Cardiorespiratory response to exercise in elite Sherpa climbers transferred to sea level

Do cardiopulmonary exercise tests predict summit success and acute mountain sickness? A prospective observational field study at extreme altitude

OBJECTIVE

During a high-altitude expedition, the association of cardiopulmonary exercise testing (CPET) parameters with the risk of developing acute mountain sickness (AMS) and the chance of reaching the summit were investigated.

METHODS

Thirty-nine subjects underwent maximal CPET at lowlands and during ascent to Mount Himlung Himal (7126 m) at 4844 m, before and after 12 days of acclimatisation, and at 6022 m. Daily records of Lake-Louise-Score (LLS) determined AMS. Participants were categorised as AMS+ if moderate to severe AMS occurred.

RESULTS

Maximal oxygen uptake (V̇O_2max) decreased by 40.5%±13.7% at 6022 m and improved after acclimatisation (all p<0.001). Ventilation at maximal exercise (VE_max) was reduced at 6022 m, but higher VE_max was related to summit success (p=0.031). In the 23 AMS+ subjects (mean LLS 7.4±2.4), a pronounced exercise-induced oxygen desaturation (ΔSpO_2exercise) was found after arrival at 4844 m (p=0.005). ΔSpO_2exercise >-14.0% identified 74% of participants correctly with a sensitivity of 70% and specificity of 81% for predicting moderate to severe AMS. All 15 summiteers showed higher V̇O_2max (p<0.001), and a higher risk of AMS in non-summiteers was suggested but did not reach statistical significance (OR: 3.64 (95% CI: 0.78 to 17.58), p=0.057). V̇O_2max ≥49.0 mL/min/kg at lowlands and ≥35.0 mL/min/kg at 4844 m predicted summit success with a sensitivity of 46.7% and 53.3%, and specificity of 83.3% and 91.3%, respectively.

CONCLUSION

Summiteers were able to sustain higher VE_max throughout the expedition. Baseline V̇O_2max below 49.0 mL/min/kg was associated with a high chance of 83.3% for summit failure, when climbing without supplemental oxygen. A pronounced drop of SpO_2exercise at 4844 m may identify climbers at higher risk of AMS.

Prolonged Sojourn at Very High Altitude Decreases Sea-Level Anaerobic Performance, Anaerobic Threshold, and Fat Mass

Background: The influence of high altitude on an organism’s physiology depends on the length and the level of hypoxic exposure it experiences. This study aimed to determine the effect of a prolonged sojourn at very high altitudes (above 3,500m) on subsequent sea-level physical performance, body weight, body composition, and hematological parameters.

Materials and Methods: Ten alpinists, nine males and one female, with a mean age of 27±4years, participated in the study. All had been on mountaineering expeditions to 7,000m peaks, where they spent 30±1days above 3,500m with their average sojourn at 4,900±60m. Their aerobic and anaerobic performance, body weight, body composition, and hematological parameters were examined at an altitude of 100m within 7days before the expeditions and 7days after they descended below 3,500m.

Results: We found a significant (p<0.01) decrease in maximal anaerobic power (MAP_WAnT) from 9.9±1.3 to 9.2±1.3W·kg⁻¹, total anaerobic work from 248.1±23.8 to 228.1±20.1J·kg⁻¹, anaerobic threshold from 39.3±8.0 to 27.8±5.6 mlO₂·kg⁻¹·min⁻¹, body fat mass from 14.0±3.1 to 11.5±3.3%, and a significant increase (p<0.05) in maximal tidal volume from 3.2 [3.0–3.2] to 3.5 [3.3–3.9] L after their sojourn at very high attitude. We found no significant changes in maximal aerobic power, maximal oxygen uptake, body weight, fat-free mass, total body water, hemoglobin, and hematocrit.

Conclusion: A month-long exposure to very high altitude led to impaired sea-level anaerobic performance and anaerobic threshold, increased maximal tidal volume, and depleted body fat mass, but had no effect on maximal aerobic power, maximal oxygen uptake, or hemoglobin and hematocrit levels.

Death Zone Weather Extremes Mountaineers Have Experienced in Successful Ascents

Background

Few data are available on mountaineers’ survival prospects in extreme weather above 8000 m (the Death Zone). We aimed to assess Death Zone weather extremes experienced in climbing-season ascents of Everest and K2, all winter ascents of 8000 m peaks (8K) in the Himalayas and Karakoram, environmental records of human survival, and weather extremes experienced with and without oxygen support.

