Altitude can be categorized based on elevation above sea level into low, moderate, high, very high, and extreme altitudes. As altitude increases, atmospheric pressure and partial pressure of oxygen decrease. This causes physiological responses from the respiratory, cardiovascular, and metabolic systems to try to compensate for the lower oxygen availability. Maximal oxygen uptake and endurance exercise performance decrease significantly with increasing altitude above 5,000 feet, though anaerobic sprint performances are generally not impaired at moderate altitude. With chronic exposure to altitude over weeks to months, the body can acclimate through various adaptations like increased ventilation, blood volume and hemoglobin levels.

1. Exercise at Altitude
Dr.Rachita Hada
M.P.T Ortho

2. Altitude type Distance (in feet)
Sea level 1,640 ft
Low altitude 1,640-6,560 ft
Moderate altitude 6,560-9,840 ft
High altitude 9,840-12,000 ft
Very high altitude 12,000-18,000 ft
Extreme altitude ~18,000 ft

3. High Altitude
• A height above 10,000 feet (3000 m) above the sea level
is defined as High Altitude.
• According to Dalton’s law, total pressure of air is equal to
sum of partial pressures of gases it contains.
P = pO2 + pCO2 + pN2 + pH2O
• pH2O and pCO2 doesn’t depend upon altitude.
• pO2 and pN2 decrease with increase in height.

4. • Barometric pressure is a measure of the
total pressure that all of the gases
composing the atmosphere exert on the
body (and everything else).
• Barometric (air) pressure (Pb) averages
about 760 mmHg at sea level.

5. • The partial pressure of oxygen (PO2 ) is
that portion of Pb exerted only by the
oxygen molecules in the air.
• The low PO2 at altitude that limits exercise
performance and can even jeopardize life
in mountain climbers.
• Low PO2 limits pulmonary diffusion of
oxygen from the lungs and oxygen
transport to the tissues.

6. • The reduced barometric pressure at
altitude is referred to as a hypobaric
environment or simply hypobaria (low
atmospheric pressure).
• The low PO2 in the air is termed hypoxia
(low oxygen), while the resulting low PO2
in the blood is called hypoxemia.

7. Atmospheric Pressure at Altitude

8. Environmental Conditions at
Altitude
Altitude
type
Effects of altitude on performance
Sea level no effects on well-being or exercise performance
Low altitude
no effects on well-being, but performance may be diminished & can
be overcome with acclimation
Moderate
altitude
effects on well-being in unacclimated individuals and decreased
maximal aerobic capacity and performance & may or may not be
restored with acclimation
High altitude
adverse health effects (acute mountain sickness)in a large percentage
of individuals and significant performance decrements even after full
acclimation.
Extreme altitude severe hypoxic effects

9. Factors affecting change in
barometric pressure
• Changes in climatic conditions
• Time of year
• Specific site at which the measurement is
taken (sea level/Mt.Everest)

10. • Although barometric pressure varies, the
percentages of gases in the air that we
breathe remain unchanged from sea level
to high altitude.
• At any elevation, the air always contains
20.93% oxygen, 0.03% carbon dioxide,
and 79.04% nitrogen.

11. Change in
PO2
PO2 that
reaches the
lungs
Gradients
between the
alveoli of the
lungs and the
blood
Gradients
between the
blood and the
tissues
Will effect on

12. Air Temperature and Humidity
at Altitude
• The combination of low temperatures, low
ambient water vapor pressure, and high
winds at altitude poses a serious risk of
cold-related disorders, such as
hypothermia and windchill injuries.
• Because of the cold temperatures at
altitude, the water vapor pressure in the air
is extremely low. Cold air holds very little
water.

13. • Even if air is fully saturated with water
(100% relative humidity), the actual vapor
pressure of water contained in the air is
low at altitude.
• The extremely low PH2O at high altitude
promotes evaporation of moisture from the
skin surface, because of the high gradient
between skin and air, and can lead quickly
to dehydration.

14. • A large volume of water is lost through
respiratory evaporation due to a
combination of a large vapor pressure
gradient between warmed air leaving the
mouth and nose and the dry air in the
environment plus an increased
respiration rate experienced at altitude.

