Hyperbaric Medicine 2012
History
 1662 Henshaw, British clergyman built a sealed chamber
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called a Domicilium. (O2 discovered 1775).
1878 French surgeon named J.A. Fontaine built a
pressurized mobile operating room.
1921 Orville J. Cunningham, a professor at the
University of Kansas built a chamber that was 10 feet in
diameter and 88 feet in length.
1928 Mr. Timkin built Dr. Cunningham the “steel ball
hospital” located in Cleveland, Ohio. It was 6 stories high
and 64 feet in diameter. It had 72 rooms with a smoking
room on the top floor, plush carpeting, and a grand
piano. It could reach 3 ATA.
Today, we have monoplace and multiplace chambers of
varying sizes and shapes.
Domicilium
1662
Fontaine’s mobile operating
room 1879
Cunningham’s chamber in 1921
Steel Ball Hospital 1928
Today
Today
Today
UHMS INDICATIONS
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1. Air or Gas Embolism.
2. Carbon Monoxide Poisoning/Cyanide Poisoning.
3. Clostridial Myositis and Myonecrosis (Gas Gangrene).
4. Crush Injury, Compartment Syndrome and other Acute Traumatic
Ischemias.
5. Decompression Sickness.
6. Arterial Insufficiencies – Enhancement of Healing in Selected Problem
Wounds and Central Retinal Artery Occlusion.
7. Severe Anemia.
8. Intracranial Abscess.
9. Necrotizing Soft Tissue Infections.
10. Osteomyelitis (Refractory).
11. Delayed Radiation Injury (Soft Tissue and Bony Necrosis).
12. Compromised Grafts and Flaps.
13. Acute Thermal Burn Injury.
14. Idiopathic Sudden Sensorineural Hearing Loss.
Absolute HBO Contraindications
PNEUMOTHORAX.
Absolute HBO Contraindications
Recent Bleomycin Use – recent is not established although a one year period
may be sufficient.
Current Doxorubicin (Adriamycin) – wait 2-3 days prior to starting HBO.
Undersea and Hyperbaric Medicine board Review Course for Physicians
Penn Medicine. August 2010.
Absolute HBO Contraindications
Disulfiram (Antabuse) – blocks superoxide dismutase which decreases
the body’s ability to neutralize oxygen free radicals; inhibits hyperoxic
induction of cytochrome P450. Potential for pulmonary toxicity.
Absolute HBO Contraindications
 Severe Acute Bronchospasm
Absolute HBO Contraindications
 http://www.eyetube.net/video/combinedfluid-gas-exchange-and-cataractextraction/
Absolute HBO Contraindications
 Untreated Pneumothorax.
 Recent Bleomycin Use.
 Severe Acute Bronchospasm.
 Current Doxorubicin (Adriamycin).
 Current Disulfiram (Antabuse).
 Intra-Ocular Gas.
Relative HBO Contraindications
 Upper Respiratory Infections, COPD, Seizure
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Disorder
Poor Ear Clearing, Fever, Prior Ear Surgery
History Spontaneous Pneumothorax, Pregnancy
Optic Neuritis, Uncontrolled Hypertension
Untreated Dental Problems, Barotitis Media
History Chest Surgery/Trauma, Claustrophobia
Decompensated Congestive Heart Failure
Congenital Spherocytosis
Potential Complications of HBO
 Middle Ear Barotrauma – the most
common with reported incidence rates of
2% - 82%.
Potential Complications of HBO
 Sinus Barotrauma – 2nd most common
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complication.
Presentation – pain and epistaxis
Frontal Sinus Squeeze – frontal pain
Maxillary Sinus Squeeze – tooth ache
Sphenoid Sinus Squeeze – occiput or vertex
pain
Potential Complications of HBO
 Claustrophobia
Potential Complications of HBO
 Hyperoxic Myopia - >20 HBO treatments,
rate of 0.25 diopters/wk throughout
treatment.
 Oxygen toxicity
 Cataracts
Mechanism of HBO
Primary Effects
Direct Pressure from Boyle’s Law and
Henry’s Law.
Hyper-oxygenation – 10-15 fold increase in
plasma oxygen, ~1500-2000mmHg oxygen
content, and 2-4 fold increase in oxygen
diffusion capacity from capillaries.
Mechanism of HBO
Secondary Effects
 Antimicrobial Effect – toxin inhibition and inactivation,
bacteriostasis (anaerobes), enhanced antibiotic activity,
elevation of pH, and improved PMN activity.
