Key Insights On Using Hyperbaric Oxygen For Wounds
The Centers for Medicare and Medicaid Services (CMS) cover HBOT for diabetic foot ulcers based on the RCT data.2 As Dr. Fife maintains, while there is no reason to believe that HBOT would not be equally effective for ischemic ulcers in non-diabetics, HBOT is only “covered” for Wagner III diabetic foot ulcers and not for similar limb-threatening ulcers in patients without diabetes. She also notes that HBOT is covered for acute arterial ischemia.
Drs. Suzuki and DellaCorte will use HBOT for patients with chronic osteomyelitis. Dr. Suzuki notes the synergy among most antibiotics and HBOT, adding that he uses magnetic resonance imaging to monitor treatment progress.
Hyperbaric oxygen is also covered for chronic refractory osteomyelitis as it increases the oxygen concentration in bone, and directly kills or inhibits the growth of organisms that prefer low oxygen concentrations, according to Dr. Fife. She notes that HBOT also augments the antibacterial effect of certain antibiotics that have an oxygen dependent transport mechanism across the bacterial cell wall. Dr. Fife says these antibiotics include aminoglycosides, vancomycin, quinolones and certain sulfonamides.3
Drs. Suzuki and DellaCorte also use HBOT for skin flap failure. When it comes to a transmetatarsal amputation, if the plantar skin flap does not heal properly, Dr. Suzuki immediately sends the patient for HBOT for skin flap salvage. He maintains that HBOT in this situation is far better than doing another proximal amputation. Dr. DellaCorte points out that transmetatarsal amputations that start to necrose do not do well with HBOT. Emphasizing that hyperbaric oxygen is not a substitute for revascularization, Dr. DellaCorte says he will refer the patient for bypass first if appropriate for the given patient.
Dr. Fife says HBOT can help treat compromised flaps that appear to have post-op ischemia. She adds that HBOT can also help minimize the amount of tissue that does not survive after a plastic surgical “flap” and reduce the need for repeat flap procedures.4
Dr. Suzuki and his partner, a plastic reconstructive surgeon, use HBOT for many cancer patients who have had radiation. Unless the patient received a very short course of radiation treatment, he says most radiation recipients suffer from radionecrosis of soft tissue (burn wound of skin to internal bleeding) and bone (spontaneous fracturing of jaw bone, etc).
“This HBOT indication is often overlooked but we have made a lot of people happy by offering this treatment option,” says Dr. Suzuki.
In regard to protocol, Dr. Suzuki starts with the initial consultation with the hyperbaric doctor on site and then prescribes 20 sessions of HBOT for wound indications such as diabetic foot ulcers. Each session is usually 60 to 90 minutes of 2.0 to 2.8 ATA, although each clinic has its own protocols. He says patients with osteomyelitis and radionecrosis indications usually need 30 sessions or more. It is rare but when it comes to traumatic amputation of toes, Dr. Suzuki would recommend twice daily HBOT treatment for a week after re-attachment of the digit and then may reduce that to once-a-day treatment.
Although treatment varies according to the patient condition, Dr. DellaCorte says most patients receive 90 minutes of HBOT at a pressure of 2.4 ATA for a total time of about 106 minutes in the chamber, including eight minutes to get to the appropriate pressure and eight minutes to decompress. Six weeks or 30 dives/treatments is his standard protocol. As Dr. DellaCorte notes, CMS requires re-evaluation every 10 dives/treatments. If there is no improvement, he stops treatment but treatment will continue if the wound is improving.
Dr. Fife uses transcutaneous oximetry to screen patients with non-healing wounds to determine if spontaneous healing is possible. If TcPO2 values are low and do not increase with sea level oxygen breathing, she says patients are likely to have vascular disease. She will perform revascularization when possible and subsequently reassess the TcPO2.5