Executive Case Summary
In October 2026, a trekker on the Annapurna Circuit developed dizziness followed by shortness of breath in Manang, a major acclimatization stop at approximately 3,500–3,550 metres in Nepal's Gandaki Province. The first oxygen saturation (SpO₂) reading, logged in HGN's rescue system at altitude in Manang, was 56%; the Manang clinic then recorded 65% on room air. Himalayan Guardian Nepal (HGN) coordinated the rescue with its helicopter partner, Alpine Rescue Service Pvt. Ltd., and the patient was evacuated by helicopter to Pokhara. Hospital records there documented High-Altitude Pulmonary Edema (HAPE) as the final diagnosis. Treatment included supplemental oxygen, intravenous medication and monitoring. Vital signs were recorded as stable and improving at discharge, which occurred at the patient's request, against medical advice, after about one day.
Case at a Glance
| Field | Documented detail |
|---|---|
| Route | Annapurna Circuit, Nepal |
| Location | Manang, Gandaki Province |
| Altitude | Approximately 3,550 m (HGN rescue record) |
| Initial concern | Altitude illness with severe low oxygen |
| SpO₂ and heart rate, in sequence | First, at altitude in Manang (HGN rescue record): SpO₂ 56%, heart rate 69 bpm. Then Manang clinic (hospital records): SpO₂ 65% on room air, heart rate 84 bpm. Then Pokhara hospital, measured later: SpO₂ 81% on room air, heart rate about 72 bpm. |
| SpO₂ detail | 56% at altitude in Manang (HGN rescue record, first reading); 65% on room air at the Manang clinic (hospital records); 81% on room air on arrival in Pokhara |
| Documented diagnosis | High-Altitude Pulmonary Edema (HAPE), per hospital records |
| Rescue | Conducted by Himalayan Guardian Nepal with rescue partner Alpine Rescue Service Pvt. Ltd.; helicopter evacuation |
| Transfer | Manang to Pokhara (roughly 800 m elevation) |
| Hospital SpO₂ on arrival | 81% on room air; 93% on supplemental oxygen via face mask |
| Hospital treatment | Oxygen, IV steroids, IV proton-pump inhibitor, symptomatic medicines, monitoring |
| Outcome documented | Vitals stable and improving; discharged at the patient's request against medical advice; outpatient follow-up advised |
What Happened in Manang?
Onset. Per the hospital's records, the trekker developed dizziness followed by shortness of breath at approximately 2:30 am on the fourth day of trekking, and was seen at the clinic in Manang.
Clinic assessment. At the Manang clinic, SpO₂ was recorded at 65% on room air, blood pressure 120/70 mmHg and heart rate 84 bpm. Dexamethasone 8 mg intramuscularly and nifedipine 20 mg orally were given as a stat dose before helicopter evacuation, according to the hospital's referral summary.
First reading at altitude (HGN rescue record). HGN's rescue system recorded the alert as a phone call reporting altitude sickness at 3,550 m, with a first SpO₂ of 56% and a heart rate of 69 bpm, measured at altitude in Manang. These are the earliest recorded values.
Evacuation. HGN received information by WhatsApp, coordinated with the trekking guide, received photo and video, coordinated with the insurer's assistance team, and activated evacuation to Pokhara. Alpine Rescue Service Pvt. Ltd., HGN's rescue partner, carried out the helicopter evacuation under HGN's coordination.
Hospital evaluation. On arrival in Pokhara the patient was conscious and responsive, with SpO₂ of 81% on room air. The hospital admitted the patient and documented HAPE.
The readings came from successive assessments. SpO₂ and heart rate were first measured at altitude in Manang (56%, 69 bpm; HGN record), then at the Manang clinic (65%, 84 bpm), then at the hospital in Pokhara after evacuation (81% on room air, 93% on oxygen; heart rate about 72 bpm). They are separate measurements at different times and locations, so they should not be read as a single continuous trend.
The Medical Findings: Why This Was Diagnosed as HAPE
Hospital documentation, not HGN, determined the diagnosis.
Field findings (Manang clinic, as summarized in the hospital's referral record)
- Dizziness followed by shortness of breath
- SpO₂ 65% on room air
- Blood pressure 120/70 mmHg; heart rate 84 bpm
- Dexamethasone and nifedipine given before evacuation
Hospital findings (Pokhara)
- Conscious and responsive, Glasgow Coma Scale 15/15 (E4V5M6)
- SpO₂ 81% on room air and 93% with oxygen by face mask
- Blood pressure 140/90 mmHg; heart rate about 72 bpm; respiratory rate 20 per minute
- Chest examination: decreased air entry on both sides with crepitations (crackles)ECG: sinus rhythm
- Hospital letters stated that, given the history of high-altitude trekking, severe hypoxemia, dizziness and breathlessness, high-altitude illness including HAPE was considered; after laboratory and clinical review, HAPE was diagnosed and the patient admitted
Final diagnosis
The discharge summary lists High-Altitude Pulmonary Edema (HAPE) as the final diagnosis. Hospital records documented HAPE; this article does not reinterpret the laboratory results.