15. • This drier air can lead to dehydration
through increased insensible water loss,
increased respiratory water loss, and
increased sweat evaporation.

16. Solar Radiation at Altitude
• The intensity of solar radiation increases
at high altitude for two reasons.
– At high altitudes, light travels through less of
the atmosphere before reaching the earth.
Less of the sun’s radiation(UVR) is absorbed
by the atmosphere at higher altitudes.
– Atmospheric water normally absorbs a
substantial amount of the sun’s radiation, the
low water vapor in the air at altitude also
increases radiant exposure.

17. • Solar radiation may be further amplified by
reflective light from snow, which is usually
found at higher elevations.

18. • As the atmosphere is thinner and drier at
altitude, solar radiation is more intense at
higher elevations.
• This effect is magnified when the ground is
snow covered (glacier).

19. Physiological Responses
to Acute Altitude
Exposure
Respiratory Responses to Altitude
Cardiovascular Responses to Altitude
Metabolic Responses to Altitude

20. Respiratory Responses to Altitude
Adequate oxygen supply to exercising muscles is
essential
Adequate supply of oxygen being brought into
the lungs though respiratory tract
O2 moved to the blood capillaries & transported
to the muscles
Adequately taken up into the exercising muscles

22. Transport of oxygen
(pulmonary ventilation)

23. Active movement of gas molecules into
the alveoli of the lungs (breathing)

24. Pulmonary Ventilation
• Ventilation increases within seconds of exposure to high
altitude, both at rest and during exercise.
• Chemoreceptors in the aortic arch and carotid arteries
are stimulated by the low PO2 and signals are sent to
the brain to increase breathing.
• The increased ventilation is associated with an increased
tidal volume and increase in respiratory rate.
• Over the next several hours and days, ventilation
remains elevated to a level proportional to the altitude.

25. Medulla

26. • Increased ventilation acts same as
hyperventilation at sea level.
• The amount of carbon dioxide in the
alveoli is reduced.
• Carbon dioxide follows the pressure
gradient, so more diffuses out of the blood,
where its pressure is relatively high, and
into the lungs to be exhaled.
• This “blowing off” of CO2 causes blood
PCO2 to fall and blood pH to increase, a
condition known as respiratory alkalosis.

27. Effects of alkalosis
1. It causes the oxyhemoglobin saturation
curve to shift to the left.
2. It helps keep the rise in ventilation
caused by the hypoxic (low PO2 ) drive
from increasing even further.
3. At a submaximal exercise intensity,
ventilation is higher at altitude than at sea
level, but maximal exercise ventilation is
similar.

29. • In an effort to offset respiratory alkalosis,
the kidneys excrete more bicarbonate
ion(the ions that buffer the carbonic acid
formed from carbon dioxide).
• Thus, a reduction in bicarbonate ion
concentration reduces the blood’s
buffering capacity.
• More acid remains in the blood, and the
alkalosis is minimized.

30. Pulmonary Diffusion
• Under resting conditions, pulmonary diffusion (diffusion
of O2 from the alveoli to the arterial blood) does not limit
the exchange of gases between the alveoli and the
blood.
• If gas exchange were limited or impaired at altitude, less
oxygen would enter the blood, so the arterial PO2 would
be much lower than the alveolar PO2 .
• The low arterial blood PO2 , or hypoxemia, is a direct
reflection of the low alveolar PO2 and not a limitation of
oxygen diffusion from the alveoli to the arterial blood.

31. Oxygen Transport
• The inspired PO2 at sea level is 159 mmHg;
however, it decreases to about 104 in the alveoli
primarily because of the addition of water vapor
molecules (PH2 O = 47 mmHg at 37 °C).
• When the alveolar PO2 drops at altitude, fewer
binding sites on the hemoglobin in the blood
perfusing the lungs become saturated with O2 .
• The oxygen-binding (or oxyhemoglobin
dissociation) curve for hemoglobin has a distinct
S shape.

