2. Definitions
History
Principles of HBOT
Physiology
Mechanism of action
Dosage and delivery
Monoplace and multiplace chambers
IndicationsAnd Controversies
Contraindications
Negative effects AND Complications
Preparations before HBOT
C
O
N
T
E
N
T
10. 1878 - Paul Bert, the father of pressure
physiology, discovered the scientific basis
of oxygen toxicity
Recommended normobaric , but not
hyperbaric, oxygen for decompression
sickness.
11. 1937- Behnke and Shaw first used
hyperbaric oxygen successfully for the
treatment of decompression sickness
suffered by deep sea divers.
In 1950’s:The modern clinical application
of HBO began, in parallel with an
increased understanding of blood gas
analysis and gas exchange physiology.
12. 1960 –
Father of modern
hyperbaric medicine
Pioneered the application
of HBO to many medical
problems.
Performs first surgery with
HBO
Discovered that Hgb
wasn’t necessary for
O2 transport
14. Burns received when his hair caught fire from fireworks during
the making of a Pepsi commercial in 1984.Treated with HBO and
eventually bought his ownchamber.
Michael Jackson and HBO
16. To brush up ....
A). PRICIPLES OF PHYSICS
a) Daltons law-
Partial pressure of a gas = (absolute pressure) x (proportion of total volume of gas)
the partial pressure of oxygen (pO2) in air is (760) × (21/100) = 160 mmHg.
b) Henry`s law –
Concentration of a dissolved gas = (pressure) x (solubility coefficient)
Oxygen: 0.024 ml blood atm pO2
Carbon dioxide : 0.57 mL plasma/atm pCO2
Nitrogen: 0.012 mL plasma/atm pN2
17. To brush up.....
A). PRICIPLES OF PHYSICS
c) Fick`s law-
Oxygen Consumption of the tissue (VO2 ) = (Q) x (C (a–v) O2 )
b) Boyle`s law –
Volume of a gas is inversely proportional to its pressure. (if the temperature
remains constant)
18. To brush up………
B) PHYSIOLOGICAL PRINCIPLE
• Oxygen is carried by blood mainly in 2 ways-
1. Hemoglobin
2. Plasma
• Hemoglobin carries majority of oxygen (97%)
• Plasma carries only minute amounts of oxygen (3%)
19. RoomAir 160mmHg
Lung Capillaries 100mmHg
Leaving Heart 85mmHg
Peripheral Arterioles 70mmHg
Organ Capillaries 50mmHg
Cells 1-10mmHg
Mitochondria 0.5mmHg
(0.3%of inhaledoxygen)
Mitochondria is the final
site ofenergy production
21. 100 ml of
blood
19 ml O2 + Hb
0.32 ml in plasma
At the same
pressure
100 % O2
inspired
O2 +
Hb
Plasma
20ml
2.09m
l
The higher pressure during
HBO treatment pushes more
oxygen
into solution
2ATA
pressure
3ATA
pressure
4.4
ml/dl
6.8ml/dl
PLASM
A
This additional O2 in solution is sufficient to meet tissue needs without
contribution from O2 bound to hemoglobin and is responsible for most
of the beneficial effects of this therapy.
23. Hyperoxygenation
• An application of Henry's law
• results from an increase in dissolved oxygen
in plasma as a result of increased partial
pressure
of arterial oxygen(pO2).
• management of crush injury,
compartment syndrome, flap salvage
and acute blood loss anaemia.
A pressure of 3 ATAresults in 6 ml of
O2being dissolved per 100 ml of
plasma, thus rendering as much O2
delivery as by haemoglobin bound
O2.
24. Decrease in bubble size
• Application of Boyle's law
• High oxygen (100%) intake saturates the blood plasma
with oxygen.
• Volume of a bubble decreases directly in proportion to
increasing pressure and is the primary mechanism at
work in management of decompression sickness and
arterial gas embolism. (Latham E et al. Hyperbaric oxygen therapy.
eMedicine. Medscape).
27. Vasoconstriction
• Hyperoxia in normal tissues
causes vasoconstriction which
reduces post-traumatic tissue
oedema.
• This contributes to the treatment of crush injuries,
compartment syndromes and burns.
• Vasoconstriction, however, does not cause hypoxia as this is
more than compensated by increased plasma oxygen content
and microvascular blood flow.
