What You Should Know About Using HBO In Diabetic Wounds
Final Thoughts On Appropriate Patient Selection
The justification for using HBO adjunctively for a specific problem wound rests upon the clinical presentation of the wound and whether there is evidence of malperfusion or persistent or progressive local infection. Measuring transcutaneous PO2 (TcPO2) in tissue adjacent to the wound can be useful in discriminating those patients without significant hypoxia who do not require HBO from those who do. In general, TcPO2 values below 40 mmHg indicate microcirculatory impairment. Impairment in healing increases as the value decreases below this threshold. Obtaining TcPO2 values during HBO treatment may offer the best prediction of who will respond favorably to adjunctive HBO.14
The best way to use TcPO2 is in a step-wise manner. A low baseline TcPO2 confirms that spontaneous healing will probably not occur. You should then proceed to revascularization if possible. If TcPO2 still remains low, then you should check the in-chamber TcPO2. If that value is greater than 200 mmHg, the likelihood of benefit from HBO is high and a course of HBO may be appropriate, assuming other criteria have been met. You must regularly re-evaluate patients undergoing HBO for evidence of benefit.
One should evaluate patients for functional outcome. You should remove necrotic toes or other material prior to initiating HBO. In many cases, a transmetatarsal amputation is an acceptable outcome. HBO cannot be used to “resurrect” necrotic material.
When HBO is used adjunctively in a setting of multidisciplinary wound care, it has the potential to significantly improve diabetic foot ulcer outcome and limb salvage in this challenging group of patients.
Dr. Warriner is the Medical Director of the Southeast Texas Center for Wound Care and Hyperbaric Medicine at the Conroe Regional Medical Center Hospital in Conroe, Tx. He is a Fellow of the American College of Hyperbaric Medicine, is a Certified Wound Specialist and is certified by the American Board of Anesthesiology.
Dr. Fife is the Medical Director of the Memorial Hermann Center for Wound Healing and Hyperbaric Medicine in Houston, Tx. She is a Clinical Associate Professor within the Department of Anesthesiology at the University of Texas Health Science Center.
Dr. Steinberg (pictured) is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.
1. Shuren J, Dei Cas R, Kucken L, Tilman K (Coverage and Analysis Group). CMS CAG-00060N, Hyperbaric Oxygen Therapy (HBO) in the Treatment of Hypoxic Wounds and Diabetic Wounds of the Lower Extremities. CMS August 30, 2002.
2. CMS Program Memorandum to Intermediaries/Carriers Transmittal AB-02-183 December 7, 2002 Coverage of hyperbaric oxygen (HBO) therapy for the treatment of diabetic wounds of the lower extremities and Medicare Coverage Issues Manual Transmittal 164 December 27, 2002 Section 35-10 Hyperbaric oxygen therapy (revised).
3. Faglia E, et al. Adjunctive systemic hyperbaric oxygen therapy in the treatment of diabetic foot ulcer. A randomized study. Diabetes Care 1996;19:1338-43.
4. BlueCross BlueShield Association Assessment Program. Hyperbaric Oxygen Therapy for Wound Healing—Parts I, II, III. 1999; 14(2, 15, 16). Blue Cross Blue Shield Association Technology Evaluation Center.
5. Medical Services Advisory Committee (MSAC), Department of Health and Aged Care, Australia. Hyperbaric Oxygen Therapy, November 2000; MSAC applications 1018-1020 Assessment Report.
6. British Journal of Medicine, Clinical Evidence. Diabetic foot ulcer. June, 2001 Issue 5.
7. Agency for Healthcare Research and Quality Contract No. 270-97-0019, September 24, 2001, Hyperbaric Oxygen Therapy in Treatment of Hypoxic Wounds.
8. American Diabetes Association (April 7-8, 1999) Consensus Development Conference on Diabetic Foot Wound Care. Diabetes Care 1999; 22(8) 1354-1360.
9. Pecoraro RE, Ahroni JH, Boydo EG, Stensel VL. Chronology and determinants of tissue repair in diabetic lower extremity ulcers. Diabetes 1991; 40:1305-1312.
10. Hampson NB (ed). Hyperbaric Oxygen Therapy: A Committee Report. Undersea and Hyperbaric Med Soc, Kensington, MD, 1999, 82pp.