33. • At sea level, when alveolar PO2 is about 104 mmHg,
96% to 97% of hemoglobin has O2 bound to it.
• When PO2 in the lungs is decreased to 46 mmHg at
4,300 m (14,108 ft), only about 80% of hemoglobin sites
are saturated with O2 .
• If the oxygen-loading portion of the curve were not
relatively flat, far less O2 would be taken up by the blood
as it passes through the lungs, and binding would be
extremely limited at altitude.
• Therefore, while arterial blood is still desaturated at
altitude, the inherent shape of the oxyhemoglobin
dissociation curve serves to minimize this problem.

34. • A second adaptation occurs very early in altitude
exposure that also aids in preventing the fall in arterial
oxygen content.
• A respiratory alkalosis accompanies the increased
ventilation caused by acute altitude exposure. This
increase in blood pH actually shifts the oxyhemoglobin
dissociation curve to the left.
• The result is, rather than 80% binding of oxygen to
hemoglobin, 89% of hemoglobin is saturated with O2 .
• Because of this shift, more oxygen binds to hemoglobin
in the lungs and more oxygen is unloaded to the tissues
at higher altitudes, where PO2 is lower in both tissues.

36. Gas Exchange at the Muscles
• Arterial PO2 at sea level is about 100 mmHg, and the
PO2 in body tissues is consistently about 40 mmHg at
rest; the pressure gradient, between the arterial PO2 and
the tissue PO2 at sea level is about 60 mmHg.
• However, when one moves to an elevation of 4,300 m
(14,108 ft), arterial PO2 decreases to about 42 mmHg
and the tissue PO2 drops to 27 mmHg.
• Thus, the pressure gradient decreases from 60 mmHg at
sea level to only 15 mmHg at the higher altitude.

37. • Because the diffusion gradient is
responsible for driving the oxygen from the
hemoglobin in the blood into the tissues,
this change in arterial PO2 at altitude is a
much greater consideration for exercise
performance than the small reduction in
hemoglobin saturation that occurs in the
lungs.

38. Cardiovascular Responses to
Altitude
• Changes occur to compensate for the
decrease in arterial PO2 that accompanies
hypoxia.

39. A) Blood Volume
• Plasma volume begins to progressively decrease from
first few hours up to 25% due to both respiratory water
loss and increased urine production, and reaches a
plateau by the end of the first few weeks.
• Compensation is done by increase in the hematocrit.
• This cause more RBCs for a given blood flow—allows
more oxygen to be delivered to the muscles for a given
cardiac output.
• Over a period of weeks at altitude, this diminished
plasma volume eventually returns to normal if adequate
fluids are ingested.

40. • Continued exposure to high altitude triggers the
release of erythropoietin from the kidneys.
• Partial compensation is done by increase in the
total number of red blood cells and creates a
greater total blood volume.
• This compensation is slow, taking weeks to
months to fully restore red cell mass.

41. B) Cardiac Output
• Increment in cardiac output is done to
compensate the need of oxygen to
exercising muscles.

42. • At high altitude, a release of
norepinephrine and epinephrine persists
for few days.
• After a few days, the muscles begin
extracting more oxygen from the blood,
which reduces the demand for increased
cardiac output.
• The increase reaches at peak after 6 to 10
days, after which cardiac output and heart
rate during a given exercise bout start to
decrease(acclimation).

43. • At maximal work levels at higher altitudes, both maximal
stroke volume and maximal heart rate are decreased.
• The decrease in stroke volume is directly related to the
decrease in plasma volume.
• Maximal heart rate may lower at high altitude as a
consequence of a decrease in the response to
sympathetic nervous system activity, possibly
attributable to a reduction in b-receptors.
• In summary, hypobaric conditions significantly limit
oxygen delivery to the muscles, reducing the capacity to
perform high-intensity or prolonged aerobic activities.

44. Metabolic Responses to Altitude
• Ascent to altitude increases the basal metabolic rate,
due to increases in both thyroxin and catecholamine
concentrations.
• This increased metabolism must be balanced by an
increased food intake to prevent body weight from
decreasing.
• In individuals who maintain their body weight at altitude,
there is an increased reliance on carbohydrate for fuel,
both at rest and during submaximal exercise.
• Because glucose yields more energy than fats or
proteins per liter of oxygen, this adaptation is beneficial.

