A Guide To Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

By Kazu Suzuki, DPM, CWS; Clinical Editor: John S. Steinberg, DPM

What Are The Guidelines For HBO In Diabetic Foot Wounds?

    Four years ago, the Center for Medicare and Medicaid Services (CMS) approved reimbursement of HBO treatments for diabetic foot wounds. Following this decision, virtually every private payor now reimburses HBO treatment of diabetic foot wounds. Medicare’s HBO reimbursement guidelines require patients to meet the following three criteria. • Presence of diabetes and lower extremity wounds • Thirty days of standard wound care have shown no improvement • Wounds must be Wagner Grade III (deep wound with abscess, osteomyelitis or tendonitis extending to those structures), Wagner Grade IV (gangrenous toes and forefoot) or V (gangrenous foot).     Hyperbaric oxygen therapy is not a “cure-all” treatment. It is an adjunctive therapy for proper wound care and is certainly not a substitute for vascular workup and revascularization efforts.    In our wound care center, we assess the vascular status of lower extremity wounds with a skin perfusion pressure (SPP) monitor (Sensilase, Vasamed). If the foot/ankle SPP is below 30 mmHg, it is diagnostic of critical limb ischemia (CLI) and this warrants an immediate referral to a vascular specialist.6    Although it is more time consuming, one may substitute a transcutaneous oximetry monitor (TCOM) as another microcirculatory test predictive of wound healing in the initial vascular assessment stage. The ankle brachial index (ABI) and toe brachial index (TBI) are useful screening tools of ischemia if the patients do not have calcified leg vessels due to diabetes or end-stage renal disease (ESRD).     I urge physicians to familiarize themselves with local HBO facilities by accessing the chamber directory on the Undersea and Hyperbaric Medical Society’s Web site (www.uhms.org). Several HBO physicians suggest calling first for referrals and “referring early” before extensive hypoxic damage occurs. Discussing the patient’s case and follow-up arrangements with a local HBO physician can determine if the patient is a candidate for treatment and if he or she will receive care. Be prepared to provide copies of the patient’s most recent history and physical, wound progress notes, lab and imaging results, a consultation request and a letter of medical necessity if applicable.

What You Should Know About The Convenience And Safety Of HBO

   Outpatient HBO treatments (commonly called “dives”) usually last 90 minutes while patients are napping or watching TV. Ideally, patients should undergo 20 daily treatments within a month’s duration. Every HBO treatment is closely monitored by a certified hyperbaric technician and supervised by a HBO physician for patient safety.

Is HBO dangerous?

   The risk versus benefit ratio of HBO is remarkably favorable. The most common side effect of HBO is otic barotrauma, which may cause ear discomfort. Physicians have traditionally reported a 2 percent incidence of this side effect but a recent retrospective review shows the incidence of otic barotrauma may be as low as 0.821 percent.1,7 While claustrophobia reportedly occurs in 2 percent of the general population, the aforementioned review cites a 0.34 percent incidence of confinement anxiety as the second most common side effect based on 90,186 HBO treatments.7 Additionally, no fire accidents or fatalities have been reported in the United States with medical HBO chambers.    As VAC therapy dressings (KCI) are compatible with HBO treatment, we often utilize VAC and HBO simultaneously for deep foot wounds, skin graft preparation and/or bolstering. (Note: The machine is disconnected temporarily while the patient is being treated within a chamber.)

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