Point-Counterpoint: HBOT: Is It Worthwhile For DFUs?
This author offers a closer examination of recent controversies in the literature on hyperbaric oxygen therapy (HBOT) and cites an ample body of literature to justify that HBOT can be a valuable treatment to promote diabetic foot ulcer healing in appropriately selected patients.
By Enoch T. Huang, MD, MPH&TM, FACEP, FUHMS, FACCWS
Clinicians have debated the use of hyperbaric oxygen therapy (HBOT) for the treatment of diabetic foot ulcers (DFUs) for years. When looking at the entire body of evidence, there have been eight randomized controlled trials, over a dozen observational studies and several meta-analyses that have shown to varying degrees that HBOT increases the rate and percentages of wound healing, decreases amputation rates, stimulates angiogenesis, increases healthcare-related quality of life, and helps in the overall treatment of DFUs.1-26
Supporters and detractors of HBOT have their own biases when looking at the literature, but both camps can agree on the huge public health problem that is associated with DFUs.
The Centers for Disease Control and Prevention (CDC) estimate that 25.8 million people, or roughly 8.3 percent of the U.S. population, are affected by diabetes.27 More than 60 percent of non-traumatic amputations occur in people with diabetes and a foot ulcer precedes 85 percent of lower-limb amputations in patients with diabetes. Contralateral leg amputation occurs in 56 percent of patients with diabetes who have had a lower-limb amputation and the five-year mortality rate for patients with diabetes who have had a single-leg amputation is 60 percent. That is higher than the mortality rate of breast cancer (10 percent), bladder cancer (19 percent), colorectal cancer (33 percent) and all cancers combined (32 percent).28,29 While the amputation itself is not the cause of the high five-year mortality, it is an indicator that this particular patient has advanced disease with a host of comorbidities.
Will HBOT reverse these comorbidities and decrease this high mortality rate? No. However, that does not mean that HBOT has no role in improving healthcare quality of life by preserving a functioning limb.
Researchers have shown that the use of comprehensive foot care programs — that include early screening and evaluation of problems, foot care education, preventive therapy, and referral to specialists — reduce amputation rates by 45 to 85 percent.27 Hyperbaric oxygen should be an integral part of a comprehensive foot care program and a preponderance of the literature supports this as well.
The biggest caveat to using HBOT is that it is an adjunctive treatment and cannot take the place of high quality wound care. The International Working Group on the Diabetic Foot guidelines for the best practice treatment of diabetic foot ulcers includes four tenets: treatment of underlying infection, revascularization if appropriate and feasible, offloading to minimize trauma to the ulcer site, and management of the wound bed to promote healing.30 Failure to address these tenets obviates any discussion about the utility of HBOT.
Assessing The Benefits Of HBOT And Discordance With CMS Reimbursement Policies
What exactly does HBOT do for the diabetic foot? HBOT is capable of oxygenating ischemic and hypoxic tissue, stimulating angiogenesis, mobilizing stem cells, up-regulating a plethora of growth factors, stimulating fibroblast and osteoclast activity, increasing collagen synthesis and cross-linking, reducing edema, increasing red blood cell deformability, and enhancing leukocyte killing activity. In short, HBOT improves wound healing.31