There are many uses for hyperbaric oxygen therapy (HBO2). The international organization that establishes standards for hyperbaric medicine is the Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy can be used in 14 cases. There are many other unapproved situations where it may also prove useful. Hyperbaric oxygen therapy involves placing a patient in a pressurized chamber with up to 3 atmospheres (ATMs) of pressure. At sea level, the ambient pressure is 1 ATM. Each ATM of additional pressure equals 33 feet (10m) of seawater depth or 14.7 pounds per sq inch (psi), (101 kilopascals). The body experiences many physiological effects from high pressure and exposure to 100% oxygen. These physiologic changes have been shown in studies to increase wound healing in chronic wounds. Many controlled studies have shown this to be true. The plasma oxygen concentration increases are one of the most noticeable effects. Plasma oxygen concentration at sea level is approximately 3 mL/L.
Plasma oxygen concentration is 60 mL/L at 3 ATM, breathing 100% oxygen. This is enough oxygen to keep swine alive even after their red blood cells are removed. It is also sufficient to supply most tissues with the resting oxygen requirements. It also delivers higher oxygen levels to ischemic tissues. Hyperbaric oxygen therapy also has the effect of decreasing the surrounding edema and increasing neovascularity within ischemic tissue. Hyperbaric oxygen therapy may be able to potentiate some antibiotics, such as aminoglycosides or quinolones. Higher concentrations can make it bacteriostatic or bacteriocidal. Hyperbaric oxygen therapy neutralizes the alpha exotoxins that are produced by bacteria like Clostridium. It increases neutrophil-mediated bacterial death in hypoxic tissues. Hyperbaric oxygen therapy reduces the release of proteases, free radicals, and other injuries. This decreases vasoconstriction and edema as well as cellular damage.
Refractory diabetic wounds can be chronically or acutely infected and may have compromised vascularity. Although most arterial compromise occurs in the distal arteries, it can also affect larger arteries. Venous congestion can cause venous stasis ulcers and arterial compromise.
Hyperbaric oxygen therapy is often contraindicated due to barotrauma. This refers to any injury that occurs in an area with closed air-filled spaces such as the lungs or middle ear. The injury results from the expansion and pressure change from the hyperbaric dive, which causes the compartment to burst (perforation or pneumothorax). Untreated pneumothorax is the only absolute contraindication. Untreated pneumothorax is the only true contraindication. This situation can lead to tension pneumothorax, which can quickly progress and cause death. Other contraindications include pulmonary blebs or emphysema containing carbon dioxide retention.
Certain drugs should not be administered. Disulfiram blocks superoxide dismutase, protecting against oxygen toxicity (a known danger of hyperbaric oxygen therapy). Wound healing can be affected by mafenide and ciplatinum. Interstitial pneumonitis can be caused by Bleomycin. Relative contraindications include pregnancy, epidural pumps, pacemakers, and seizures. Claustrophobia can also be a problem, particularly in the case of monoplane chambers.
A chamber that is approved and inspected for hyperbaric oxygen therapy can be used. There are two types of chambers: monoplace chambers, which can only hold one patient at a given time; or multiplace chambers that can house multiple patients and an over-seeing physician. Multiplace chambers can accommodate more patients such as patients who require special equipment or ventilators. This activity regulates everything, from exhaust carbon dioxide to oxygen purity. Regular inspections are required and staff must be trained to supervise hyperbaric diving. Each facility is assigned a safety director to ensure compliance with specifications.
A failure of the fire or chamber is the most serious complication associated with hyperbaric diving. The failure of the chamber can be avoided with frequent inspections and vigilant vigilance by the staff. Dive safety is also a concern. A combustible substance, a spark or fire source, and oxygen are all necessary for lighting a fire. The maximum amount of items that patients can bring into the chamber is limited. Oils, electronics, and other items that are not approved for use are not allowed. They are required to wear only approved gowns and not street clothes. To prevent static sparks, patients are grounded. Non-approved electronic equipment cannot be used in the open chamber.
All staff members, including physicians, must have received special training in hyperbaric medicine. Each physician who is responsible for supervising must have completed a minimum 40-hour training program in hyperbaric medicine. A year-long fellowship can be completed by physicians to become certified in hyperbaric and undersea medicine. A 40-hour course in hyperbaric technology is required. An appointed safety officer is responsible for safety and maintenance training. Cleaning staff must be familiar with the precautions required to clean acrylic monoplace chambers as well as the special details involved in maintaining and caring for multiplace chambers.
The patient must have had at least 30 days of failed standard treatment that included chemical and mechanical debridements, alginates, collagens, and treatment of underlying issues like pressure relief, malnutrition, infection, and malnutrition. For reimbursement, patients must be approved by their insurance. The patient is then required to undergo orientation, a thorough history, and a physical exam to rule out contraindications. They are required to demonstrate their ability to open their ears by Valsalva, and that they do not exhibit claustrophobia when using the monoplace chambers. They are instructed about what is permissible and prohibited in the chambers as well as any possible dangers of diving. To confirm their ability to respond to hyperbaric oxygen therapy, wound patients often require transcutaneous oximetry (TCOM), which is usually done to check for bleeding. Because these numbers can change during a dive, blood glucose and pressure must be checked before each dive. Pre-dive and after-dive, eardrums are checked to rule out barotrauma.
According to the condition being treated, Hyperbaric dives follow a specific set of proven dive protocols. Two 10-minute oxygen breaks are required to prevent oxygen seizures. Dives take approximately two hours each day. Dives are usually at a pressure of 2.4 ATM with 100% oxygen. A typical dive session lasts 33 sessions, but it can be extended if necessary.
Barotrauma is the most common side effect of hyperbaric oxygen therapy. Barotrauma results from the expansion of gases within a restricted space. The most common forms of barotrauma are rupture or irritation to the tympanic skin membrane. Pneumothorax, rupture or irritation of small vessels, damage to the inner, middle, and outer ear canals, and pneumothorax are all other serious injuries. Hemorrhage, oxygen seizures, convulsions, pulmonary edema, and hemorrhage are all more serious dangers. Explosions and chamber fires are two examples of catastrophic complications.
Hyperbaric oxygen therapy adds another dimension to the arsenal for treating complex chronic wounds. Although it may not be for everyone, many patients have experienced significant wound healing benefits.
Anyone who treats chronic wounds must be well-versed in the indications of hyperbaric medicine. Hyperbaric therapy is not approved for all wounds. However, it is important to properly refer and initiate hyperbaric medicine. For maximum healing and the best effect, a proper assessment must be done by the primary caregiver wound physician, and hyperbaric physician.
Sources:
https://www.mayoclinic.org/tests-procedures/hyperbaric-oxygen-therapy/about/pac-20394380
https://www.ncbi.nlm.nih.gov/books/NBK459172/
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