Hyperbaric Oxygen Therapy

INTRODUCTION
• Hyperbaric oxygen is defined as
therapy
administration of 100% oxygen to a patient
placed inside a chamber pressurized to greater
than 1 atmosphere.
 Not Hyperbaric Therapy!!!
• Local application of pressurized oxygen to a part of the body
without completely enclosing the patient is not hyper baric
oxygen therapy
 History
• Initial discovery
– 1662  Henshaw built first hyperbaric chamber
• English physician and clergyman Called the chamber
the “Domicilum”
 Background
• Elemental Oxygen
– 1775  Discovered by Priestly (English)
• Surgical use
– 1870’s Fontaine & Bert (France)
• Prolong anesthesia
• Improved surgical outcomes
– Wound healing
• Decompression sickness
– 1910-30’s Drager, then Behnke & Shaw
• Reduced morbidity of decompression
• Studies of cardiopulmonary effects initiated
 Physiology
• Cardiopulmonary
– Increase in PaO2
• Saturation of
available
hemoglobin
molecules
– Hb 97%
saturated at
atmospheric
pressure
– Maximization
does NOT
significantly
increase O2
 Mechanisms of Action

Increased Oxygen Tension

Vasoconstriction
Increased Fibroblast Replication
Increased Collagen Response
Angiogenesis
Enhanced Leukocyte Function
Attenuation of Reperfusion Injury
 Mechanism of Action
• Three main effects of HBO2:
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
 Dosing and Delivery
• Parameters
– All regimens use
100% O2
– Pressure more
variable
• Most use 2.4
atm
• Maximum
tolerated is 3 atm
• 4 atm induces
seizures
M
o
Dosing and Delivery
 Dosing and Delivery
• Common regimens
– Dives between 30 and
120 minutes
• May be daily or BID
• Total number varies by
indication
– Most treatments
around 30 dives
– Optional
addition of 10
or more dives
– Monoplace &
Multiplace Hyperbaric Chamber.
Multiplace chambers
 Advantages of a Monoplace Chamber
1.Patients are cared for individually thereby maintaining
patient privacy.
2.Isolation of patients insures that there is no
amplification or spread of disease or infection from other
patients.
3.Patient can enjoy a more comfortable and relaxing
treatment.
4.Multiplace chambers require an awkward and
restraining facemask, Monoplace Chambers do not.
6. Technicians can easily monitor patients.
7.Ideal for patients confined to bed in acute stages of
illness or injury.
 INDICATIONS
Investigational
Autism
Auto-immune Disorders
Cancer Treatment
Cerebral Palsy
Chemical Toxicity
Chronic Fatigue Syndrome
Crohn’s Disease
Fibromyalgia
Headache Syndromes
Lyme Disease
Macular Degeneration
Pre And Post Surgical
Healing (Cosmetic
Surgery)
Multiple Sclerosis
Near Drowning
Respiratory distress syndrome
Seizure Disorder
Spinal Cord Injury
Sports Injuries
Stem Cell Recovery Treatment
Stroke
Tinnitus
Traumatic Brain Injury
 Contraindications
• One absolute contraindication
– Pneumothorax
• Pressure converts to tension
pneumothorax
– All patients get screening CXR
• Relative contraindications
– History of spontaneous
pneumothorax
– History of throacic
surgery
– Concurrent URI
– Emphysema and COPD
– Seizure disorders
 Complications
• Barotrauma
– Lung parenchyma
• Elevated pressures
may damage alveoli
– Alveolar
hemorrhage
– Hemoptysis
– Pneumonitis
– Alveolar rupture
• Pneumothorax
• Pulmonary interstitial
emphysema
Pneumothorax
 Complications..
• Lens deformation causes temporary myopia
• Exacerbation of other processes
– Dental abscess, sinusitis, laryngocele, etc.
• Claustrophobia, anxiety, etc.
• Oxygen toxicity
– Very rare, but may cause seizures
• Potential effects on tumor growth
– Controversial
 Fire Risk
• Especially monoplace
– 100% oxygen
– Highly pressurized
– Enclosed space
• Rare… but not rare enough
– 50 deaths due to HBO2-related fires since 1980
– Must remove all flammable materials
– Fire safety protocol is essential
• Risk reduced in multiplace chambers
– Chamber pressurized
– O2 delivered individually via tight-fitting masks
– Attendants may enter in an emergency
 Contraindications

• Absolute Contraindications
– Untreated Pneumothorax
– Bleomycin –cardiotoxicity
– Cisplatin- delayed wound healing
– Disulfiram- blocks superoxide dimutase
(SOD)
Absolute HBO Contraindications

Recent Bleomycin Use – recent is not established although a one year period
may be sufficient.

Current Doxorubicin (Adriamycin) – wait 2-3 days prior to starting HBO.

Undersea and Hyperbaric Medicine board Review Course for Physicians
Penn Medicine. August 2010.
Absolute HBO Contraindications
Disulfiram (Antabuse) – blocks superoxide
dismutase which decreases the body’s ability to
neutralize oxygen free radicals; inhibits
hyperoxic induction of cytochrome P450.
Potential for pulmonary toxicity.
 Contraindications
Relative Contraindications
• URI
• COPD with bullous emphysema or CO2 retention
• Claustrophobia
• Seizures
• Ear or sinus surgery or recent thoracic surgery
• Optic neuritis
• Pacemakers (verify for pressure tolerance)
• Pregnancy
• Congenital Spherocytosis
 Costs
• HBO2 is relatively expensive…
– Monoplace chamber < Multiplace chambers
– Most facilities have multiplace chamberss, etc.
– But…
• Medicare reimburses for most accepted indications
 Summary
• HBO2 derives its clinical benefit via
– Increase in the oxygen delivery to hypoxic tissue
– Promoting native mechanisms of healing
– Decreasing tissue edema & reperfusion injury
• Dosing
– Most commonly 30-40 dives of 90 min at 2.4atm but
less than 3 atm
• Costs
– Significant, yet analyses support cost savings in proven
indications
 Summary
• Supported ORL-HNS indications
– ORN & CRN, radiation soft tissue injury
– Flap & graft survival
• Unsupported ORL-HNS indications
– Sudden SNHL, tinnitus, Bell’s palsy
• Areas of uncertainty
– Likely effect: MOE & skull base osteo, fistulas
– Poor side effect profile: radiation sensitization
 Summary
• Further research
– Molecular mechanism incompletely understood
• Animal studies
• Human tissue studies
– Need ethical randomized control trials
• Variety of indications
– More combination regimens for cancer treatment
& post-XRT reconstruction salvage
• What are the optimal dose & delivery shemes?
 Summary
• Further research
– Molecular mechanism incompletely understood
• Animal studies
• Human tissue studies
– Need ethical randomized control trials
• Variety of indications
– More combination regimens for cancer treatment
& post-XRT reconstruction salvage
• What are the optimal dose & delivery shemes?