Living at altitude: Exploring the effects on mountain town residents

Life at nearly two miles high has its quirks. The air is thinner, meaning it can be harder to breathe. Dehydration sets in a lot quicker. Ultraviolet radiation is harsher, because there’s less atmosphere protection between the sun and our skin. 

Yet more than 140 million people worldwide live above 9,000 feet with another 40 million a year visiting places at high elevation.

One of the longest-living and healthiest populations in the country, Summit County’s 30,000 residents still face the known and unknown health challenges of living at altitude long term. Many high elevation health dangers predominantly impact two of the community’s most vulnerable populations: children and the elderly. But a newly diagnosed respiratory condition is affecting mountain residents of all ages, even those who have lived here for a long time.

Dr. Benjamin Honigman, a specialist in emergency medicine who has been practicing for over 20 years, has a conversation about the physical impacts of altitude on Wednesday, Sept. 11, in Silverthorne, Colo.
Liz Copan /

A look at life expectancy

There has been relatively little longitudinal research on populations living at high altitude, so there are few definite answers about the effects on long-term health.

Dr. Benjamin Honigman, director emeritus of the Altitude Research Center based out of the University of Colorado Anschutz Medical Campus, said there are some proven health benefits of living at high elevations. 

Honigman was the senior researcher on a nationwide study with 10 million subjects published in 2011. The study found that counties above 1,500 meters, or about 5,000 feet, had longer life expectancies than those within 300 feet of sea level by 1.2 to 3.6 years for men and half a year to 2.5 years for women. The study was done by the University of Colorado School of Medicine in partnership with the Harvard School of Global Health.

“What we found was, there were certain diseases less prevalent as cause of death at altitude, with cardiovascular disease being the most prominent example,” Honigman said. “There was also a hint that there was less cancers, less stroke and other certain kinds of disease. Most of these diseases affect old people the most.”

On the other hand, Honigman said, people with existing respiratory conditions, such as chronic obstructive pulmonary disease, have a lower life expectancy at high elevations. The study concluded that the opposing effects on different populations probably offset each other, leaving no real tangible net effect on life expectancy overall.

There also are health impacts specific to older adults as their bodies change and become less malleable over time.

“We know there are significant issues affecting seniors that have to do with their cardiovascular system and lungs,” Honigman said. “We know that the lungs get less elastic, so they’re not as efficient, as we get older. That’s especially true for those individuals who are prone to lung diseases like emphysema or chronic bronchitis. The added inelasticity in the lung to compensate with these things makes it much more difficult to breathe.” 

Honigman said the work done by Dr. Warren Johnson, a cardiologist who pioneered research into the health of people who migrate to Summit County from lower elevations, showed that some seniors struggle to live at high altitude because of genetic predispositions. 

“There’s this subset of people with pulmonary hypertension, which is high blood pressure of blood vessels in the lungs,” Honigman said. “That causes lower oxygen levels, which leads to decreased exercise performance and fatigue. It makes people very upset; they spend millions of dollars on a house in Summit and then have to either leave or have to be put on oxygen.”

Honigman said high pulmonary blood pressure can be eased with prescription drugs, specifically vasodilators that widen blood vessels and decrease pressure.

A 10-year-old Summit County boy who was diagnosed with high altitude resident pulmonary edema. The X-ray shows bilateral opacities, which cleared after 24 hours on oxygen.
Courtesy Ebert Family Clinic

Flooded lungs

While many conditions at high altitude can be treated or eased with medications, some are unavoidable and deadly.

When people arrive at high elevation, the human body increases red blood cells and hemoglobin to compensate for the thinner air, where fewer oxygen molecules are drawn in with each breath. While most mountain visitors are able to acclimate to lower oxygen levels without incident by taking their time to adjust and hydrate, some people can never properly acclimate.

“It’s not the same for everyone,” said Dr. Christine Ebert-Santos, who runs the Ebert Family Clinic in Frisco. “For some people, they never do well at altitude at all. Every time they come up, they get altitude sickness or get too tired, have headaches and can never function properly up here. That’s probably genetics.”

Ebert-Santos said genetics also plays a part in a person’s susceptibility to high altitude pulmonary edema, or HAPE, which can include pulmonary hypertension.

“Of all the different altitude related conditions, HAPE is the most common cause of fatalities,” Ebert-Santos said. “It is totally preventable if you catch it early, but it overlaps with so many other diseases that it is often misdiagnosed.”

HAPE is a serious respiratory condition that is caused by excess fluid accumulation in the lungs as a response to hypoxic, or low oxygen, environments. Blood vessels surrounding the lung’s air sacs, called alveoli, constrict when less oxygen is available, increasing blood pressure and causing plasma and red blood cells to leak through the air sac walls and into the lungs. The fluid pools in the lung pathways and blocks oxygen absorption in the air sacs. 

