- Bhutan Highlights with Ura Yakchoe Festival
- A Cultural Exploration of Western Bhutan
- Bhutan West to East Traverse
- Cultural and Walking Tour of Thimphu and Paro
- Glimpse of the Dragon Kingdom
- Grandeur of Western Bhutan
- Paro Festival Tours 2012
- Punakha Festival Tour
- The cultural exploration and walking tours of Western Bhutan
- The Cultural Heart of Bhutan
- Thimphu Festival Tour
- Western and Central Bhutan Highlights
- Druk Air Schedule
- Airline Information
- Druk air Flight Schedule Feb to 14 May 2012
- Druk air Flight Schedule 15 May to 27 Oct 2012
- Druk air Flight Schedule 28 Oct to 31 Jan 2013
Trip Facts
Duration: 12 days
Accommodation: hotels in the cities and camping during trekking
Activities: Temples, Dzongs and farm house visits., Short and easy hikes., Attend week-end markets.
Trip Grading: Easy
Trip Type: Popular
Group Size:1-10 pax
Start From:Paro
Finish In:Paro
Highest Altitude:10, 998 ft (3, 353 m)
Best Season: Spring and Fall
Bumthang Cultural Trek
Day 1: Your flight descending over the final Himalayan ridge brings you to Paro International Airport, elevation 7500 feet. Your Druk Air experience has been highlighted with breathtaking views of Himalayan peaks, including the sacred Mount Chomolhari and Jitchu Drake in Bhutan. Your excitement mounts and you are received at Paro Airport by your tour representative, visas are processed and you are escorted to your hotel for lunch and check-in. After lunch visit the National Museum (Ta-Dzong). Once the watchtower for the Rinpung Dzong, it was converted into the National Museum in 1968. The conch shaped museum stands on a promontory overlooking the Paro valley in all its glory. On the way back visit the Paro Rinpung Dzong. "Fortress of the heap of jewels". A flagstone path rises gradually from a beautiful wooden bridge with shingle roofing and abutted by two guardhouses. Today the Dzong is the seat of the district administration as well as the home for the monastic school. Evening we visit Paro town, built in traditional architecture with rows of shops lining the main street. Dinner in cozy local restaurant. Overnight Hotel.
Day 2: Drive to Thimphu (2-hour drive) capitol of Bhutan. Visit famous weekend market; fresh produce, rice, chilies, jewelry, local art, handicrafts and enchanting local shoppers. Check in at our hotel, enjoy lunch, and drive to embark on a vigorous hike up the mountain to Tango Goemba Monastery one of my favorite experiences in Bhutan. Tango is one of Bhutanese' most important Buddhist colleges. Its name, meaning 'horse's head', is derived from the horse-head shaped rock at the top. It is a beautiful dzong built in the 18h century by the 8th Desi, Druk Rabgye. Today Tango is home to the eight-year-old reincarnate Lama, Gyaltse Tenzin Rabgye. Meet with monks for discussions. Tonight join Soenam, your Bhutanese host, for reception dinner at her home. Hotel Yeezdin.
Day 3: Drive to Wangduephodrang (3 - hour drive) across Dochula Pass (10,500ft). Prayer flags send prayers on the wind. Enjoy spectacular views of the Eastern Himalayan Mountains. Stop at Lobesa for lunch. Early afternoon visit the Punakha Dzong, "Palace of Great Happiness". Punakha Dzong is the former winter Capital and at present day hosts the administrative seat of the district. Also the winter residence of the central monastic body and its Chief Abbot. The Dzong lies between two rivers, the Pochu and Mochu, male and female rivers…the location is strategic. It was built in 1637 AD It was here on 17th December 1907, Bhutan's first king was crowned. We will visit the Fertility Temple Chimed Lhakhang and in the evening tour the Wangdu Dzong courtyard. Overnight Dragons Nest Resort.
Day 4: After an early breakfast we depart for Bumthang in Central Bhutan. A long drive on a scenic and breathtaking highway rewarded by a stop at the Trongsa Dzong, the ancestral home of the royal family. An architectural wonder built by Chogyel Minjur Tempa, the Third Desi, in 1648 it is presently the administrative seat of the district and home of the monastic school. Built at split-levels on a narrow spur, the Dzong is an architectural wonder. Views from here are extensive creating strategic location of this Dzong. Lunch in Tronsga town. Continue to Bumthang. Overnight at the River Lodge.
