Hyperbaric Medicine Treatment or Placebo

1
Hyperbaric MedicineTreatment or Placebo
2
Early Microscopes
3
Placebo (Remembered wellness)
Placebo is safe, inexpensive and has withstood
the test of time It is enhanced by a good
therapeutic relationship, trust, confidence,
positive beliefs and expectations, compassion,
rapport and touch Kaptchuk, Ted. The Placebo
Effect in Alternative Medicine Can the
Performance of a Healing Ritual Have Clinical
Significance? Ann Int Med Volume 136(11)  4 June
2002 pp 817-825
Im addicted to placebos. Id give them up
but it wouldnt make any difference -Jay Leno
4
Being loved is cardioprotective
Ohio State University Animal study of diet high
in fat and cholesterol
Loved, petted, and talked-to rabbits demonstrated
a 60 lower incidence of atherosclerosis Nerem
RM, Levesque MJ, Cornhill JF. Social environment
as a factor in diet-induced athersclerosis.
Science. 19802081475-1476.
5
Definition

• Hyperbaric Oxygen Therapy (HBOT)
• treatment with 100 oxygen
• while inside a chamber
• at pressures higher than sea level (1ATA)
• (Feldmeier,2003)

6
History of Hyperbarics

• First used to treat caisson workers using
  pressurized air
• Later used to treat divers.

7
Early Hyperbarics

• Cunningham Sanitarium was built in 1920s
• 64 feet in diameter and 5 stories high
• Pressurized with air to a pressure of 30 psi or 2
  ATA

8
Early Hyperbarics

• The theory was that the increased pressure and
  oxygen would alleviate many diseases (wrongly
  attributed) to anaerobic bacteria.
• In 1941 the chamber was dismantled for scrap
  metal to further WWII

9
Modern HBOT

• Modern scientific use began in post WW2
• Churchill-Davidson augmented beneficial effects
  of radiation therapy for cancer, 1955
• In mid 1970s the UHMS systematically reviewed
  all available scientific evidence
• Modern indications for HBOT use
• (Bookspan 2000)

10
Chambers
11
Effects of HBOT

• Bubble reduction
• Hyperoxygenation
• Vasoconstriction
• Host immune function
• Microbiological
• Others stem cell

12
IndicationsPrimary Treatment

• Decompression Illness
• Reduction in bubble size
• Increase concentration gradient
• Arterial Gas Embolism
• Reduction in bubble size
• Gas gangrene
• Bactericidal
• UHMS HBOT Committee Report 1999

13
Diving Medicine
14
Adjunctive Treatment

• Problem wounds
• Crush injury, compartment syndrome, other acute
  ischaemias
• Necrotizing soft tissue infections
• Skin grafts and flaps
• Thermal burns
• Osteomyelitis (refractory)
• Radiation Injury
• CO poisoning
• Intracranial abscess
• Exceptional anemia
• UHMS HBOT Committee Report 1999

15
Tissue oxygen tensions (mmHg)

• 1.0 ATA 1.0 ATA 2.4 ATA
• Air 100 O2 100 O2
• Site
• Ambient 159 760 1824
• Arterial 100 550 1,450
• Subcut 30-50 90-150 250-500
• Chest 67 450 1,312
• Mid-foot 63 280 919
• Dooley 1997

16
Oxygenation post HBOT

• Tissue O2 levels stay raised
• Blood plasma 5 min
• Muscle 11/2 2 hours
• Subcutaneous tissue 3-4 hours
• Poorly perfused tissue 3-5 hours
• Specific dose duration curves

17
Factors That Prevent Healing

• Poor blood supply
• Scarring
• Oedema
• Inflammation
• Infection
• Microvasculitis (radiation, diabetic,
  auto-immune)
• All impair oxygen supply to tissues

18
Normal Healing

• Need 30-40 mmHg tissue pO2 to produce
• Normal leukocyte activity (Rabkin 1988)
• Normal collagen synthesis (Knighton 1981)
• Normal collagen cross linking (Pai 1972)
• Normal angiogenesis (Meltzer 1986)
• Fibroblasts activity (Prokop 1979)

