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High Fructose Corn Spirit
Gym climber
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Topic Author's Original Post - Dec 6, 2016 - 04:53pm PT
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Use of this term - "bubbly lungs" - in a recent thread re climbing at high altitude caught my attention.
Obviously it is associated with, or else a symptom of, High Altitude Pulmonary Edema (HAPE).
I'm curious if anyone here has had first hand experience specifically with "bubbly lungs" either in the first person or third person... and would like to give some description of this condition.
PS
Is the term "bubbly lungs" a frequent term? in discussions of HAPE? Are the terms "girgling" and "gargling" also (correctly) used to describe the condition?
re: "rales" << Fr rattles
https://en.wikipedia.org/wiki/Crackles
So a main question I have is... Does "bubbly lungs" in HAPE sound more like rales (fine or course crackles) or the awful "death rattle"?
https://en.wikipedia.org/wiki/Death_rattle
(3) Does "bubbly lungs" assoc with HAPE progress in severity? over hours? days? eventually approaching the very dramatic loudness of the textbook "death rattle"?
(4) In HAPE and "bubbly lungs" is the cough reflex eventually lost with severity as it (often or always) is with the "death rattle"?
Thanks for any first-hand experience replies.
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Ricky D
Trad climber
Sierra Westside
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This isn't going to turn into one of those "How to kill your wife at altitude and get away with it" threads is it?
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PSP also PP
Trad climber
Berkeley
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Having dinner at At Tuolume lodge my friend announces that he has to leave because his lungs were filling up with water. They left immediately down the east side and he said they had to pull over several times to pee large amounts.
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ontheedgeandscaredtodeath
Social climber
SLO, Ca
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I've seen HAPE first hand. I'd describe it as gargling or rattley but from the chest as opposed from the throat if that makes sense. It sounds gnarly. The person in the situation I was involved with lived, to my surprise to be honest.
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Brian in SLC
Social climber
Salt Lake City, UT
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Frothy pink sputum.
Had it in Peru in 1986. Good times.
Rails. Ugh. Nearly no energy.
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BuddhaStalin
climber
Truckee, CA
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bubbly lungs is a made up term. Adventitious lung sounds can come from many things including HAPE.
Death rattle is also a made up slang type term. Proper term is cheyne stokes breathing and occurs when someone is very near dying. Not the same. Not 'rattling' because of respiratory reasons. Because of pooling in the oropharynx.
The sounds associated with the conditions listed generally come from fluid and or inflammation leading to increased permeability, allowing fluid to fill in the lungs. this includes ARDS, HAPE, pulmonary hypertension and even simple pneumonia.
Its not a simple thing or simple black and white answer.
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High Fructose Corn Spirit
Gym climber
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Topic Author's Reply - Dec 7, 2016 - 08:32am PT
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Thanks for the replies. I'm still unclear but I guess real clarity on this topic only comes commensurate w experience. A few years back I had a "bubbly lungs" event in my life (not me but another) and wished I had known more at the time. Thanks again.
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fear
Ice climber
hartford, ct
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I've had bad pneumonia and been directly involved with rescuing two people with severe HAPE.
Either way the lungs "sound" really bad. I doubt there's a way to differentiate the initial stages very well. The HAPE victims eventually both deteriorated rapidly and were literally foaming at the mouth, something that doesn't happen with pneumonia to my knowledge.
Either way, if you're at altitude and suspect either one, get thee down asap.
FWIW, one man carried from ~18k in Africa we were sure was dead. He recovered fully once down to 4k within 2 days without hospital care (not that I'd recommend that). Simply amazing.
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looks easy from here
climber
Ben Lomond, CA
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Death rattle is also a made up slang type term. Proper term is cheyne stokes breathing and occurs when someone is very near dying.
Death rattle would be more closely described as agonal respiration, imo.
Cheyne-Stokes is a specific pattern of increasing to decreasing to increasing respiration depth and speed.
(Cheyne-Stokes is still bad, but not as bad as agonal respiration.)
Back on-topic, in 13 years in EMS I've never heard the phrase "bubbly lungs" (and we have nicknames for about every condition anyone might encounter), with the caveat that my entire career has been within about 400 feet of sea level.
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Brian in SLC
Social climber
Salt Lake City, UT
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I got "diagnosed" by a British military doctor from around 50 feet away...