28. Collagen Formation
Oxygen is vital for
• Hydroxylation of lysine and proline residues during
collagen synthesis
• for cross linking and maturation of collagen which
is required for strong wound healing.
• Lack of oxygen is corrected during HBOT,
leading to adequate amounts of mature
collagen formation.
29. Angiogenesis
Hypoxia is a vital stimulant for angiogenesis, but
development of adequate capillary network
requires adequate amounts of tissue oxygen
concentration..
This along with fibroblastic proliferation
leads to increased
neovascularisation.
HBOT increases the oxygen gradient
between the centre and periphery of the
wound, thus creating a strong angiogenic
stimulus.
30.
31. What is hypoxia???
Hypoxia or hypoxiation is a pathological
condition in which
• the body as a whole (generalized hypoxia)
• or a region of body (tissue hypoxia) is
deprived of adequate oxygen supply.
32.
33.
34. HBOT is carried out in 2
chambers-
1. Monoplace chamber
2. Multiplace chamber
35. MonoplaceChambers
•Small and designed to accommodate only one adult
individual, usually in a supine or semi-recumbent position
•pressure capability of 3.0 ATA, and compressed with 100%
oxygen
36. •Cost efficient delivery of
HBO2.
•No risk of
decompression
sickness.
•Portable, less space,
less equipments, no
hood or mask.
•No risk of iatrogenic
decompression
sickness in patient or
staff
Advantag
es
Disadvantag
es
•Relative patient isolation.
•Associated fire hazard.
• Inability to use certain
diagnostic and/or therapeutic
equipment.
• Limited access to the patient
inside chamber with only
visual and auditory
communication available to
the patient and observers.
37. MultiplaceChambers
• These units can accommodate between 2 and
18 or more patients and commonly incorporate
a minimum pressure capability of 6.0 ATA.
38. Advantag
es• Constant patient attendance and
evaluation (particularly useful in
treating evolving neurological
diseases such as decompression
sickness and cerebral arterial gas
embolism).
• Multiple patients treated per
session.
•Greater working pressure.
•Reduced fire risk
• More room available, which allows
medical personnel to enter to deal
with acute problems, e.g.,
pneumothorax
•Higher
capitalization
requirements.
•risk of cross infection
when used to treat
wounds
•Major space
requirements; basement
and/or ground floor level
limitations.
•Higher operating costs.
Disadvantag
es
39. Other Chambers
• Two other types of chambers are mentioned, although they
are not considered HBOT.
1. Topical oxygen, or Topox, is administered through a
small chamber that is placed over an extremity and
pressurized with oxygen.
• The patient does not breathe the oxygen, nor is the remainder
of the body pressurized.
• The patient cannot benefit from most of the positive effects of
HBOT, which are systemic or occur at a level deeper than
topical oxygen can penetrate
40. • Topox is based on the concept that
oxygen diffuses through tissue at a
depth of 30-50 microns.
41. 2. Portable "mild" hyperbaric chamber
• These soft vessels can be pressurized to 1.5-1.7
atmospheres absolute (ATA).
• They are only approved by the FDA for the treatment of
altitude illness.
43. Dosage and Delivery
• All regimens use 100%
oxygen
• Pressures are more variable-
Mostly used 2.4 atm
Maximum tolerated is 3 atm
4 atm induces seizures
44. Dives between 30
and 120 minutes
May be daily or BID
Total number varies
by indication
Most treatments
include 30 sessions
Optional addition of
10 or more sessions
are accepted.
46. INDICATIONS
According to Undersea and Hyperbaric Medicine Society
(UHMS)-
1. Air or gas embolism.
2. Carbon monoxide poisoning or carbon monoxide
poisoning complicated by cyanide poisoning.
3. Clostridial myositis and myonecrosis (gas gangrene).
4. Crush injury, compartment syndrome, and other
acute traumatic ischemia.
5. Decompression sickness.
6. Enhancement of healing in selected problem wounds;
a. Diabetically derived illness, such as diabetic foot,
diabetic retinopathy, diabetic nephropathy.
