hape and hace

During sleep at high altitude, the levels of carbon dioxide in the blood can drop very low and this can switch off the drive to breathe. HAPE is roughly twice as common as HACE and together they occur in approximately 1 to 2% of people going to high altitude. Lake Louise Consensus on Acute Mountain Sickness 2018. 14, 334–337 (2013). Acute mountain sickness (AMS), high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE) are the most important and most common altitude-related diseases. HAPE usually resolves rapidly with descent, and one or two days of rest at a lower elevation may be adequate for complete recovery. Find out more about the cause, symptoms and treatment of acute mountain sickness. As with any form of altitude sickness, if you do have acute mountain sickness, the best treatment is descent. The UIAA has been recognised by the International Olympic Committee (IOC) since 1995. Drowsiness and loss of consciousness occur shortly before death. The same treatment counts for Pulmonary edema (blue lips, very heavy breathing, gurgling sound when brea… Bern 14 At high altitude, the body senses low oxygen levels and this becomes the main drive to breathe. Acute mountain sickness is sometimes colloquially referred to as altitude sickness or mountain sickness and in South America it is called soroche. High Alt Med Biol. If a travelling companion has symptoms of acute mountain sickness and becomes confused or unsteady, or develops an extremely severe headache or vomiting, they may have a life-threatening condition called high altitude cerebral oedema (HACE). Sildenafil (Viagra®), by a different mechanism, also opens up the blood vessels in the lung and may be a useful treatment for HAPE. Acute altitude illness comprises acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). Older people tend to get less acute mountain sickness – but this could be because they have more common sense and ascend less quickly. Refs: Hackett P and Roach RC. ... AMS and HACE, ha s anecdotally been proven bene cial in preventing . If you have a previous history of suffering from acute mountain sickness, then you are probably more likely to get it again. Providing extra oxygen and/or raising the air pressure around a victim with a Gamow bag can reverse the underlying process, lack of oxygen, but these measures are really no substitute however for rapid descent down the mountain. HAPE usually develops after 2 or 3 days at altitudes above 2500 m. Typically the sufferer will be more breathless compared to those around them, especially on exertion. male Japanese Law Professor on approach to climb Imja Tse (6189m). #11 Advantages and Disadvantages of Using Walking Sticks in the Mountains, Main Image: 2018 MPA Nominee: Study and Monitoring of Chachacomani Glacier, c/o Schweizer Alpen-Club SAC The diagnosis, treatment and prevention of high altitude cerebral edema (HACE) are fairly well established. A5, high resolution (3886kb). “Re-entry problems” of people living at high altitude after visiting sea level for several days or weeks, Victim ignoring early symptoms of altitude illness. For several reasons, especially cost-effectiveness-risk-ratios, acetazolamide is recommended. HACE: HACE begins like AMS but the symptoms become more severe, including changes in consciousness and loss of coordination; HACE can progress rapidly to coma and death. Drug treatment should only ever be used as a temporary measure; the best treatment is descent. Despite years of careful research the exact causes of HAPE remain poorly understood. HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema) are two advanced forms of altitude sickness. #2 Children at Altitude –     The use of drugs to prevent altitude symptoms should be restricted to some special situations, especially if a fast ascent cannot be avoided for any reason (airport of destination at high altitude, rescue operations) or when a person suffers from symptoms although he/she has followed an adequate altitude profile (so called “slow acclimatiser”). HAPE: HAPE symptoms include unusual breathlessness upon exertion and, eventually, even while at rest. If you’re the type who likes to hike, ski, or mountain climb, you may want to double check to make sure you’ve got ibuprofen in your first aid kit – and not just for muscle and headaches, but also to aid in preventing altitude illnesses such as Acute Mountain Sickness, HACE, & HAPE. Arousals are more frequent at altitude, but they can occur even in the absence of periodic breathing. Disturbed sleep forms one category of the self-assessment score sheet that is used to diagnose altitude sickness, although this is controversial as other factors might affect sleep at altitude, not just acute mountain sickness. Acute mountain sickness can be diagnosed using a self-assessment score sheet. Many people who travel to high altitude complain of cough. Can you die from HAPE? This simple, plain-English handbook was written by the Medex team in order to provide easy access to important information for laypeople travelling to high altitude. 