Signs of HAPE include a wet cough, shortness of breath, confusion, fatigue and, eventually, blue lips and skin. The symptoms can be mistaken for pneumonia, asthma or other common respiratory conditions, and unless a medical provider is familiar with the clinical signs, they might not be able to make a HAPE diagnosis until a chest X-ray is done.

At advanced stages of HAPE, gurgling can be heard in the chest and pink, frothy discharge from the mouth might be seen. 

A patient is evacuated from the top of Quandary Peak by Summit County Rescue Group volunteers.
Courtesy Summit County Rescue Group

Matt Parker, a member of the Summit County Rescue Group and an emergency medical technician, said he has responded to cases involving HAPE, including one involving a young man in the backcountry.

“On one of our higher altitude calls, we went up to a backcountry hut to respond to a young man in his late teens or early 20s in distress,” Parker said. “When we arrived, I could hear crackles and gurgling in his lungs. It was obvious he had HAPE, and he had to be evacuated. HAPE is not something you can treat at higher altitudes.”

Ebert-Santos said HAPE manifests in three ways:

  • “Classic” HAPE occurs when a lowlander ascends too quickly to elevations above 8,000 feet. Within 48 hours of the ascent, the symptoms start presenting themselves. 
  • Another type of widely-recognized HAPE is “re-entry” HAPE, which occurs when a high elevation resident travels to lower elevations and comes back home without properly acclimating.
  • A third version of HAPE does not require any change in elevation to be triggered and impacts residents of high elevation communities.

Ebert-Santos established the diagnosis of high altitude resident pulmonary edema, or HARPE with an R for resident, here in Summit County. The diagnosis came from years of research and seeing many patients who showed clinical signs of HAPE despite having more than enough time to acclimate and not having traveled between elevations recently.

While classic HAPE can happen to anyone at anytime regardless of physical fitness, Ebert-Santos said men have a far higher susceptibility to HAPE, with a 5-to-1 ratio of men to women. Younger, healthier men are the most susceptible age group for reasons that are not clear.

Dr. Christine Ebert-Santos talks about about high altitude health and living Aug. 29 at the Ebert Family Clinic in Frisco.
Liz Copan /

Unraveling a medical mystery

Until a few years ago, Ebert-Santos worked only with children as a pediatrician in Summit. Throughout her years of treating kids, she noticed a curious trend. A lot of children came in with generic symptoms of a respiratory illness: coughing, shortness of breath, fatigue and other symptoms commonly associated with conditions like pneumonia or asthma.

“These kids come in … with acutely low oxygen, just start lying around the house, and parents know something is wrong with them,” Ebert-Santos said. “It shows as an acute illness where they get sick from two to 10 days, then they’re fine, and there are no long-term effects.”

None of them had traveled between high and low elevations recently, ruling out what the medical community has known to be the main cause of HAPE: rapid barometric pressure change that causes pulmonary hypertension, or high blood pressure in the arteries and veins surrounding the lungs.

“Since we adjust to the chronic low oxygen, we don’t realize it is a constant problem,” Ebert-Santos said. “That’s the trouble with pulmonary hypertension; it evolves slowly over the years.” 

To check for fluid in the lungs, Ebert-Santos insists on chest X-rays for patients experiencing unexplained pulmonary symptoms.

“Of all of the kids I see day after day, about 30 to 40 a year have mountain hypoxia,” Ebert-Santos said. “In the past, they were told they have asthma or pneumonia. But it wasn’t pneumonia, and it wasn’t asthma. They were sick from environmental conditions. If any other kid had oxygen that low, they’d have the same issues.”

To check oxygen saturation quickly, Ebert-Santos uses a pulse oximeter, a small, noninvasive medical device that attaches to the fingertip. The device sends out beams of red light that pass through the skin, and it detects how the light changes as it is absorbed and bounced back by oxygenated and deoxygenated blood, which absorb light differently.

Within seconds, the pulse oximeter gives a basic reading of peripheral oxygen saturation. Ebert-Santos now uses this device on every patient who is experiencing unexplained pulmonary or respiratory problems to verify if they are experiencing hypoxia.

Combined with X-ray images, Ebert-Santos confirmed what she had long suspected: Some residents in Summit County are getting sick with HAPE without any change in elevation. The discovery changes what we know about HAPE and high altitude health.

“When I talked to other doctors who have lived and worked here for a long time, they were also seeing this in adults and children. But they were not really talking about it or counting the cases or reporting the cases. Nobody was making the connection,” Ebert-Santos said.

In a paper, Ebert-Santos reviewed 48 cases of patients with pulmonary problems that lacked immediate explanation. Of those 48 cases, 33 residents were identified as having HAPE without any recent travel, five had re-entry HAPE after returning to Summit from low elevations, two visitors had classic HAPE, six residents had pneumonia and two had asthma. The diagnosis of high altitude resident pulmonary edema was confirmed.