47. 7. Exceptional blood loss (anemia)
8. Intracranial abscess.
Additional indications recommended by European
ConcensusConference 2004 –
1. Surgery and implant in irradiated tissue (Preventive
action)
2. Sudden deafness
3. Neuroblastoma stage IV
4. Post anoxic encephalopathy
5. Limb replantation
48. INDICATIONS
IN PLASTIC
SURGERY
1. Necrotizing soft tissue infections (necrotizing fasciitis
2. Osteomyelitis (refractory).
3. Delayed radiation injury (soft tissue and bony necros
4. Skin grafts and flaps (compromised).
5. Thermal burns.
6. Limb replantation
OTHER CONDITIONS WHERE IT IS BEING STUDIED
1. Hypertrophic scarring
2. Ear reconstruction complications
3. Penile replant
49. QUESTIONS ????
INDICATIONSAND EVIDENCE
INDICATIONSAND DOSAGE
IS IT ECONOMICAS COMPAREDTO CONVENTIONAL
DRESSINGS
RECOMMENDATIONSAND FINALTAKE
Supposing is Good But Finding Out is Better-
MarkTwain
50. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF
EVIDENCE/TYPE OF
STUDY
RESULTS
D J Perrins Lancet (1967) the Survival of Split
Skin Grafts
Case control trial- 48
pts
a statistically significant
improvement in graft take
FabricioValandro
Rech et al
Acta Cir Bras (2015) Action of HBOT in the
Rat Skin Flap
Animal study (40 rats) Hyperbaric oxygenation reduced
the area of necrosis and
preserved the morphology and
collagen content in skin flaps of
rats.
RachelWeber et al Undersea Hyperb
Medicine (2018)
Random Flap Survival
With Hyperbaric
Oxygen: DailyVersus
Twice-Daily
Treatments
Animal study Both QD and BID HBO₂
protocols can significantly
decrease random flap necrosis.
However, the results of this
study suggest there is no
additional benefit gained with
BID treatments.
51. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF EVIDENCE/
TYPE OF STUDY
RESULTS
J Albuquerque E
Sousa
Rev Port Cir
CardiotoracVasc
(2005)
Long-term Evaluation
of Chronic Diabetic
Foot Ulcers
Retrospective
controlled study
96 pts over 55 months
Mean healing rate of chronic
ulcers was significantly higher in
the HBO group;The need for
amputation was significantly
less in the HBO group
David Lebel et al Harefuah (Israel)
(2007)
Chronic Diabetic
Wounds of the Lower
Limbs
Systematic review Evidence that HBO therapy
reduces the need for major
amputations among DM pts with
chronic ulcers of the LL. HBOT
enhance the rate of healing.
Supaporn
Opasanon et al
J Am Coll Clin
Wound Spec (2014)
Clinical effectiveness in
Complex wounds
Prospective cohort
study – 40 pts
Wound healing process was
accelerated by HBOT.
Significant wound size
reduction was noted after 5 HBO
treatments
Trientje B Santema
et al
Diving Hyperb Med
(2015 )
Economic Outcomes
HBOT in theTreatment
of Acute and Chronic
Wounds
Systematic review little direct evidence on the cost-
effectiveness of HBOT in the
treatment of acute and chronic
wounds
52. Figure shows sequential photographs of a 53-year-old male diabetic
suffering from spontaneous gangrene of the thigh who was managed
successfully with HBOT at a tertiary care hospital of theArmed Forces.
53. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF
EVIDENCE/TYPE OF
STUDY
RESULTS
Mesut Mutluoglu et
al
Diving Hyperb Med
(2016)
Poorly Designed
Research Does Not
Help Clarify the Role
of HBOT in the
Treatment of Chronic
Diabetic Foot Ulcers
Editorial (review of
current literature)
Recent evidence based
guidelines, while
recommending its use, urge
further studies to identify the
patient subgroups most likely to
benefit from HBOT
Daria O'Reilly et al Clinical trial .gov
(2011) toronto
Treatment of Chronic,
Non-Healing Ulcers
of the Lower Limb in
Patients With
Diabetes Mellitus:A
Study Protocol
Prospective double
blinded RCT
Phase 4 trial
results of the study will be used
to make policy decisions
regarding the funding and
further utilization of HBOT
therapy for people with DM foot
ulcer
I-Han Chiang et al IntWound J (2017) Is HBOT Indispensable
for Saving Mutilated
Hand Injuries
Case series (45
patients)
Adjunctive to microsurgery Early
HBOT was effective in
preserving partially viable tissue
and restoring hand function.
54.
55. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF
EVIDENCE/TYPE OF
STUDY
RESULTS
Jennifer A.Thackam
et al
Wound repair and
regeneration
(2008)
HBOT to treat chronic
wound
Systematic review Inconclusive about the role of
HBOT in Chronic wounds , more
research needed.
Laurenz Weitgasser
et al
Central European
Journal of Medicine
(2019)
Update on Hyperbaric
OxygenTherapy in
BurnTreatment
Systematic review Although beneficial effects of
HBOT seem very likely
insufficient evidence to support
or disprove the routine use of
HBOT in the treatment of burn
care was found
Si Jack Chong et al Diving Hyperb Med
(2013 )
Characterization of
EarlyThermal Burns
and the Effects of
Hyperbaric Oxygen
Treatment: A Pilot
Study
Randomized control
trial
Early HBOT had no apparent
effects on any of the parameters
measured in this small pilot
study
HBOT had no significant effect
on burn depth
56.
57. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF EVIDENCE/
TYPE OF STUDY
RESULTS
Ashish Francis ,
Richard C Baynosa
Advances inWound
Care (New Rochelle)
(2017)
Undersea Hyperb
Med.(2012)
Compromised Graft
or Flap
Literature Review Of
AllAnimal and clinical
studies
HBO is not indicated for healthy
noncompromised tissue, but is a
valuable salvage adjunct in the
treatment of threatened grafts
and flaps.
HBOT improves graft and flap
survival, limits tissue death,
improves flap circulation
Friedman et.al Plast Reconstr Surg.
(2006)
An Evidence-Based
Appraisal of the Use
of Hyperbaric
Oxygen on Flaps
and Grafts
Systematic review significant animal data
supporting HBOT for grafts and
flaps, Only case reports and
series. Multicenter prospective
comparative clinical studies are
clearly needed.
S Gehmert et al Clin Hemorheology
Microcirculation
(2011)
Evaluation HBOT
Free Flaps Using
Planar OpticalO2
Sensors. Preliminary
Results
Case series increase of oxygen supply over
the entire flap after hyperbaric
oxygen therapy.
58. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF
EVIDENCE/TYPE
OF STUDY
RESULTS
GVishwanath Med J Armed
Forces India (2011)
HBOT in Free Flap
Surgery: Is It
Meaningful?
RCT (10 patients) No significant difference was
found in terms of flap survival,
time to resolution of venous
congestion, resolution of
oedema, and period of postop
recovery.
Davis Nolen et al Wiley online library
(2014)
Comparison of
Complications in Free
Flap Reconstruction for
Osteoradionecrosis
multisite
retrospective review
No significant differences in free
flap reconstruction complication
rates b/t HBOT and Non HBOT .
increased infections in the
patients with a history of HBO
therapy
Zachary Borab JPRAS (2017) HBOT forTreatment of
Radiation-Induced Skin
Necrosis
Systematic Review HBOT safe intervention with
promising outcomes; however,
additional evidence is needed
Kamonwan
Jenwitheesuk et al
Biores OpenAccess
(2018)
Efficacy of Adjunctive
HBOT in
Osteoradionecrosis
Prospective case
series
HBOT improved wound healing
of ORN patients with stages 1
and 2.
59. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF EVIDENCE/
TYPE OF STUDY
RESULTS
Jizen Ren
Qiang zhang etal
J Cosmet Dermatol
(2018)
Chinese paper
HYPERTROPHIC
SCAR Formation in
Rabbit Ears
Animal study – 20 new
Zealand rats
hyperbaric oxygen can up-regulate
bax/bcl-2 value, increase the cell
apoptosis rate, and inhibit the
early hypertrophic scar in rabbit
ears.
Wen – Bo Li et al Am JTranslational
Res (2020)
Pruritus and Pain of
Keloid Patients
Case contol study HBO therapy might relief pruritus
of keloid patients by regulating
pruritic factors
Min-Zi Zhang et al Medicine ,
Baltimore (2018)
Ameliorate the EMT
Phenomenon in
Keloid
RCT (9 patient each gp) HBOT may be an effective therapy
against the epithelial-to-
mesenchymal transition (EMT)
phenomenon in keloid patients
Ke- Xin Song ,
Min-Zi Zhang et al
J Zhejiang Univ Sci
B (2018)
Improves the Effect
of Keloid Surgery
and RT by Reducing
the Rec. Rate
RCT (240 patient ) Adj. HBOT effectively reduces the
keloid rec rate after surgical
excision and RT by improving the
O2 level of the tissue.