Materials and Methods

We analyzed 528 ascents of 8K peaks: 423 non-winter ascents without supplemental oxygen (Everest–210, K2–213), 76 ascents in winter without oxygen, and 29 in winter with oxygen. We assessed environmental conditions using the ERA5 dataset (1978–2021): barometric pressure (BP), temperature (Temp), wind speed (Wind), wind chill equivalent temperature (WCT), and facial frostbite time (FFT).

Results

The most extreme conditions that climbers have experienced with and without supplemental oxygen were: BP 320 hPa (winter Everest) vs. 329 hPa (non-winter Everest); Temp –41°C (winter Everest) vs. –45°C (winter Nanga Parbat); Wind 46 m⋅s^–1 (winter Everest) vs. 48 m⋅s^–1 (winter Kangchenjunga). The most extreme combined conditions of BP ≤ 333 hPa, Temp ≤ −30°C, Wind ≥ 25 m⋅s^–1, WCT ≤ −54°C and FFT ≤ 3 min were encountered in 14 ascents of Everest, two without oxygen (late autumn and winter) and 12 oxygen-supported in winter. The average extreme conditions experienced in ascents with and without oxygen were: BP 326 ± 3 hPa (winter Everest) vs. 335 ± 2 hPa (non-winter Everest); Temp −40 ± 0°C (winter K2) vs. −38 ± 5°C (winter low Karakoram 8K peaks); Wind 36 ± 7 m⋅s^–1 (winter Everest) vs. 41 ± 9 m⋅s^–1 (winter high Himalayan 8K peaks).

Conclusions

[Adaption to chronic hypoxaemia by populations living at high altitude]

Permanent life at high altitude induces important physiological stresses linked to the exposure to chronic hypoxia. Various strategies have been adopted by diverse populations living in the Andes, Tibet or East Africa. The main mechanism is an increase in red blood cell production, more marked in Andeans than in Tibetans or Ethiopians. Other changes are observed in the cardiovascular or respiratory systems, as well as in the utero-placental circulation. Sometimes, a de-adaptation process to hypoxia develops, when erythrocytosis becomes excessive and leads to haematological, vascular and cerebral complications (Monge's disease or chronic mountain sickness). Pulmonary hypertension may also appear. Therapeutic options are available but not sufficiently used. Genetic studies have recently been undertaken to try to better understand the evolution of the human genome in populations living in various high altitude regions of the world, as well as the genetic risk factors for chronic diseases. A new model has appeared, intermittent chronic hypoxia, due to the development of economic activities (mainly mining) in desert regions of the Altiplano.

Into Thick(er) Air? Oxygen Availability at Humans' Physiological Frontier on Mount Everest

Global audiences are captivated by climbers pushing themselves to the limits in the hypoxic environment of Mount Everest. However, air pressure sets oxygen abundance, meaning it varies with the weather and climate warming. This presents safety issues for mountaineers but also an opportunity for public engagement around climate change. Here we blend new observations from Everest with ERA5 reanalysis (1979-2019) and climate model results to address both perspectives. We find that plausible warming could generate subtle but physiologically relevant changes in summit oxygen availability, including an almost 5% increase in annual minimum VO₂ max for 2°C warming since pre-industrial. In the current climate we find evidence of swings in pressure sufficient to change Everest's apparent elevation by almost 750 m. Winter pressures can also plunge lower than previously reported, highlighting the importance of air pressure forecasts for the safety of those trying to push the physiological frontier on Mt. Everest.

Why Are High-Altitude Natives So Strong at Altitude? Maximal Oxygen Transport to the Muscle Cell in Altitude Natives