46. Nutritional Needs at Altitude
• At altitude, the body has a natural tendency to lose fluids
and this water loss is exaggerated with exercise as
sweat evaporation increases from the wetted skin to the
relatively dry air producing dehydration.
• A rule of thumb at altitude is to consume at least 3 to 5 L
of fluid per day to prevent adverse effects of dehydration.

47. • Decreased energy consumption coupled with
increased metabolic rates can lead to daily
energy deficits of up to 500 kcal/ day, resulting in
weight loss over time.
• Consuming adequate calories to support
exercise and recreational activities is important,
and climbers should be taught to eat more
calories than their appetite suggests.

48. • Successful acclimation and acclimatization to
high altitude depend on adequate iron stores in
the body.
• Iron deficiency may prevent the increase in red
blood cell production that occurs for first four
weeks.
• Consumption of iron-rich foods and iron
supplements is recommended before and during
altitude exposure.

49. Exercise and Sport
Performance at Altitude

50. Maximal Oxygen Uptake and
Endurance Activity

51. • Maximal oxygen uptake decreases as altitude increases.
• VO2max decreases begins at an altitude of about 5,000
ft.
• At altitudes between 5,000 -16,400 ft, VO2max
decreases approximately 8% to 11% for every 1,000 m
increase in altitude above 5000 ft.
• The rate of decline may become even steeper at very
high altitudes.
• There is no sex differences in the rate of decline in
VO2max.

52. • Climber(Mount Everest 1981) experienced a change in
VO2max from about 62 ml/kg/min at sea level to only
about 15 ml/kg/min near the mountain’s peak.
• Pugh showed that men with VO2max values of 50
ml/kg/min at sea level would be unable to exercise, or
even to move, near the peak of Mount Everest because
their VO2max values at that altitude would decrease to 5
ml/kg/.
• Enough oxygen would be consumed to barely meet their
resting requirements.

54. • At the summit of Mount Everest, VO2max is reduced to
10% to 25% of its sea-level value.
• This severely limits the body’s exercise capacity.
• Individuals with larger aerobic capacities can perform a
standard work task with less perceived effort and with
less cardiovascular and respiratory stress at altitude than
those with a lower VO2max.

55. Anaerobic Sprinting, Jumping,
and Throwing Activities
• Anaerobic sprint activities that last less than a minute
(such as 100 m to 400 m track sprints) are generally not
impaired by moderate altitude.
• Such activities place minimal demands on the oxygen
transport system and aerobic metabolism as most of the
energy is provided through the adenosine triphosphate
(ATP), phosphocreatine, and glycolytic systems.
• The thinner air at altitude provides less aerodynamic
resistance to athletes’ movements.

56. Acclimation: Chronic
Exposure to Altitude

57. • When people are exposed to altitude over days,
weeks, and months, their bodies gradually
adjust to the lower PaO2 but never fully
compensate for the hypoxia.
• Even endurance trained athletes who live at
altitude for years never attain the level of
performance or the VO2max values that same
as at sea level.

58. Physiological adaptations with
prolonged altitude exposure
1. Pulmonary adaptations,
2. Blood adaptations,
3. Muscle tissue (cellular) adaptations,
4. Cardiovascular adaptations.

59. • These adaptations take longer to fully develop
(several weeks to several months).
• About three weeks are needed for full
acclimation to even moderate altitude.
• For each additional 1,970 ft altitude increase,
another week is needed on average.
• All of these beneficial effects are lost within a
month of return to sea level.

62. 1.Pulmonary adaptations
• Within three or four days at 13,123 ft, the
increased resting ventilation rate levels off at a
value about 40% higher than at sea level.
• In submaximal exercise, ventilatory rate also
plateaus at about 50% higher but over a longer
time frame.
• Increase in ventilation during exercise are more
pronounced at higher exercise intensities.