Cerebral involvement. Hospital records show a GCS of 15/15 on arrival. A brain MRI was listed and the patient declined it. No supplied medical record documents a diagnosis of HACE, and this article does not make one.
What Is High-Altitude Pulmonary Edema?
High-Altitude Pulmonary Edema (HAPE) is a non-cardiac form of fluid accumulation in the lungs that can develop after ascent to high altitude, causing breathlessness and dangerously low blood oxygen.
Fluid collects in the air sacs and tissue of the lungs, which impairs oxygen transfer and produces hypoxemia (low blood oxygen). Reported features include breathlessness beyond what exertion explains, reduced exercise tolerance, cough, and crackles on lung examination. HAPE can worsen quickly and is considered a life-threatening altitude illness. The Wilderness Medical Society's guideline groups HAPE with acute mountain sickness (AMS) and high-altitude cerebral edema (HACE) as the three forms of acute altitude illness.
Can HAPE Occur in Manang?
Yes. HAPE can occur in Manang. Manang is a major acclimatization stop on Nepal's Annapurna Circuit at approximately 3,500–3,550 metres. The Himalayan Rescue Association has staffed an aid post there since 1981, and it lists the post at 3,550 m.
Susceptibility varies between individuals, and ascent rate matters. The Wilderness Medical Society's guideline notes that sleeping altitude and gradual ascent are central to prevention. A 2017 study of the HRA Manang clinic examined the road from Besisahar (760 m) to Manang (3,540 m) and reported that, in fall 2016, 54% of altitude-illness patients had travelled to Manang by motor vehicle and 33% had arrived from low altitude in under 48 hours. A 2024 report on one season at the HRA Manang aid post (376 patients) found altitude illness accounted for 16% of presentations.
Proper acclimatization lowers risk but does not eliminate it.
Why Severe Low Oxygen at Altitude Matters
SpO₂ is a pulse-oximeter estimate of how much haemoglobin is carrying oxygen. Readings at altitude are naturally lower than at sea level, and no single number defines HAPE.
Clinicians interpret SpO₂ alongside altitude, symptoms, breathing rate, chest findings, mental status and the accuracy of the device. In this case the readings are presented strictly as recorded facts, in order: 56% at altitude in Manang (first reading, HGN rescue record), 65% on room air at the Manang clinic, and 81% on room air on arrival in Pokhara, measured later (hospital records). The hospital described the picture as severe hypoxemia. The diagnosis rested on the overall clinical picture, not on a single value.
For context, the Wilderness Medical Society guideline recommends supplemental oxygen sufficient to raise SpO₂ above 90% or relieve symptoms while awaiting descent when descent is not feasible, and during descent of severely ill patients. In this case, SpO₂ rose to 93% on face-mask oxygen at the hospital.
Why Descent Matters in HAPE
Descent is a central management principle. The Wilderness Medical Society guideline states that descent is indicated for individuals with HAPE. Supplemental oxygen, medical evaluation and evacuation support descent when walking is unsafe.
Lower altitude means higher oxygen availability, which can speed recovery. In this case, the patient received medication at the Manang clinic and was evacuated to a lower-altitude hospital, where oxygen was given. This article is not self-treatment guidance. A trekker with suspected HAPE needs urgent medical assessment and descent planning.
How the Helicopter Rescue Was Coordinated
This rescue was conducted by Himalayan Guardian Nepal. HGN worked with Alpine Rescue Service Pvt. Ltd., its rescue partner, which provided the helicopter evacuation. Based on HGN's rescue records:
- Alert. A phone call reported altitude sickness at Manang.
- Information gathering. HGN received a WhatsApp message, photo and video, and coordinated with the trekking guide.
- Insurer coordination. HGN coordinated with the traveller's insurance assistance team.
- Activation. HGN activated evacuation to Pokhara. The recorded rescue method was helicopter, operated through Alpine Rescue Service Pvt. Ltd.
- Destination. Overseas Friendship International Hospital, Pokhara.
From Manang to Pokhara: The Medical Transfer
Moving a patient from about 3,550 m to Pokhara, at roughly 800 m, rapidly increases ambient oxygen, and Pokhara has hospital-level diagnostics (imaging, laboratory work, continuous monitoring) that a mountain aid post does not.
Operational fact: the patient was flown from Manang to Pokhara.
Medical fact: on arrival, hospital documentation recorded SpO₂ 81% on room air, and 93% with oxygen by face mask, crackles on both sides, GCS 15/15.
What the Hospital Records Documented
- Emergency treatment: oxygen by face mask at 5 L/min, then IV paracetamol, pantoprazole, ondansetron and dexamethasone as stat doses
- Investigations: blood counts, renal and liver function, CRP, urine, ECG, serology, chest X-ray, and chest HRCT were listed; MRI brain was declined by the patient. Results of imaging are not stated in the supplied records.