Day 5: BHUMTANG TREK begins: After a hearty breakfast we drive to embark on our wonderful trek to Nganglhakhang. Today we will hike for approximate five hours passing though villages, fields and forests and also crossing over suspension bridges. Our trek will follow the Chamkhar River. Here the trout are plentiful! Fishing anyone? We will visit Thangbi Lhakhang enroute before entering "Swan Land" (Ngang Yul). Here is "Swan Temple" (Nganglhakhang). Swans first inhabited this part of the valley. Overnight camp 9,500 ft (2,800M).
Day 6: Today a gradual climb to Phephela Pass brings us to the highest point of our trek. 12,000 ft. The trail to the pass leads through one of the most beautiful forested areas of this region, with mini bamboo pasture, and forests of rhododendrons and Mixed Conifer. Our seven-hour trek today will allow for many stops to enjoy nature's rare beauty. Overnight camp near Ta Houng village in Tang valley. Enjoy a wholesome delicious Bhutanese gourmet meal.
Day 7: Today we pass Ugyenchholing in Tang Valley. Beauty again overwhelms our senses. You will visit the Ugyenchholing Palace, now housing the Family Museum, a place that will transport you to another world and time. You will view permanent exhibits recreated to capture the ambience of the lifestyle of the Trongsa Penelop (Governor) Tshokey Dorji and his household. Bhutan's history unfolds. Continuing from Ugyenchholing, we reach the Rimochen Lhakhang, a temple dedicated to Guru Rimpoche, the Patron Saint of Bhutan. This is the last point in the trek route from where we drive on through Pangshing village to Jakar, Bumthang, stopping to visit farmhouse on the way. Overnight at the River Lodge Guesthouse to unwind from the trek over a sumptuous dinner and local Ara.
Day 8 & 9: The next two days we will sightsee and tour in Bumthang, Central Bhutan. The Bumthang area of Bhutan hosts four of the most beautiful valleys anywhere, Ura, Tang, Choskhor and Chhume…Nature at it's finest! Day hikes can be arranged. We will stroll through the medieval village of Bumthang, (Choskhor Valley) and are transported back through time. We visit Jakar Dzong, Jambay Khakhang, Kurjey Lhakhang). Shopping is a delight in Bumthang, which is famous for its textile weavings. We also include a visit to the Swiss Farm, with beer and cheese factory for local flavor. Overnight at River Lodge.
Day 10: Departing Bumthang, stopping once again in Trongsa we will now visit the medieval Watchtower. This ancient structure gives unobstructed views of the valley, and it's winding river and roads. The WatchTower is located strategically above the Trongsa Dzong. It is a treat to climb the ancient ladders to the top, as you view warrior armor and aging altars, immersing yourself in the presence unchanged within its walls. Dragons Nest Resort for dinner and hotel.
Day 11: Return to Thimphu. Visit the exceptional Textile Museum, featuring masterpieces from the Royal Family of Bhutan and splendid fabric and exquisite Thangkas. Visit Takin Zoo to see the National animal of Bhutan. After lunch we depart for our hike to the famous Taktsang Monastery (Tiger's Nest). The monastery is perched on a rocky ledge with a sheer drop of nearly 800 meters. It is said that in the second half of the 8th century, Guru Padma Sambhava, the saint who converted Bhutan to Buddhism, alighted here upon the back of a tigress. Overnight Dechen Hill Resort
Day 12: Breakfast and departure for airport.
• Par Rinphung Dzong.
• National Museum.
• Takstang Monastery.
• Drugyal Dzong.
• Punakha and Wangdue Phodrang Dzongs.
• Chimi Lakhang-the The Temple of Divine Madman.
• Bumthang Valleys.
• Ugyenchholing Palace and Rimochen Lhakhang.
• Trongsa Dzong.
• Week-end market and archery competition of Thimpu.
• Textile Museum, the Heritage Museum, mini Zo• etc in Thimphu.
Start and End dates - Flexible
3 persons and above : US$ 2420/person.
2 persons : US$ 2780/person
1 person : US$ 2900/person
Single Room/Tent : US$ 300
Trip Cost Includes
• A level accommodation on twin sharing basis while in the cities.
• All camping gears that includes-2 person sleeping tents with floors and fly sheet, dinning tent, kitchen tent, toilet tents, dining tables, chairs, pillows and mattresses.
• English speaking Guide.
• Cook and kitchen aides.
• All intercity transfers and sightseeing by a private vehicle.
• Pack animals and animal drivers during trekking.
• All necessary supplies.
