Does This Patient Have Acute Mountain Sickness?: The Rational Clinical Examination Systematic Review.

TitreDoes This Patient Have Acute Mountain Sickness?: The Rational Clinical Examination Systematic Review.
Publication TypeJournal Article
Year of Publication2017
AuthorsMeier, D, Collet, T-H, Locatelli, I, Cornuz, J, Kayser, B, Simel, DL, Sartori, C
JournalJAMA
Volume318
Issue18
Pagination1810-1819
Date Published11/2017
DOI10.1001/jama.2017.16192
ISSN1538-3598
Mots-clésActivities of Daily Living, Acute Disease, Altitude, Altitude Sickness/diagnosis, Altitude Sickness/physiopathology, Humans, Male, Middle Aged, Prevalence, Severity of Illness Index, Surveys and Questionnaires, Visual Analog Scale
Abstract

Importance: Acute mountain sickness (AMS) affects more than 25% of individuals ascending to 3500 m (11 500 ft) and more than 50% of those above 6000 m (19 700 ft). AMS may progress from nonspecific symptoms to life-threatening high-altitude cerebral edema in less than 1% of patients. It is not clear how to best diagnose AMS.

Objective: To systematically review studies assessing the accuracy of AMS diagnostic instruments, including the visual analog scale (VAS) score, which quantifies the overall feeling of sickness at altitude (VAS[O]; various thresholds), Acute Mountain Sickness-Cerebral score (AMS-C; ≥0.7 indicates AMS), and the clinical functional score (CFS; ≥2 indicates AMS) compared with the Lake Louise Questionnaire Score (LLQS; score of ≥5).

Data Extraction and Synthesis: Searches of MEDLINE and EMBASE from inception to May 2017 identified 1245 publications of which 91 were suitable for prevalence analysis (66 944 participants) and 14 compared at least 2 instruments (1858 participants) using a score of 5 or greater on the LLQS as a reference standard. To determine the prevalence of AMS for establishing the pretest probability of AMS, a random-effects meta-regression was performed based on the reported prevalence of AMS as a function of altitude.

Main Outcomes and Measures: AMS prevalence, likelihood ratios (LRs), sensitivity, and specificity of screening instruments.

Results: The final analysis included 91 articles (comprising 66 944 study participants). Altitude predicted AMS and accounted for 28% of heterogeneity between studies. For each 1000-m (3300-ft) increase in altitude above 2500 m (8200 ft), AMS prevalence increased 13% (95% CI, 9.5%-17%). Testing characteristics were similar for VAS(O), AMS-C, and CFS vs a score of 5 or greater on the LLQS (positive LRs: range, 3.2-8.2; P = .22 for comparisons; specificity range, 67%-92%; negative LRs: range, 0.30-0.36; P = .50 for comparisons; sensitivity range, 67%-82%). The CFS asks a single question: "overall if you had any symptoms, how did they affect your activity (ordinal scale 0-3)?" For CFS, moderate to severe reduction in daily activities had a positive LR of 3.2 (95% CI, 1.4-7.2) and specificity of 67% (95% CI, 37%-97%); no reduction to mild reduction in activities had a negative LR of 0.30 (95% CI, 0.22-0.39) and sensitivity of 82% (95% CI, 77%-87%).

Conclusions and Relevance: The prevalence of acute mountain sickness increases with higher altitudes. The visual analog scale for the overall feeling of sickness at altitude, Acute Mountain Sickness-Cerebral, and clinical functional score perform similarly to the Lake Louise Questionnaire Score using a score of 5 or greater as a reference standard. In clinical and travel settings, the clinical functional score is the simplest instrument to use. Clinicians evaluating high-altitude travelers who report moderate to severe limitations in activities of daily living (clinical functional score ≥2) should use the Lake Louise Questionnaire Score to assess the severity of acute mountain sickness.

Notes

Research Support, Non-U.S. Gov't

Alternate URL

http://www.ncbi.nlm.nih.gov/pubmed/29136449?dopt=Abstract

WOS ID (UT)

000415660700019

Alternate JournalJAMA
Citation Key / SERVAL ID8396
Peer reviewRefereed
PubMed ID29136449

                         

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