Key Insights On Using Hyperbaric Oxygen For Wounds
- Volume 23 - Issue 1 - January 2010
- 14645 reads
- 1 comments
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
If values continue to be low and patients have a diagnosis for which HBOT would be covered, Dr. Fife performs in-chamber TcPO2 studies. As she notes, outcome studies suggest that 84 percent of diabetic foot ulcers with in-chamber values >200 mmHg are likely to respond to HBOT. Dr. Fife says treatment can be at 2.0 ATA or greater as long as in-chamber TcPO2 values are >200 mmHg.6 Dr. Fife says it is not clear whether the same in-chamber values are predictive of success for arterial ulcers or failing flaps. The average number of treatments for a DFU is around 35, says Dr. Fife. She notes that if patients fail to demonstrate benefit after 20 treatments, then HBOT should stop.
Q: In your experience, what is the main barrier to treatment with HBOT?
A: Dr. Suzuki notes one contraindication is untreated pneumothorax. However, Dr. Fife adds that one can treat pneumothorax if it is vented. Dr. Suzuki asks patients to refrain from getting the treatment when they have sinus congestion as high pressure may exacerbate the symptoms. If the patient is having a hard time clearing the ears during HBOT, both he and Dr. Fife suggest putting pressure equalization tubes in the patient’s ears.
Dr. DellaCorte adds that ear barotrauma due to chamber pressure and claustrophobia are other barriers to treatment. Dr. Fife notes another relative contraindication includes pulmonary air trapping (chronic obstructive pulmonary disease). Patients with COPD are at risk for pulmonary barotrauma and Dr. Fife says one must decide whether it is safe for these patients to undergo HBOT. Patients with uncontrolled seizures are not recommended for HBOT, according to Dr. Fife.
Dr. Suzuki’s patients sometimes complain of logistical problems since the ideal HBOT occurs Monday through Friday for 20 days, meaning four weeks of commitment. For out-of-town patients (commuting for an hour or longer) or dialysis patients, he recommends treatment three times a week (on non-dialysis days). Outcome data suggest that regular attendance to therapy affects whether patients benefit, according to Dr. Fife.7 She adds that therapy five days per week can be difficult for chronically ill patients.
Dr. Suzuki refutes the claim that patients on VAC therapy (KCI) cannot be in the chamber. He says as long as the HBOT technicians know how to disconnect and reconnect the suction hose to keep the machine outside of the chamber, patients using VAC therapy can successfully undergo treatment with HBOT.
Drs. DellaCorte and Fife note the barrier of insurance coverage. Although it is likely that non-diabetic patients with ischemia would benefit, Dr. Fife says in the absence of acute arterial insufficiency, a failing flap or osteomyelitis, patients whose only diagnosis is chronic arterial disease do not meet current coverage guidelines.
“This is unfortunate since there are no other interventions likely to prevent limb loss if revascularization has failed to sufficiently increase tissue oxygen levels,” explains Dr. Fife.