HBO 101 Metroplex Adventist Hospital January 11, 2010

Hyperbaric Oxygen Therapy (HBOT) H. Sprague Taveau IV, DO, MBA, FACOFP Medical Director

Center for Wound Care and Hyperbaric Medicine

Faculty Disclosure H. Sprague Taveau IV, DO, MBA, FACOFP It is the policy of Diversified Clinical Services and Metroplex Adventist hospital to ensure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational programs. Dr. Taveau is the Medical Director for Metroplex Adventist Hospital’s Center for Wound Care and Hyperbaric Medicine in Killeen, TX, and is a Regional Medical Director for Diversified Clinical Services. He has no other affiliations nor does he own stock in any company that produces equipment or products discussed in this presentation.

REGRETABLY!!

Objectives Become familiar with the fundamental aspects of wound healing and its interrelationship with oxygen  Become familiar with the process of evaluating patients for and instituting hyperbaric oxygen therapy  Recognize the physiologic and pharmacologic benefits of hyperbaric oxygen therapy 

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

Essential step 1: Adequate perfusion?

If You Don’t Get Water to the Garden, the Garden Won’t Grow!!

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

If you can’t get water to the garden……the garden won’t grow!!!!

Essential step 2: Non viable tissue?

Wounds Won’t Heal in a SEWER!!

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Wounds Won’t Heal in a SEWER!!

Essential step 3: Inflammation or infection?

Wounds With BUGS Don’t Heal!!

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Wounds With BUGS Don’t Heal!!

Essential step 4: Edema?

Wounds Don’t Heal in a Swamp!!

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Wounds Don’t Heal in a Swamp!!

Essential step 5: Wound microenvironment conducive to healing?

Wounds Don’t Heal Unless The Environment Supports Healing

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Wounds Don’t Heal Unless The Environment Supports Healing

Essential step 6: Tissue growth optimized?

Tissue Growth is YOUR Business

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Tissue Growth is OUR Business

Essential step 7: Offloading, pressure relief?

Wounds Don’t Heal Under Pressure!!

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Wounds Don’t Heal Under Pressure!!

Essential step 8: Pain controlled?

Controlled Pain = Better Compliance

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Controlled Pain = Better Compliance

Essential step 9: Host factors optimized?

Wounds Don’t Heal Without Building Blocks!!

The Nine Essentials of Wound Healing 1. 2. 3. 4. 5. 6. 7. 8. 9.

Adequate Perfusion Non-Viable Tissue Inflammation or Infection Edema Wound Microenvironment Tissue Growth Optimized Off-Loading Pain Control Host Factors

The Nine Essentials of Wound Healing

Wounds Don’t Heal Without Building Blocks!!

Selecting Patients for HBO  By

ability to reverse specific pathophysiology …of wound healing failure

By

diagnosis

Benefits of Hyperbaric Oxygen Physiologic Effects: • Improved leukocyte function and bacterial killing • Antibiotic potentiation • Enhanced collagen synthesis and cross-linking

Pharmacological Effects: • Direct antimicrobial effects, toxin synthesis suppression • Blunting of systemic inflammatory responses • Prevention of leukocyte activation and adhesion • PDGF-BB receptor stimulation (multiple effects) • VEGF release and angiogenesis • Detoxification (CO, CN, H2S)

Selecting Patients for HBO  By

ability to reverse specific pathophysiology …of wound healing failure

By

diagnosis

Emergency/Acute Indications      

Cerebral Arterial Air or Gas Embolism Carbon Monoxide Poisoning Cyanide Poisoning Hydrogen Sulfide Poisoning Clostridial Myositis & Myonecrosis Acute Traumatic Ischemia   

Crush Injury Compartment Syndrome Replantation Limb/Digits Etc.

Emergency/Acute Indications Decompression Sickness  Exceptional Blood Loss (Anemia)  Intracranial Abscess  Necrotizing Soft Tissue Infections  Thermal Burns (Not CMS Approved)  Combined Synergistic Necrotizing STI  Compromised Skin Grafts/Flaps 

Acute Traumatic Ischemia 

 

4 year old slipped and fell into a riding lawn mower, sustaining a mid-calf amputation of his leg. Leg was successfully replanted. Ischemic time: 10 hours Tx’d aggressively with HBO

Acute Traumatic Ischemia 

Appearance of muscle three days after replantation shows 100% viability as HBO counteracted reperfusion injury.