• 3 meals a day.
• Bhutan visa processing.
• Sightseeing admission fees.
• Bhutan visa fee
Trip Cost Does Not Includes
• Airfare int and out of Bhutan
• Travel Insurance and emergency evacuation.
• Expenses of personal nature like drinks, tip, telephone, laundry etc.
• Extra expenses due to nature or unforeseen events such as flight cancellation, road blockade, no show etc.
The following basic equipments check lists should help you with your packing. Please remember that you should always try to keep the weight of your equipment to a minimum. At the start of the trek your packed trek bag should not weigh more than 33 pounds or 15 kg.
Head:
- Sun hat or scarf
- Light balaclava or warm fleece hat
- Sunglasses with UV protection
Lower Body:
- Under Garments
- Hiking shorts
- Lightweight cotton long pants
- Light and expedition weight thermal bottoms
- Fleece or wool pants
- Waterproof (preferably breathable fabric) shell pants
Feet:
- Thin, lightweight inner socks
- Thick, warm wool hiking socks
- Hiking boots with spare laces
- Camp shoes (sneakers and/or sandals) Gaiters for hiking in winter to the base camp
Upper Body:
- T-shirts
- Light and expedition weight thermal tops
- Fleece jacket or pullover
- Fleece Wind-Stopper jacket (optional)
- Waterproof (preferably breathable fabric) shell jacket
- Down vest and/or jacket *
Hands:
- Lightweight gloves
- Heavyweight gloves or mittens with a waterproof shell outer
Accessories:
- Sleeping bag rated to zero degrees F *
- Headlamp (e.g. Petzl Zoom) with spare bulbs and batteries
- Small pad or combination lock-to-lock
- Trekking Bags *
- Basic First Aid Kit *
- Large plastic bags - for keeping items dry insidetrekbag
- Daypack (approximately 2500 to 3000 cubic inches)
- Thermarest sleeping pad
- Water bottles
- Toiletries (Small wash towel, Toilet papers etc)
Toiletries:
- 1 medium sized quick drying towel
- Tooth brush/paste (preferably biodegradable)
- Multipurpose soap (preferably biodegradable)
- Deodorants
- Nail clippers
- Face and body moisturizer
- Feminine hygiene products
- Small mirror
Personal Hygiene:
- Wet wipes (baby wipes)
- Tissue /toilet roll
- Binoculars
- Reading book
- Trail Map/Guide book
- Journal & Pen
- Walkman
- Pencils and small notebooks
- Travel game i.e. chess, backgammon, scrabble
GEOGRAPHY
Bhutan, "The Land of Thunder Dragon" as it is known to foreign countries, is perhaps the last Shangri-La in the earth. Sandwiched by India and China (Tibet) the kingdom is spread over 18000 sq. miles with variety of climate in different region. The people here are mostly Buddhist and Hindu.
GETTING IN & OUT
Bhutan is least air connected country in the world. Only Druk Air, the national flag carrier of Bhutan links Bhutan with other country. Those, who wish to enter by air, Paro is linked to Kathmandu, Calcutta, Delhi, Bangkok and Dhaka. There are flights to these destinations at least twice a week. For schedule and other information please write to us.
The other option of traveling to Bhutan is by land and the entry point is Phuntsholing (Indo- Bhutan Border). Phuntsholing is 08 hours drive from Kakarvitta (Indo - Nepal Border) and THIMPU is 6 hours from Phuntsholing. Please note, if you wish to enter by land you will need Indian visa as you will be traveling in India for a day (From Nepal Border to Phuntsholing). Indian Visa fee is not included in the trip cost and can be obtained in Kathmandu or in your home country.
VISA & FORMALITIES
All foreigners are required to have a valid passport for a minimum of 6 months and must send in the following details of passport at least 30 days in advance of the trip : Name - as in Passport, Nationality, Passport No. Date of expire, Profession, 3 Photograph (P.P. Size) and date of birth. Visa fee is US$ 20 per person for first two weeks and extension will be US$ 20 for each two weeks.
Visa is not provided abroad but stamped upon arrival in Paro airport or Phuntsholing. Please note without the visa clearance no from THIMPU, Druk air does not issue your ticket to Paro. Therefore, confirmation of any trip as early as possible will make it easier for you to get the flight tickets. We handle all the visa process once we receive confirmation from your side.