Once I descended from our ABC (Pisco) down to Huarez and started on Diamox, I cleared up in 5 or so days. Probably foolish, but, went up and climbed Huasaran after that.
Been a lot more careful since.
Glad that at least for me, and mostly I think especially HAPE is a young man's game.
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Mark Force
Trad climber
Ashland, Oregon
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Cheyne-Stokes breathing can show up in some otherwise healthy people while sleeping at altitude at night while asleep. I can get it when sleeping ~10,000 feet or up.
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Reilly
Mountain climber
The Other Monrovia- CA
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'Bubbly lungs'? I've seen somebody blowing pink bubbles out of his mouth.
Not pretty, especially in the middle of the night. A big dose of Lasix
probably saved his life and tided him over until a helo could get to him.
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wbw
Trad climber
'cross the great divide
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Death rattle is also a made up slang type term. Proper term is cheyne stokes breathing and occurs when someone is very near dying.
That is not even close to the truth. While Cheyne-Stokes breathing is certainly a symptom of "altitude sickness", and a very uncomfortable one at that, it does not occur when someone is very near death. I've had it multiple times trying to sleep above 17,000 ft., after not acclimating lower for the proper amount of time.
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Mark Force
Trad climber
Ashland, Oregon
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The mention of Cheyne-Stokes breathing being near death has a grain of truth in that people that are near death - totally unrelated to HAPE - can develop it a few hours to a few days before death.
Rales (crackles) are lighter tinkling or crackling sounds - some people liken the sound to velcro coming apart - deeper in the lungs that can be heard with a stethescope or your ear against the rib cage.
Rhonchi are snoring-like or rattling-like sounds that you may are may not be able to hear without a stethescope or ear to the rib cages. When severe, you can definitely hear with the "naked" ear. It will often clear up temporarily after coughing.
HAPE lung signs will proceed from rales to rhonchi to the coughing up of frothy/bubbly mucus/blood.
Cheyne-Stokes is a result of degnerative changes in the brainstem that prevents normal triggering of breathing by rising CO2 levels. I probably get it at such a relatively low level (~10, 000 feet or more) while sleeping as a result of Listeria meningitis in Honduras in 2010. There is a continuum from cyclical breathing and Cheyne-Stoke and, arguably, my apnea at night may be relative rather than absolute and not quite meet the criteria for being Cheyne-Stokes.
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High Fructose Corn Spirit
Gym climber
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Topic Author's Reply - Dec 8, 2016 - 08:33am PT
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Thanks, Mark.
Curious about the "pink" in the froth(ing), which seems to be a standard sign along the process. Is it actually traces of what is intuitive, in other words, blood? Can you or anyone confirm?
From injured alveoli, perhaps?
Actually...
"What causes pink frothy sputum?"
https://en.wikipedia.org/wiki/Pulmonary_edema
"The overwhelming symptom of pulmonary edema is difficulty breathing, but may also include symptoms such as coughing up blood (classically seen as pink, frothy sputum)..."
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looks easy from here
climber
Ben Lomond, CA
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Pulmony edema (and associated pink, frothy sputum) around sea level is usually connected to too much pressure inside the capillaries in the lungs, caused by conditions like congestive heart failure, forcing fluid and blood cells across the capillary-alveolar walls (in healthy individuals normally only gas exchange occurs across that barrier).
At high elevation pulmonary edema is caused by low atmospheric pressure outside that is insufficient to keep blood and fluid from being pushed into the alveoli by normal internal pressure.
Slight diversion, insufficient atmospheric pressure to push O2 through the alveolar and capillary walls is an even bigger influence on difficulty breathing at altitude that the fact that there are physically fewer oxygen molecules taken in per breath.
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Al Barkamps
Social climber
Red Stick
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Slight diversion, insufficient atmospheric pressure to push O2 through the alveolar and capillary walls is an even bigger influence on difficulty breathing at altitude that the fact that there are physically fewer oxygen molecules taken in per breath.
atmospheric pressure has almost nothing to do with "difficulty breathing". You can simulate "high altitude" at sea level pressure by simply reducing 02 partial pressure, by removing 02, as in a hypoxic tent, or, re-breathing a few times into a plastic shopping bag.