63. 2.Blood adaptations
• During the first two weeks at altitude, the
number of circulating erythrocytes increases.
• Within the first 3 h after the athlete arrives at a
high elevation, the blood’s EPO concentration
increases; it then continues to increase for two
or three days and returns to baseline levels in
about a month.
• After a person lives for about six months, his or
her total blood volume increases by about 10%.

64. • These adaptations improve hemogobin
content as so far oxygen-carrying capacity
of a fixed volume of blood.

65. • Thus, overall oxygen delivery capacity is increased with
acclimatization but not to the extent needed to achieve
sea-level VO2max values.
• The concentration of 2,3-diphosphoglycerate (2,3-DPG)
increases in red blood cells, which shifts the Oxy-
hemoglobin curve to the right.

66. 3.Muscle tissue (cellular)
adaptations
• Climbers experiences four to six weeks of
chronic hypoxia which can have muscle fiber
cross-sectional area decreased due to a loss of
appetite, extracellular water and a noticeable
weight loss.
• Capillary density in the muscles increased,
which allowed more blood and oxygen to be
delivered to the muscle fibers.
• Muscles’ inability to meet exercise demands at
high altitude might be related to a decrease in
their mass and their ability to generate ATP.

67. • Several weeks at altitudes above 8,202 ft,
reduce the metabolic potential of muscle.
• Both mitochondrial function and glycolytic
enzyme activities of the leg muscles are
significantly reduced after four weeks at altitude.
• Muscles lose some of their capacity to perform
oxidative phosphorylation and generate ATP.

68. 4.Cardiovascular Adaptations
• Reduction in VO2max at high altitude
improved little for the duration of their
exposure to hypoxia.
• Aerobic capacity remained unchanged for
up to two months at altitude.

69. Altitude: Optimizing
Training and
Performance

70. Does Altitude Training Improve
Sea-Level Performance?
• Altitude training evokes substantial tissue
hypoxia.
• The altitude-induced increase in red blood cell
mass and hemoglobin content improves oxygen
delivery on return to sea level.
• Theoretically this should provide an advantage
for the athlete.

71. • Recent studies have shown no additional
benefit of living and training at altitude for
increasing sea-level VO2max or improving
sea-level aerobic performance.
• Living at sea level and training in a
hypobaric chamber do not provide any
advantage over the same volume of sea-
level training.

72. • Athletes have used altitude training in an
attempt to improve sea-level endurance
performance; as a conclusion the existing
research on endurance athletes does not
support its effectiveness.

73. • Most studies show that training at altitude
leads to no significant improvement in sea-
level performance. Living at high altitudes
and training at low altitudes currently
appears to be the best alternative

74. Optimizing Performance at
Altitude
• Training of the athlete at higher altitudes require
a minimum of three to six weeks.
• Several weeks of intense aerobic training at sea
level to increase the athletes’ VO2max will allow
them to compete at altitude at a lower relative
intensity than if they had not trained aerobically.

75. • Extended training for optimal performance at
altitude requires an elevation between 4,921 ft to
9,840 ft.
• Work capacity is reduced during the initial days
at altitude.
• When first reaching higher altitudes, athletes
should reduce workout intensity to between 60%
and 70% of sea-level intensity, gradually
working up to full intensity within 10 to 14 days.

76. Artificial “Altitude” Training
• The largest and most important adaptations to
altitude are physiological changes caused by the
hypoxia, so training require adaptations simply
by breathing gases with a low PO2 .
• But no evidence supports the idea that brief
periods (1-2 h per day) of breathing hypoxic
gases or hypobaric mixtures induce even a
partial adaptation similar to that observed at
altitude.

77. • There are studies on “living high and training
low”.
• One approach has been to develop a hypoxic
apartment where athletes sleep and live. The
gas mixture inside the apartment is adjusted so
that nitrogen represents a higher percentage of
the inspired air, reducing the percentage of
oxygen in the inspired air as well as its partial
pressure.
• Hypoxic sleeping devices or tents have also
been proposed.