 Blunt Ischemia Reperfusion Injury – attenuation of PMNendothelial interactions, prevention of lipid perioxidation,
and preservation of marginal tissues.
 Vasoconstriction/Decreased Edema – Alpha-like effect,
~20% reduction in blood flow, and ~20% reduction in
edema.
 Angiogenesis/Wound Healing – increased oxygen
gradient within wound, increased growth factor
synthesis, stimulation of vasculogenic stem cell
mobilization from bone marrow, and results in
angiogenesis and reversal of local tissue hypoxia.
Mechanism of HBO
Mechanism of HBO
Henry’s Law
Indication of HBO
Primary Effects
DECOMPRESSION SICKNESS:
 Insufficient off-gassing of nitrogen during a
dive that can result in bubble formation in
various organs.
 Signs and symptoms are determined by
the location.
Indication of HBO
Primary Effects
AIR or GAS EMBOLISM.
 Reported during accidental intravenous air injection,
cardiopulmonary bypass accidents, lung needle biopsy,
hemodialysis, central venous catheter placement or
disconnection, gastrointestinal endoscopy, hydrogen
peroxide irrigation or ingestion, arthroscopy,
cardiopulmonary resuscitation, percutaneous hepatic
puncture, blowing air into the vagina during orogenital
sex, and sexual intercourse after childbirth.
 Reported during procedures in which the surgical site is
under pressure – laparoscopy, transurethral surgery,
vitrectomy, endoscopic vein harvesting, and
hysteroscopy.
AGE
Indication of HBO
Primary Effects
CARBON MONOXIDE POISONING:
 Auto exhausts, smoke inhalation, and
some water heaters.
 >40,000 annually in US
 Fatality 0.5-1.0/100,000. Most common
cause of death in fire victims.
 Affinity to hemoglobin is 220 times more
than oxygen.
 Most common symptom – Headache
NEJM
 Hyperbaric Oxygen Therapy for Acute
Carbon Monoxide Poisoning. Lindell K.
Weaver, et, al. Vol 347: 1057-67, Oct 3,
2002, Number 14.
Indication of HBO
Primary Effects
CYANIDE POISONING:
 Major uses – construction, residential and
commercial building interiors, and vehicle
interiors. The most common source in the ED is
combustion.
 Most common presentation is a patient involved
in a fire or explosion with altered LOC or
convulsions.
 HBO improves effectiveness of Na+ thiosulfate
and may directly lower methemoglobin.
Indication of HBO
Enhancement of Healing in Selected
Wounds – Diabetic Foot Ulcer (DFU).
 DFU’s have decreased platelet derived
growth factors and receptors and
circulating endothelial progenitor cells.
 10 evidenced based reviews and 5
randomized controlled trials since 1996 led
to Medicare coverage in 2003 for Wagner
grade 3 or higher.
Wagner Grading System
Grade 0 – intact
1 – superficial.
2 – involves ligament, tendon, joint capsule, or fascia but no
osteomyelitis or abscess.
3 – deep ulcer with abscess, osteomyelitis, or tendonitis.
4 – gangrene of a portion of the forefoot or heel.
5 – extensive gangrene of most of the foot.
Indication of HBO
Delayed Radiation Injuries
 Complications typically seen after 6 months.
 1.2 million cases of invasive cancers will be diagnosed in
US this year.
 Half of these patients will receive radiation therapy.
 Serious complications will be seen in approximately 5%
or 30,000 cases/year.
 HBO stimulates collagen synthesis, vascular networking,
metabolism of bone, and may increase stem cells.
Indication of HBO
Delayed Radiation Injuries
OSTEORADIONECROSIS of the mandible (ORN)
 Incidence 0% below 6,000 cGy,1.8% 6,000-7,000 cGy,
and 9% >7,000 cGy.
 Pathophysiology – hypoxia, hypovascularity, and
hypocellularity.
 Marx Protocol – prophylaxis, stages 1-111R all at 2.5
ATA for 90 minutes.
 Evidence – 1975-2001(14 case series using HBO and
surgery) – 13/14 found benefit and 86% patients
improved.
 Cost saving in 2006 – $168,000 without HBO and
$53,000 with HBO.
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Feldmeier JJ, Hampson NB: Undersea Hyperbaric Med 2002, Marx RE, 1999 www.westegg.com/inflation.