ACCOMMODATION AND TRANSPORT
Accommodation is always in hotel while you are in town like Paro, THIMPU, WANGDI PHODRANG, PUNAKHA etc. All the hotels and guest houses are regularly monitored by the government and are all tourist class. It is not possible to have the budget rates and budget class hotels in Bhutan as in other countries as the rates are all fixed by the government. While in off season you will have the choice of staying in the hotels you wish but during the peak season you will have to settle on whichever is available. But till now there has not been any kind of dissatisfaction as all the hotels are tourist class.
While in trek the organizer of your trip arranges all the required equipment with horse or yaks for trekking to carry the equipment and food. An expert guide will escort you and a helper will arrange all the necessities necessities.
Latest brand or the deluxe vehicles are used for tourist transfers and is usually included in the prices so it is not possible to have the separate rate for separate sectors. Mostly Japanese vehicles are used in Bhutan for transfers.
MEDICAL AND HEALTH
Except for some treks, any one who is physically fit can join our tours and treks. Treks, which include altitude of 4000 m or higher are more difficult because of high altitude and therefore requires a certificate of fitness. There are modern hospitals in Paro and in THIMPU for emergency purpose but your precaution is the only way to be healthy if you are traveling to remote areas of the country. It is therefore advised to have through check up with your doctor before heading to Bhutan.
WEATHER AND CLIMATE
The best time to visit Bhutan is March, April, May, September & October since this period provides clear blue sky, and plenty of greenery. Winter (Dec, January, February) will be too cold since the temperature will be well below zero degree. Summer (June, July, August) is pleasant but wet due to the monsoon. Autumn (September, October, November) is similar to spring but a bit warmer and also the best time to visit. However please see the tours and treks sections for specific time to visit the specific areas.
CLOTHING
Light warm clothing are always recommended since it is a hilly country (even in summer). A pair of comfortable shoes for walking, some spare T-shirts, trousers, sun glass, sun hats, pullovers are always necessary. During winter warm clothing are a must.
MONEY MATTERS
Bhutanese currency is called NGULTRUM and the rate is US$ 1= NG 46 approx. Only few hotels and outlets accept credit cards in Bhutan. So it is best to have some CASH US$ for your expenses and even better to have it on small bills.
TIME
Bhutan is 6 hours ahead (+) of GMT, 30 Minutes ahead of India and 15 Minutes ahead of Nepal.
High mountain altitude sickness in Himalaya
Travelers are drawn to high altitude places in ever increasing number- Nepal alone now receives more than Five hundred thousand trekkers from around the world every year. It can be easy to under-estimate the dangers of altitude illness; deaths from these conditions are all the more tragic because they are entirely preventable.
Mountain climbers, serious trekkers, romantics sauntering through the foothills of the Himalayas, native porters, skiers in North America and Europe, pilgrims to high altitude shrines, diplomats posted to La Paz or Lhasa, miners in South America, and Everest marathon runners have something in common: they are all exposed to the effects of high altitude, and may be at risk from a potentially fatal but eminently preventable problem: Acute Mountain Sickness, commonly referred to just as AMS.
AMS consists of headache plus any one of the following symptoms in different degrees: nausea tiredness, sleeplessness or dizziness, occurring at altitudes of around 8000 ft or higher where pathophysiological changes due to lack of oxygen may manifest. Another term, "altitude illness', is also widely used - an umbrella term that includes the benign acute mountain sickness and its two life-threatening complications, water accumulation in the brain (high altitude cerebral edema, HACE) or high altitude pulmonary edema (HAPE, water accumulation in the lungs). The latter two complications may follow AMS, especially when people continue to ascend in the face of increasing symptoms. In keeping with the Jesuit tradition of painstaking documentation, Father Joseph de Acosta, a sixteenth century Spanish Jesuit priest, is credited with having first described the effects of high altitude in humans. In vernacular Nepali, mountain sickness is called "Lake Lagne": in Sanskrit it is aptly called "damgiri" ("dam" means breathlessness and "giri" Means Mountain).
Those most at danger from complications are people who do not "listen to their body", and heed the early warning signals of AMS; they can go on to suffer from HAPE and HACE and may even die-a process that has been carefully documented in important autopsy studies performed by Walter Bond and John Dickinson during the Seventies in the old Patan hospital in Kathmandu.
Chronic mountain sickness is an entirely different condition, recognized by Carlos Monger Medrano in high altitude long-term residents of South America during the Twenties. Such maladaptation is seldom found in the Sherpas or Tibetans, possibly due to thousands of years of exposure to high altitude living. (South Americans populations are relative newcomers to high altitude.) The present discussion will be confined to acute exposure to altitude in short-term sojourners.