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High Fructose Corn Spirit
Gym climber
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Topic Author's Reply - Dec 8, 2016 - 10:00am PT
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Thanks Al and LEFH...
Interesting, Al. In your case as posted, with reduced O2 at sea level you wouldn't get fluid and blood crossing capillary and alveoli (thus for eg no pink frothy sputum) according to above mechanism. So it seems the "difficulty breathing" would come primarily from CO2 buildup (in the case of breathing in a bag) and its detection. I think this is right.
I've learned from sources (eg cardiologist and further research) that the sense of breathlessness in a closed compartment is due to C02 sensing (a buildup) and not O2 sensing (any reduction). Learning that was pretty interesting.
This could mean, in a closed compartment, for eg, if somehow the carbon dioxide were drawn off (eg Co2 scrubber), a person might just get increasingly sleepy with falling O2 and just go to sleep. The so-called "sweet death".
In any case, thanks for the greater clarity.
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Al Barkamps
Social climber
Red Stick
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Interesting, Al. In your case as posted, with reduced O2 at sea level you wouldn't get fluid and blood crossing capillary and alveoli (thus for eg no pink frothy sputum). So the "difficulty breathing" would come primarily from CO2 buildup (in the case of breathing in a bag) and its detection. I think this is right.
You can get pulmonary edema at sea level for many different medical reasons, not including outright injury to alveoli. Hypoxic tents simply lower the partial pressure of 02 by scrubbing some of it out. (let's NOT use CO2 as an example because CO2 is not inert and initiates distinct physiological responses, unlike nitrogen).
There's nothing linking the effort of unobstructed "difficult breathing", like gasping for air, for example, with pulmonary edema. In the simplest of terms, rupturing the thinnest of capillaries, like those deep in the lungs, requires an extreme pressure gradient, either positive or negative. To take two extreme examples, pinch off your nose, and put a compressed air hose in your mouth and fire away! Or....put a vaccuum cleaner hose in your face. Either should rupture your alvoeli.
edit- Moose, capillaries don't expand unless the heart and the rest of the plumbing system is doing weird sh#t.
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looks easy from here
climber
Ben Lomond, CA
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atmospheric pressure has almost nothing You can simulate "high altitude" at sea level pressure by simply reducing 02 partial pressure, by removing 02, as in a hypoxic tent, or, re-breathing a few times into a plastic shopping bag.
That's a "low oxygen atmosphere", different than a "low pressure atmosphere". Both are examples of insufficient oxygen pressure gradient, but the details of the mechanics vary slightly.
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fear
Ice climber
hartford, ct
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Also why people who enter say, a confined space filled with 99% Nitrogen often pass out with only a few breaths and die shortly thereafter...
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Al Barkamps
Social climber
Red Stick
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^^^^
exactly.....but they will "gasp" for breath during their slow death. Which is why in toxicology, nitrogen, like other inert gases are known as "simple asphyxiants".
Similar kinds of things used to happen (and probably still do in developing countries) when workers enter large metal storage tanks to clean them out. If they're not wearing SCBA or the tanks are poorly ventilated, they will die; the O2 has been chemically bound up in rust or some other oxide leaving the atmosphere depleted in O2.
Years ago, 3 workers were killed when two of them lowered themselves into an empty storage tank to de-scale the surfaces. Seeing them unconscious at the bottom of the tank, their supervisor went in, also passing out and dying. They thought enough to test the air for poisonous fumes, but not for oxygen content.
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fear
Ice climber
hartford, ct
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So why is it you can hold your breath for several minutes with a little practice? Back in my whitewater Class 4+ days I got to 110 seconds.
Is it the residual O2 still in that last gulp of air that sustains you for that long?
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Al Barkamps
Social climber
Red Stick
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That's a "low oxygen atmosphere", different than a "low pressure atmosphere".
"Low Pressure" is irrelevant. Consider the use of supplemental oxygen at altitude. The demand regulator releases pure O2 into the mask attached to your face. The pressure in the space between your face and the mask is exactly the same as the pressure outside of the mask. If it weren't, oxygen would constantly be forced OUT of the seal between your face and the mask.