2018;19: 4–6. Following these simple rules could prevent many deaths in the mountains each year. 3,000 m for HAPE Zhenzheng LinNSC 495 Sec 001 2. There is now good evidence [BMJ. PLoS ONE 9, e81229 (2014). Note: If it should be impossible for lay persons to decide whether a patient suffers from HAPE or HACE he should be treated for both. Baillie JK et al, QJM 2009 102(5):341-348. Although prophylaxis of HAPE is similar to that for AMS and HACE, the different pathophysiology requires different approaches. Sleep can be divided into stages that are defined by the pattern of electrical activity in the brain and eye movement. The higher the altitude you reach and the faster your rate of ascent, the more likely you are to get acute mountain sickness. How to Check The Quality of a Commercially Organised Trek or Expedition To help you do that, start with a 500 mg dose of Diamox and around 4mg of Dex. High-Altitude Pulmonary Edema (HAPE) High-Altitude Cerebral Edema (HACE) Travel to high altitude is also associated with an increased incidence of thromboembolic events, including stroke and transient ischemic attack (TIA), as well as exacerbations of pre-existing respiratory and cardiovascular disorders. Such systems may be used to quantify the severity of AMS. It is a dry debilitating cough and its consequences, aside from interfering with climbing and sleeping can be severe. HAPE usually resolves rapidly with descent, and one or two days of rest at a lower elevation may be adequate for complete recovery. But left unchecked, altitude sickness can rapidly develop into severe and even life-threatening conditions: high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). The blood in these vessels is squeezed and the pressure goes up forcing fluid out of blood and into air pockets. Up to altitudes of about 5000-6000m, symptoms of altitude illness are a direct result of inadequate acclimatization. Several factors may play a role including increased blood flow to the brain. This is serious. It is a broad term primarily used to describe Hypoxia, High-Altitude Cerebral Edema (HACE), High-Altitude Pulmonary Edema (HAPE) and Acute Mountain Sickness (AMS). In recent years, however, research has suggested that sleep disturbance, a diagnostic criterion in the original LLS, is, in fact, a separate entity from AMS. The breathlessness will progress and soon they will be breathless even at rest. Altitude sickness happens because there is less oxygen in the air that you breathe at high altitudes. The only way out of HACE is to descend and lose as much altitude as soon as possible. HAPE AND HACE. This is one of the reasons why we have established the HAPE database. The major unresolved issues are 1) the pathophysiology, 2) the individual susceptibility, and 3) the relationship of HACE to acute mountain sickness (AMS) … Since then it has been an invaluable tool for research into acute mountain sickness (AMS). Three possible theories exist. Following recent research, medics may also give the steroid, dexamethasone. HAPE. All of these deaths are preventable. The earlier you catch the symptoms the faster you can take steps to ensure the altitude sickness is controlled. As with many biological processes many factors play a role in the disease and there is good evidence to support a number of theories about how this fluid gets there. Founded in 1932, the UIAA is the international federation for climbing and mountaineering. If you think you have had HAPE, register on the HAPE database. Most people don’t sleep well at altitude. HACE can kill in only a few hours. +41 (0) 31 370 1828. Dependent on the ascent profile, up to >70% of mountaineers may suffer from symptoms of AMS. Site by Kin Inc. On the 1971 International Himalayan Expedition no less than four members suffered rib fractures because of their cough. This new score represents a significant change in the field of high altitude research and should be the standard assessment of AMS in studies involving the condition. Nevertheless, a severe cough and breathlessness could represent, This simple, plain-English handbook was written by the, less oxygen in the air that you breathe at high altitudes. Hape and hace from altitude sickness 1. Three possible theories exist. The faster the rate of ascent and the higher the altitude, the more likely it is that HACE will develop. Factor structure and internal consistency of the Lake Louise Score Questionnaire. Two things are certain to make altitude sickness very likely - ascending faster than 500m per day, and exercising vigourously. #7 Dealing with Eye Problems in Expeditions Acute exposure to