Luiz H Ferreira et
al
Minerva Medica
(2020)
Bone
Reconstruction
Systemic review Positive results in the included
studies, there are still lack of
standardized clinical studies
60.
61. AUTHOR JOURNAL AND
YEAR
TITLE LEVEL OF EVIDENCE/
TYPE OF STUDY
RESULTS
Feng Xu et al J craniofac Surg
2019
Ear reconstruction
complication
Case series - 42 pts 41 recovered , 1 had infection.
traditional salvage procedures, +
HBOT effectively treated various
complications of ear
reconstruction.
John M Harbison
etal (USA)
Curr Opin
Otolaryngol Head
Neck Surg
. 2012
Composite Grafts in
Nasal
Reconstruction
Review of articles 5 authors found statistically
significant improvement in graft
survival , 2 authors found it
worsens survival or no benefit
over control group.
HeidiWingard et al Undersea Hyperb
Med ( 2019)
Replantation of
amputated penis
Case report potential benefit of HBOT
preserving viability of a severed
body part. Fluorescent
angiography -potential utility in
monitoring efficacy of HBO2.
Kun hwang J Craniofac Surg
(2016)
Avoid Blindness From
Filler Injection
Case reports HBOT might be applied to
patients who have central retinal
artery occlusion following a filler
injection.
62. Questions
HBOT In
Compromised
grafts and Flap
When to start?
Clinical judgment is required to identify flap and graft
compromise.
Tc PO2 around flap / graft site < 30 mm Hg within the 1st
36 post –op hrs
Graft compromise, for which HBO may help, may be evident
in the first 24– 48h,
-- characterized by a dusky appearance, epidermolysis, and
later, desiccation and necrosis.
Flap compromise is characterized by
--arterial insufficiency (pale, delayed capillary refill, decreased
turgor, and cool temperature),
--venous congestion (bluish-purple, brisk capillary refill, in-
creased turgor, and warm temperature), or complete
arterial/venous occlusion.
63. Questions
HBOT In
Compromised
grafts and Flap
What should be done first revision or
HBOT ?
Etiologies of graft or flap compromise that
can be reversed surgically should be
addressed first.
If no mechanical cause is identified or
tissue compromise persists, HBO should
be administered expediently to maximize
its therapeutic benefit.
64. Questions
HBOT In
Compromised
grafts and Flap
WHAT PROTOCOLTO FOLLOW ??
For compromised grafts or flaps, HBO should be
administered at
2.0–2.5 ATA
90 to 120 mins (atleast 60 min for a total of 5-10
compressions
twice daily initially and then transitioned to once-
a-day treatments when clinical assessment and
other adjuncts such as.
Tc PO2 > 30 mm Hg ---- HBOT can Be STOPPED
Tc PO2 < 30 mm Hg ---- proceed with 5 more compressions at 2.2 – 2.5
ATA
65. ITALIANUNDERSEAAND HYPERBARIC MEDICINE
SOCIETY (2019 RECOMMENDATION)
INDICATION INCLUSION CRITERIA PROTOCOL
CLINICAL
CONSIDERATION
1. ACUTE SOFT
TISSUE INFECTION
MYOSITIS, NEC
FASCITIS
1ST 3 DAY- MAX O2 DOSE- 2.8 ATA , 2-3
SESSIONS/ DAY)
DAY 4 : OD/BD -2.4-2.8 ATA, 80-120 MIN ..