19
HBOT for Chronic Wounds

• 2 community 29 of hospital patients (Levin
  1998)
• Correction of hypoxia is beneficial (Sheffield
  1998)
• Fibroblast and collagen production (Hunt 1972)
• Angioneogenesis (Knighton 1981)
• Epithelialisation (Uhl 1994)
• Improved leucocyte killing of bacteria (Mader
  1980)
• Direct toxic effects on anaerobic bacteria
• Synergism with antibiotics
• Reduction of local tissue oedema

20
Transcutaneous Oxygen Monitoring of tcpO2
21
Wound Hypoxia
(Sheffield 1998)
22
Response to oxygen challenge
(Prince of Wales Hospital)
23
Number of HBOT treatments
(Prince of Wales Hospital)
24
Vascular Density
25
Diabetic UlcersPrediction of HBOT success

• Retrospective analysis of 1,144 diabetic ulcers
• Best discriminator of success is an in-chamber
  PtcO2 in excess of 200mmHg (74 reliable)
• (Fife 2002)
• Amputation likely if PtcO2 of 20-40mmHg (OR 7.5,
  95CI 4.0-14.1)
• If lt20mmHg amputation very likely (OR 161, 95CI
  55-469)
• (Reiber 1992)

26
Efficacy of HBOT

• Author Design Regimen Outcome-HBO
  Outcome-control
• Baroni C/NR 2.5x34 2/18 amputation
  4/10 amputation
• 1987
  16/18 healed (89) 1/10 healed (10)
• Oriani C/NR 2.5x72 3/62 amputation
  6/18 amputation
• 1990 59/62 healed (95) 12/18 healed (66)
• Faglia C/R 2.2x38 3/35 amputation
  11/33 amputation
• 1996 32/35 healed (91) 22/33 healed
  (66)
• Kalani C/R 2.5x40-60 2/17 amputation
  7/22 amputation
• 2002 15/17 healed (88) 15/22 healed (68)

27
Diabetic Ulcers
HBOT 02
Post HBOT
28
Diabetic Ulcers
Pre HBOT
Post HBOT
29
Diabetic Ulcers Cost-Effectiveness

• Studies show an overall saving by combining HBOT
  with standard care improved outcomes (Cianci
  1998, Abidia 2003)
• Overall saving of approx 8,000 per patient
  compared to non-HBOT care
• Cost of amputation gt70,000 vs 13,000 (Cianci
  1998 (USA), Gordois 2003 (UK))

30
Restoring Normoxia

• Select problem wounds
• Crush injuries
• Irradiated tissue
• Osteomyelitis
• Compromised flaps and grafts
• Thermal burns

31
Crush Injury and Acute Ischemia
4-year-old male
32
Refractory Osteomyelitis
33
Osteo-Radionecrosis (ORN)

• Highly significant cost reductions (34,000 vs
  102,000) and gains in resolution at one year
  (100 vs 8)
• (Myers 1990, Castillo-Gomez 2005 similar results
  with NNR3)

34
Compromised Grafts and Flaps
Treatment 1
Treatment 4
Treatment 7
Treatment 9
35
Compromised Grafts and Flaps
Treatment 10
Follow up visit
36
Thermal Burns

• 23 year old Caucasian female with facial burns
  from flaming gasoline
• 12 hours post injury

37
Thermal Burns

• 24 hours later
• 36 hours post injury
• 2 hyperbaric oxygen treatments

38
Thermal Burns

• 72 hours later
• 84 hours post injury
• Six hyperbaric oxygen treatments

39
Thermal Burns

• Four weeks post injury

40
Potential Side-Effects

• Barotrauma
• Serous otitis
• Near sightedness
• Temporary improvement in far sightedness
• Maturing of cataracts
• Numb fingers
• Fatigue
• Medication related
• Oxygen toxicity
• Decompression illness
• Gas embolism
• Fire risks