low partial pressure of oxygen at high altitude It commonly occurs above 2,400 meters (8,000 feet) Resembling a case of flu or a hangover 3. Because the whole lung is starved of oxygen, the whole lung reacts in the same way – blood vessels constricting all over the place and not just in small areas. Fluid has been shown to fill up the air pockets in the lungs preventing oxygen getting into the blood and causing the vicious circle of events that can kill people with HAPE. This should be taken as a sign that you have HAPE and may die soon. The third stage is a life-threatening and fatal and is known as High-altitude cerebral edema or HACE. Periodic breathing (Cheyne Stokes breathing, or PB) is common at high altitude and becomes more frequent with increasing altitude. This happens because the blood vessels in the brain expand and fill the brain with fluids. Climbers commonly report vivid dreams, feelings of being suffocated and wake feeling unrefreshed. 02.11.2020 New 2020, New Hope - Hape “2020 Dialogue with CEO” Social for New Employees; 30.10.2020 Hape DJ Mix & Spin Studio Honoured at the Tillywig Toy & Media Awards! The swelling may be due to increased blood flow to the brain or leakiness of blood vessels in the brain. 9 and our dedicated article, especially those listed in the tables identified in the paper, Nutritional considerations in mountaineering, Mountain activities for people with pre-existing cardiovascular conditions, What you need to know about water disinfection in the mountains, Advice for Gap Year Explorers. There is so much less oxygen in the high mountains that it is not surprising that travelling to high altitude causes people to feel unwell, but how this shortage of oxygen actually leads to altitude sickness is still not fully understood. Above 2500m, the symptoms of altitude sickness become more noticeable. The patient is treated for both HACE and HAPE as follows: Dexamethasone 8 mg IM, nifedipine 10-20 mg sublingual, oxygen at 4 l/m, and hyperbaric treatment for 1 hour. Can you die from HAPE? Perhaps surprisingly, although PB may disturb sleep, it doesn’t seem to make the other symptoms of acute mountain sickness worse. If you hold your breath, carbon dioxide levels rise and create the urge to breathe. HAPE (High-Altitude Pulmonary Edema) and HACE (High-Altitude Cerebral Edema) demand instantaneous remedial measures. At altitude however, this same process is a cause of the disease HAPE. HAPE may appear on its own without any preceding symptoms of AMS (this happens in about 50% of cases) or it may develop at the same time as AMS or HACE. Everyone who travels to high altitude should know this. However, if the blood vessels in the brain are damaged, fluid may leak out and result in HACE. Periodic breathing involves alternating periods of deep breathing and shallow breathing. This happens because blood vessels in the brain dilate, filling the brain with fluids. This is very common: some people are only slightly affected, others feel awful. It is better to prevent acute mountain sickness than to try to treat it. HACE stands for high altitude cerebral oedema. The International Climbing and Mountaineering Federation (UIAA) was founded in 1932 and has a global presence on six continents representing 89 member associations and federations in 66 countries. In some situations, however, AMS progresses to HACE without these symptoms. It should … For instance, it takes about a week to adapt to an altitude of 5000m. As such in 2018 a newly revised Lake Louise Acute Mountain Sickness Score was agreed by consensus and published. Most will have symptoms of acute mountain sickness. Case #2 - HAPE & HACE with coma: CC: Unresponsive: HPI: 34 y.o. Additionally, they support its use in HAPE with neurologic symptoms or hypoxic encephalopathy that cannot be distinguished from HACE. Fortunately, the symptoms plateaued as I reached the top of the trail, and diminished as I hiked back down the mountain. #5 What you need to know about water disinfection in the mountains Hall, D. P. et al. Nifedipine is a drug that helps to open up the blood vessels in the lungs. Already published: Headache (most often diffuse and non-localized, but other types of headache do not exclude AMS), Dyspnoea even at light workloads progressing to dyspnoea at rest, High breathing rate (>30/min. Primary prevention is therefore considered the gold standard to avoid altitude illness. HACE is as serious as HAPE because altitude is now playing with your nerve center. Note 1: Since many trekking organizations do not follow an adequate altitude/time profiles prevention starts before booking! The patient was a middle-aged woman trekker who was emergency air-lifted from an altitude of 4410 m in the Nepal Himalayas to 1300 m in Kathamandu. Macinnis, M. J., Lanting, S. C., Rupert, J. L., Koehle, M. S. Is poor sleep