78. Health Risks of Acute
Exposure to Altitude
Acute Altitude (Mountain) Sickness
High-Altitude Pulmonary Edema
High-Altitude Cerebral Edema

79. • A large proportion of people who ascend to moderate
and high altitudes experience symptoms of acute altitude
(mountain) sickness.
• This disorder is characterized by symptoms such as
headache, nausea, vomiting, dyspnea (difficult
breathing), and insomnia.
• These symptoms can begin anywhere from 6 to 48 h
after arrival at high altitude and are most severe on days
2 and 3 & can be incapacitating for several days or
longer.
• In some cases, the victim can develop the more lethal
altitude-related illnesses of high-altitude pulmonary
edema or high-altitude cerebral edema.

80. Acute Altitude (Mountain)
Sickness
• The incidence of acute altitude sickness varies
with following factors.
– The altitude,
– The rate of ascent,
– Individual’s experience
– Susceptibility.

81. • Studies have been conducted to
determine the incidence of acute altitude
sickness in groups of tourists and more
experienced climbers.
• Results vary widely, ranging from a
frequency of less than 1% to almost 60%
at altitudes of 9,840-18,045 ft.

83. • Headache is the most common affecting majority
of people having symptom associated with
ascent to high altitude(12,000 ft) which is rarely
experienced below 8,000 ft.
• Which is continuous and throbbing & getting
worse in the morning and after exercise.
• Alcohol consumption worsens the symptoms.
• The main cause for headache is hypoxia,
causes dilation of the cerebral blood vessels and
stretching of pain receptors.

84. • Another consequence of acute altitude sickness is an
inability to sleep even if the individual is markedly
fatigued.
• Some people suffer from a pattern of interrupted
breathing, called Cheyne-Stokes breathing, which
prevents them from falling asleep and remaining asleep.
• Cheyne-Stokes breathing is characterized by alternating
periods of rapid breathing and slow, shallow breathing,
usually including intermittent periods in which breathing
completely stops.
• The incidence of this irregular breathing pattern
increases with altitude, occurring in 24% of people at
8,005 ft, 40% of people at 14,009 ft, and almost
everyone at altitudes above 20,669 ft.

85. How can athletes avoid acute
altitude sickness?
• Do gradual ascent to altitude, spending periods of a few
days at lower elevations but no more than 984 ft per day
at elevations above 9,840 ft .
• The drug-acetazolamide sometimes combined with
dexamethazone can be started the day before ascent.
• This drug can decrease headache, tiredness, nausea,
dizziness, and shortness of breath which can occur due
to sudden climbing.
• The definitive treatment for severe symptoms is a
retreat to lower altitude, high-flow oxygen and the use of
hyperbaric rescue bags are also effective in severe
cases.

86. Portable hyperbaric bag

87. High-Altitude Pulmonary Edema
• Accumulation of fluids in the lungs, is called as HAPE
which is life threatening.
• The cause of HAPE is likely related to the pulmonary
vasoconstriction resulting from hypoxia, causing blood
clots formation in the lungs.
• Remaining tissue becomes over perfused, and fluid and
protein leak out of the capillaries.
• This seems to occur most frequently in unacclimatized
people who rapidly ascend to altitudes above 8,202 ft.
• The disorder occurs in otherwise healthy people and has
been reported more often in children and young adults.

88. • The fluid accumulation interferes with air movement into
and out of the lungs, leading to shortness of breath, a
persistent cough, chest tightness, and excessive fatigue.
• Disruption of normal breathing impairs blood
oxygenation and, if severe enough, cyanosis of the lips
and fingernails, mental confusion, and loss of
consciousness may occur.
• Treatment include administration of supplemental
oxygen and movement of the victim to a lower altitude.

89. High-Altitude Cerebral Edema
• The fluid accumulation in the cranial cavity which is a
rare condition(complication of HAPE), have been
reported at altitudes greater than 14,108 ft.
• This neurological condition is characterized by mental
confusion, lethargy, and ataxia, progressing to
unconsciousness and death.
• The cause of HACE involves hypoxia-induced leakage of
fluids from cerebral capillaries, causing edema and a
resultant pressure buildup in the intracranial space.
• Treatment involves administration of supplemental
oxygen, a hyperbaric bag, and prompt descent to a lower
altitude. If descent is delayed, permanent impairment
may ensue.