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Hyperbaric Oxygen Therapy Mark Wilson, CHT Hyperbaric Oxygen Therapy (HBO) • Involves breathing 100% oxygen at greater than ambient pressure • Think of oxygen as a drug and the hyperbaric chamber as a dosing device • 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; • Hyperbaric Oxygen Therapy (HBOT) • • • • • 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 • • • Air or Gas Embolism Decompression Sickness Carbon Monoxide Poisoning • • • • • • • • • • • • • 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) • commonly known as flesh-eating disease, is an infection that results in the death of the body's soft tissue • HBO is a recognized as an accepted adjunct to surgical debridement and antibiotic therapy • 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 • 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 • Result of gas bubbles in tissues and or blood causing organ dysfunctions (not following diving decompression schedule) • HBOT is intended accelerate bubble size reduction and to counteract ischemia • HBOT accelerates removal of nitrogen • Improves tissue oxygenation • Normally treated at 60 fsw on Navy TT6 Approved Indications • Air Gas Embolism • Blood vessel blockage caused by one or more bubbles of air or gas in the circulatory system • HBOT is intended to counteract ischemia and accelerate bubble size reduction • • Accelerates removal of nitrogen Improves tissue oxygenation • • Normally treated at 60 fsw on Navy TT6 Can go to 165 fsw depending on severity Approved Indications Central Retinal Artery Occlusion • CRAO is a disease of the eye where the flow of blood through the central retinal artery is blocked • The challenge is to provide oxygen early enough after the onset of vision loss to prevent irreversible ischemic damage to the retina. • Proper treatment in the first 24 hours is critical • one of the few treatments proven effective for central retinal artery occlusion Approved Indications Carbon Monoxide Poisoning • • • • • • • 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 • The newest indication approved by the Undersea and Hyperbaric Medical Society's Hyperbaric Oxygen Therapy Committee • Involves an acute unexplained hearing loss, nearly always unilateral, that occurs over less than a 72-hour period • Although the cause is not clear, it may be related to a lack of oxygen secondary to a vascular problem not yet identified • The best results are obtained when HBO is initiated within two weeks of symptom onset • Improvement of hearing deficits from the moderate/severe range into the slight/no impairment range • 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 • Ears Patients are taught how to equalize pressure • Sinuses Nasal decongestants or oral anti-histamines can be prescribed • Oxygen Toxicity Air breaks / Lower treatment pressure • Myopia None / vision will return to normal after treatments • Maturing Cataracts maturing None / Individuals with cataracts have occasionally had a or ripening of cataracts • 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 • • • • • 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 • • • • • • Relax Watch TV Sleep Constant ventilation Air breaks 90-100 minutes Typical HBO treatment Depressurization phase • 7-10 minutes • Temperature change • Total time 110-120 minutes 2.4 ATA HBO Treatment 2.0 ATA HBO Treatment Questions