Download Hyperbaric Oxygen Therapy

Hyperbaric Oxygen Therapy
Mark Wilson, CHT
Hyperbaric Oxygen Therapy
(HBO)
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Involves breathing 100% oxygen at greater than ambient
pressure
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Think of oxygen as a drug and the hyperbaric chamber as
a dosing device
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Elevating tissue oxygen tension is the primary effect
Hyperbaric Oxygen Therapy (HBO)
• Hyperbaric oxygen (HBO) chambers are currently located in over 1200
facilities in the United States
• Hyperbaric facilities can be accredited through Undersea and Hyperbaric
Medical Society (UHMS)
• Patients undergoing HBO therapy enter a chamber filled with 100 percent
oxygen pressurized to 2.0 to 2.5 ATA (Equivalent to the pressure 33 to 48
feet below sea level)
• Hyperbaric oxygen therapy treatment “force feeds” oxygen through the
lungs to the rest of the body
• A 90-minute hyperbaric treatment induces oxygen levels to over 10
times the normal amount in the bloodstream
Hyperbaric Oxygen Therapy (HBO)
• Physician must be specifically trained and credentialed to
deliver HBO therapy
• Physicians can obtain board certification in Hyperbaric medicine
through American Board of Emergency Medicine and the
American Board of Preventive Medicine
• Useful as an adjunct in select wounds and conditions in
conjunction with comprehensive wound management
• Not a stand alone therapy
In Selected Wounds and
Conditions;
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Hyperbaric Oxygen Therapy (HBOT)
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Elevates oxygen tensions in ischemic/infected wounds
Enhances fibroblast replication
Enhances collagen synthesis
Enhances neutrophil antibacterial activity
Promotes neovascularization
Current Indications for HBO
• The Hyperbaric Oxygen Therapy Committee of the UHMS recognizes
14 indications for HBOT
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Air or Gas Embolism
Decompression Sickness
Carbon Monoxide Poisoning
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Carbon Monoxide Poisoning Complicated By Cyanide Poisoning
Clostridial Myositis and Myonecrosis (Gas Gangrene)
Crush Injury, Compartment Syndrome and Other Acute Traumatic Ischemias
Central Retinal Artery Occlusion
Enhancement of Healing In Selected Problem Wounds
Severe Anemia
Intracranial Abscess
Necrotizing Soft Tissue Infections
Osteomyelitis (Refractory)
Delayed Radiation Injury (Soft Tissue and Bony Necrosis)
Compromised Grafts and Flaps
Acute Thermal Burn Injury
Idiopathic Sudden Sensorineural Hearing Loss
Current Indications for HBO
• These 14 indications should be considered appropriate for third party
insurance coverage.
• CMS intermediaries do interpret coverage of these indications
differently.
• Private insurances seem to approve and disapprove HBO indications
at will.
Approved Indications
Diabetic wounds of the lower extremity
Three main effects of HBO:
1) Delivery of O2 to hypoperfused tissues
• Limit ischemic damage, cell death, and inflammation
• Promotes collagen synthesis and angiogenesis
• Decreases lactate production and tissue acidosis
2) Generation of oxygen free radicals
• Aids in oxygen-dependent killing of bacteria
• Facilitates oxygen dependent transport of antibiotics
3) Vasoconstriction
• Limits leukocyte adhesion and degrannulation
• Decreases tissue edema
Approved Indications
Diabetic wounds of the lower extremity Cont.…
Requirements for treatment:
• Patient with type I or type II diabetes and has a lower extremity wound that is due to
diabetes
• Wound classified as Wagner grade III or higher
(deep wound with abscess, osteomyelitis or tendonitis extending to those structures)
• No measurable signs of healing for at least 30 days of treatment with standard wound
therapy
• Wounds must be evaluated at least every 30 days during administration of HBO therapy
• Not covered if measurable signs of healing have not been demonstrated within any 30-day
period of treatment
Approved Indications
Diabetic wounds of the lower extremity Cont.…
Treatment duration:
• HBOT is generally performed daily for a minimum of 30 treatments
• Normally a maximum of 60 HBO treatments
• generally at 2.0 to 2.4 ATA for a total of 90 minutes
Approved Indications
Delayed radiation injury (soft tissue and bony necrosis)
• Radionecrosis ranks among the most well-researched and common uses of