Acute Traumatic Ischemia   

Three Months after Injury HBO @ 2.4 ATA x 90 minutes q8h x 6 Then q12h x 4

Acute Traumatic Ischemia 

The result was excellent function of the leg. The patient regenerated his nerves and ended up with a sensate foot. He was able to walk and run with the aid of a brace.

Crush Injury 

Crush Injury with avulsion of palmar skin 

Appearance at time of presentation 1 hour after injury

Crush Injury



Elevation of avulsed palmar skin of crushed right hand

Crush Injury  

Immediate post-op view Note vertical blue line through midpalm 

Area not expected to survive

Crush Injury  

11 weeks post injury HBO @ 2 ATA x 90 minutes q8h x 3 then q24h x 17

Crush Injury

 

11 weeks post injury Full range of motion

Non-approved Emergent Indications Retinal Artery Insufficiency  Actinomycosis 

Chronic/Elective Indications 

Problem Wounds   

 

Chronic Refractory Osteomyelitis Delayed Radiation Injury  



Diabetic Foot Ulcers (Chronic; Wagner III) Arteriolar Insufficiency Etc.

Soft Tissue Bony

Meleny Ulcer (Invasive Group A Strep)

Age associated differences in cellular Proliferation (in vitro)…

11000 10000

Number of Cells

9000 8000 7000

New born Young adult Old adult

6000

NB 5000

YA 4000

OA

3000 2000 1000 0

0

1

2

3

4

5

6

7

8

9

10

11

12

13

Day

(Buras and Buras, Harvard Medical School, MGH, Boston)

Decreased cellular proliferation with diabetes…

35

30

# Cells X 10 4

25

20

15

Diabetic

10

Non-Diabetic 5 1

2

3

4

5

6

7

8

9

Days

(Buras and Buras, Harvard Medical School, MGH, Boston)

HBO Dramatically Increases Old Adult Fibroblast Proliferation…

(Buras and Buras, Harvard Medical School, MGH, Boston)

HBO Dramatically Increases Diabetic Fibroblast Proliferation… 30

# Cells X 10

4

25 20 15 Diabetic

10

Diabetic + HBO

5 1

2

3

4

5

6

7

8

Days

(Buras and Buras, Harvard Medical School, MGH, Boston)

9

PtcO2 As A Predictor of Wound Healing in Diabetic Foot Wounds… = Initial healing success = Initial healing failure

PtcO2 < 30 mmHg indicated 39 fold increased risk of early healing failure. Pecoraro, et al. Diabetes 40:1305-1313, 1991

Wound Healing Impairment with Decreasing PtcO2 40 mmHg

0 mmHg

118.0

110.3

158.7

68.0

2 hours pre…………………………2 hours post

Pre Smoking Baseline

Post Smoking

Smoking Effects on Benefit from HBO H B O T re a tm e n ts fo r S m o k e rs 120 110

M in im u m P la n n e d

Number of HBO Treatments Projected

100

E xp e cte d N u m b e r

90 80 70 60 50 40 30 20 10 0 0

10

20

30

40

50

60

70

80

90

100

110

P a ck- Y e a r s o f S m o kin g

The avg pt with > 10 pk/yrs who benefitted from HBOT needed 8-14 more HBO treatments than a non smoker for the same outcome (Otto & Fife, UHM 2000;27(2):83-89.

Ulcers      

Grade 0: Intact skin Grade I: Superficial without penetration deeper layers Grade II: Deeper reaching tendon, bone, or joint capsule Grade III: Deeper with abscess, osteomyelitis, or tendonitis extending to those structures Grade IV: Gangrene of some portion of the toe, toes, and/or forefoot Grade V: Gangrene involving the whole foot or enough of the foot that no local procedures are possible

Grade I or II w/Infection = Grade III Wagner FW. Foot & Ankle 1981, 64-122

DFU Treated with HBO

DFU Treated with HBO

DFU Treated with HBO

DFU Treated with HBO

DFU Treated with HBO

DFU Treated with HBO

DFU Treated with HBO

DFU Treated with HBO

DFU

10/16/09

DFU

11/20/09

DFU

12/30/09

Problem Wounds 

Achilles tendon rupture repair  



4 months post-op Suture line breakdown 2 weeks post-op Multiple failed attempts at secondary closure