TOTAL SESSSIONS – 20 /40
HBOT ADJUNCTTO
SURGICAL DEBRI./ RX
2. CRUSH INJURIES
MESS 3-6: CO –
MORBIDE CONDITIONS
≥7 : ALL PTS
PRESSURE ≥ 2.4 ATA , OD/BD,
10-12 COMPRESSIONS
ASSESSAT 10
COMPRESSIONS
3. CHRONIC
REFRACTORY
OSTEOMYELITIS
CIERNY – MADAR
CLASSI. 3-4 BL/BS
2.4 -2.5 ATA , 30-60 COMPRESSION
40 HBOT >
INTERVENTION> 20 HBOT
66. INDICATION INCLUSION CRITERIA PROTOCOL
CLINICAL
CONSIDERATION
4. CHRONIC NON
HEALING WOUNDS
PERIPHERAL
ARTERIOPATHY
2.4 -2.5 ATA , FOR ATLEAST 60 MIN
30-40 COMPRESSION
TcPO2≥ 40 MMHG – FAV
OUTCOME
TcPO2 < 30 MMHG – 15
MORE COMPRESSION AT
2.2-2.4 ATA
5. RADIATION
INJURIES
RADIATION ULCERS 2.4 -2.5 ATA , 40-60 COMPRESSION
ASSESSAT 30
COMPRESSIONS
TcPO2≥ 40 MMHG – FAV
OUTCOME
TcPO2 < 40 MMHG – 20
MORE COMPRESSION AT
2.2-2.5 ATA
67. INDICATIONS
AND
EVIDENCES
(FINALTAKE)
Therapeutic uses of hyperbaric oxygen
Strong scientific evidence
Main treatment
Decompression sickness
Arterial gas embolism
Severe carbon monoxide poisoning and smoke inhalation
Adjunctive treatment
Prevention and treatment of osteoradionecrosis
Improved skin graft and flap healing
Clostridial myonecrosis
68. Suggestive scientific evidence
Adjunctive treatment
Refractory osteomyelitis
Radiation induced injury
Acute traumatic ischaemic injury
Prolonged failure of wound healing
Exceptional anaemia from blood loss
72. Potential Complications After HBO
1.OXYGEN TOXICITY - Seizures, dry cough, chest pain or
burning.
2.VISUAL REFRACTION CHANGES - Cataract, progressive
myopia with prolonged number of treatments.
3. BAROTRAUMA - In ears, sinus, lungs, tooth
caries/fillings.
Risk of fire
73. PREPARATIONS BEFORE HYPERBARIC OXYGEN
THERAPY
1. Medication : drug history before treatment
2. Cold and Other symptom-
3. Smoking
4. Cosmetics
5. Clothing - 100% cotton gowns. No nylon or polyester to wear
Techniques for adequate clearing of the ears
74. Take-Home Messages
• HBOT remains among the safest therapies used today.
• HBOT is the treatment of patients with 100% oxygen at higher than atmospheric pressure. It is both the
primary and secondary effects that result in its beneficial effects and side effects.
• One of the most common side effects identified in the peer-reviewed literature is MEB.
mild and self-limited . Can be prevented with patient training
• Oxygen toxicity seizure is one of the most feared side effects of HBOT.
remember that this is an uncommon and self-limiting side effect.
resolved with withdrawal of 100% oxygen and has no long-term implications.
Continued HBOT is permissible and may be done with adjustment to maximum pressure and addition of
air breaks.
History
Hyperbaric air use
Oxygen under hyperbaric condition
REFERENCE ON COMMITTEE ON HYPERBARIC OXYGEN
it has very interesting history
The first well-known chamber was built and run by a British clergyman named Henshaw. He built a structure called the domicilium that was used to treat a multitude of diseases.
The chamber was pressurized with air or unpressurized using bellows.
The idea of treating patients under increased pressure was continued by the French surgeon Fontaine, who built a pressurized, mobile operating room in 1870
MOIR USED THESE CHAMBERS TO TREAT DECOMPRESSION SICKNESS
in Usa
The structure, was 6 stories high and 64 feet in diameter.
The hospital could reach 3 atmospheres of pressure.
The hospital was closed in 1930 because of the lack of scientific evidence indicating that such treatment alleviated disease.
It was deconstructed during World War II for scrap.
THIS prohibited the use of oxygen in hyperbaric chambers for long time
almost after 50 years ,
associate of borema
But the real attention to HBOT was given when Michael Jackson underwent HBOT
Media Sensationalism
at work
Dalton’s law states that in a gas mixture, each gas exerts its pressure according to its proportion of the total volume:.
Oxygen constitute 21% of total air, and exerts partial pressure of 160mm hg
At this point I would like to emphasis Pressures exerted by gases dissolved in water or body fluids are certainly different from those produced in the gaseous phase. The concentration of a gas in a fluid is determined not only by the pressure but also by the “solubility coefficient” of the gas
From this one can see that CO2 is, remarkably, 20 times more soluble than oxygen.
Fick`s principle - oxygen consumption of the tissues (pO2) is equal to the blood flow to the tissues (Q), multiplied by the amount of oxygen extracted by the tissue, which is the difference between the arterial and the mixed venous oxygen contents, C(a − v)O2:
Boyle`s law with increasing pressure (P) the volume (V) of a gas decreases proportionately.”
