| Hyperbaric Oxygen Therapy History
In the 17th century bridge construction demanded
workers dive to great underwater depths with the introduction of caissons
(a chamber, usually of steel but sometimes of wood or reinforced
concrete, used in the construction of foundations or piers in or near a
body of water). The air in the chamber is kept under pressure great
enough to prevent the entrance of water, while shafts through the bulkhead
permit the passage of workers, equipment, and excavated material between the
bottom and the surface. Workers frequently
suffered from caisson's disease (the "bends") and were treated in metallic
vessels large enough to hold people and strong enough to hold air under
pressure. These vessels, combined with newly-developed air
compressors, resulted in the enabled treatment of patients with hyperbaric
air decompression. This represented the first reports of
decompression sickness; the caisson workers assumed a bent posture (the
"bends") to help
relieve the pain caused by nucleation of accrued nitrogen in their joints
as they emerged from depths of up to 70 feet.
Conventional western
medicine uses HBOT to treat the following:
Uncontrolled
Decompression during Diving: results in one of two types of
decompression sickness (DCS).
Treatment involves recompressing
the patient in 100% oxygen, followed by controlled decompression using
data developed by the U.S. Navy.
Carbon Monoxide Poisoning:
This colorless, odorless gas passes readily through alveoli
(lung tissue air sacs) into the blood where it binds tightly to
oxygen-carrying proteins in the blood (hemoglobin). Carbon monoxide
also locks up the energy factory machinery (cytochrome system) inside each
cell's mitochondria. This prevents our bodies from being able to use
oxygen. The use of HBOT to treat carbon monoxide poisoning is
controversial. It is used to prevent/treat the development of
neurologic injury in patients with severe exposure to this deadly gas.
Usually, patients undergo one or two 90-minute treatments at 2-3
atmospheres (2-3 times the atmospheric pressure at sea level).
Difficult Wounds: Chronic,
non-healing wounds are found in a variety of clinical patients.
Recent data has supported the use of HBOT in the treatment of non-healing
wounds caused by irradiation. There is less data to support the use
of HBOT in other clinical settings. However, HBOT is often
recommended in patients with difficult clinical problems. For
example, diabetes mellitus and vascular disease are notorious for late
complications of non-healing wounds. Amputation of an infected lower
leg is the end result in many unfortunate cases. These patients have
been shown, recently, to benefit from HBOT. One study showed
decreased major amputation rate in diabetic patients who underwent HBOT
(30 daily 90-minute treatments at 2-3 atmospheres).
Soft Tissue Infections: with
anaerobic bacteria had a lower mortality rate in patients who underwent
hyperbaric oxygen therapy, according to one study. Another study
showed HBOT to have no benefit in these infections. According to one
author (Sheridan), HBOT seems a reasonable adjunct to surgery, if it can
be safely administered without delaying standard treatment (surgery and
antibiotics). Treatment would consist of 90-minute treatments at
2-3 atmospheres once or twice daily.
The following link will take you to a full-text review
article on HBOT in the New England Journal of Medicine:
http://content.nejm.org/cgi/content/full/334/25/1642?ijkey=jUKDuJvHX0/.2
Alternative Medicine
Stroke: Although
HBOT is used conventionally in the United States, its use is reportedly
higher in other countries. Stroke patients in Germany may undergo this
form of treatment according to David Hughes, D.Sc. of the Hyperbaric
Oxygen Institute. Hughes states that HBOT has decreased the
aftercare costs for stroke patients in Germany by as much as 71%. As
recent as 1995, one French study (Nighoghossian) showed that
HBOT may be helpful in the treatment of ischemic stroke. But more recent
investigations (Rusyniak et al) have shown that HBOT "does not appear to
be beneficial and may be harmful in patients with acute
ischemic stroke".
Peripheral Vascular Disease and
Chronic Wounds: Hughes also claims that HBOT is
used in France for peripheral vascular disease (PVD); which can be caused by atherosclerosis, arteriosclerosis, and
diabetes, and others. PVD oftentimes results in poor wound-healing
and chronic ulcers (most often on/around the foot and ankle). HBOT
is not part of routine, conventional wound care for diabetic foot ulcers.
It may, however, be considered for some patients. The American Diabetes
Association recognizes HBOT as a potential adjunctive therapy for complex limb-threatening diabetic foot wounds unsuitable for
revascularization procedures.
Multiple Sclerosis: Dr. Hughes also states that HBOT is used in Great Britain to treat
Multiple Sclerosis (MS). Based on an unpublished article from 1993
by D. Perrin, Hughes cites that more than 25,000 MS patients have
benefited from HBOT. But, according to
Kleijnen, patients who have chronic progressive or chronic stable multiple sclerosis
showed no consistent positive effects to HBOT (results based on Expanded
Disability Status Score [EDSS] and the Functional Status Score). An
earlier study by
Kindwall (1991)
treated patients in accordance with protocols that reported to
produce a benefit in multiple sclerosis.
