Assessing The Potential Impact Of HBOT For Your Practice

Jay G. Levine, DPM, and Bernie Chowdhury, BA, CHT

Any podiatrists seeking better patient outcomes should consider adding hyperbaric oxygen therapy (HBOT) to their treatment options. The practice of putting patients inside a hyperbaric chamber — either a monoplace or a multi-place chamber — and having them breathe 100 percent oxygen while under increased atmospheric pressure is gaining currency, and is well documented in the scientific literature.1

   Hyperbaric oxygen therapy has several proven mechanisms of action, including:

• hyperoxygenation;
• vasoconstriction;
• edema reduction;
• fibroblast proliferation and collagen formation;
• angiogenesis (neovascularization);
• enhanced bacterial killing;
• toxin inhibition and inactivation;
• antibiotic synergism; and
• neutrophil reperfusion response.1

   The advantages of HBOT include faster rates of wound healing through angiogenesis and anti-bactericidal properties of 100 percent oxygen, limb salvage and reduced hospital length of stay.2-4 While HBOT is not for every patient, it has been the lead author’s experience that HBOT is a powerful modality that can make all the difference in a successful clinical outcome for appropriate patients. A typical wound care program will have 15 to 20 percent of its patients as potential HBOT candidates.

   Whether you are part of an established wound care program, have your own private practice or are a hospital-based podiatrist, your patients can benefit from HBOT. In order to make the best use of HBOT, it is critical to understand which medical conditions and clinical parameters will make a patient a candidate for HBOT. It is also critical to understand hyperbaric medicine’s mechanisms of action in order to begin the patient selection process for HBOT.

   After identifying patients as HBOT candidates, one must perform several tests to rule out potential complications during oxygen treatment. Typically, these tests will include electrocardiography, chest X-rays, and lab tests, including a complete blood cell count with differential and chemistry. Clinicians should also obtain a solid patient history and perform a physical exam to rule out ear, nose and throat issues; cardiac and pulmonary problems, including congestive heart failure, chronic obstructive pulmonary disease, decreased ejection fraction; and renal failure. Clinicians should also determine whether there are issues with diabetic glucose control. One should determine if there is a history of seizures and carefully review the patient’s medication history.

   A vascular evaluation may be required. In some cases, HBOT reimbursement is contingent on demonstrating vascular proficiency through the use of transcutaneous oximetry (TCOM or TcPO2) testing. When it comes to diabetic lower extremity wounds, the Centers for Medicare and Medicaid Services (CMS) now require a positive vascular assessment. Barring that, any claims for HBOT related to that patient will be denied. Prior to beginning HBOT, one must address, correct and verify the correction of vascular deficiencies. Limitations in podiatric scope of practice dictate that an MD or DO conduct the history and physical although a DPM can direct the TCOM testing providing that the area being tested falls within the DPM scope of practice.

Case Study One: Using HBOT For A Patient With Osteomyelitis And Gas Gangrene

A 67-year-old obese female presented to the ER with a septic wound, a white blood cell count of 23,000 and gas in the soft tissues. The patient had diabetes and hypertension. She was taking insulin and lisinopril. She initially received treatment for interdigital tinea but did not follow up with her podiatrist.

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