Review ArticleHyperbaric Oxygen Therapy
Introduction
Hyperbaric oxygen is a treatment in which a patient breathes 100% oxygen intermittently while inside a treatment chamber at a pressure higher than at sea level pressure (ie, >1 atm abs). In certain circumstances, hyperbaric oxygen therapy (HBOT) is the primary treatment modality, whereas in others, it is an adjunct to surgical or pharmacologic interventions.1
Treatment can be carried out in either a monoplace or a multiplace chamber. In a monoplace chamber, a single patient is accommodated, the entire chamber is pressurized with 100% oxygen, and the patient breathes the ambient chamber oxygen directly. A multiplace chamber holds 2 or more people and is pressurized with compressed air while patients breathe 100% oxygen via masks, head hoods, or endotracheal tubes.
Topical oxygen therapy is not HBOT. The patient must receive the oxygen by inhalation within a pressurized chamber, and the Undersea and Hyperbaric Medical Society position paper indicates that pressurization should be at least 1.4 abs or higher for the therapy to be considered HBOT.2
After reviewing all the scientific evidence available to date, the Undersea and Hyperbaric Medical Society, in its latest publication, Hyperbaric Oxygen Therapy Indications (12th ed.), recommends the following 13 indications for HBOT.1
- 1.
Air or gas embolism
- 2.
Carbon monoxide poisoning and carbon monoxide poisoning complicated by cyanide poisoning
- 3.
Clostridial myositis and myonecrosis (gas gangrene)
- 4.
Crush injury, compartment syndrome and other acute traumatic ischemias
- 5.
Decompression sickness
- 6.
Arterial insufficiencies
- a.
Central retinal artery occlusion
- b.
Enhancement of healing in selected problem wounds
- a.
- 7.
Severe anemia
- 8.
Intracranial abscess
- 9.
Necrotizing soft tissue infections
- 10.
Osteomyelitis (refractory)
- 11.
Delayed radiation injury (soft tissue and bony necrosis)
- 12.
Compromised grafts and flaps
- 13.
Acute thermal burn injury
Most of these indications are approved by Medicare and other insurance, but it is advisable to check with local Medicare intermediaries and insurance companies for coverage determination.
The indications that we commonly see in our wound care practice are discussed in detail in the following sections of this article.
Section snippets
Clostridial Myositis and Myonecrosis (Gas Gangrene)
Clostridial myositis and myonecrosis, or gas gangrene, is an acute, rapidly progressive nonpyogenic, invasive clostridial infection of the muscles, characterized by profound toxemia, extensive edema, massive death of tissue, and a variable degree of gas production. This infection is most commonly caused by anaerobic, spore forming, gram-positive, encapsulated bacilli of the genus Clostridium. The most commonly isolated organism is Clostridium perfringens type A.3
The onset of gas gangrene may
Crush Injuries and Skeletal Muscle Compartment Syndromes
Crush Injuries represent a spectrum of injury to body parts as a result of trauma. Typically the injury may involve skin, subcutaneous tissue, muscle, tendons, bone and joint. Complications arising from crush injuries can be osteomyelitis, nonunion of fractures, failed flap and amputations that occur in approximately 50% of the cases. HBOT can be used as an adjunct to get better outcomes.1, 4
Compartment syndrome is another consequence of trauma. Edema, bleeding, or a combination within the
Problem Wounds
Problem wounds represent a significant and growing challenge to our health care. The hypoxic nature of all wounds has been demonstrated, and the hypoxia, when pathologically increased, correlates with impaired wound healing and increased rates of wound infection.1, 8 The rate at which all normal wounds heal has been shown to be oxygen dependent.8, 9 Fibroblast replication, collagen deposition, angiogenesis, resistance to infection, and intracellular leukocyte bacterial killing are
Necrotizing Soft Tissue Infections
Necrotizing fasciitis is an acute, potentially fatal infection of the superficial and deep fascia of the skin and soft tissues and progresses to ischemic dermal necrosis after involvement of the dermal blood vessels, which traverse through the fascial layers.1, 15
Refractory Osteomyelitis
Osteomyelitis is an infection of bone or bone marrow, usually caused by pyogenic bacteria or mycobacteria. Refractory osteomyelitis is defined as a chronic osteomyelitis that persists or recurs either after definitive surgical debridement or after a period of 4 to 6 weeks of appropriate antibiotic therapy.1, 17
The Cierny-Mader classification of osteomyelitis can be used as a guide to determine which patients will most likely benefit from adjunctive HBOT. Stage 1 disease in the Cierny-Mader
Delayed Radiation Injuries (Soft Tissue and Bony Necrosis)
Delayed radiation injuries are typically seen after a latent period of 6 months or more and may develop many years after the radiation exposure. Sometimes, delayed injuries are precipitated by an additional tissue insult such as surgery within the radiation field.1, 18
Delayed radiation injury causes vascular changes characterized by obliterative endarteritis and stromal fibrosis. HBOT induces neovascularization in hypoxic tissues by stimulating angiogenesis and improving tissue oxygenation,
Compromised Grafts and Flaps
All flaps, by definition, have an inherent blood supply, whereas grafts are avascular tissues that rely on quality of the recipient bed for survival and revascularization. Therefore, diagnosis of a compromised graft begins with proper assessment of the recipient wound bed. Compromised grafts can be salvaged by prompt institution of HBOT.1, 19
There are many etiologies for flap compromise, mainly random ischemia, venous congestion, and occlusion to arterial circulation.
Free flaps can be exposed
Acute Thermal Burn Injury
Severe thermal injury is one of the most devastating physical and psychological injuries a person can suffer. The goal of burn treatment include survival of the patient, with rapid wound healing, minimal scarring and abnormal pigmentation, and cost-effectiveness.1, 20
The burn wound is a complex and dynamic injury characterized by a central zone of coagulation surrounded by an area of stasis, bordered by an area of erythema. The zone of coagulation or complete capillary occlusion may progress
Conclusion
HBOT has proved to be an useful adjunct in the treatment of multiple conditions in the wound care clinic. Judicious use of HBOT will greatly increase wound healing rates in patients with compromised split thickness skin grafts or flaps, refractory osteomyelitis, radiation injury, and progressive necrotizing fasciitis.
References (20)
Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy
Am J Surg
(2004)- et al.
Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis
Am J Surg
(2005) - et al.
Hyperbaric oxygen as adjunctive therapy for osteomyelitis
Infect Dis Clin North Am
(1990) - et al.
UHMS position statement: Topical oxygen for chronic wounds
Undersea Hyperb Med
(2005) Gas Gangrene
- et al.
The role of clostridial toxins in the pathogenesis of gas gangrene
Clin Inf Disease
(2002) Management of Open Fractures and Their Complications
(1982)- et al.
Delayed use of hyperbaric oxygen for treatment of a model compartment syndrome
J Orthop Res.
(1986) Crush injury, compartment syndrome and other acute traumatic peripheral ischemias
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Conflict of interest: The author reports no conflicts of interest.