HBO Nuggets of the Week
A forum to discuss interesting aspects of hyperbaric medicine.
Wednesday, April 16, 2014
As hyperbaric medicine physicians, we may be asked to evaluate patients with compromised or failing flaps following reconstructive surgical procedures. With improved techniques in vascular and plastic surgery, there are an increasing number of these procedures being performed. Examples include:
· Breast reconstruction flaps
· Procedures to cover tissue defects after trauma
· Oral and maxillofacial procedures
One of the indications for the use of hyperbaric oxygen therapy (HBOT) is that of a failing flap or graft. HBOT can be used to promote flap survival. There are several theories describing how the flaps may benefit. One proposed theory is that there are small arteriovenous shunts that form within the flap and that HBOT may reduce these by causing vasoconstriction, thus increasing flow to more ischemic areas. The other is the well-known effect of migration of fibroblasts into hypoxic areas and induction of angiogenesis.
Typical recommended therapy is 2.0 ATA for 90 minute dives and, in some situations, the frequency could be twice a day. Treatment should always include close communication with the operating surgeon so that progress of the graft can be monitored.
Wednesday, February 26, 2014
One of the approved uses of hyperbaric oxygen therapy (HBOT) is for the treatment of chronic refractory osteomyelitis. This is a chronic condition of infection involving the cortex and medullary portions of the bone. For a patient to be considered a candidate for HBOT, he or she must have failed a course of standard therapy that includes debridement and a course of antibiotics. There is no exact point where one can differentiate between acute and chronic osteomyelitis, however, the accepted guidelines by the Centers for Medicare & Medicaid Services for treatment is generally 3 months.
One of the more common places that we encounter osteomyelitis is in diabetic patients with foot ulcers that penetrate to the bone or with a history of prior extremity trauma. The use of HBOT for osteomyelitis involving the long bones has decreased with the advent of improved surgical techniques for fracture repair and the use of plastic surgical flaps. Healing can be compromised by the interruption of blood supply to the bone either by infection, trauma, or repetitive injury. Physical examination may demonstrate exposed bone, odor, drainage, and tenderness. Although X-rays may be helpful, magnetic resonance imaging has emerged as the diagnostic tool of choice. Bone biopsy may provide pathologic diagnosis and also provide deep wound culture.
The mechanism of action of HBOT is similar to what has been discussed here before: enhancement of angiogenesis, increased leukocyte killing and improved bone healing through increased fibroblastic activity, and deposition of collagen with subsequent osteoblastic bone deposition.
The typical course of therapy for the treatment of chronic refractory osteomyelitis is 2.0-2.5 ATA, 30 dives for 90 minutes each, but the number of treatments may increase based on the severity of the disease.
Wednesday, January 08, 2014
Referring a wound care patient for hyperbaric oxygen therapy requires a commitment of time. Typically, the patient would require 20 to 40 treatments or “dives,” with 30 being the average amount of treatments. The patient must arrive before the treatment can start to have their vital signs taken and their glucose checked if they are diabetic and also be screened for safety. Contraband cannot be allowed in the chamber. Recall that 3 things are required for a fire: fuel, ignition source, and an accelerant. For example, street clothes, hand warmers, cell phones, and hairspray are not permitted in the chamber.
Pressurization, or descent, usually takes about 10 minutes. After arrival at the required depth, the standard treatment time is 90 minutes. The patient must then ascend, or depressurize, which again takes about 10 minutes. Total time in the hyperbaric chamber (monoplace) is usually 110 minutes. Clearly, the amount of time needed exceeds 2 hours. However, for many, the benefits of having a wound healed and closing the door to infection far outweigh any time inconvenience.
Wednesday, December 04, 2013
Hyperbaric oxygen therapy is very well tolerated. The patient lies comfortably while breathing 100% oxygen typically at 2.0 ATA (atmospheres absolute). The most common complication that we discussed previously is barotrauma, particularly to the tympanic membranes. However, another area of risk, although extremely low, is CNS oxygen toxicity.
Oxygen is a toxic gas if breathed at high concentrations for prolonged periods of times. Paul Bert, a 19th century French zoologist and physiologist is credited with the description. The risk for CNS oxygen toxicity rises if breathing 100% oxygen at pressures greater than 3.0 ATA or the equivalent of 99 feet of seawater. There may be little warning before convulsions occur. The risk associated with HBOT is approximately 0.01% if patients are screened for risk. Typically for our wound patients, risks would include fever or hyperthyroidism although both are not absolute contraindications for HBOT.
Another option to consider is that if a wound patient is thought to be at high risk for CNS oxygen toxicity they can be provided with periods of normoxia, or, air breaks. In a monoplace chamber, the patient would be provided with a mask connected to a tank of medical air located outside the chamber. The patient would breathe air for 5 minutes every half hour or a total of 10 minutes. Using the typical parameters for treating wound patients, a 90 minute ‘dive’ at, 2.0 ATA, CNS oxygen toxicity is very rare.
Monday, October 21, 2013
One of the more common uses of hyperbaric oxygen therapy is in the treatment of diabetic foot ulcers (DFUs). Diabetic foot ulcers are one of the feared complications of diabetes. They occur in about 15% of persons with diabetes, and an article by Brem and Tomic-Canic1 stated that approximately 84% of lower extremity amputations are preceded by them.
The Centers for Medicare & Medicaid Services requirements for treatment of DFUs include the following 3 criteria:
• Patient has type 1 or type 2 diabetes and has a lower extremity wound that is a result of having diabetes
• Patient has a wound classified as Wagner grade III or higher
• Patient has failed an adequate course of standard wound therapy for at least 30 days (including debridement, revascularization if indicated, offloading, and so on)
The Wagner’s classification of diabetic foot ulcers is as follows. Although not a perfect grading system (doesn’t take into account vascular status or superficial ulcers), it is the grading system that is used to determine candidacy for HBOT at the present time:
0 No open lesions: may have deformity or cellulitis
1 Superficial ulcer
2 Deep ulcer to tendon or joint capsule
3 Deep ulcer with abscess, osteomyelitis, or joint sepsis
4 Local gangrene – forefoot or heel
5 Gangrene of entire foot
Treatment is typically 30 dives at 2.0 ATA and if improvement is shown, the number of dives may be increased.
1. Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest 2007;117:1219-22.