Hyperbaric Oxygen Therapy

1. (HBOT) Hyper Baric Oxygen
Therapy
Dr Faeyz F Orabi MD, PM&R
1/10/2012‫باألردن‬ ‫العربي‬ ‫التأهيل‬ ‫وإعادة‬ ‫الفيزيائي‬ ‫الطب‬ ‫مؤتمر‬

2. History of HBOT
What is HBOT?
How HBOT Works?
Trends in Hyperbaric Medicine

(HBOT) Hyper Baric Oxygen Therapy

3. History of Hyperbaric Therapy
British physician, Henshaw, in 1662 used a chamber fitted with a
large pair of organ bellows, so that air could either be compressed
into the chamber or extracted from it.
 In this ‘domicilium' increased pressures were used for the treatment of
acute disease, and reduced pressures for the treatment of chronic
diseases.
Oxygen discovered in 1775

4. 1889 – Moir used hyperbaric therapy
to treat workers building railroad
tunnels underneath the Hudson River.
Reduced mortality rate of
decompression sickness from 25% to
only 1.6% per year.
1926 - Six-story “steel ball hospital” in
Cleveland, Ohio. The facility was
capable of treating patients in 72 rooms
over 12 floors at pressures of 3 atm
absolute.

5. ..No oxygen?
Brain damage in 3-4 minutes.
..No vitamin C?
Scurvy in 3-4 months.
..No vitamin D?
Osteoporosis in 3-4 years.
We can supplement vitamins and minerals,
but…
How do you get more
Oxygen?????

6. Room Air 160 mmHg
Lung Capillaries 100 mmHg
Leaving Heart 85 mmHg
Peripheral Arterioles 70 mmHg
Organ Capillaries 50 mmHg
Cells 1-10 mmHg
Mitochondria 0.5 mmHg
(0.3% of inhaled oxygen)
Mitochondria is the final
site of energy production

7.  Breathing more oxygen not enough.
Room air contains 21% oxygen, enough to fill most of the oxygen-
binding sites on our red blood cells, carried by hemoglobin.
 Breathing even 100% oxygen
Fills the few remaining sites on hemoglobin. Increases blood
oxygen by a small percentage. Can be life-saving, especially if blood
oxygen levels are low, but results in minimal gains when O2 levels
start out normal.
 Encourage oxygen to dissolve in serum and plasma by increasing
pressure of oxygen.
Pressure is provided by a chamber with above-normal pressure,
called a “hyperbaric” oxygen chamber. Patient enters chamber and
pressure is slowly increased to a level appropriate for the person’s
condition.
How To Get More Oxygen?

8. Hyperbaric Oxygen Therapy
(HBO)
Involves intermittently breathing pure
oxygen at greater than ambient pressure
Think of oxygen as a drug and the hyperbaric
chamber as a dosing device
Elevating tissue oxygen tension is the
primary effect

9. Hyperbaric oxygen therapy (HBOT) is the inhalation of
100 percent oxygen inside a hyperbaric chamber that is
pressurized to greater than 1 atmosphere (atm). HBOT
causes both mechanical and physiologic effects by
inducing a state of increased pressure and hyperoxia.
HBOT is typically administered at 1 to 3 atm. While the
duration of an HBOT session is typically 90 to 120
minutes, the duration, frequency, and cumulative
number of sessions have not been standardized.
What is HBOT?

10.  What is HBOT?
 How HBOT Works?
 Trends in Hyperbaric Medicine

(HBOT) Hyper Baric Oxygen Therapy

11. Basic Mechanisms
 Boyle’s Law – pressure and volume
inversely proportional under
constant temperature
 By increasing ambient pressure to 2
atm, decreases the volume by ½
 Therapeutic for bubble forming
diseases such as decompression
sickness or arterial gas embolism
 Henry’s Law – at a given
temperature, the amount of gas
dissolved in solute is directly
proportional to the partial pressure
of the gas.
 By increasing ambient pressure,
more oxygen can be dissolved in the
plasma
Solubilty of Gas (equilibirium
concentation): C = KH Pgas

13. Pressurized Oxygen
Capillary PressureOxygen PressureOxygen %
50 mm Hg pO2Normal Air
75 mm Hg pO21 Atmos.100% O2
246 mm Hg pO21.3 Atmos.100% O2
437.5 mm Hg pO21.5 Atmos.100% O2

14. pressure
O2absorption

15. What does this have in common?
HBOT
Oncology
Complicati
on of
Diabetes
Orthopedic
Vascular

16. Tissue Compromise
• Hypoxia – generates signal to
commence wound healing cascade
• Hyperbaric Oxygen environment
augments the signal
• Action – HBOT acts as a signal
transducer.

17. Recent studies suggest low oxygen state after a stroke, cerebral
palsy, autism, or chronic viral infections.
Some of the cells around the area of injury are still alive - not
sufficient oxygen to function well. Not dead, but too little oxygen to
do their jobs.
Thousands of people are affected every year by an event or
condition that causes some body tissues to live in a perpetually-
low oxygen state. Can be improved with acceptable blood flow,
oxygen saturation.
•Limb reattachment
•Radiation therapy
•Head injury
•Surgical wound
•Skin graft
•Plastic surgery
•Severe burns
•Carbon-monoxide poisoning

18. The macrophage is sensitive to variations in levels of
oxygen present in the tissues; sensitive to an oxygen
gradient
Persistent Hypoxia signal results in an attempt , by
local tissues to build new blood supply to the affected
area.
This is how tissues communicate to other neighboring
structures, the need for routine tissue repair to
commence.

