In a Nutshell: Altitude Sickness Prevention for Tibet

In this post we offer you a summary of the most effective tips for altitude sickness prevention in Tibet.

Our goal is to give you user-friendly and evidence-based information that you can use to plan a more safe and enjoyable trip to Tibet.

(If you need help connecting to a reliable Tibetan travel agency that we partner with to help travelers with avoiding altitude sickness, contact us here).  

The most effective way to avoid altitude sickness is straightforward:

• Ascend slowly
• Recognize and respond to warning signs
• Descend quickly to avoid worsening symptoms

We will walk you through each of these important points to help you plan your trip.

But first we need to be clear that we are experts in Tibetan culture, not in high altitude medicine, and we’re not doctors. We first learned about altitude sickness through personal experience, in 2002, when Lobsang returned to Tibet after a long absence, and on Yolanda’s first trip. (If you’re new to YoWangdu, here’s a little bit about who we are.)

Learning about altitude sickness the hard way

Here’s a picture of us one harsh, headachy morning after a sleepless night at Lake Namtso (4700m/15,400ft). We took the photo as a joke, but it was no joke that we felt miserable. We wish we knew then what we know now about preventing altitude sickness.

Since then, we’ve learned a lot, partly through more personal experience, but mostly through studying the highest quality sources we could find, including the US Centers for Disease Control and Prevention, The Wilderness Medical Society, The International Society for Mountain Medicine and, among others.

A lot of altitude sickness prevention “help” is junk

The more we’ve learned, the more passionate we’ve become about providing people with easy to use information that is based on science. Sadly, the great majority of information found on Tibet travel websites cannot be trusted. Here’s an excerpt from the website of a popular Chinese agency:

“The reaction varies form [sic] person to person, and experts can not say who will be affected, but statistically old people are more likely to feel stronger altitude sickness than the young, the unfit/unhealthy are more likely than the fit/healthy, and males are affected more strongly than females.”  

That’s just hooey! Older people actually have a somewhat lesser incidence of altitude sickness. Physical fitness has, surprisingly, no impact on it, and neither sex is more likely to develop altitude sickness.

There are two major risk factors for altitude sickness: your individual genetic makeup, and the rate of ascent. (Get more detail about your risk of getting high altitude sickness at this post.) You have no control over your genetics, but fortunately you do have considerably more control over your rate of ascent. Ascending high and fast has a high correlation with getting altitude sickness. The critical thing to do is to ascend slowly.

To Prevent Altitude Sickness: Ascend slowly

To avoid getting mountain sickness at high altitude, the most critical thing to do is follow the basic rules of acclimating. That means simply that you need to let your body adjust to the fact that at altitude your body is working harder to obtain oxygen. (It’s a myth that the air at altitude contains “less oxygen.” Air always contains about 21% oxygen, but as you ascend, the barometric pressure decreases, and each breath contains fewer and fewer molecules of oxygen.¹)

Once you get to high altitude, at around 8000 feet/2500 meters, your body needs time to adjust.

Here are good rules of thumb:

• Take at Least 2 days to reach 9000 feet/~2700 meters.  You could plan to spend at least a night, and preferably more, somewhere between ~6500 feet/2000 meters and 9000 feet/~2700 meters.
• Once you are at 9000 feet/2700 meters, do not increase your sleeping altitude more than ~ 1500 feet/ 500 meters per night.
• Spend an extra night at the same elevation every ~3000 feet/~1000 meters.
• Note that it is the elevation at which you sleep that counts here, not so much how high you climb or drive during the day.

Learn more on how to avoid altitude sickness with slow ascents here >>

Most Tibet travelers ascend too quickly. Why is that?

One major reason is that trips to Tibet are expensive, so some travelers don’t want to take the extra days and money needed to acclimate at intermediate altitudes. We think, though, if people had better information, that they would make better decisions.

There is a real lack of clear information on how to identify a route for travel on the Tibetan Plateau that ascends slowly. A lot of the information available about altitude sickness is good in theory, but is actually really hard to apply to any specific itinerary. It doesn’t help that, for a multitude of reasons, typical Tibet tourist routes ignore some of the basic rules of acclimating. This isn’t anyone’s fault – it’s more that the situation is complicated and that there are few or no perfect solutions.

The problem is that there are real-life consequences for Tibet travelers. A lot of travelers unwittingly make poor choices and spend at least part of their time in Tibet feeling like they’ve got a bad hangover (without a drop of alcohol) or worse. We know this very well – we’ve done it ourselves.

We hope to help begin to improve this situation. Specifically, we have worked to develop some itineraries that make it easier for travelers to identify a good route to take. See the next section for three such itineraries. (And if you need help connecting to a reliable Tibetan travel agency that can offer you an easier acclimatizing trip, contact us here). 

