Pneumonia in Summit County kids may actually be ‘HAPE’
“Children who live in the mountains may develop high-altitude pulmonary edema (HAPE) even when they have not traveled,” according to pediatrician Christine Ebert-Santos. “This is not widely recognized, but it is important because HAPE is preventable and pneumonia is not.”
“During the 10 years I have been treating children in Summit County at Ebert Children’s Clinic, I quickly recognized that low oxygen levels were common,” said Ebert-Santos. “When parents call me and say their child has a cough or is very congested, I make arrangements to see that child as soon as possible, whether it is nights, weekends, or holidays.”
Preschool and school-age children are often brought to their physician or to the emergency room with cough, fever and runny nose. Usually this indicates a viral infection that will resolve in a few days. When their oxygen is low, a chest x-ray is ordered. The x-ray is commonly read as pneumonia, due to shadows that indicate fluid in the lungs. Dr. Ebert-Santos started to wonder about this diagnosis because the children are not as ill as those with pneumonia.
“I’ve been a pediatrician for 33 years, working overseas and treating very sick kids in the ICU with pneumonia,” she said. “These children in Summit County would have very low oxygen readings, in the 70s, and very mild changes on x-ray. This did not fit my experience of pneumonia.”
She realized they were better the next day with oxygen treatment, whether they received antibiotics or not.
“The importance of diagnosing HAPE in these children is that it is recurrent and preventable,” she said, adding that children with recurrent pneumonia at lower altitude often have some underlying condition predisposing them to lung problems – such as asthma, cystic fibrosis or immune deficiency. Children in the mountains with recurrent “pneumonia” probably have blood vessels in their lungs which are more sensitive to low oxygen levels, causing them to narrow, which puts back pressure on parts of the lung where fluid accumulates. Many of these children have classic “re-entry HAPE,” needing oxygen at times when they return from trips to low altitude.
“We have long known that visitors to the mountain resorts who arrive during a respiratory illness are more likely to develop HAPE,” says Dr. Ebert-Santos. “One of our own emergency department doctors at the Summit Medical Center, Ed Noordeweir, contributed to the research on this. So it makes sense that children with respiratory infections could get HAPE.”
The most common age is preschool through early high school ages. A child may have only one episode or several. They tend to outgrow this beyond then. However, complications such as pulmonary hypertension (high blood pressure in the lungs which exerts back pressure on the heart) may occur over time. A few of these children will be found to have a shunt or hole in the chambers of their heart, but most are normal.
Recently the equipment used to measure oxygen levels – pulse oximeters – became available in local pharmacies and online at prices of about $100. At Ebert Children’s Clinic, they advise any family that has a child on oxygen to purchase this so parents can know if their child is having more problems. This saves clinic and emergency visits and gives parents control over the situation. Dr. Ebert-Santos advises starting supplemental oxygen for anyone whose levels are below 89 percent saturation.
“When a child comes to our clinic with respiratory symptoms, we always check their oxygen level,” Dr. Ebert-Santos said. “If low, we give a breathing treatment with Albuterol to see if they have asthma. If the oxygen level is still low, we start them on oxygen and give parents a choice of immediate x-ray or wait to see if they are better the next day. Most are. The physical exam can be normal or show trouble breathing with wet sounds in both lungs. The x-ray can also be normal or show small areas of fluid.”
Dr. Ebert-Santos has a research proposal and is collecting data to try to pneumonia and HAPE. She emphasizes that there is no test or reliable clinical symptom that is unique to HAPE. The diagnosis is based on the combination of symptoms, lab and x-ray findings, and response to treatments.
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