Key Insights On Using Hyperbaric Oxygen For Wounds
Hyperbaric oxygen therapy (HBOT) can be a valuable adjunctive treatment for patients with various types of wounds. These expert panelists discuss their indications for HBOT, their treatment protocol and barriers to the use of HBOT.
Q: Do you use HBOT for your wound patients and what are the indications?
A: As Caroline E. Fife, MD, explains, hyperbaric oxygen therapy is the administration of oxygen to the entire body at atmospheric pressures greater than 1.5 times sea level pressure. She notes one should not confuse this with topical oxygen administered to part of the body or oxygen (or air) via “zip up” chambers at very low atmospheric pressures. The usual treatment pressure for wound-related problems is at least 2.0 atmospheres absolute (ATA) although she notes that sometimes patients receive pressures of 2.4 or 2.5 ATA depending on the situation. At these pressures, one can expect tissue oxygen levels in excess of 600 mmHg.
Dr. Fife notes hypoxia is a common cause of wound healing failure. Non-healing amputations, ulcers due to vascular insufficiency and diabetic foot wounds all share the problem of tissue hypoxia, which Dr. Fife says is usually due to ischemia from vascular disease.
She says normalizing tissue PO2 enhances resistance to infection, collagen deposition and angiogenesis. However, Dr. Fife sees a disconnect between the rationale for HBOT and what physicians can treat in terms of current Medicare coverage policy.
“While third-party payers require us to ‘bucket’ wounds and ulcers into neat diagnostic categories, real patients rarely cooperate by falling into clear disease classification systems,” explains Dr. Fife. “A variety of problem wounds exist and are usually the result of multiple local and systemic factors.”
Kazu Suzuki, DPM, thinks HBOT is “an invaluable adjunctive therapy in modern wound care clinics.” He notes about 10 to 15 percent of his patients who present at his wound care centers have indications for HBOT and he recommends it routinely when indicated. Dr. Suzuki works with the three HBOT centers near his wound care clinic. Two of the centers have monoplace chambers while the other has a multi-place chamber that fits about 10 people at the same time.
Dr. Suzuki has discovered that most patients prefer monoplace chambers because of the privacy with more open appointment times. This is in contrast to multi-place chamber clinics, which have a fairly rigid schedule for treatment, according to Dr. Suzuki. If the patient is five minutes late, he or she will miss the treatment. However, he always emphasizes that the efficacy of HBOT would be the same in either size chamber, since “oxygen is oxygen” regardless of which clinic they use.
Michael DellaCorte, DPM, CHT, uses HBOT as an advanced treatment for patients with diabetes and says he has attained “very positive” results. He combines several treatment options with HBOT. These treatment options include negative pressure wound therapy (NPWT), PICC lines, Apligraf (Organogenesis) or Dermagraft (Advanced Biohealing) along with weekly wound care and offloading.
Q: What are the indications for HBOT? When would you incorporate HBOT into your treatment protocol?
A: Dr. Suzuki follows the guidelines of the Undersea Hyperbaric Medical Society (UHMS, www.uhms.org). Both he and Dr. DellaCorte use HBOT for diabetic foot ulcers of Wagner grade III or higher.
In evaluating all the randomized controlled trials (RCTs) on diabetic foot ulcers over the past 10 years, Dr. Fife says only HBOT trials have enrolled patients with Wagner III grade ulcers and/or significant tissue ischemia. She points out that all other RCTs excluded patients with ischemia.1 Accordingly, Dr. Fife says HBOT “stands alone in demonstrating benefit for ischemic diabetic foot ulcers.”