of breath at times. You guys ain't got no air up there!
post #25 of 49
bear in mid that congenital factors are ususally the most definitive indicators of how you'll deal with altitude.
i spent a season coaching and instructing at keystone, and never acclimatized. my lineage is primarily low-altitude celt/slave/roman....
my girlfriend at the time, a dual-citizen born in bern, but whom spent most of her life in scarsdale, flew out after i was there for a few months and was unaffected from the moment she lit at stapleton.
your genetics play a much bigger role in altitude tolerance than does any prep.
most of europe is far lower altitude than out rockies, and much of the alps are even lower altitude than NC's fine resorts.
if you have altitude issues, consistently, try tahoe or europe. both have served me and my weak-assed altitude tolerance splendidly.
post #26 of 49

Kids & AMS


My son got AMS when he was four years old on a ski trip to Breckenridge.

The following year -- when he was five -- we went to Lake Tahoe (7,500'), both in August to hike, and in March to ski, and he had no problems.

Now he is six and we are going to Winter Park (9,000') this month (we won't have a chance to stay overnight in Denver).

We live at sea level.

You wrote that some individuals are more prone to repeat episodes of AMS. Is that less true for kids? Are they less likely to have problems as they age?

Thanks, WN
post #27 of 49
WN- kids seem to have about the same problems as adults. There has been some speculation that they may be more prone to AMS, but that has not been substantiated in the few studies that have been methodologically more "clean". There is now a pediatric (preverbal) version of the Lake Louise criteria that was developed here at Denver Children's. There is one confounding factor- kids are more likely to get colds, and a cold may make you more predisposed to AMS.
post #28 of 49
kids have a greater predisposition to most ailments and conditions; this is how their immune and compensatory systems develop.
post #29 of 49
dp and vlad: Thanks. WN
post #30 of 49
Well I have returned from Breck and I sucked wind the whole time there. Not sure if theginseng had any effect or not. I did use a blood oxygen saturation test while there and it was about 91%. I was told that was average for that altitude.
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