Normally 97% of the oxygen transported from the lungs to the tissues is carried in chemical combination with hemoglobin of red blood cells and the remaining 3% in a dissolved state in plasma.
Sequence of drop of air pressure from 760-160--------------few mm in mitochondria
1 g of Hb can combine with 1.34 mL oxygen . The normal concentration of hemoglobin is 15 g/100 mL blood. WHEN Hb is 100 % saturated with 02, 100 mL blood can transport about 20 ml O2 in combination with hemoglobin. Since the hemoglobin is usually only 97.5 % saturated, the oxygen carried by 100 mL blood is actually 19.5 mL.
We know 19 ml o2 carried by 15 gm hb at 1 ATA ( 21%).. When we increase partial pressure of o2 from 21- 100 % - o2 content In hb and plasma increase application of daltons law
atmospheres absolute (ATA)
Micro/nanobubbles (MNBs), which range anywhere from 100 μm to <1 μm in diameter and are relatively stable for hours, offer a new mode of oxygen delivery to wound
the use of intravascular microbubbles generated by an I.V. infusion of 2% dodecafluoropentane enhanced the denitrogenation of
Process of treatment
Initial compression for 30 minutes
All regimens use 100% O2 only pressure can be variable
Pressure -
Most use 2.4 atm
Maximum tolerated is 3 atm
4 atm induces seizures
10 m =
In a 120 min session
Treatment for 90 minutes with air breaks (10 minutes every 30 minutes is standard)
Decompression for 30 minutes
2ND PART OF MY PRESENTATION
What are evidences in support of these indications
Over 30 animal studies have documented efficacy of HBOT in preserving both pedicled and free flaps in multiple models
Human case studies documentng benefit of hyperbaric treatment for flap survival were first reported in 1966. A controlled clinical trial showing improved survival of split skin grafts.
Not much human studies hd been done in this regard .
The journal of American college clinical wound specialist
Author highlighted many flaws in design of studies done on HBOT and their implication and need of standardisation
There is one RCT going on in Toronto Canada which aims to generate authentic and high level significant data for HBOT in chr NHU DM
Results are awaited
Mutilated hand – for flap coverage, most patients received a free flap using an anterolateral thigh flap (18 patients) or local flap using an abdomen/groin flap (nine patients). The average time from the first reconstruction or revascularisation to the first HBOT was 6·5 hours (range 2-12). The average number of HBOT sessions was 9·1 (range 6-14 sessions). The survival rate of the replanted fingers was 81%, and the survival rate of the palms was 100%.
Clinical presentation at admission (7 days after injury)
immediately started on daily HBO treatment sessions (<24 hours from admission)
New surgical debridement and wound coverage with artificial dermal substitute on the palm and autologous skin graft on the forearm (post-injury day 39). The der- mal substitute required revision and re-application 34 days after the procedure. E) Final wound coverage with autologous skin graft on the palm (post-injury day 96). F) Ten-month follow-up. Total number of treatment sessions: 19.
Many studies which do not found Hbot to be better than conventional dressing in chronic wound... ............Homogenic data required......
Burn wounds are one major application for HBOT
Mendy J Hatibie et al
Advances in skin and wound care (2019)
Second-Degree Burn Healing: An Experimental Study in Rabbits
Animal study
HBOT may improve second-degree burn healing by increasing inflammatory cell migration and re-epithelialization
hbot in Compromised Graft or Flap IMPORTANT KEY POINTS
Important study by AShISH and similar study by baynosa
Animal studies demonstrate a benefit of HBO in the treatment of compromised tissues. Clinical studies support these findings, but are limited to case reports and series. Further research is needed to provide multicenter prospective clinical studies and cost analyses comparing HBO to other adjunctive therapies in the treatment of compromised grafts/flaps.
Important and only RCT on free flap ........on a very small group....
Various other plastic surgical condition for which scope of HBOT is under evaluation like Keloid and hypertrophic scar.. Mostly animal studies and done by Chinese group of scientist
Blindness from fillers- In the literature, only 2 papers were found in which hyperbaric oxygen therapy (HBOT) was used in ophthalmic artery obstruction. However, no improvement of vision was obtained in either patient. Recently, the authors treated a patient who had central retinal vein occlusion and cilioretinal artery occlusion with HBOT (daily 2-hour sessions at 253 kPa for 14 days), and his visual acuity returned to normal.