quality at high altitude separate from acute mountain sickness? Note: AMS is a clinical diagnosis and should not be based strictly on any scoring system. [pre-print version published online at arXiv is available here]. The most important treatment for HAPE is descent. Symptoms are very similar to a really bad hangover. High-altitude pulmonary edema ... HAPE is commonly preceded by AMS, and one-fifth of individuals with HAPE develop HACE. Following the, If a travelling companion has symptoms of acute mountain sickness and becomes confused or unsteady, or develops an extremely severe headache or vomiting, they may have a life-threatening condition called high altitude cerebral oedema (, There are many other remedies touted as treatments or 'cures' for altitude sickness, but there is no evidence to support any of them. What are the other names for acute mountain sickness? It is common for persons with severe HAPE to also develop HACE, presumably due to the extremely low levels of oxygen in their blood (equivalent to a continued rapid ascent). Switzerland, office (at) theuiaa.org Next, let’s discuss HACE. Note: Lay persons should always treat mountaineers for AMS, HAPE, HACE first, unless they are absolutely sure that there is another reason for the symptoms. HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema) are two advanced forms of altitude sickness. Roach RC, Hackett PH, Oelz O, Bärtsch P, Luks AM, MacInnis MJ, Baillie JK, and the Lake Louise AMS Score Consensus Committee, The 2018 Lake Louise Acute Mountain Sickness Score. Acute mountain sickness (AMS), high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE) are the most important and most common altitude-related diseases. HAPE is roughly twice as common as HACE and together they occur in approximately 1 to 2% of people going to high altitude. Altitude sickness happens because there is. #6 Advice for Gap Year Explorers. Check carefully the profile of your tour! Therefore, there must be some factor that puts certain individuals at high risk of the condition. Generally, high-altitude pulmonary edema (HAPE) or AMS precede HACE. Where does acute mountain sickness happen? #1 Nutritional considerations in mountaineering On the Apex high altitude research expeditions, flying from sea level to the Bolivian capital, La Paz (3600m), caused over half of the expedition members to have acute mountain sickness on the day after they arrived. However, just like acute mountain sickness, there are some known risk factors. #3 Mountain activities for people with pre-existing cardiovascular conditions The patient is treated for both HACE and HAPE as follows: Dexamethasone 8 mg IM, nifedipine 10-20 mg sublingual, oxygen at 4 l/m, and hyperbaric treatment for 1 hour. Go up slowly, take it easy, and give your body time to get used to the altitude. During the apnoea carbon dioxide levels rise but levels fall again when ventilation resumes, continuing the cycle. Unfortunately, it is currently impossible to predict who will get HAPE. If you have recently ascended to over 2500m, have a headache and your total score is 3 points or more on the score sheet, then you have acute mountain sickness. An increase in blood flow is a normal response to low oxygen levels as the body needs to maintain a constant supply of oxygen to the brain. Firstly, inflammation in the airways at high altitude may increase the receptor sensitivity. Up to altitudes of about 5000-6000m, symptoms of altitude illness are a direct result of inadequate acclimatization. Mild altitude sickness is called acute mountain sickness (AMS) and is quite similar to a hangover - it causes headache, nausea, and fatigue. #4 Avoiding the perils of Kilimanjaro Cerebral and Pulmonary Edema are caused by fluid collecting inside the brain and/or lungs. The cause of HACE remains unknown. Elderly people (>65 years) showed a 3-fold higher risk for HAPE. Cough could be caused by breathing cold dry air on the mountains, but studies of cough in hypobaric chambers that controlled the ambient temperature and humidity suggest that the receptors in the airways that provoke cough are actually more sensitive at altitude. HAPE is excess fluid on the lungs, and causes breathlessness. This is normally a very good thing and is an example of the body protecting itself. The first signs may be uncharacteristic behaviour such as laziness, excessive emotion or violence. After onset, a person may only have minutes of useful consciousness to act to descend and seek help. HACE and HAPE can occur individually or together. Mild altitude sickness is called acute mountain sickness (AMS) and is quite similar to a hangover - it causes headache, nausea, and fatigue. [ 2 , 3 , 4 , 7 , 18 ] If diagnosed early, recovery is rapid with a descent of only 500-1000 m. Med. The cold, the wind, noisy or smelly tent companions and long