High altitude pulmonary edema (HAPE) is a common, potentially life threatening condition seen in health care facilities at elevations above 2500 m. Forty-four thousand people live between 2430 to 3352 meters in Summit, Lake and Park Counties, Colorado. In contrast to the populations in the mountains of Nepal, Ethiopia and the Andes, few families have lived at elevation for more than a generation. In addition, there were 18.4 million tourists coming to the central Rockies Mountain region (2022). Residents may be acclimatized, but not adapted. Visitors are likely neither acclimatized nor adapted. This results in altitude related medical conditions, some needing treatment. The author reviewed 248 medical records of children aged 18 years and under presenting to the St. Anthony Summit Medical Center at 2800 m with the diagnosis of hypoxia, pneumonia, acute altitude sickness (AMS), pulmonary edema or respiratory distress. After excluding duplicates and other diagnoses, 64 cases were determined to be HAPE. The most prominent characteristics of HAPE cases were rapid onset of symptoms at altitude with marked hypoxia that improved within hours on high flow oxygen. Pneumonia cases at altitude rarely exhibit hypoxia and are more toxic with a longer duration of cough. This is the largest contemporary primary case analysis defining the presentation and characteristics of HAPE cases in children in the US. The objective of this study was to find factors supporting the diagnosis of HAPE to increase provider confidence and avoid unnecessary treatment. Suggested management and further research needed are discussed.