Low pressure atmosphere, if I remember my Charles Houston correctly, does funky stuff to other parts of the body, but when it comes to oxygen diffusion across capillary walls, has no effect. It's all about that O2 partial pressure.
edit: Fear- Maybe you were practicing to hyperventilate....which flushes the lung's residual volume of "stagnant air" with fresh air. Which is, in itself, sorta dangerous, as it fools the brain into not wanting to flush accumulated CO2. Out on a limb here, but I think people die every year doing solo breath-holding contests, unsupervised, in a pool.
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matisse
climber
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At high elevation pulmonary edema is caused by low atmospheric pressure outside that is insufficient to keep blood and fluid from being pushed into the alveoli by normal internal pressure.
Sue wanders in for the first time in ages and pulls specs off the top of her head plops them on her nose and sighs. hmmp hmmph. leave for a while and you rabble get completely out of control. cheese louise................All kinds of nonsense in this thread.
Short answer : Um no.
Longer answer:
A quick lesson on what we think is the pathophysiology of HAPE:
First of all the biggest predictor of who will get HAPE in the future is a past history of HAPE and because of this we can study people who have had this quite rare condition.
You have two circulations for blood the systemic circulation out to your body and the pulmonary circulation to your lungs. The systemic circulation has a relatively high pressure (i.e around 120/80 mm Hg) whereas the pulmonary circulation is a low pressure low resistance circuit (~15/5 mmHg). This is a good thing because the walls of the pulmonary capillaries are very thin to allow for gas exchange and aren't very strong. High pressures in the pulmonary circulation can cause the capillaries to rupture and that isn't a good thing. It's called "Stress Failure".
When your systemic circulation encounters hypoxia, it vasodilates..i.e. the blood vessels relax and the local pressure may fall, but the pulmonary (lung) circulation is the opposite. When the pulmonary circulation encounters hypoxia it vasoconstricts, a phenomena known as hypoxic pulmonary vasoconstriction or HPV. What happens with HPV is that muscle in the blood vessel walls located upstream of the capillaries constricts and this causes the pressure in the lung blood vessels to go up. Fortunately the capillaries don't see this pressure because they are down stream of the constriction, in the same way that if you kink a garden hose the pressure before the kink is high but after the kink is low.
People who have had HAPE have exaggerated HPV, so when they become hypoxic the pressure in the pulmonary circulation rises to a much greater extent than normal people. There is very good evidence (very, very, very good..I think someone should get a noble prize for this brilliant research if I do say so myself) that HPV in people who are susceptible to HAPE is UNEVEN: some areas get constricted so the overall pressure rises but some areas don't constrict and they see the pressure. This causes small areas of capillary ruputure (stress failure) and then you get an inflammatory response and then you get a bigger leak and a cascade of events that leads to HAPE.
wanders off to her dusty lab again....
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fear
Ice climber
hartford, ct
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yeah..... what she said...
What about for HACE? Similar reasons for leakage inside the poorly designed pressure vessel?
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High Fructose Corn Spirit
Gym climber
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Topic Author's Reply - Dec 8, 2016 - 07:19pm PT
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Sue, your post seems to imply then that any general hypoxia (not just at HA) over some length of a time (eg, a number of hours) would lead to PE (pulmonary edema) by these mechanisms. Do I have that right?
Well, at least for those with "exaggerated HPV," that is.
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matisse
climber
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Fear. I'll try to get to your question tomorrow. I'm tired and it isn't a simple answer.
HFCS. As a physiologist, I tend to think of hypobaric hypoxia i.e. that from high-altitude, and normobaric hypoxia, that induced by giving lower inspired oxygen concentrations to breathe are equivalent. However, there is some research that suggests that the effects of hypobaric hypoxia are more marked for reasons that we don't understand. I'm not talking specifically about the pulmonary circulation, but as a general effect of altitude/hypoxia on the body.
I'm not sure anybody has really done the definitive study to answer your question, which would be to take people that were HAPE susceptible and stick them in a hypoxic tent (not hypobaric) for two days maybe exercise them a bit, or exercise them a lot and see if you could induce HAPE in that setting. There may be some indirect evidence out there, where people were looking at different things but I don't recall any off the top of my head.
Years ago there was a study called operation Everest II in which they simulated an ascent of Mount Everest inside an altitude chamber and made a large number of physiologic measurements on a small group of research subjects. One of those subjects developed HAPE and had to leave the study, so we know that you don't have to be out in the real world to get it.