ORN – Mandible
Indication of HBO
Delayed Radiation Injuries
RADIATION CYSTITIS
 Symptoms include - hematuria, nocturia,
frequency and or urgency.
 18/20 published reports showed significant
improvement or resolution in 76%.
Undersea and Hyperbaric Board Review course for physicians – Penn Medicine Aug 2010
.
Indication of HBO
Delayed Radiation Injuries
RADIATION PROCTITIS
 Symptoms include – rectal bleeding/pain,
diarrhea, and tenesmus.
 Combined results from trials including a total of
199 cases – complete resolution in 41% and
86% had at least partial response.
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Clark RE et al. Hyperbaric oxygen treatment of chronic refractory radiation proctitis: a randomized and controlled double-blind
crossover trial with long-term follow-up. Int. Journal Radiation Oncology /Biology Phys 2008.
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Undersea and Hyperbaric Board Review course for Physicians. Penn Medicine. August 2010.
Indication of HBO
COMPROMISED GRAFTS AND FLAPS
 Initial treatments should be twice daily.
Once it is more viable and stable then
daily treatment.2-2.5 ATA 90-120 minutes.
Compromised Flap
Before HBO treatments
After 1 HBO treatment
Compromised Flap
After 8 HBO treatments
Indication of HBO
CRUSH INJURY, COMPARTMENT
SYNDROME, AND ACUTE TRAUMATIC
ISCHEMIAS
 Improved wound healing, reduced amputation
rates, and lowered surgical procedure rate.
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Wattel, et al (1990), Undersea and Hyperbaric Medicine Board Review course for Physicians. Penn Medicine.
August 2010.
Indication of HBO
ACUTE THERMAL INJURY
 > 2 million/year in U.S.
 14,000 deaths and approximately 20,000 sustain injuries requiring
admission to a burn center.
 Indicated to treat if >20% total body surface area and/or with involvement of
the hands, face, feet or perineum, that are deep partial or full thickness
injuries.
 2-2.4 ATA 3 times within the first 24hrs then twice daily for 90 minutes.
Indication of HBO
CENTRAL RETINAL ARTERY OCCLUSION
 Sudden painless loss of vision in the range
of light perception to counting fingers.
 Consider HBO if presenting within 24hours
of symptoms.
Indication of HBO
SEVERE ANEMIA
 On average, the body extracts 5-6 ml of oxygen
for every 100 ml of blood that circulates to
organs. Hemoglobin carries 1.38 ml of oxygen
per gram. As Hemoglobin drops below 6g/dL,
oxygen delivery starts to become deficient.
Indication of HBO
Infections
 Bacteriostatic
 Bactericidal
 Antibiotic Enhancement
Indication of HBO
CHRONIC REFRACTORY
OSTEOMYELITIS
 Failed to respond to medical and/or
surgical treatment after 4-6 weeks.
Indication of HBO
CLOSTRIDIAL MYOSITIS AND
MYONECROSIS (GAS GANGRENE)
 Onset may occur between 1 and 6 hours after injury or operation
and begins with severe pain.
 Infection can advance at 6 inches per hour.
 3 ATA for 90 minutes, 3 times in first 24 hours and then twice daily
for the next 2-5 days.
Indication of HBO
NECROTIZING SOFT TISSUE
INFECTIONS
 Beta-hemolytic strep is common.
 Diabetes, obesity, alcoholism, smoking and intravenous drug use
are strong risk factors.
 2-2.5 ATA twice daily for 90 minutes until no further extension of
necrosis in debrided areas and the infection is controlled.
Indication of HBO
 INTRACRANIAL ABCESS
 Multiple abscesses, abscess in a deep or
dominant location, compromised host,
surgery contraindicated, or no response to
standard surgical and antibiotic therapy.
Idiopathic Sudden Sensorineural
Hearing Loss
Research and Future
Indications
 HBO and Traumatic Brain Injuries?
 HBO as a Radiation Sensitizer?
 HBO and Acute Coronary Syndromes?
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References
 Neuman and Thom. Physiology and Medicine of
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Hyperbaric Oxygen Therapy. 2008.
Undersea and Hyperbaric Medical Society. Hyperbaric
Oxygen Therapy Indications. 12th Edition. 2008.
Undersea and Hyperbaric Medicine Board Review
Course for Physicians. Penn Medicine. August 2010.
Kindwall EP, Whelan HT. Hyperbaric Medicine Practice.
3rd Edition. 2008.
American College of Hyperbaric Medicine.