hyperbaric oxygen therapy today
• Not for acute radiation injuries
• Chronic radiation tissue injury causes scarring and narrowing of blood
vessels which results in death or necrosis of the radiated tissue
• Increasing oxygen promotes tiny new blood vessels to grow inside and
around the radiated site
• Reduces swelling which allows the blood to flow more freely to the area,
bringing with it oxygen
Approved Indications
Delayed radiation injury (soft tissue and bony necrosis)
• High oxygen levels increases the ability of the ‘infection fighting’ cells (white
blood cells) to kill bacteria
• HBO is utilized as an adjunct treatment of radiation injury, including the
mandible, larynx, chest wall, bladder, and rectum
• Most commonly used for treatment of radiation cystitis and proctitis
• Treated at 2.0 to 2.5 ATA for a maximum of 60 treatments
Approved Indications
Osteomyelitis (Chronic)
• Must be chronic to usual standard of care management (i.e., antibiotics, drainage of the
abscesses and surgical debridement)
• HBO helps kill anaerobic bacteria and stops them from replicating, spreading, and
releasing damaging toxins
• HBOT can also improve circulation, boost the effect of antibiotics
• Helps to strengthen the bone cells that reabsorb dead bone
• Enhances the function of the immune system's white blood cells which depend on oxygen
Treatment duration:
• daily sessions lasting 90-120 minutes
• up to a maximum of 60 treatments
• normally treated at 2-2.5 ATA’s
Approved Indications
Skin grafts and flaps (compromised or failing)
• Substantial data suggest HBO therapy can improve composite graft survival
in the immediate postoperative period when viability appears threatened
• CMS requires presence of graft (flap) with confirmed initial viability,
followed by evidence of failing or compromised
• Bioengineered or allogenic skin grafts do not meet interpretation for
coverage per CMS
• Not unusual to receive two treatments per day for up to three days
• Number of HBO treatments not to exceed 20
Approved Indications
Necrotizing soft tissue infections (necrotizing fasciitis)
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commonly known as flesh-eating disease, is an infection that results
in the death of the body's soft tissue
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HBO is a recognized as an accepted adjunct to surgical debridement
and antibiotic therapy
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HBO can reduce the amount of hypoxic leukocyte dysfunction
occurring within an area of hypoxia and infection, and provide
oxygenation to otherwise ischemic areas, thus limiting the spread
and progression of infection
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Recommended treatment is 2.5 ATA’s every 8 hours the first day,
then twice daily for up to 10 treatments
Approved Indications
• Decompression sickness
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Result of gas bubbles in tissues and or blood causing organ
dysfunctions (not following diving decompression schedule)
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HBOT is intended accelerate bubble size reduction and to
counteract ischemia
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HBOT accelerates removal of nitrogen
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Improves tissue oxygenation
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Normally treated at 60 fsw on Navy TT6
Approved Indications
• Air Gas Embolism
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Blood vessel blockage caused by one or more bubbles of air or
gas in the circulatory system
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HBOT is intended to counteract ischemia and accelerate bubble
size reduction
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Accelerates removal of nitrogen
Improves tissue oxygenation
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Normally treated at 60 fsw on Navy TT6
Can go to 165 fsw depending on severity
Approved Indications
Central Retinal Artery Occlusion
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CRAO is a disease of the eye where the flow of blood through
the central retinal artery is blocked
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The challenge is to provide oxygen early enough after the
onset of vision loss to prevent irreversible ischemic damage to
the retina.