What Tibet itineraries are good for altitude sickness prevention?

We have created versions of several popular Tibet travel itineraries that are designed specifically to ascend at a reasonable pace.

• Sky Train and Lhasa Highlights Tour (from How to Make the Most of Your Time in Lhasa)
• Everest Base Camp Adventure (via Tibet train and Lhasa)
• Mount Kailash Trek  (via Tibet train, Lhasa and Everest Base Camp)

Does it help to take the Tibet train?

Yes, generally speaking, it’s better to take the train than to fly in to Lhasa. Flying, unlike the train, puts you at some risk of getting pulmonary edema (See more about that in the HAPE section below).  However, just taking the train is not enough. The train travels too low and then too high to be an effective means of the “slow ascent” that you need. The best thing to do is combine the train with a 2-night stop in Xining. So, make your way by plane or train to Xining, stay in Xining for two nights, then take the train on to Lhasa. Here’s a popular post on this subject, called The Biggest Mistake People Make about the Tibet Train.

Tell your travel agent you care about altitude sickness prevention

You can work with your Tibetan agents and guides to plan a trip in which you can acclimate at a reasonable rate. Let them know you do care about ascending slowly. Too many agents have no acclimatization strategy beyond “resting for a day or two in Lhasa to adjust to the high altitude.”  If you’re going to Central Tibet, you do definitely want to rest, for at least several days, in Lhasa, but there is more that you should know and do. (For help connecting to a reliable Tibetan travel agency, contact us here). 

A sample script to send your agent

Here is a sample script (for a trip that starts in Lhasa) that you can send to the travel agent planning your trip:

“I am concerned about getting altitude sickness, and I want to follow the basic rules of acclimatizing as much as possible on my trip, by:

• Spending at least one night at an altitude between about 2000 meters and 2700 meters before I get to Lhasa. For example, I could fly or take the train to Xining, spend 2 nights there, and then continue to Lhasa on the train.²
• Not increasing my sleeping elevation more than about 500 m per night after reaching an altitude of about 2700 m.
• Sleeping at the same altitude one extra night for every ~1000 meters (= a rest day about every 3 days of ascending)

I would like to know the altitudes of the cities I will visit, and the elevation gain or loss for each day of the trip [in meters or feet, according to your needs]. Also, I would like to know if your guides have any training for managing altitude sickness problems? How do they identify clients with altitude sickness problems and how do they deal with such problems?”

We’ll tell you straight up that very few agencies, even the best ones, are following any of the recommendations above. We hope that traveler demand will raise the level of awareness and traveler safety and general well-being across the Tibetan Plateau.

As a starting place for your planning, here is a partial list of the altitudes of places in Tibet.

What should I do if I can’t ascend slowly?

By far the best way of preventing altitude sickness is to ascend gradually. If you have no choice but to ascend too high too fast, you may want to consider consulting a travel doctor to see if you could benefit from taking medicine for altitude sickness. The only altitude sickness medication that has been well studied in clinical trials and is widely considered to be effective in preventing altitude sickness and speeding acclimation is acetazolamide, which is sold as a prescription under the brand name Diamox.³ See the Altitude Sickness Medicine section on our post on How to Avoid Altitude Sickness for a breakdown on who might be advised to take Diamox. Ibuprofen has recently shown promise to help prevent AMS (Acute Mountain Sickness)⁴, although the US CDC website notes that it “was not as effective as acetazolamide.”⁵

What about natural remedies?

A number of natural remedies are being used by travelers for altitude sickness prevention. However it is clear that there is not yet enough reliable clinical evidence that supports their efficacy or use. Here’s a partial list of some of the natural remedies now in use:

• Coca leaves
• Gingko Biloba
• Rhodiola
• Chinese herbal medicines, including Fufang yi hao pills, Sheng nao kang pills, Shu li kang capsules, Xing nao jing injection, and Danhong injection.

Several reputable scientific reviews of current research show that while some of the remedies hold promise, more rigorous testing is required to confirm popular opinion and anecdotal evidence. See Natural Remedies for Altitude Sickness for more detail on this.

Recognize and respond to warning signs

There are three main forms of altitude sickness, and each has a set of signs and symptoms:

• AMS – Acute Mountain Sickness
• HACE – High-altitude Cerebral Edema, a life-threatening swelling of the brain with fluid
• HAPE – High-altitude Pulmonary Edema, a life-threatening accumulation of water in the lungs

We have described in detail the symptoms and warning signs of each of these in the post called Altitude Sickness in Tibet: How Bad are the Symptoms, along with the common recommendations for how to respond to each. We strongly encourage you to read that post with care.