HBOT found its application in rplantation surgery where people tried it as adjunctive therapy for treatement of complication
Ear complication - Patients suffered from 4 different complications: hematoma (15), flap venous congestion (13), frame exposure (10), and postoperative infection (4). After HBOT, 41 patients recovered without a need for additional surgical repair. One patient developed an infection and required further treatment.
Amputated penis - Delayed microvascular replantation was performed approximately 14 hours following injury. He was treated with a phosphodiesterase inhibitor postoperatively, and adjuvant hyperbaric oxygen (HBO2) therapy was started 58 hours after replantation; 20 treatments at 2.4 atmospheres absolute (ATA), twice daily for eight days, followed by once daily for four days.
HBO facilitated the success of a penile replantation complicated by postoperative Pseudomonas wound infection.
Subjectively
Objectively use of transcutaneous oxygen pressure difference. increased oxygen tension with compression
When not to give – arterial and venous thrombosis
Transcutaneous oxygen measurement (TCOM or TcPO2) is a non-invasive method of measuring the oxygen level of the tissue below the skin. To perform the test, one set of electrodes are placed on viable tissue (e.g. the chest) as a control and a second set is placed around the tissue in question (e.g. legs or feet). The electrodes may mildly heat the skin to increase blood flow into the area
Fluorescent angiography
atmospheres absolute (ATA). One atmosphere absolute, or 1 ATA, is the average atmospheric pressure exerted at sea level
≥ ≥. ≤ ≤
≥ ≥. ≤ ≤
The ideal intensity and duration of HBO treatment needed to achieve benefits are again unknown
HBO may also prove to be too expensive or impractical for many patients.
END SPEECH –
Advances in the treatment of chronic wounds* have steadily occurred over the past decade and include the specialized use of dynamic compression therapy, implementation of moist wound care techniques, chronic lymphedema therapy, negative pressure wound therapy, arterial compression therapy and application of off-loading devices. General medical practitioners should recognize when timely patient referral to a comprehensive wound care center is indicated. The clinical practice of HBOT and its scientific basis has also advanced significantly during this same time period. HBOT is a therapeutic tool with many qualities that are unique to medical care and enable difficult and otherwise untreatable conditions to be safely and effectively managed. Level 1 evidence exists for HBOT and the therapeutic indications are growing. It is the responsibility of all practitioners to become informed about the modern principles and practice of HBOT. Clinicians should take the advice of Mark Twain: "Supposing is good but finding out is better." It is the responsibility of educational institutions and medical societies to become informed and actively engaged in hyperbaric medical care, education and research. This will benefit our patients as well as our systems of medical care. There is now ample access to hyperbaric oxygen facilities and expertise with the state. There is a growing need for HBOT services due to the rising incidence of obesity and diabetes combined with an aging demographic. Appropriate networks and patterns of referral have lagged behind this demand due to a generalized lack of understanding of the true risks, benefits and indications for HBOT. This review will hopefully begin to address this problem. Hyperbaric medicine is in an early phase of development. The current and future demand for clinical services will drive development of research and educational programs. Only through continued efforts for perform high quality research and education will the full potential of HBOT be realized. Much remains to be done. As systems for the delivery of healthcare enter an era of population management, the regenerative potential of hyperbaric therapies should improve quality of and reduce costs and enable us to meet the challenge of providing care for the growing population of chronic wound patients.
Seizures potential 4 ATA
High doses of prednisolone (or similar cortisone type drugs), and morphine, or alcohol, insulin within 8 h of treatment.
Cosmetics, hair spray, nail polish, perfume, or shaving lotion containing petroleum, alcohol or oil base are not allowed while in the HBO chamber
valsvery gently blow through nose while holding the nose and lips tightly closed
4. Moving lower jaw from side to side or an in or out motion
Middle-ear barotrauma (MEB)
Increasing role in veterinary
Last but not the least
The experience has proven that it is a safe treatment that has the same low side effects in the adult and pediatric populations
The management of neonates in hyperbaric chambers needs special equipment and trained personnel . Hypoxic ischemic encephalopathy0-
Risk of retinopathy
HBO is generally considered to be safe in the aged persons unless they have a medical contraindication.
