Point-Counterpoint: HBOT: Is It Worthwhile For DFUs?
46. Londahl M, Katzman P, Hammarlund C, et al. Relationship between ulcer healing after hyperbaric oxygen therapy and transcutaneous oximetry, toe blood pressure and ankle-brachial index in patients with diabetes and chronic foot ulcers. Diabetologia. 2011; 54(1):65-8.
For further reading, see “How Effective Is HBOT For Diabetic Foot Ulcers?” in the May 2013 issue of Podiatry Today. To access the archives, visit www.podiatrytoday.com.
This author points to conflicting results in the literature on HBOT and the fact that only a few randomized controlled trials involving humans have examined HBOT in relation to treatment for diabetic foot ulcers. He says there is also a need for more specific criteria in regard to HBOT for patients with diabetic foot ulcers.
By Javier La Fontaine, DPM, MS, FACFAS, FASPS
The clinical history of hyperbaric medicine dates back to the 17th century but its benefits for wound healing and infection did not appear in the medical literature until the 1960s. A report by the Hyperbaric Oxygen Therapy Committee of the Undersea and Hyperbaric Medical Society lists several indications for hyperbaric oxygen therapy (HBOT) that are directly applicable to lower extremity pathology.1 These include clostridial myonecrosis, acute traumatic ischemia, enhancement of healing in problem wounds, necrotizing soft tissue infections, refractory osteomyelitis, compromised skin grafts and flaps, and thermal burns.
Although HBOT has gained popularity as an adjunctive treatment for diabetic foot wounds, there are surprisingly few published reports that support its efficacy. Only a few randomized, controlled clinical trials involving human patients exist on the use of HBOT for the treatment of these conditions. Two meta-analyses have also examined the subject.
Furthermore, there seem to be no objective measures to assist clinicians in appropriately selecting patients for HBOT. More than half of the published research reports dealing with HBOT for diabetic foot disease originated from a group of researchers at the Center of Diabetology and Metabolic Diseases at Niguarda Hospital, and the Department of Anesthesia and Hyperbaric Medicine at Galeazzi Institute in Milan, Italy.2-5
What The Research Does Reveal
The most convincing work in the medical literature to date demonstrates that HBOT can reduce the number of major amputations in patients with Wagner grade IV wounds.6 Even these results should receive re-evaluation in a larger multicenter trial in which researchers can control many of the potential confounding factors or evaluate the factors in the model. The study authors’ anecdotal experience is that HBOT is in common use as an adjunct to standard wound care in many types of wounds, deep and superficial, infected and non-infected, ischemic and well-perfused.
Hyperbaric wound care centers often use the TcPO2 response to 100% oxygen challenge as a criterion to determine if the wound would benefit from HBOT.7 Given the relatively high cost of this treatment modality, perhaps a more acute awareness of the medical literature would reduce the economic burden that HBOT places on entities that are financially at risk for patient care.
There are three randomized control trials from 1987 until 2011. Most of these clinical trials compare HBOT to standard of care with debridement, dressing changes, etc., with the exception of the study by Londahl and colleagues in 2010.8 The aim of this study was to evaluate the effect of HBOT in the management of chronic diabetic foot ulcers. The study was a randomized, single-center, double-blinded, placebo-controlled clinical trial. The authors compared outcomes for the group receiving HBOT with those of the group receiving treatment with hyperbaric air (sham). Treatments occurred in a multi-place hyperbaric chamber for 85 minutes daily, five days a week for eight weeks (40 treatment sessions).