AMS

: Acute Mountain Sickness

Recognize AMS

AMS, to put it simply, is the mildest form of altitude sickness and manifests as a strong headache, along with other symptoms like dizziness, fatigue, shortness of breath, nausea difficulty sleeping.

Respond to AMS

The International Society for Mountain Medicine (ISMM) offers excellent advice: 


 “The mainstay of treatment of AMS is rest, fluids, and mild analgesics: acetaminophen (paracetamol), aspirin, or ibuprofen. These medications will not cover up worsening symptoms. The natural progression for AMS is to get better, and often simply resting at the altitude at which you became ill is adequate treatment. Improvement usually occurs in one or two days, but may take as long as three or four days. Descent is also an option, and recovery will be quite rapid.”

HACE: High-altitude Cerebral Edema

Recognize HACE

The hallmark of HACE is confusion or disorientation, because the brain is impaired. Travelers with HACE display more severe symptoms, like a splitting headache that is not relieved by medication, excessive tiredness, shortness of breath, loss of coordination (can’t walk a straight line) and confusion or disorientation.  Please see this post for a more thorough discussion of all the symptoms for HACE.

Respond to HACE

You must take immediate action to get a person with signs of HACE to a lower elevation, hopefully at least 2,000 – 4,000 feet / ~ 600 – 1,200 meters, but even a few hundred feet (~ 100 meters) may help. You do not want to leave it until the person’s illness progresses to the point to which she or he cannot walk at all. Often HACE happens at night, but you cannot wait until morning as delay can be fatal. It is recommended to descend to the last point at which the traveler woke up feeling well, without AMS.

HAPE: High-altitude Pulmonary Edema

Recognize HAPE

HAPE is the most serious of the three and can be rapidly fatal. The victim’s lungs are impaired, which manifests as increasing breathlessness on exertion leading to shortness of breath even at rest, a cough (possibly producing froth), extreme fatigue, sounds of gurgling, rattling or wheezing when breathing, a feeling of fullness or congestion in the chest, gray or blue lips or fingernails, and fast breathing.  

Respond to HAPE

On first realizing that the traveler may have early signs of HAPE, immediate descent is critical. It is far better to descend while the traveler is still mobile rather than waiting for severe symptoms that would force the victim to be carried. Learn more about treatment of HAPE in the links in the Resources section on our post on altitude sickness symptoms.

We don’t have room for a full discussion of how to recognize and respond to AMS, HACE and HAPE in this summary, but again we urge you to read this post for critical information every Tibet traveler should know: Altitude Sickness in Tibet: How Bad are the Symptoms?.

Descend quickly to avoid worsening symptoms

Because it is so important, we want to say this again. If you display signs of any form of AMS, never go higher, not even if the symptoms are “mild.” Even if you have only “mild” symptoms, you need to descend if the symptoms become worse while you are resting at the same altitude. Most importantly, if you have symptoms of HACE or HAPE, immediate descent is critical. Delay may be fatal.

There are a variety of medical treatments for AMS, HACE and HAPE. We will not discuss those here, since our goal is altitude sickness prevention. To learn more about treatment options, see the links in the Resources section on our post on altitude sickness symptoms.

Conclusions

In this post we have summarized for you the most effective tips for altitude sickness prevention. It seems to us that the study of altitude sickness is still very young, and there is much to be learned about who gets it, and why, and how we might best prepare ourselves to prevent it.

Our goal here is to offer you the best information now available, in an easy-to-use way, to help you plan a more safe and enjoyable trip to Tibet. 

What to do next to stay healthy and safe?

For the information to help you, you will need to actually implement what you learned about altitude sickness prevention. How?

• Check out our How to Avoid Altitude Sickness Guide, which offers a checklist with 10 steps for preventing altitude sickness, and cheat sheets you can print and consult on your trip.

• Another good idea is to choose a Tibetan travel agency that is among the best when it comes to taking care that their travelers. A little shockingly, most agencies don’t really know much about altitude sickness, and do very little to help you prevent it. We have been working with one of the best Tibetan-owned travel agencies to develop safer itineraries. You can connect with them by filling out this short form here >>

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Want to learn more?

Check out our How to Stay Healthy at High Altitude in Lhasa and Everywhere in Tibet post.

Footnotes

1. International Society for Mountain Medicine 
2. Note that many agents can help you with flights or train tickets from mainland China, but note that the train can be very expensive and hard to get seats for in high season, and that you may need to buy train tickets several months in advance.
3. Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness (Section on prevention.)
4. Stanford study on ibuprofen
5. US CDC