Problem Wounds 

TCOMs in the periwound area demonstrated soft tissue hypoxia immediately adjacent to wound edges

Problem Wounds    

5 weeks post-HBO HBO @ 2 ATA x 90 minutes q24h x 20 Routine wound care Oral antibiotics

Problem Wounds   

Posterior view Excellent range of motion Ambulating without difficulty

Problem Wounds 

Non-healing transmetatarsal amputation 





Suture line breakdown 3 mos s/p Fem/Tib bypass

Considering BKA

Problem Wounds 

10 weeks post-HBO  

 



Complete healing No surgical debridement No revision No BKA

HBO @ 2 ATA x 90 minutes q24h x 20

Soft Tissue Radionecrosis 

Malignant FibroHistiocytoma  



Wide excision Radiation therapy

2 months post-op   

Dehiscence Radionecrosis Purulent drainage

Soft Tissue Radionecrosis



Close-up view  

9 x 6.5 cm Stage III/IV Ulceration

Soft Tissue Radionecrosis 

1 week post-HBO     

 

2 ATA 90 minutes each Q24h 20 treatments 5 days/week

Routine wound care Oral antibiotics

Soft Tissue Radionecrosis   

10 days post-STSG Ambulating without difficulty No further procedures required

Compromised Flap 

ORIF open fracture right Tibia    

 

Wound break down Exposed plate Flap rotated Skin graft to donor site

Distal ischemia Impending necrosis

Compromised Flap



Post-HBO x 10 Treatments

Compromised Flap 

Complete Healing 





HBO @ 2.4 ATA x 90 minutes q12h x 6 Then 2 ATA x 90 minutes q24h x 14

No further procedures necessary

Old Absolute Contraindications  Known

Malignancies

 Increased

 Pregnancy

Vascularity

 Retrolentil

Fibroplasisa  Premature Closure of PDA

 Implanted

Pacemakers

 Manufacturing

Defects

Absolute Contraindications

 Untreated Pneumothorax  Pregnancy (Almost)

Barotrauma ALL Barotrauma is directly related to BOYLE’S LAW V 1 P 1 = V2 P 2 V1P1

“The volume of a gas varies inversely with the absolute pressure (at a constant temperature)”

V2P2

LOPI

LOPI

LOPI



P

LOPI



P

LOPI

 P

LOPI



P

LOPI



P

Relative Contraindications Upper Respiratory Infections  Chronic Sinusitis  Emphysema w/CO2 Retention  High Fevers  History of Seizure Disorder  Pregnancy 

Oxygen Toxicity: Pulmonary & Cardiac Bleomycin *(Pulmonary)  Anthracyclines** (Cardiac) 

Doxorubicin  Taxotere  Daunorubicin  Epirubicin  Idarubicin  Mixoxantrone 

*UNQUALIFIED ABSOLUTE CONTRAINDICATION to simultaneous administration with HBO. OK >1 year since last dose. Monitor pulmonary status closely. **For the anthracyclines, a last dose interval >6 weeks appears to be sufficient to allow initiation of HBO.

Chemotherapy and HBO Risks 

Oxygen Toxicity (Cardiac, Pulmonary and CNS) 

Alkylating Agents  

       

Plant Alakaloids Anthracyclines (Unqualified Absolute Contraindication)

Antineoplastic/Cytotoxic Agents Anti-tumor Antibiotics Cyto-skeletal disrupters (Taxanes) Epipodophyllotoxins Epothilones Peptide Antibiotics Platinum Based Agents Topoisomerase II Inhibitors

Chemotherapy and HBO Risks Since there are no case series nor RCTs and very few case reports regarding chemotherapeutic agents and HBO, we can only extrapolate from information in the literature as it pertains to mechanism of action. In OUR OPINION, patients undergoing chemotherapy with the aforementioned agents should not be treated with HBO for at least 6 weeks or 5 half lives (whichever is longer) after their last dose of that agent.