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Proper treatment in the first 24 hours is critical
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one of the few treatments proven effective for central retinal
artery occlusion
Approved Indications
Carbon Monoxide Poisoning
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CO binds to hemoglobin with 200 times more readily than oxygen
based upon the theory that oxygen competitively displaces CO from
hemoglobin
While breathing room air, this process takes about 300 minutes
While on a 100% oxygen nonrebreather mask, this time is reduced to about
90 minutes
With HBOT, the time is shortened to 32 minutes
HBOT is administered at 2.5-3 ATA for periods of 60-100 minutes. Depending
on patient presentation and response
1-5 treatments are recommended
Approved Indications
Idiopathic sudden sensorineural hearing loss
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The newest indication approved by the Undersea and Hyperbaric Medical
Society's Hyperbaric Oxygen Therapy Committee
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Involves an acute unexplained hearing loss, nearly always unilateral, that
occurs over less than a 72-hour period
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Although the cause is not clear, it may be related to a lack of oxygen
secondary to a vascular problem not yet identified
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The best results are obtained when HBO is initiated within two weeks of
symptom onset
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Improvement of hearing deficits from the moderate/severe range into the
slight/no impairment range
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The recommended treatment profile consists of 100% O2 at 2.0 to 2.5
atmospheres absolute for 90 minutes daily for 10 to 20 treatments
Potential Side Effects and Prevention
Side effect
Barotrauma
Prevention
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Ears
Patients are taught how to equalize pressure
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Sinuses
Nasal decongestants or oral anti-histamines can be prescribed
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Oxygen Toxicity
Air breaks / Lower treatment pressure
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Myopia
None / vision will return to normal after treatments
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Maturing Cataracts
maturing
None / Individuals with cataracts have occasionally had a
or ripening of cataracts
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Claustrophobia
Education / anxiety medication
Relative Contraindications
Relative
Contraindications
Reason
Contraindicated
Necessary Conditions Prior
to HBOT
Asthma
Air trapping upon ascent
leading to pneumothorax
Must be well controlled with
medications
Claustrophobia
Anxiety
Treatment with benzodiazepines
Chronic obstructive
pulmonary disease (COPD)
Loss of hypoxic drive to
breathe
Observation in chamber
Eustachian tube
dysfunction
Barotrauma to tympanic
membrane
Training, PE tubes
Pacemakers or epidural
pain pump
Malfunction of device
under pressure
Ensure company has pressuretested device and learn to what
depth
Relative Contraindications
Relative
Contraindications
Reason
Contraindicated
Necessary Conditions
Prior to HBOT
Pregnancy
Unknown effect on fetus
None, but HBOT may be used in
emergencies
Seizures
May have lower seizure
threshold
Should be stable on medications;
may be treated with
benzodiazepines
Upper respiratory infection
(URI)
Barotrauma
Resolution of symptoms or
decongestants
High fever
Higher risk of seizures
Provide antipyretic
Contraindications
Absolute
Contraindications
Reason
Contraindicated
Necessary Conditions Prior
to HBOT
Untreated pneumothorax
Tension pneumothorax
Thoracostomy
Bleomycin
Interstitial pneumonitis
No treatment for extended time
from use of medication
Cisplatin
Impaired wound healing
No treatment for extended time
from use of medication
Doxorubicin
Cardiotoxicity
Discontinue medication
Sulfamylon
Impaired wound healing
Discontinue and remove
medication
Types of Hyperbaric Facilities
Monoplace
Multiplace
Inpatient and Outpatient
Monoplace chamber
Monoplace chambers compress one
person at a time
The gas used to pressurize the vessel
is usually 100% oxygen.
Most chambers have air masks
available for air beaks
Monoplace chamber
Technicians tend the patient from
outside of the chamber
Equipment such as ventilators and
intravenous lines remain outside the
chamber
Newer Duoplace chambers can hold
two people. Their operation is similar
to that of a monoplace chamber.
Multiplace chamber
Treat multiple patients at the
same time
Nurse or observer monitors the
patients inside the chamber
Multiplace chamber
Patients breathe 100% oxygen via a
mask or close-fitting plastic hood
Physicians and nurses tenders can
enter and exit chamber as needed
Multiplace chamber
All equipment used with patients, such as
ventilators and intravenous lines are
placed inside the chamber
Usually can be pressurized to six
atmosphere's of pressure (165 fsw)
HBO Pre-treatment Exam
Hyperbaric physician conducts:
• History & Physical
• EKG
• CXR
• Possible side effects
• Diabetic sugar level 120-200
• Meet requirements
• HBO Consent
• Orientation
Typical HBO treatment
Pre-treatment
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Patient changes into scrubs (cotton polyester blend)
Vitals are taken (blood pressure / Sugar)
Water bottle
Grounding Strap
Checkoff list
Typical HBO treatment
Pressurization phase
• Equalize pressure (ears)
• Temperature change
• 7-10 minutes
Typical HBO treatment
At treatment pressure
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Relax
Watch TV
Sleep
Constant ventilation
Air breaks
90-100 minutes
Typical HBO treatment
Depressurization phase
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7-10 minutes
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Temperature change
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Total time 110-120 minutes
2.4 ATA HBO Treatment
2.0 ATA HBO Treatment
Questions