High-Altitude Pulmonary Edema in Two Pediatric Patients with Pre-Existing Lung Disease

Round 1

Reviewer 1 Report

I have read the paper with great interest. Medical problems resulting from impaired adaptation to high altitude are clinically important but, especially concerning children, are rarely discussed in the professional literature. Thus, case reports covering this topic are welcomed. However, I would appreciate more detailed information about the general pathomechanisms of HAPE as well as proposed HAPE pathomechanisms in the presented cases. I fully agree that HAPE prevention in susceptible individuals is of crucial importance. Consequently, only understanding possible pathomechanisms allows one to identify individuals at risk and introduce the most effective preventive attempts.  

In addition, the paper needs some substantive, editorial, and linguistic improvements. For example:

·        line 48: “inspired partial pressure of oxygen” – it should be: “partial pressure of oxygen in inspired air”

·        line 88: “connected to mechanical ventilation” – it should be: “mechanically ventilated” or “connected to a ventilator”

·        Line 187: “Both cases had lung hypoplasia” – indeed, there is hypoplasia in case 1 but what proofs/indicates pulmonary hypoplasia in case 2? She had an undiagnosed pulmonary disease but with no “hard” evidence of hypoplasia.

·        line 188:  “Case 2, it arose due to underlying interstitial lung disease” is confusing with line 110: “was fully investigated without any exact underlying pulmonary disease.” Thus, either “interstitial lung disease” or “any exact underlying pulmonary disease” is the truth, but not both.

 Please note, that all abbreviations must be explained with the first use. I also strongly recommend the paper should be reviewed by a professional and native proofreader. 

Author Response

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Author Response File: Author Response.doc

Reviewer 2 Report

In order to write a proper article about HAPE among children your article should be less delusive as a whole. Everything should be rewritten with the language used less misleading; use a concise title, and avoid unnecessary details in general. The reader should easily recognize the author’s message. The hypothetical relationship between the height of a child and the likelihood of falls is fascinating, bearing in mind that a level of height fall is a good predictor of overall outcome and survival, as said by  Alizo et al. in 2018. However, this accounts for a height, not an altitude. For the environmental factors of fall risk geographic altitude has been tackled by Kitayuguchi et al. (2021). Unfortunately, none of these references was included in this manuscript.

1.      lns. 38 to 53 do not fit into a scientific publication, this section looks more like a tourist guide. Some facts might be valid and valuable, but it is hard to recognize them. Authord sre suggested to re-shape this into a pithy and informative paragraph.

2.      lns. 149 – 157 should be merged with the paragraph starting in ln 59. Together with reshaped text from above, this could be a new; super-informative introduction.

3.      While the author's work is interesting and valid, the list of the works cited is a chaotic compilation of works on the topic. This pile lacks any organizational consistency whatsoever. Not only that, all of these works were venerable, and a few typos (as O'toole is, in fact, O'Toole…) were identified.

4.      All the works in the bibliography were numbered twice. Please correct.

5.      Acronyms/Abbreviations/Initialisms should be defined the first time they appear in each of three sections: the abstract; the main text; the first figure or table. When defined for the first time, the acronym/abbreviation/initialism should be added in parentheses after the written-out form.

Author Response

A response document addressing Reviewer 2's comments has been uploaded in Microsoft Word format.

Author Response File: Author Response.doc

Round 2

Reviewer 1 Report

I accept the improvements done. I have found two minor disadvantages that might be improved:

·         line 129 HFNC is not defined. In addition, information about oxygen percentage in respired air is missing

·         line 141 NP – this abbreviation is not defined too but should be deleted as used only once. 

Author Response

A response document addressing Reviewer 2's comments has been uploaded in Microsoft Word format.

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Reviewer 2 Report

This paper is much improved so I don'h have any further questiins. Anyway, for what it's worth, a title without the ",Early Ascent, Early Peril.." would fit better.

Author Response

A response document addressing Reviewer 2's comments has been uploaded in Microsoft Word format.

Author Response File: Author Response.doc