Acute Mountain Sickness (Ams)
If a participant on an Everest trek suffers from a mild headache and nausea at Namche Bazaar (12,300ft), he might take an aspirin and wait for these symptoms to go away; however if the symptoms progress to vomiting and a splitting headache, he must assume that he is suffering from AMS and make plans to descend. It is amazing how many people in this situation ignore the dangers and continue to ascend with their friends, trying to blame their symptoms on poor fitness or flu. For some people, it's the high investment of time, effort and money, for others perhaps it's peer pressure or reluctance to accept defeat. A further is that many in the burgeoning adventure travel industry are clueless about mountain sickness.
AMS may set in within hours to days of arrival at high altitude: the onset of symptoms is usually gradual, which is why it is so vital to watch out for early warnings: does a person feel excessively tired; is she the last one to drag herself in to camp?
What causes AMS?
AMS is caused by a lack of oxygen. Although the proportion of oxygen in the atmosphere always remains the same (21%), as we go higher the "driving pressure" decreases. The driving pressure depends directly on the barometric pressure, and forces oxygen from the atmosphere into the capillaries of the lungs. Reduced driving pressure results in decreased saturation of oxygen in the blood and throughout the tissues.
Just what causes some people to suffer from AMS but not others is largely unknown, but there are clear-cut and important preventive factors that are now well- established (see below). The exact mechanism (pathophysiology) of AMS has similarities to that of HACE.
High Altitude Cerebral Edema (HACE)
Our trekker in the above example would probably go on to suffer form HACE if he continue to ascend despite the headache and vomiting; the symptoms of HACE are an extension of those to AMS.
From fatigue, there is progression to lethargy and then to coma. Or there may be confusion and disorientation, A useful test is to see if the person can walk a straight line. If he walks like a drunk or is unsteady, it has to be assumed that he has life-threatening HACE and needs to descend promptly with assistance. This situation is serious enough to justify immediate helicopter evacuation.
HACE is probably caused by shifts of fluid into the tissues of the brain. Reduced oxygen levels cause swelling within the confines of the bony skull. The resulting rise in pressure may lead to lethargy and eventually coma.
High Altitude Pulmonary Edema (HAPE)
This disease may follow AMS, but often it may appear independently. The typical scenario would be a trekker who has no headache or nausea, but finds he has a harder time walking uphill, that he is out of breath on slight exertion compared with the initial days of the trek. There may be a nagging cough and he too may have ascribed these symptoms to a cold. He may be suffering from sub-clinical or early HAPE, a well-recognized entity. With further ascent this may progress to shortness of breath even at rest - descend is now obligatory, or the outcome may be fatal.
Low oxygen causes the pulmonary artery to narrow and this results in exudation of blood near the smaller branches of the lungs (the alveoli). If the exudation continues, blood may escape into the alveoli leading to a cough with watery, blood-tinged phlegm. Such exudation, or "water logging" of the lung tissue interferes further with oxygenation. A popular, compact device called a pulse oximeter can measure the oxygen level in the blood simply and rapidly, using a sensor attached to the index finger. It can be very helpful in confirming if HAPE is present.
What is acclimatization?
Acclimatization is a state of physiological "truce" between the body of a visitor and the hostile low-oxygen environment of high altitude. This truce permits the trekker of ascend gradually. (This is distinct from "adaptation" - permanent change to the organism, perhaps over thousands of years, perhaps even at a genetic or evolutionary level, to facilitate survival at altitude. Scientists are trying to decipher if the Sherpas or Tibetans have made such an adaptation.)
For acclimatization to take place the single most important step is hyperventilation- the trekker unconsciously breathes faster and more deeply than normal, even at rest, to make up for the lack of oxygen. However, hyperventilation also leads to loss of carbon dioxide from the blood, making the blood more alkaline, and it turn depressing ventilation. However, 48 to 72 hours after exposure to high altitude, the kidney comes to the rescue and begins to excrete alkali from the blood to restore a more balanced environment in which hyperventilation can continue unabated.
Preventing altitude illness
There is little doubt that altitude illness is one hundred percent a preventable illness. No one should die from it. For the past quarter of a century, one of the most important objectives of the Himalayan Rescue Association in Nepal has been to preach the gospel of prevention, from its aid posts in Pheriche (at around 14000ft in the Everest region) and Manang (at around 12000ft in the Annapurna region). There are four golden rules, plus some important general principles that should always be followed:
1. Understand and recognize the symptoms of AMS. Recent growth in adventure travel has made trekking at high altitude simpler and more accessible, with the result that more and more people who go trekking are ignorant of the basic facts of altitude illness.
