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

Comments

Dear Editor,

In regards to your recent article, Key Insights On Using Hyperbaric Oxygen For Wounds, published in Volume 23, January 1, 2010:

Dr. Kazu Susuki’s and Dr. Caroline E. Fife’s concerns over equalization of pressure in patients’ middle ears and sinuses during compression is certainly an important one. Middle ear squeeze has been recognized as the most common complication in hyperbaric oxygen therapy. Likewise, as noted by Dr. Michael DellaCorte, pulmonary barotrauma resulting from impaired elimination of gas from the lungs of patients with COPD during decompression is another complication with potentially serious consequences relating to the effects of Boyle’s Law.

What is not mentioned in this discussion, however, is that methods to significantly reduce the incidence of middle ear barotrauma during compression, and to more effectively manage patients with COPD during decompression, have been developed. Dr. Benton P. Zwart of the U.S. Air Force investigated the consequences of pressure change conducted with a constant rate of volume change over time rather than a constant rate of pressure change over time.2 He reported that this approach significantly reduced the incidence of middle ear barotrauma and would, as a result of the same physical principles, make decompression safer for patients with COPD, emphysema, and asthma.

While implementing the pressure-change protocols investigated by Zwart on chambers with manual pneumatic control systems, and even rudimentary electronic control systems, is impractical, they have been implemented during both compression and decompression on chambers with computer-based automatic control systems. Feedback on the practical use of these methods over a number of years has confirmed Zwart’s findings.

Very truly yours,

Russell E. Peterson, Ph.D.
Technical Director
Environmental Tectonics, Corporation
Biomedical Systems
Southampton, Pennsylvania
www.etcbiomedical.com

1 Vrabec JT, Pirone C, Goble S, Mader JT. Middle ear barotrauma from hyperbaric oxygen therapy: Severity,
prevention and management. In: Mueller PHJ, Pirone C, Barach P, eds. Patient safety: Prevention and treatment of complications in hyperbaric medicine. Kensington, Maryland: Undersea and Hyperbaric Medical Society, Inc., 2002:107-113.

2 Zwart BP. The "smooth ride" profile: Development, implementation, and evaluation of a hyperbaric chamber descent and ascent based on a constant rate of volume change with time. Davis Hyperbaric Laboratory Report, Brooks AFB, Texas, 1998.

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