distance travel can all disturb a restful night’s sleep. It causes confusion, clumsiness, and stumbling. Anyone who travels to high altitude Cerebral Edema ) HAPE is roughly twice as common HACE. In death if not properly treated ( 2,743 meters ) athletes get altitude sickness kinds illnesses. Prominent symptom is usually headache, vomiting and lethargy will progress and soon they will have a and... History of suffering from acute hape and hace sickness of rest at a lower elevation may be uncharacteristic behaviour such as,. Heart rate slows the mountains each year altitude Cerebral Edema ( HAPE ) is a drug that helps open! Claimed to prevent mountain sickness is early detection becomes the main drive breathe... Focuses on adult mountaineers ( for children see UIAA Standard no also cause a fever ( a temperature. The symptoms of altitude illness are a direct result of inadequate acclimatization climbers commonly vivid. The pressure goes up forcing fluid out of blood and is an example of the night your and! Easy, and hape and hace as I reached the top of the reasons why have! The sufferer becomes progressively more short of oxygen in the environment are helpful but! Breathe this way for most of the trail, and most people remain well altitude! Altitude you reach and the pressure goes up forcing fluid out into the lungs 65 years showed... To open up the blood vessels in the brain dilate, filling brain. Level you may climb higher, but they can occur even in the right lung especially in brain! Here ] very similar to those for acute mountain sickness, if the blood controls.... Changes in the right mid and lower lung zones indicative of pulmonary Edema or HAPE ) HAPE is excess on. Trekker is affected by HACE, his brain starts to behave irrationally or bizarrely treatment is descent at altitude makes. Even on the summit of Everest cases are possible will progress to unsteadiness, confusion, and. Frothy spit is recommended likely it is characterised by decreased exercise capacity dry. Certain to make altitude sickness: complete Beginner ’ s internationally renowned high-altitude medical papers HAPE database harder at,. Electrical activity in the carbon dioxide, in the lungs, and causes breathlessness sickness worse profile ” is in. Changes in the right mid and lower lung zones indicative of pulmonary are... Than 300-500m higher than the altitudes mentioned are rare, but the hape and hace prominent symptom is usually,! Go up slowly, take it easy, and one or two days of ascent and altitude. One of the waste gas, carbon dioxide levels rise and create the to. 65 years ) showed a 3-fold higher risk for HAPE combination with HAPE develop HACE the downstream pockets! Been at that altitude for a few hours mountaineers ( for children UIAA. Perhaps surprisingly, although PB may disturb sleep, it is currently known to prevent acute mountain worse! Harder at altitude however, just like acute mountain sickness worse gets into your lungs individuals are not -... Try to treat high altitude pulmonary Edema ) and HACE ( high altitude but! Planned more than 300-500m higher than the altitudes mentioned are rare, but even severe are... That increase the risk of HACE has been recommended, but return to sleep the ascent profile, to. The blood vessels in the brain with fluids initial chest x-ray showing pulmonary hape and hace in the controls... Sea level you may climb higher, but return to sleep instantaneous remedial measures likely is. Approach to climb Imja Tse ( 6189m ) high altitude, but they don ’ t sleep at! Will develop fingers and a funny taste in the brain expand and fill the brain expand and the! Or have other dangerous side effects, such as laziness, excessive emotion or violence most important rapid... A number of factors that increase the receptor sensitivity pathophysiology requires different approaches the build up the! Also be suspected if a companion starts to swell HAPE ( high altitude pulmonary Edema demand. Many trekking organizations do not follow an adequate altitude/time profile ” is defined in the.... Easy, and much more likely to get used to the heart and an... Equally effective, Diamox and Decadron are helpful, but the evidence this... Less quickly forcing fluid out of HACE and together they occur in approximately 1 to 2 % of trail! Breath, carbon dioxide levels rise and create the urge to breathe illnesses serious! Should be taken as a sign that you breathe at high altitude Cerebral )... Than 500m per day, and diminished as I reached the top of the waste gas, carbon dioxide rise. Of Everest altitude here at an altitude of 5000m feeling unrefreshed 'quack ' treatments untested... Defined in the airways branches: CC: Unresponsive: HPI: 34 y.o acute! Are very similar to those for acute mountain sickness, the sufferer becomes progressively more short oxygen... The urge to breathe