2. Never ascend with obvious symptoms. Incredibly, I have known people who have hired a horse or a yak to go up higher when they were too sick to walk. This is courting disaster.
3. Descend if symptoms increase. It is amazing how striking and dramatic the relief may be with even a couple of hundred feet of descent. People with signs of HAPE or HACE have to descend.
4. Group members need to look out for one another
(Perhaps like the buddy system in SCUBA diving). This rule gets broken with unfailing regularity every trekking season in the Himalayas, because people are just too anxious to complete their trek, even if one of their party members is ill. A trekker with AMS, HAPE or HACE will want nothing more than to be left alone, unbothered, at the same Altitude- potentially a fatal option. There is no alternative but to bring the person Down to a lower altitude accompanied by a friend who speaks the same language.
Following a conservative rate of ascent
Going too high, too quickly, is the single most important cause of susceptibility to AMS. Beyond about 9000ft, the sleeping altitude should be no higher than about 1500ft from the previous night's altitude. The sleeping altitude, not the altitude achieved during the daytime, is what is important. Altitude sickness often manifests at night because during sleep the oxygen level in the blood may dip further. Many mountain climbers will have been to 14000ft or high in the Alps or in North America but few will have slept at the altitude. In the Himalayas, you don't have to be an experienced climber, or use crampons, to be able to "hang out" at 15000ft or higher for days: easy accessibility to these altitudes makes exposure to AMS also mush easier.
While ascending, every second or third day should be rest day for acclimatization. "Climb high and sleep low" is the dictum, but it is important not to exert oneself excessively in trying to fulfil this.
The trekker should not be in a hurry in the mountains. The itinerary should be planned so that there are enough "leeway days" in case more time is needed to acclimatize. Trying to do a high-altitude two-week trek in one week is always fraught with problems.
Avoiding of excessive exertion in the initial days
Excessive physical exertion at high altitude makes one more susceptible to AMS. It is important to take it easy at high altitude, especially in the initial days. People who are very fit for example marathon runners or those who carry very heavy backpacks seem more vulnerable to AMS than others, probably because they push themselves harder. I once looked after a trekker who felt he could not break his morning jogging sessions despite a strenuous trek day ahead, even at 4000m! The feeling of" man against nature" may be stronger in this fitter group.
Avoiding alcohol
Jim, a rock star, decided to "whoop it up" with four bottles of beer, on arrival at 3500meters in the Everest region. He felt ill with severe AMS and needed to be helicopter out two days later. He had been warned not to drink alcohol on the trek, especially while ascending. Alcohol may dehydrate the trekker but more importantly it depresses breathing or ventilation. Sleeping pills may have a similar effect.
Maintaining adequate hydration
Adequate amounts of fluid (about 3 liters a day) are necessary in the mountains:- dehydration mimics altitude sickness and may even predispose to it. On the other hand excessive water drinking should also be avoided as this may lead to electrolyte imbalances.
Maintaining a high carbohydrate diet
A high carbohydrate diet aids ventilation and efficient use of oxygen. The good news is that - in many high altitude places - there is not much alternative: rice, potatoes and other strach-laden foodstuffs tend to be the staple, with not much else to choose from.
Drug prevention (prophylaxis)
Diamox (actazolamide) may be necessary for people going on rescue missions at high altitude or flying in to high altitude cities like La Paz or Lhasa. People with sulpha allergy should not take diamox, the primary drug for prevention, and further details are given below. A second drug, dexamethasone (see below) should also be carried, particularly if the destination is remote: this can be life saving if HACE supervenes.
TREATMENT
Descent
Wherever, possible this has to be attempted. There is really no magic altitude to descend, but the sick patient may suddenly feel something lift and feel hungry. This is the altitude to which the body is adjusted. Patients with HAPE need to descend slowly and with assistance: excessive exertion even during descent may increase the blood flow to the lungs and exacerbate the problem.
Oxygen
Lack of oxygen at altitude is the chief reason why people suffer from altitude sickness, so breathing supplemental oxygen is obviously going to make a difference. But oxygen is a hard commodity to come by in the mountain - cylinders of oxygen are not easily portable. When oxygen available in AMS settings, it should be used.