- Selected laboratory findings: renal function and electrolytes were within normal limits; the white cell count was mildly raised with neutrophil predominance. Interpretation is left to the treating doctors.
- Admission: for oxygen administration, observation and conservative management; hospital advised continued inpatient treatment for a few days
- Discharge: after about one day, at the patient's request against medical advice; vitals documented as stable and improving; follow-up advised at the medicine outpatient clinic as needed
HAPE vs AMS vs HACE
| Condition | Main system affected | Typical warning signs | Why it matters |
|---|---|---|---|
| AMS (acute mountain sickness) | Whole body, mainly symptomatic | Headache plus nausea, fatigue, dizziness, poor sleep | Most common; stop ascending; can progress |
| HAPE | Lungs | Breathlessness at rest, cough, crackles, falling SpO₂, reduced exercise ability | Can cause severe hypoxemia; descent is the central treatment |
| HACE | Brain | Ataxia (loss of coordination), confusion, altered mental status | Neurological emergency; needs urgent descent |
Not every altitude illness is HAPE. Not every AMS case progresses to HAPE or HACE. HAPE and HACE can occur together. The records for this case document HAPE only.
Does Every HAPE Case Require a Helicopter?
No. Helicopter evacuation is one option, and the choice depends on severity, ability to walk, the available descent route, terrain, weather, medical advice, and operational feasibility. Options include walking or assisted descent, vehicle transport where roads exist (the Besisahar-Manang road is documented in the research literature), animal transport in suitable circumstances, and helicopter evacuation for patients who cannot safely descend by other means. Helicopter rescue is not guaranteed in every situation.
What Annapurna Circuit Trekkers Can Learn from This Case
- Treat increasing breathlessness as a warning, especially breathlessness at rest.
- Do not ascend while seriously unwell. Seek medical assessment at a clinic.
- Respect acclimatization. Plan itineraries around sleeping altitude, not only daily distance.
- Know where medical posts are, including the HRA aid post in Manang.
- Share symptoms early with your guide and group; deterioration can be rapid, and symptoms began in the early hours in this case.
- Understand your itinerary's altitudes and make sure your insurance matches them.
- Know the emergency procedure and have contact details accessible.
Trekking Insurance and High-Altitude Medical Evacuation
Policies differ. Before departure, check:
- the maximum altitude covered
- whether emergency medical transportation and helicopter evacuation are included
- exclusions and pre-existing condition termsmedical-necessity requirements and insurer approval processes
- the exact policy wording
This article makes no claim that HAPE evacuations are universally covered. HGN's record for this case lists a trekking-insurance product with a 5,500 m altitude limit.
FAQ Section
Can you get HAPE in Manang? Yes. Manang, at approximately 3,500–3,550 m on the Annapurna Circuit, is high enough for high-altitude illness including HAPE. The Himalayan Rescue Association operates an aid post there.
What altitude is Manang on the Annapurna Circuit? Approximately 3,500–3,550 metres. HRA lists its Manang aid post at 3,550 m; published studies cite figures between about 3,500 and 3,540 m.
What is HAPE? High-Altitude Pulmonary Edema is fluid accumulation in the lungs after ascent to altitude, causing breathlessness and low blood oxygen.
What are the warning signs of HAPE? Breathlessness out of proportion to effort or at rest, cough, reduced exercise ability, and falling oxygen saturation. Clinicians may hear crackles in the chest. Anyone with these signs at altitude needs urgent medical assessment.
Is HAPE the same as altitude sickness? HAPE is one serious form of altitude illness. Acute mountain sickness (AMS) is the milder, more common form, and HACE affects the brain.
Does HAPE require immediate descent? Descent is indicated for HAPE according to the Wilderness Medical Society guideline. Supplemental oxygen and medical care support descent; the method depends on the situation.
Does every HAPE case need helicopter evacuation? No. Evacuation method depends on severity, mobility, terrain, weather, road access and medical advice.
How does rescue from Manang work? In this case: an alert reached Himalayan Guardian Nepal, information was gathered from the guide, the insurer's assistance team was contacted, and HGN activated a helicopter evacuation to Pokhara with its rescue partner, Alpine Rescue Service Pvt. Ltd. Other cases may differ.
Is altitude sickness common on the Annapurna Circuit? It is a recognized problem. A 2024 report on one season at the HRA Manang aid post found altitude illness in 16% of 376 patients seen.
Does trekking insurance cover HAPE evacuation? It depends on the policy. Check the altitude limit, evacuation wording, exclusions and approval process before you travel.
Medical Disclaimer
This article is educational and is not individualized medical advice. Serious altitude symptoms require professional medical assessment. Emergency decisions depend on the patient's condition and local circumstances. Medication doses cited from the records describe what was given in this case and are not recommendations.