Chemotherapy and HBO Risks 

Probably Safe Monoclonal antibodies  Nucleotide analogs and precursor analogs  Retinoids 

Medication and HBO Risks Amiodarone 1. Amiodarone has been associated with cases of acute pulmonary fibrosis in association with exposure to increased FiO2. 2. All cases reported (about 7 in the literature) have occurred in critically ill patients receiving the drug by intravenous administration which appears to lead to an increase in pulmonary uptake. 3. Animal models have demonstrated a similar occurrence. 4. All human cases have received Amidarone dosages > 200mg/day.

Medication and HBO Risks Amiodarone Our pulmonologist colleagues, with extensive HBO experience and some experience in treating patients receiving oral Amiodarone believe that it is probably safe at doses of < 200mg/day (all cases of toxicity reported in the literature were in the dose range of ≥ 400mg/day).

Medication and HBO Risks Amiodarone In light of this new information we have altered our position to allow HBO in patients receiving oral Amiodarone at doses < 200mg/day with a normal preHBO PFT and CXR. PFT and CXR should be repeated as indicated by the onset of pulmonary symptoms.

Relative Contraindications (Continued) 

History of Surgery for Otosclerosis 



Viral Infections 



Get worse

Congenital Spherocytosis 



PE tubes

Hemolysis in presence of increased paO2

History of Optic Neuritis 

May be associated with blindness

Complications & Side Effects 

Barotrauma of the Ear 

PE tubes

CNS Oxygen Toxicity  Pulmonary Oxygen Toxicity  Visual Refractive Changes 

Complications & Side Effects (Continued) Numb Fingers  Dental Problems 





Occult abcess

Claustrophobia

What’s on the HBO Horizon? The Latest on Potential Indications

Source Material Abstracts From the 38th Annual Undersea and Hyperbaric Medical Society Scientific Meeting 16-18 June, 2005 Las Vegas, Nevada

Chronic Wounds 

ALL Chronic Wounds 

Not JUST Diabetic Wounds

Hawkins, G.; et al

Radiation Induced Anosmia Eight of Nine Patients Improved  Larger Study of Greater Duration Required 

Johnson, E.G.; et al

Acute Acoustic Trauma (AAT) 

HBO is Most Effective When started within 48 hours of injury  When continued for 10 treatments 



Concomitant Steroids are Contraindicated

Kapetanakis, E.; et al

Sub-Acute Global Cerebral Ischemia 

Post Cardio-Respiratory Arrest 



Effective well beyond hyper-acute reperfusion period

Further Formal Study Required

Murphy-Lavoie, H.; et al

Acute Traumatic Brain Injury Significant Decrease in Mortality  Improved Speech, Language & Cognitive Function  Further Study Recommended 

Bennett, M.H.; et al, Hoggard, M.L.; et al

Acute Coronary Syndrome 

Initial Studies Optimistic Improved Quality of Life  No Improvement in Prolongation of Life 



Further Study Recommended

Bennett, M.H.; et al

Acute Myocardial Infarction 

The Dark Ages (Early 60’s & 70’s) 



Too little, too late

The Renaissance (Late 70’s & 80’s) Controlled studies  Improvement with HBO and Vasodilators 



The Age of Rationality (Early 90’s) 

Immediate HBO & Thrombolysis 

Reduced infarct size by 95%

Hart, G.B.; et al

Acute Myocardial Infarction  The

Age of Reason (The Present)

2

Hour Treatments at 2 ATA  Pre and Post HBO Improves Long Term Patency  PTCA  CABG  Coronary

Artery Stents Hart, G.B.; et al

Acute Myocardial Infarction 

The Future Improved Long Term Patency  Yet to be established 



HBOT’s role in: – – – –

Hart, G.B.; et al

Reperfusion Injury (Mechanism now elucidated-2007) Endothelial Inflammatory Reaction Lipid Metabolism Angiogenesis of Myocardial Vasculature

Sepsis 79% Mortality – Untreated  65% Mortality – Treated 





90 minutes BID @ 2.5 ATA

Reduction in splenic bacterial CFUs

Buras, J.A.; et al

UT/Hermann Memorial Multiplace

Perry Sigma 40

Perry Sigma 34

Seachrist 3600E

Seachrist 3200

Brooks AFB Research Chamber

Dive Ship Deck HBO “Can”

Hyperbaric Oxygen Therapy

Thanks for your attention! Do you have any questions?

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