In hypoxia aerobic exercise performance of high-altitude natives is suggested to be superior to that of lowlanders; i.e., for a given altitude natives are reported to have higher maximal oxygen uptake (VO2max). The likely basis for this is a higher pulmonary diffusion capacity, which in turn ensures higher arterial O2 saturation (SaO2) and therefore also potentially a higher delivery of O2 to the exercising muscles. This review focuses on O2 transport in high-altitude Aymara. We have quantified femoral artery O2 delivery, arterial O2 extraction and calculated leg VO2 in Aymara, and compared their values with that of acclimatizing Danish lowlanders. All subjects were studied at 4100 m. At maximal exercise SaO2 dropped tremendously in the lowlanders, but did not change in the Aymara. Therefore arterial O2 content was also higher in the Aymara. At maximal exercise however, fractional O2 extraction was lower in the Aymara, and the a-vO2 difference was similar in both populations. The lower extraction levels in the Aymara were associated with lower muscle O2 conductance (a measure of muscle diffusion capacity). At any given submaximal exercise intensity, leg VO2 was always of similar magnitude in both groups, but at maximal exercise the lowlanders had higher leg blood flow, and hence also higher maximum leg VO2. With the induction of acute normoxia fractional arterial O2 extraction fell in the highlanders, but remained unchanged in the lowlanders. Hence high-altitude natives seem to be more diffusion limited at the muscle level as compared to lowlanders. In conclusion Aymara preserve very high SaO2 during hypoxic exercise (likely due to a higher lung diffusion capacity), but the effect on VO2max is reduced by a lower ability to extract O2 at the muscle level.

Polygenic study of endurance-associated genetic markers ACE I/D, ACTN3 Arg(R)577Ter(X), CKMM A/G NcoI and eNOS Glu(G)298Asp(T) in male Gorkha soldiers

Background

Gorkhas, a sub-mountainous population of the Himalayan region, are known for strength and bravery. In the present study when “Gorkha” is used without brackets, we are mentioning Gorkhas of Tibeto-Burman origin. Physical capability, strength and endurance are important components of fitness associated with genetic traits. The aim of this study was to examine the endurance potential of male Gorkha soldiers, based on endurance-related genetic markers ACE I/D, ACTN3 Arg (R)577Ter(X), CKMM A/G NcoI and eNOS Glu(G)298Asp(T).

Methods

Genotypic and allelic frequencies were determined in 374 male Gorkha soldiers (Tibeto-Burman). These frequencies were compared with frequencies obtained from Gorkha (Indo-Aryan), high-altitude natives (Tibeto-Burman) and Indian lowlanders (Indo-Aryan). “Total genotype score” (TGS) was calculated from accumulated combination of polymorphisms with maximum value “100” for theoretically “optimal” polygenic score. Probability of occurrence of “optimal” endurance profile was also determined.

Results

ACE II genotypic frequency was highest in Tamangs followed by Gurungs, Rais, Limbus and Magars. No statistical difference in genotypic and allelic frequency of ACTN3 Arg(R)577Ter(X) was noted within the groups. Rais showed the highest CKMM A allele frequency (0.908) compared to other Gorkha (Tibeto-Burman) groups. Limbus and Tamangs showed the highest eNOS G allele frequency (0.938 and 0.915, respectively) compared to that of other groups. Probability of male Gorkha soldiers possessing a theoretically optimal polygenic endurance profile for four candidate polymorphisms was ~3.35% (1 in 30). Four percent of the population of male Gorkha soldiers (15 in 374) exhibited an optimal TGS 100, and 16% exhibited TGS 87 for endurance compared to male Indian soldiers belonging to the lowland (Indo-Aryan) and Gorkha (Indo-Aryan) populations suggesting an overall more “favourable” polygenic profile in the male Gorkha soldier (Tibeto-Burman) population.

Conclusions

This study presents evidence of higher frequency of endurance-associated genes in the Gorkhas implying thereby that such genetically endowed individuals from the population may be selected and trained for achieving excellence in endurance-related elite sports activities.

Electronic supplementary material

The online version of this article (doi:10.1186/s40798-017-0085-0) contains supplementary material, which is available to authorized users.

King of the Mountains: Tibetan and Sherpa Physiological Adaptations for Life at High Altitude

Anecdotal evidence surrounding Tibetans' and Sherpas' exceptional tolerance to hypobaric hypoxia has been recorded since the beginning of high-altitude exploration. These populations have successfully lived and reproduced at high altitude for hundreds of generations with hypoxia as a constant evolutionary pressure. Consequently, they are likely to have undergone natural selection toward a genotype (and phenotype) tending to offer beneficial adaptation to sustained hypoxia. With the advent of translational human hypoxic research, in which genotype/phenotype studies of healthy individuals at high altitude may be of benefit to hypoxemic critically ill patients in a hospital setting, high-altitude natives may provide a valuable and intriguing model. The aim of this review is to provide a comprehensive summary of the scientific literature encompassing Tibetan and Sherpa physiological adaptations to a high-altitude residence. The review demonstrates the extent to which evolutionary pressure has refined the physiology of this high-altitude population. Furthermore, although many physiological differences between highlanders and lowlanders have been found, it also suggests many more potential avenues of investigation.

