When O 2 availability is reduced unavoidably, as it is at high altitude, a potential mechanism to improve O 2 delivery to tissues is an increase in blood flow. Nitric oxide (NO) regulates blood vessel diameter and can influence blood flow. This field study of intrapopulation variation at high altitude tested the hypothesis that the level of exhaled NO (a summary measure of pulmonary synthesis, consumption, and transfer from cells in the airway) is directly proportional to pulmonary, and thus systemic, blood flow. Twenty Tibetan male and 37 female healthy, nonsmoking, native residents at 4,200 m (13,900 ft), with an average O 2 saturation of hemoglobin of 85%, participated in the study. The geometric mean partial pressure of NO exhaled at a flow of 17 ml/s was 23.4 nmHg, significantly lower than that of a sea-level reference group. However, the rate of NO transfer out of the airway wall was seven times higher than at sea level, which implied the potential for vasodilation of the pulmonary blood vessels. Mean pulmonary blood flow (measured by cardiac index) was 2.7 Ϯ 0.1 (SE) l/min, and mean pulmonary artery systolic pressure was 31.4 Ϯ 0.9 (SE) mmHg. Higher exhaled NO was associated with higher pulmonary blood flow; yet there was no associated increase in pulmonary artery systolic pressure. The results suggest that NO in the lung may play a key beneficial role in allowing Tibetans at 4,200 m to compensate for ambient hypoxia with higher pulmonary blood flow and O 2 delivery without the consequences of higher pulmonary arterial pressure. high altitude; oxygen delivery; oxygen availability; hypoxia WHEN OXYGEN AVAILABILITY is reduced, as it is at high altitude, an increased blood flow could potentially improve O 2 delivery to tissues. However, the pulmonary vasoconstriction response to hypoxia decreases blood flow in the lung, the first point of contact with the circulation. This response probably evolved at sea level to maintain gas exchange by redistribution of blood flow from temporarily small, poorly oxygenated to betteroxygenated areas of the lung (17, 32). At high altitude, the entire lung is always hypoxic, and the resulting general vasoconstriction does not redistribute blood flow; instead, it increases pulmonary arterial pressure, sometimes causing pathological remodeling of the heart and lungs (30). However, many people live at high altitude without pulmonary hypertension or cardiac hypertrophy, which suggests that another factor may intervene to maintain blood flow when the blood carries less O 2 and the usual vasoconstriction response increases pulmonary resistance. That factor may be nitric oxide (NO), a vasodilator found in high concentrations in the lungs of high-altitude natives, particularly among Tibetans (5).A wealth of studies support a key role for NO in determining basal pulmonary vascular tone at sea level and in effecting the hypoxic vasoconstriction response. An animal study using NO synthase gene transfer to the airway demonstrates elegantly that increasing NO decreases hypoxic pulmonary v...