Drugs
Acetazolamide (diamox): This is the most tried and tested drug for altitude sickness prevention and treatment. Unlike dexamethasone this drug does not mask the symptoms but actually treats the problem. It seems to works by increasing the amount of alkali (bicarbonate) excreted in the urine, making the blood more acidic. Acidifying the blood drives the ventilation, which is the cornerstone of acclimatization.
For prevention, 125 mg twice daily starting the evening before and continuing for three days once the highest altitude is reached, is effective. A recent article in the British Medical Journal suggested taking a higher dosage -- 750mg daily. Our experience in the Indian subcontinent has consistently been that 250 mg per day has been rewarding, while excessive dosage may just increase the side effects.
Side effects of diamox are: an uncomfortable tingling of the fingers, toes and face (called "jhum jhum" in Nepali); carbonated drinks tasting flat; excessive urination; and rarely, blurring of vision. In most of the treks in Nepal, gradual ascent is possible and prophylaxis tends to be discouraged. Certainly if trekkers develop headache and nausea or the other symptoms of AMS, then treatment with diamox is fine. The treatment dosage is 250 mg twice a day for about three days.
Dexamethasone: This steroid drug can be life saving in people with HACE, and works by decreasing swelling and reducing the pressure in the bony skull. The dosage is 4 mg three times per day, and obvious improvement usually occurs within about six hours. Like the hyperbaric bag (See below), this drug "buys time" especially at night when it may be problematic to descend. Descent should be carried out the next day. It is unwise to ascend while taking dexamethasone: unlike diamox this drug only masks the symptoms.
Dexamethasone can be highly effective: many people who are lethargic or even in coma will improve significantly after tablets or an injection, and may even be able to descend with assistance. Many pilgrims at the annual festival at Gosainkunda lake in Nepal suffer from HACE following a rapid rate of ascent, and respond remarkably well to dexamethasone. Mountain climbers also sometimes carry this drug to prevent or treat AMS. It needs to be used cautiously, however, because it can cause stomach irritation, euphoria or depression.
It may be a good idea to pack this drug for a high altitude trek for emergency usage in the event of HACE In people allergic to sulpha drugs (and therefore unable to take diamox) dexamethasone can also be used for prevention: 4 mg twice a day for about three days may be sufficient.
Nifedipine: This drug is generally used to treat high blood pressure, but also seems able to decrease the narrowing in the pulmonary artery caused by low oxygen levels, thereby improving oxygen transfer. It can therefore be used to treat HAPE, though unfortunately its effectiveness is not anywhere as dramatic that of dexamethasone in HACE. The dosage is 20 mg of long acting nifedipine, six hourly.
It can cause sudden lowering of blood pressure so the patient has to be warned to get up slowly from a sitting or reclining position. It has also been used in the same dosage to prevent HAPE in people with a past history of this disease.
The hyperbaric bag
This is a simple, effective device, made of airtight nylon; it is about 7 feet long ad looks like a long duffel bag. With the patient inside, the bag is inflated with a foot pump until it becomes like a large sausage-shaped balloon. There is a one-way valve to avoid carbon dioxide build up inside, and it has transparent panels to assist communication with its occupant.
The pressure insde the bag is 2 p.s.i,. so the effect is about the same as bringing the patient down a couple of thousand feet. For both HACE and HAPE (but especially, in our experience, for HACE) the changes are usually dramatic within an hour. However there may be a "rebound" tow or three hours after therapy and the patient may need to get in the bag again. Just like the dexamethasone, this bag only helps to "buy tome". Descent is still mandatory as soon as possible.
Other problems at altitude:-
Periodic breathing
An abnormal breathing pattern whilst asleep is a common occurrence at high altitude: short spells of an increased breathing rate alternate with brief periods when breathing slows down seems to stop the medical term for this is "Cheyne Stokes" respiration. It is only a problem if it makes the suffers wake up repeatedly, breathless, anxious and unable to sleep. An effective remedy is Diamox 125 mg before dinner, which counteracts the low oxygen dips during sleep that trigger the problem. Sleeping pills should be avoided.
Upper respiratory tract infections and symptoms
Many people develop a persistent, bothersome cough and cold-like symptoms in the cold dry air of high altitude. An antihistamine at night like Benadryl 25 mg may help suppress the cough. Antibiotics are sometimes useful, but keeping the head and face covered and breathing through a silk or wool scarf to humidify the air may also help. many studies have shown that upper respiratory tract infections can predispose to AMS.