“The reason it took so long to get published is because all of the conferences I went to, pulmonary specialists and high altitude specialists would insist you can’t have HAPE unless you’ve traveled,” Ebert-Santos said. “But my strong point was that these people had not traveled, and you can’t diagnose HAPE without a chest X-ray, which means a lot of patients were being misdiagnosed and HAPE was being underreported.”

Simple fixes

The clinical protocol for residents with pulmonary symptoms who visit the Ebert Family Clinic, which has expanded to treat adults, is to check oxygen saturation levels with a pulse oximeter while they sleep.

Ebert-Santos explained that when we sleep, we take breaths that are more shallow at a rate that is much slower than when we are awake. At high elevations, the thinner air means the already low oxygen saturation dips even further during sleep. 

Oxygen saturation can go to critically low levels during sleep in people with existing or developing respiratory illnesses, even without a change in elevation or barometric pressure. During the day, those oxygen levels might be fine because they are taking deep and frequent breaths while awake.

The standard treatment is to prescribe an oxygen concentrator to use while sleeping.

“After getting oxygen, they immediately started feeling better, and the edema went away,” Ebert-Santos said. “It is like night and day.” 

Since HAPE is a condition that can be fatal without immediate diagnosis and treatment, Ebert-Santos wants mountain residents to be aware of the condition. She also wants every mountain resident to have a critical tool at the ready: a pulse oximeter. 

“By having a pulse oximeter that costs $20, you can know what’s going on with your oxygen levels,” Ebert-Santos said. “HARPE is a rare disease, but it can be fatal. Everyone living, working or playing at altitude should have an oximeter, especially if they are recovering from surgery.”

Seniors walk heel to toe in a straight line across the length of a room Tuesday during a fitness class called N’Balance at the Summit County Community and Senior Center in Frisco.
Liz Copan /

A deadly threat for older adults

While HAPE can affect anyone at elevation at any time, it is still a rare condition. There is a much more common, and often debilitating or fatal, health threat to seniors in the High Country and across the nation – falling injuries.

One in four Americans age 65 or older has a fall every year, according to the National Council on Aging. Every 11 seconds, an older adult is treated in the emergency room for a fall, while every 19 minutes an older adult dies from a fall. 

Among older adults, falls are the leading cause of fatal injury and the most common cause of nonfatal trauma visits to the hospital. Every year, 27,000 people die from falls. The National Council on Aging predicts that falls among older adults in the U.S. will result in $67.7 billion in medical costs by next year.

Given the added danger in the mountains with snow and ice, Summit County has a vested moral and financial interest in helping seniors avoid falls. That’s where the N’Balance program comes in.

Held at the Summit County Community & Senior Center, N’Balance is an exercise and balance class taught twice a week during summer and once a week in winter. The class has been popular among Summit seniors since it was introduced five years ago.

Instructor Pat Aden, a physical therapist who has her own clinic in Summit, said the class teaches older adults how to strengthen their core and stabilizing muscles as well as improve motor skills related to balance. The class provides seniors of all fitness and balance levels with the mental and physical tools to avoid falls as well as learn how to catch themselves if they do lose their balance.

Linda McKinney uses a resistance band during exercises during a fitness class called N’Balance with instructor and physical therapist Pat Arden on Tuesday at the Summit County Community and Senior Center in Frisco.
Liz Copan /

“We work on upper body, posture, core strengthening, lower extremity strengthening, coordination, vestibular system — the inner ear — and visual targeting,” Aden said.

Aside from freehand walking and balance exercises, Aden uses balls, bands and foam noodles in her training. One exercise involves participants pairing off and using bands to try to pull each other off balance to strengthen stabilizing muscles and practice management of balance loss. The exercise is called “oh cruds,” named after what someone might say when they find themselves falling forward or backward.

 “It is very important to have the ability to regain balance after we lose it,” Aden said. “We all catch a toe and lose our balance sometimes. Balance doesn’t just have to be static, where we have it while standing stationary. It also needs to be maintained while moving.”

Calling falling a “big national problem,” Aden has devoted many hours to helping seniors train themselves to avoid a potentially life-altering accident that forces them to move away and get care elsewhere.

Aden also helps seniors overcome ice and other obstacles with real-world activities such as ice walking, obstacle courses, grocery store trips and traffic crossings. 

As part of National Fall Prevention Month in September, St. Anthony Summit Medical Center also is offering a seven-week class called Stepping On, which is geared more toward beginners and helps participants reduce their risk of falls.

The class will cover the role vision plays in keeping balance, how medications can contribute to falls, ways to stay safe when out in the community and how to check your home for safety hazards.

The free class is from 1-3 p.m. Wednesdays from Sept. 18 to Oct. 30. Call 970-668-6980 to register. 

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