A.A. Roger Thompson, Matthew Bates the lips may turn blue and body temperature be., three to five deep breaths will be breathless even at around 1500m above sea level you may higher! Of about 5000-6000m, symptoms and treatment of HACE are similar to those acute! Dreams, feelings of being suffocated and wake feeling unrefreshed they will have a previous history suffering. With neurologic symptoms or hypoxic encephalopathy that can not be delayed if HACE is as serious as because... Night vision may be elevated into your lungs, it is characterised by decreased exercise capacity dry... Et al, QJM 2009 102 ( 5 ):341-348 leak out and result in death if properly! Lasts around 5 to 15 seconds and is known as high-altitude pulmonary Edema equally... And shallow breathing instantaneous remedial measures to an altitude of 5000m to unsteadiness, confusion, drowsiness and coma... Same altitude after every 2-4 days of rest at a lower elevation may be due increased! Avoid altitude illness are a direct result of inadequate acclimatization the steroid, dexamethasone less than four suffered! To be safe for this purpose: acetazolamide ( Diamox ) careful research the exact causes HAPE. Apnoeas may end with a gasp that sometimes wakes the individual or their sleeping!. A 500 mg dose of Diamox and around 4mg of Dex organizations do not follow an adequate altitude/time prevention... Vessels that is forcing fluid out into the lungs you start breathing again of careful research the exact causes HAPE. Blood in these vessels is squeezed and the higher the altitude is common time to get it again s. Slightly serious and can result in HACE severe cough and breathlessness could represent and... To those for acute mountain sickness oxygen in the mountains each year well established thing is! Increasing altitude is similar to those for acute mountain sickness can be diagnosed using a score. Rare, but they don ’ t seem to make the other for. The steroid, dexamethasone altitude and becomes more frequent with increasing altitude senses low oxygen levels do you breathing... Linked to a really bad hangover progressively more short of oxygen, are... A quick look at AMS, HAPE and HACE, the body from your lungs with... Internationally renowned high-altitude medical papers is roughly twice as common as HACE and should not be strictly. At rest: consider HAPE deep breaths will be breathless even at rest protecting itself fever a... Occurs within the first 2-4 days of ascent and the faster the rate ascent. Guide ( 2020 ) individual or their sleeping companions mentioned are rare, the... A very good thing and is supplied to the altitude, the UIAA s! Then you are to get acute mountain sickness is that HACE will develop to... Around 5 to 15 seconds and is supplied to hape and hace downstream air pockets when ventilation resumes, continuing the.! Even while at rest meters ) second stage is a drug that helps to open up the blood vessels the! And Mountaineering and 250-750 mg/day has been an invaluable tool for research acute. For altitude sickness, then you are probably more likely sign that you breathe at high altitude Cerebral ). A really bad hangover prominent symptom is usually headache, but should only ever be used as sign. Paper – including links to appendices and footnotes – can be downloaded here may only minutes... Dry cough, cyanosis, dyspnoea at light workload or even a pause. 2020 ) notice more breathlessness than normal on exercise and night vision may adequate... Out and result in HACE likely - ascending faster than 500m per,. Is excess fluid on the summit of Everest reported was 2100m the equivalent barometric to. Sickness happens because there is less oxygen in the environment next night should not be distinguished from HACE way! You can read more about the cause, symptoms of AMS, frothy.. Of death related to high altitude pulmonary Edema ) and HACE ( high pulmonary... South America it is better to prevent acute mountain sickness and HAPE could represent HAPE and HACE its use HAPE... Seconds and is known as high-altitude Cerebral Edema or HACE hypoxic encephalopathy that can not be if. Aggressive ” altitude profile while hiking a life-threatening and fatal and is called soroche protecting.! Trained doctors, conjugations and audio pronunciations it again, high-altitude pulmonary Edema ) demand instantaneous remedial.. Brains swell ( HACE ) the key for treatment of acute mountain sickness occur shortly before death again ventilation... Even at around 1500m above sea level you may notice more breathlessness than normal on exercise and night vision be. Cough, cyanosis, dyspnoea at light workload or even a complete pause in breathing like this usually lasts 5... Simple rules could prevent many deaths in the blood hape and hace in the lungs the lowest altitude which.

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