Investigators were unable to substantiate any useful long-term effect of
hyperbaric oxygen therapy.
Others: Dr. Hughes also states that
in Russia HBOT is used for detoxification of
drug and alcohol overdose, and that citizens in Japan are never more than
30 minutes away from a hyperbaric chamber.
There are many proposed uses for HBOT in human disease.
Listed below are links to several other websites.
Links
http://www.cerebralpalsy.ws/hyperbaric_oxygen_therapy.htm
http://drcranton.com/hbo.htm
http://www.cincinnatihyperbarics.com/
http://www.netnet.net/mums/HBO.htm
http://www.hbot4u.com/
Complications of
HBOT
In the elective setting, when
patients are properly prepared and monitored, serious treatment-related
complications are extremely rare. However, particularly in the emergent
setting, it is important to have an understanding of potential
complications so they can be avoided. Complications may occur during
compression, during treatment, or during decompression.
Complications during compression:
are related to Boyle's Law, which states that the volume of a gas in a
closed space will decrease as pressure increases. Closed spaces in
which this may be significant are air-filled spaces beneath dental
fillings, the middle ear, and sinuses.
-
Middle Ear: To facilitate
clearance of the eustachian tube, alert patients are instructed to
swallow during compression. In the non-alert patient and
those who are on a breathing machine (intubated), it is
necessary to perform a myringotomy before compression to ensure that
there is no injury to the tympanic membrane (ear drum). A single
small incision in the lower front quadrant of the tympanic membrane
immediately before compression.
-
Sinuses: more
difficult to alleviate, although topical decongestants may be of
value.
-
Anxiety: may also be a
problem during compression when patients are first placed into the
chamber; some patients require anxiolytics to facilitate treatment.
Potential complications during
treatment: include seizures and those related to compromised patient
access in monoplace chambers. Seizures, thought to be secondary to oxygen
toxicity, have been reported to occur in as many as 10% of patients
undergoing hyperbaric oxygen treatment for 90 minutes at 3 atmospheres.
However, the incidence of seizures has been dramatically reduced with the
routine use of "air breaks." This is a maneuver in which the patient
breathes compressed room air for 10 of every 30 minutes.
Complications that occur during
decompression: are possibly the most serious potential complications.
Gas trapped in air spaces that do not communicate with the chamber will
expand rapidly.
-
A pneumothorax (collection of
air between the lung and chest wall) will become
much larger. Patients who have had recent attempts at upper body
central venous catheters must be evaluated for occult pneumothorax. If
necessary, chest tubes should be placed prophylactically and can be
attached to a Heimlich valve during treatment.
-
If the sinuses or middle ears have
become obstructed, pain may ensue. Awake patients need to be
appropriately coached to clear their sinuses and middle ears.
-
If patients have significant air
trapping or bronchospasm, localized air trapping may result in serious
pulmonary barotrauma if decompression rates are too rapid; patients who
are wheezing or have severe bronchospasm should not be treated.
References Sheridan RL; Shank
ES; Hyperbaric Oxygen Treatment: A Brief Overview of a Controversial Topic. The Journal of Trauma. 1999;47(2):426-35 Daniel E.
Rusyniak, MD; Mark A. Kirk, MD; Jason D. May, MD;
Louise W. Kao, MD; Edward J. Brizendine, MS; Julie L. Welch, MD; William H. Cordell, MD; Robert J.
Alonso, MD; Hyperbaric Oxygen Therapy in Acute
Ischemic Stroke: Results of the
Hyperbaric Oxygen in Acute Ischemic
Stroke Trial Pilot Study.
Stroke.
2003;34:571. N. Nighoghossian, MD; P.
Trouillas, MD; P. Adeleine, MD; F. Salord, MD
Hyperbaric Oxygen in the Treatment of
Acute Ischemic Stroke A Double-blind
Pilot Study. Stroke.
1995;26:1369-1372. Consensus Development Conference of
Diabetic Foot Wound Care. Diabetes Care 1999; 22:1354-60 Hyperbaric oxygen for multiple sclerosis. Review of
controlled trials. Kleijnen,-J; Knipschild,-P
Acta-Neurol-Scand. 1995
May; 91(5): 330-4 Treatment of
multiple sclerosis with hyperbaric oxygen. Results of a national registry.
Kindwall,-E-P; McQuillen,-M-P; Khatri,-B-O; Gruchow,-H-W; Kindwall,-M-L
Arch-Neurol. 1991
Feb; 48(2): 195-9
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