We know that exercise is important in the development of HAPE and a group from UCSD several years ago showed that something like 70% of climbers who ascended rapidly to over 4000 m had some evidence for very mild pulmonary edema, however only a couple of those had overt HAPE. I also think that probably cold temperatures may be important too for reasons that nobody really seems to understand. We see a lot less HAPE in California compared to Colorado and one factor is that it tends to be a lot colder in Colorado. Of course it just could be that the California climbers/skiers are vastly superior physical specimens. :p
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High Fructose Corn Spirit
Gym climber
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Topic Author's Reply - Dec 9, 2016 - 08:18am PT
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Matisse, thanks for the elaboration, interesting stuff.
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Rockies Obscure
Trad climber
rockiesobscure.com....Canada
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I have climbed a few Andean peaks, but only two times I had illness strike....
Poorly acclimatised in Ecuador after being on the coast, spending little time around Quito, and going to climb Chimborazo. Made it to the summit fine, but on the descent started developing "gurgly lungs". Near the rock feature at the bottom known as "El Castillo" the gurgling lung sound intensified and i started spitting up blood into the snow. Coughing like crazy and more blood- took me forever to get to the hut. Got flu like symptoms overnight back in the city, the blood stopped very soon after driving down to lower altitude. Coughed non-stop for weeks, went to the doc and he said i had bronchitis, something I never had in my life.
About 18 years before that I was well acclimatised for Huascaran, but around the 6000m level stated to hallucinate over night in the tent and next morning we boogied out of there and i was seeing images and my head couldnt figure out how to tie a figure 8.
Other Andean adventures I had no problems.
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Reilly
Mountain climber
The Other Monrovia- CA
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The temperature relationship is counter-intuitive given that warmer temps result in a higher
'density altitude'.
A trip I was on we were flown from low altitude to over 12,000' to our base camp. Daytime
temps were very warm resulting in a density altitude of about 15,000'. Three of the six of us
came down with HAPE to varying degrees, one very seriously.
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High Fructose Corn Spirit
Gym climber
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Topic Author's Reply - Dec 9, 2016 - 09:40am PT
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"Near the rock feature at the bottom known as "El Castillo" the gurgling lung sound intensified and i started spitting up blood into the snow. Coughing like crazy and more blood- took me forever to get to the hut. Got flu like symptoms overnight back in the city, the blood stopped very soon after driving down to lower altitude. Coughed non-stop for weeks..."
Rockies Obscure, thank you for this description.
So I imagine you probably think that if you didn't get relief from going down this "gurgling lung sound" would've intensified even more to the point of serious horror and incapacitation?
Thank goodness you didn't lose your cough and swallowing reflexes during this event. (I hear during PE events in general, this may happen, then it becomes impossible to clear the airway.)
"went to the doc and he said i had bronchitis, something I never had in my life"
as you probably know, generally speaking "bronchitis" means inflammation of the bronchi, the inflammation probably a result of your trouble (not the cause).
...
"but only two times I had illness strike...."
:)
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Rockies Obscure
Trad climber
rockiesobscure.com....Canada
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hi Fructose,
No i did not know that info about bronchitis, the doc may have told me but I may have forgotten.
The coughing did certainly intensify and if we didnt return within a few hours, as we did, to much lower altitude I think it would have gotten worse for sure. I was certainly very worried about this sudden condition that overcame me. I paid a tourist who hiked to the hut, like $10 to carry my backpack from the hut to the where cars park.
Of course I was tired from climbing, but wearing the pack made it worse.
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matisse
climber
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The temperature relationship is counter-intuitive given that warmer temps result in a higher
'density altitude'.
Cold activates the sympathetic nervous system and that seems to be the most plausible, but nothing really has been studied. I'm not sure it has anything to do with density altitude. (whatever that is)
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Al Barkamps
Social climber
Red Stick
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The temperature relationship is counter-intuitive given that warmer temps result in a higher'density altitude'.
A trip I was on we were flown from low altitude to over 12,000' to our base camp. Daytime temps were very warm resulting in a density altitude of about 15,000'.
Reilly, your brain has been afflicted with higher density attitude as this makes zero sense.
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Reilly
Mountain climber
The Other Monrovia- CA
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You guys really don't know about density altitude? Mr Google is yer friend.
I do realize it may be more germane to hypoxia but it seems to me it could
also effect HAPE.