19. Note that although there may be insufficient
stimulus to initiate the tissue repair cascade
under normal conditions, by increasing the
local oxygen delivery the oxygen gradient is
magnified ….resulting in a stronger signal and
augmented repair.

20. Clinical Hyperbaric
Oxygen Therapy
Emergency Indications
Diving injury
Carbon monoxide poisoning
Surgical infections
Acute traumatic ischemia
Failed flaps and grafts
Cerebral Edema
Burns
Scheduled Indications:
Generally related to healing of
compromised wounds

21. Uses
Certain non-healing wounds (post-
surgical or diabetic)
Radiation soft tissue necrosis and
radiation osteonecrosis
Necrotizing fasciitis (flesh eating
bacteria)
Carbon monoxide poisoning
Decompression sickness
Air or gas embolism

22. Uses
Acute arterial ischemia (crush injury,
compartment syndrome, etc.)
Compromised skin grafts or flaps
Severe infection by anaerobic bacteria
(such as gas gangrene)
Severe uncorrected anemia when blood
transfusion is not available (e.g., in a
Jehovah's Witness)
Chronic refractory Osteomyelitis

23. HBOT and Medicare
An HBOT session costs anywhere from $100to $300in private
clinics, to over $1,000in hospitals. More U.S. physicians are
lawfully prescribing HBOT for "off label" conditions such as
Lyme Disease and stroke. Such patients are treated in
outpatient clinics, however it is unlikely that their medical
insurance will pay for off label treatments.

24. Controversial
HBOT is controversial and health policy regarding its uses is
politically charged. Both sides of the controversy on the
effectiveness of HBOT is available in the form of PUBMED and
the Cochrane reviews, a discussion of Multiple Sclerosis in
particular.

25. Mechanism and Effects
Hyper-oxygenation Greater oxygen
carrying capacity
Increased oxygen diffusion in tissue fluid
Diffusion distance proportional to the
square root of dissolved oxygen
Severe blood loss anemia (unable to
carry oxygen)
Crush injury, compartment syndrome
graft, and flap salvage (decreased
perfusion)

26. Mechanism and Effects
Edema (increased diffusion barrier)
Decrease gas bubble size
Boyle law - Gas volume inversely
proportional to pressure
Hyperbaric diffusion gradient favors gas
leaving the bubble and oxygen moving
in, metabolizing oxygen in the bubble
Decompression sickness
Air embolus syndrome

27. Secondary Effects
Vasoconstriction
Decreased inflow into tissues
Decreased edema
Increased oxygen gradient between wound
and surrounding environment
Increased fibroblast proliferation leading to
increased collagen deposition and increased
fibronectin, which aids in neovascularization

28. Additional Effects
Leukocyte oxidative killing
Increased oxygen free radicals
Anaerobes lack superoxide dismutase to control
oxygen free radicals (Necrotizing soft-tissue
infections)
Toxin inhibition
Decreased clostridial alpha toxins (gas gangrene)
Decreased cardio toxins
Antibiotic synergy

29. Mechanism of action
Angiogenesis in ischemic tissues
Bacteriostatic/bactericidal actions
Carboxyhemoglobin dissociation hastened
Clostridium perfringens alpha toxin synthesis
inhibited
Vasoconstriction
Temporary inhibition of neutrophil Beta 2 integrin
adhesion

30.  Published clinical studies describing results from treating stroke patients with
hyperbaric oxygen, performed at 11 different hyperbaric centers, were analyzed
for benefit (a total of 265 patients). The cumulative amount of hyperbaric oxygen
therapy (DHBOT) was calculated by multiplying chamber oxygen pressure (ATA)
times the duration of each HBOT (in hours), times the total number of hyperbaric
treatments. Efficacy of HBOT (EfHBOT) was computed from the number of patients
in each study who showed significant clinical improvement of their neurologic
status as a result of HBOT (percentage of the total number of patients who
improved). The amount of benefit was compared with the total amount of HBOT.
Analysis showed that benefit increased progressively as more treatments were
given, as graphically depicted below.
Research Report of Hyperbaric
Oxygen Benefit for Stroke Victims

31. From the graphic plot above it can
be seen that average improvement
increased with each treatment and
that 30 one-hour HBOT treatments
resulted in progressive benefit. For
many patients that benefit
continued to increase with
additional therapy and 30
treatments is not usually considered
adequate for full benefit.

32. Migraine and cluster headaches are severe and disabling. Both
hyperbaric oxygen therapy (HBOT) and normal pressure oxygen
therapy (NBOT) have been suggested as effective treatments to
end acute attacks and prevent future attacks. HBOT involves
people breathing pure oxygen in a specially designed chamber. In
our review, we found some weak evidence to suggest that HBOT
helps people with acute migraine headaches and possibly cluster
headaches, and that NBOT may help people with cluster headache.
We found no evidence that either can prevent future attacks.
Because many migraines can be treated simply with appropriate
drug therapy, further research is needed to help choose the most
appropriate patients (if any) to receive HBOT.
Normal pressure oxygen therapy and
hyperbaric oxygen therapy for migraine and
cluster headaches
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The
Cochrane Database of Systematic Reviews 2011 Issue 10, Copyright © 2011 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The
full text of the review is available in The Cochrane Library (ISSN 1464-780X).