41
Fire Suppression System
Fire Suppression
Prevention
Extinguish
Limiting Fuel Ignition Sources
Deluge System
Hand Line
42
ACC Approved Indications

• Decompression sickness
• Arterial air or gas embolism
• Crush injury
• Acute traumatic ischemia
• Replantation of severed limbs
• Accidental carbon monoxide poisoning
• Clostridial myositis and myonecrosis
• Necrotizing soft tissue infections
• Diabetic wounds (traumatic)

43
(No Transcript)
44
(No Transcript)
45
Treatment Tables
46
Summary

• Improve non-healing wounds (especially diabetic)
• Reduce inflammatory swelling (compartment
  syndrome, burns, injury, infection)
• Help manage some severe chronic infections
  (hypoxic, anaerobic, fungal)
• Create new capillaries in hypoxic, injured
  irradiated tissues
• Potential for improvement of sports injuries and
  other conditions, eg fibromyalgia

47
Possible New Indications

• Sports injuries
• Pre and post surgery to improve wound healing
• Bells palsy
• Cerebral palsy
• Stroke recovery
• Multiple Sclerosis
• Head injuries and concussion
• Chronic infections, including Lymes disease
• Chronic fatigue and fibromyalgia
• ADD/ADHD and autism
• Migraine headaches and trigeminal neuralgia
• Vascular disease and Raynaud's phenomenon
• Crohn's disease
• Decreased immune function
• Venomous bites and sunburn

48
HBOT for Lower-Extremity Soft-Tissue Sports
Injuries

• Injuries at areas of reduced perfusion such as
  muscletendon junctions and ligaments seemed to
  benefit more from HBOT than injuries at the
  muscle belly
• differences in the magnitude of the injury and in
  the time between injury and treatment may also
  affect outcomes
• (Kanhai 2003)

49
HBOT reduces muscle tenderness and raises pain
threshold in fibromyalgia

• Double-blinded randomised controlled trial with
  intention-to-treat
• Marked improvement in number of tender points,
  pain threshold and VAS pain scores (plt0.001)
• HBOT may work by correcting hypoxia, increasing
  new blood vessels collagen matrix and
  decreasing NO production
• (Yildiz 2003)

50
Bell's palsy

• RCT of HBOT(n42) vs prednisone (n37)
• HBO2 group treated 2.8 atm for 60 min, twice a
  day, 5 days a week
• Prednisone group - 2.8 atm abs of 7 O2 same
  schedule 450 mg in 8 days
• Both groups treated for up to 30 sessions or
  recovery
• Followed up for 9 months
• Results
• Complete recovery in 95.2 with HBO2, and 75.7
  with prednisone
• Average time for recovery 22 vs 34.4 days
  (Plt0.001)
• (Racic 1997)

51
HBOT Improves Cognitive Abilities After Brain
Injury

• Patients with long-standing but stable traumatic
  brain injury (TBI)
• Improvement in speech, memory and attention
• 60 min at 1.5 ATA x 80 sessions
• increase in penumbral area cerebral blood flow on
  SPECT
• (Harch)

52
Eye Disease

• Retinal Artery Occlusion
• Comparative retrospective review of records of
  all HBO treated patients compared to matched
  controls
• All recevied HBOT within 8 hours onset of
  symptoms
• Improvement in visual acuity 82.9 in HBOT group
  vs 29.7 of controls (p lt 0.00001)
• (Beiran 2001)
• Limited evidence of usefulness in
• Post-radiation optic neuropathy (Levy 2006)
• Retinitis pigmentosa (Inv Ophth1997)
• Macular degeneration (Bojic 1994)

53
(No Transcript)
54
(No Transcript)
55
Additional Information Resources

• Websites
• Oxygen Therapies Ltd.
• www.hbot.co.nz
• The Undersea and Hyperbaric Medical Society
• www.uhms.org
• Hyperbaric Evidence
• www.hboevidence.com