I was just guessing but I just ran the numbers for our basecamp and the
density altitude was more like 16,000' for the conditions at 12,400'.
The air density was about 0.0463 lb/cu ft and the absolute pressure was
18.75" Hg.
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Al Barkamps
Social climber
Red Stick
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You mean "pressure altitude", and you have it backwards.....perhaps by an order of magnitude. Remember, the bong is not always your friend.
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Reilly
Mountain climber
The Other Monrovia- CA
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Mr Bongkamp, I told you to Google it, don't dig yerself a deeper hole.
Pressure altitude is not the same as density altitude. I guess yer not
in possession of an ATP license, are you?
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matisse
climber
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Reilly,
Ahh. Now I know what you are talking about.
You are conflating concepts. This is not aviation. Density altitude is irrelevant for this discussion. This is because by the time the inspired air clears your upper airway it is fully saturated with water vapor, and is at body temperature. What it is in ambient air plays no role in the physiology with the exception that you will have less heat and water loss out of your upper airway when you breathe warm wet air than cold dry air.
The one thing that is relevant is that for a given altitude barometric pressure will vary: with weather as a high or low pressure system blows in, seasonally and and with latitude. The barometric pressure at a given altitude is on average less at the poles than it is at the equator.
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Reilly
Mountain climber
The Other Monrovia- CA
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That's all I was implying - that at the same altitude as the temp rises
you get less O2 per lungful, just like an airplane engine unless it is
turbocharged. :-)
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Al Barkamps
Social climber
Red Stick
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The barometric pressure at a given altitude is on average less at the poles than it is at the equator.
really? You mean sea level is lower at the poles than it is at the equator? That explains why it's further to walk out to the water in Anchorage than Mancora....
Sorry Reilly, I was under the impression that you knew the difference between breathing at altitude and flying at altitude.
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matisse
climber
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That's all I was implying - that at the same altitude as the temp rises
you get less O2 per lungful, just like an airplane engine unless it is
turbocharged. :-)
NO you don't
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matisse
climber
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really? You mean sea level is lower at the poles than it is at the equator?
the atmosphere is thicker at the equator than the poles for a variety of reasons. This means for a given elevation the barometric pressure is, on average, higher.
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matisse
climber
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here's the citation below. the full text should be free.
West got really interested in this because he had predicted, based on analysis of available data (some of which he had collected during the silver hut expedition of 1960-1961) that it would be impossible to climb Everest without supplemental oxygen. Then in 1978 Messner and Habler went out and did it leaving West to figure out how.
In 1981 he mounted AMREE the American Medical Research Expedition to Everest which culminated in Chris Pizzo getting barometric pressure measurements and an alveolar gas sample on the summit. The PO2 was higher than expected, and the PCO2 was astonishingly low (7.5 torr if memory serves, normal is 40) indicating a huge amount of hyperventilation. Importantly barometric pressure was higher than expected. That led to this piece of research:
J Appl Physiol (1985). 1996 Oct;81(4):1850-4.
Prediction of barometric pressures at high altitude with the use of model atmospheres.
West JB.
Abstract
It would be valuable to have model atmospheres that allow barometric pressures (PB) to be predicted at high altitudes. Attempts to do this in the past using the International Civil Aviation Organizations or United States Standard Atmosphere model have brought such models into disrepute because the predicted pressures at high altitudes are usually much too low. However, other model atmospheres have been developed by geophysicists. The critical variable is the change of air temperature with altitude, and, therefore, model atmospheres have been constructed for different latitudes and seasons of the year. These different models give a large range of pressures at a given altitude. For example, the maximum difference of pressure at an altitude of 9 km is from 206 to 248 Torr, i.e., approximately 20%. However, the mean of the model atmospheres for latitude of 15 degrees (in all seasons) and 30 degrees (in the summer) predicts PB at many locations of interest at high altitude very well, with predictions within 1%. The equation is PB (Torr) = exp (6.63268 - 0.1112 h - 0.00149 h2), were h is the altitude in kilometers. The predictions are good because many high mountain sites are within 30 degrees of the equator and also many studies are made during the summer. Other models should be used for latitudes of 45 degrees and above. Model atmospheres have considerable value in predicting PB at high altitude if proper account is take of latitude and season of the year
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