*Review* **The Hen or the Egg: Impaired Alveolar Oxygen Di**ff**usion and Acute High-altitude Illness?**

**Heimo Mairbäurl 1,\*, Christoph Dehnert 2, Franziska Macholz 3, Daniel Dankl 3, Mahdi Sareban <sup>4</sup> and Marc M. Berger <sup>3</sup>**


Received: 25 June 2019; Accepted: 20 August 2019; Published: 22 August 2019

**Abstract:** Individuals ascending rapidly to altitudes >2500 m may develop symptoms of acute mountain sickness (AMS) within a few hours of arrival and/or high-altitude pulmonary edema (HAPE), which occurs typically during the first three days after reaching altitudes above 3000–3500 m. Both diseases have distinct pathologies, but both present with a pronounced decrease in oxygen saturation of hemoglobin in arterial blood (SO2). This raises the question of mechanisms impairing the diffusion of oxygen (O2) across the alveolar wall and whether the higher degree of hypoxemia is in causal relationship with developing the respective symptoms. In an attempt to answer these questions this article will review factors affecting alveolar gas diffusion, such as alveolar ventilation, the alveolar-to-arterial O2-gradient, and balance between filtration of fluid into the alveolar space and its clearance, and relate them to the respective disease. The resultant analysis reveals that in both AMS and HAPE the main pathophysiologic mechanisms are activated before aggravated decrease in SO2 occurs, indicating that impaired alveolar epithelial function and the resultant diffusion limitation for oxygen may rather be a consequence, not the primary cause, of these altitude-related illnesses.

**Keywords:** high-altitude pulmonary edema; acute mountain sickness; oxygen diffusion limitation
