A Guide To Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

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

    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.)

What The Clinical Evidence Reveals

   Diabetic foot wounds are precursors to 85 percent of major leg amputations, which lead to increased morbidity and mortality rates rivaling that of many cancers.8 The medical, rehabilitation, social and emotional costs of major leg amputations are all enormous. The concept of “limb preservation” advocates best practice wound care and multidisciplinary team approaches, which are known to save “at-risk” limbs.

   In 2005, Kranke, et al., systematically reviewed “HBO and chronic wounds” based on publications from 1966 to 2003, including five randomized controlled trials (RCT).9 This review came to the conclusion that HBO for diabetic foot ulcers “significantly reduced the risk of major amputation and may improve the chance of healing at one year.” The study also suggested that “the application of HBOT to these patients may be justified where HBOT facilities are available.” The analysis predicts surgeons avoided one major leg amputation per four patients treated via HBO.

   In March 2007, a similar conclusion was published by the Canadian Agency for Drugs and Technology in Health with the report “Adjunctive HBOT for Diabetic Foot Ulcer.” In this report, adjunct HBO therapy in diabetic foot ulcer treatment was more effective and healed more wounds versus standard care (SC) alone, and subsequently lowered the incidence of major leg amputations (11 percent for the HBO group versus 32 percent for standard care).10 Moreover, this review calculates the economic benefit of avoiding major leg amputations, which translates to significantly lower treatment costs ($40,695 HBO versus $49,786 SC) and increased “quality of life years” (3.64 HBO versus 3.01 SC).

A Guide To Indications For HBO In Non-Diabetic Wounds

   Although the clinical evidence is less robust in these “non-diabetic wound” indications, HBO treatments are nonetheless effective and reimbursable by Medicare and most payors.

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