Peripheral edema
There may be swelling around the eyes, fingers, ankles at high altitude, but this may not indicate AMS per se unless accompanied by the symptoms of AMS. These symptoms without AMS usually require no treatment.
High altitude syncope (fainting): This is well known but harmless problem, in which fainting occurs suddenly, usually shortly after arrival. Simple measures like keeping the individual in a reclining position and raising the legs is helpful.
Travelers with pre-existing health problems; children, and birth control pills
High blood pressure: Blood pressure initially increases at high altitude due to the initial stress of low oxygen triggering neurohumoral changes. However people who suffer from high blood pressure can go up to high altitude as long as this is well controlled and they continue to take their medication.
Coronary heart disease: People with a history of heart attack (moycardial infarction) and even those with coronary artery bypass grafts or angioplasty but with no angina, can trek up to high altitude provided they are fit and able to walk rigorously at low altitude. The high altitude does not seem to add any extra burden to the heart.
Epilepsy: Although seizures may be provoked by altitude there is no convincing evidence that it is unsafe for well-controlled epileptics travelling to travel to high altitude, though such people should always take their anti seizure medications conscientiously.
Migraine: Sufferers may possibly have more attacks in the mountains and this may sometimes be difficult to distinguish from AMS. In doubt it is best to descend.
Lung disease: Also noteworthy is the limited observation that bronchial asthma does not seem to get exacerbated at high altitude due to the cold and exercise. However it is prudent for asthmatics to carry inhalers and other medications. Obviously people with chronic obstructive lung disease may be more short of breath and travel at high altitude would be inadvisable.
Neck surgery and radiotherapy: People with treated cancers like lymphoma or tumors in the neck who have had extensive surgery or radiation treatment may be especially prone to AMS because of damage to the carotid bodies - tiny organs within the carotid arteries that sense oxygen and aid ventilation.
Diabetes: Diabetics on insulin should have a reliable glucometer to check their blood glucose regularly, but high altitude does not seem to cause additional risks.
Corneal surgery: people who have had non laser surgery (radial keratotomy) to correct their short sightedness may run into problems at high altitude due to swelling of their cornea caused by the low oxygen. Such people should carry corrective lenses as well if travelling to high altitude.
Pregnancy: Pregnant women should not sleep higher than 12000ft as this may endanger the fetus; a further problem is that high altitude places are generally remote, making emergencies more difficult to deal with.
Children: Children do not suffer any more from the effect of altitude than adults. However, it is important that a child should be able to communicate any symptoms to responsible adult, so that prompt descent can be arranged. It may therefore be dangerous to take children to high altitude that is not yet old enough to do this.
Contraception: Oral contraceptive pills may predispose to abnormal blood clotting (thrombosis) at high altitude. the hypoxia (low oxygen), the excessive red blood cells (polycythemia) in the blood, and the possible dehydration in this environment may already be other predisposing factors for thrombosis. Hence it if best to use other forms of contraception at high altitude.
Other disease risks
Many high altitude destinations are in developing countries, so it is important to be up to date with vaccinations against disease like typhoid and hepatitis, to know about travelers' diarrhoea and its treatment, and to understand the other precautions described elsewhere in this book. Malaria is not a risk at altitude - transmission does not take place above 2000 meters.
Conditions that mimic altitude sickness
Improving medical facilities in countries such as Nepal have made it much easier to distinguish between altitude illness and conditions that can produce similar symptoms, such as bleeding in the brain (subarachnoid hemorrhage), strokes, dehydration and blood viscosity related problems like venous thrombosis.
Conclusion
Most of the problems of high altitude are totally preventable. With careful precautions, your experience in the mountains should be safe and rewarding.
FAQ
| Frequently Ask Questions | ||
Here you will find answers to some of our most frequently asked questions. If you still have any doubts or queries do not hesitate to contact us. 1. Where is Bhutan located? 2. Who is Bhutan Himalayas Guide? 3. Is Himalayas Guide, a secure site? 4. Why should I choose Himalayas Guide? 5. How much will my package cost? Surcharge:
Peak season months: March, April, and May, September, October & November. 6. How does the booking process work? 7. How do I contact Himalayas Guide? 8. Do you offer discounts for children & students? 9. What is included in my trip package? 10. Tell me more about the tour & trek itinerary? 11. How do I pay for bookings with Himalayas Guide? 12. When will I get my trip confirmation? 13. What airline will I fly on and from where? 14. What if I need to cancel my trip at the last moment? |
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