Ventricular structure, function, and mechanics at high altitude: chronic remodeling in Sherpa vs. short-term lowlander adaptation

Short-term, high-altitude (HA) exposure raises pulmonary artery systolic pressure (PASP) and decreases left-ventricular (LV) volumes. However, relatively little is known of the long-term cardiac consequences of prolonged exposure in Sherpa, a highly adapted HA population. To investigate short-term adaptation and potential long-term cardiac remodeling, we studied ventricular structure and function in Sherpa at 5,050 m (n = 11; 31 ± 13 yr; mass 68 ± 10 kg; height 169 ± 6 cm) and lowlanders at sea level (SL) and following 10 ± 3 days at 5,050 m (n = 9; 34 ± 7 yr; mass 82 ± 10 kg; height 177 ± 6 cm) using conventional and speckle-tracking echocardiography. At HA, PASP was higher in Sherpa and lowlanders compared with lowlanders at SL (both P < 0.05). Sherpa had smaller right-ventricular (RV) and LV stroke volumes than lowlanders at SL with lower RV systolic strain (P < 0.05) but similar LV systolic mechanics. In contrast to LV systolic mechanics, LV diastolic, untwisting velocity was significantly lower in Sherpa compared with lowlanders at both SL and HA. After partial acclimatization, lowlanders demonstrated no change in the RV end-diastolic area; however, both RV strain and LV end-diastolic volume were reduced. In conclusion, short-term hypoxia induced a reduction in RV systolic function that was also evident in Sherpa following chronic exposure. We propose that this was consequent to a persistently higher PASP. In contrast to the RV, remodeling of LV volumes and normalization of systolic mechanics indicate structural and functional adaptation to HA. However, altered LV diastolic relaxation after chronic hypoxic exposure may reflect differential remodeling of systolic and diastolic LV function.

High Altitude Adaptation in Tibetans

Since the beginning of the Himalayan climbing era, the anecdotal extraordinary physical performance at high altitude of Sherpas and Tibetans has intrigued scientists interested in altitude adaptation. These ethnic groups may have been living at high altitude for longer than any other population, and the hypothesis of a possible evolutionary genetic adaptation to altitude makes sense. Reviewed here is the evidence as to whether Tibetans are indeed better adapted for life and work at high altitude as compared to other populations and, if so, whether this better adaptation might be inborn. Tibetans, compared to lowlanders, maintain higher arterial oxygen saturation at rest and during exercise and show less loss of aerobic performance with increasing altitude. Tibetans have greater hypoxic and hypercapnic ventilatory responsiveness, larger lungs, better lung function, and greater lung diffusing capacity than lowlanders. Blood hemoglobin concentration is lower in Tibetans than in lowlanders or Andeans living at similar altitudes. Tibetans develop only minimal hypoxic pulmonary hypertension and have higher levels of exhaled nitric oxide than lowlanders or Andeans. Tibetans' sleep quality at altitude is better and they desaturate less at night. Several of these findings are also found in Tibetans born at low altitude when exposed for the first time to high altitude once adult. In conclusion, Tibetans indeed seem better adapted to life and work at high altitude, and this superior adaptation may very well be inborn, even though its exact genetic basis remains to be elucidated.

Normoxic ventilatory response in lowlander and Sherpa elite climbers

The differences in ventilatory response to exercise of some highland ethnic communities is a controversial issue. We have evaluated the differences in ventilatory response to exercise at sea level between two groups of elite climbers, four Himalayan Sherpas (S) and four Caucasian lowlanders (C), after descent from extreme altitude. All of them performed a progressive-intensity exercise test on a treadmill under normoxic conditions. Pulmonary gas exchange was obtained until exhaustion by means of an automatic gas-analyzer system. Significant differences in expired ventilation and carbon dioxide production were found between the two groups, the VE x VO2(-1) being lower in the S at rest (41.9 +/- 5) in comparison with C (48.7 +/- 9) (P < 0.05), higher at medium loads of the test (S = 28.2 +/- 4 vs. C = 25.7 +/- 2; P < 0.05) and reaching similar values at higher loads (S = 34.5 + 2 vs. C = 35.6 +/- 4; NS). We conclude that the special ventilatory response observed in these highlanders could explain their adaptation to altitude, allowing higher oxygen blood saturation at medium working loads and reducing the risk of neurological injury caused by a high ventilatory response when exercising at high intensity effort under extreme altitude environment.