Hyperbaric Oxygen: Therapeutic Uses - More Indications Than Many Doctors Realise

by Kindwall, Eric P

from "British Medical Journal"
August 28, 1993 v307 n6903 p515(2)

     Subjects:    Hyperbaric oxygenation Therapeutic use

     Many  British  doctors  are   ignorant  of  the  indications  for

     hyperbaric oxygen and skeptical of its benefits, according  to  a

     recent survey of hyperbaric oxygen facilities. The survey, by the

     BMA's  Board  of  Science and Education, concluded that given the

     present level  of  use  then  provision  was sufficient, although

     doctors may be underusing the treatment.[1]

     They need to know for which conditions  hyperbaric  oxygen  works

     and refer accordingly. The telephone advisory service, run by the

     Institute  of Naval Medicine at Gosport (similar to the National

     Poisons Unit help line), should be better known.

     Treatment with hyperbaric oxygen was  introduced as an adjunct to

     cardiovascular surgery before cardiopulmonary  bypass  techniques

     and  deep  hypotheria  became  available.  But  when surgery in a

     hyperbaric chamber was no  longer  necessary most of the original

     researchers stopped studying it. Britain helped  to  pioneer  the

     use  of  hyperbaric  oxygen  to  treat carbon monoxide poisoning,

     refractory osteomyelitis,[2]  and  compromised  skin  grafts. But

     with no  formal  training  programs  and  little  funding,  the

     treatment now attracts little attention in Britain.

     When  administered  at  pressures  greater  than  one atmosphere,

     oxygen can assume properties more  akin  to  a drug than a simple

     support  for  metabolism.  In  carbon  monoxide  poisoning,   for

     example,  it stops lipid peroxidation, which spares neuronal cell

     membranes.[3]

     It reduces odema by  about  50%  in post ischaemic muscle through

     preserving adenosine triphosphate.[4] In acute burns  it  reduces

     fluid  requirements  by  35% in the first 24 hours, thus reducing

     oedema.[5-8] It reduces  white  cell  adhesion to capillary walls

     after ischaemic or traumatic insult,  mitigating  the  no  reflow

     phenomenon.[9]  Red  cell  flexibility  is  doubled  in  about 15

     treatments.[10] White cell killing  of  aerobic bacteria and some

     fungi  is  greatly  enhanced  at   high   oxygen   pressures,[11]

     facilitating control of osteomyelitis[12] and reducing the number

     of   operations   and  mortality  in  necrotising  fasciitis.[13]

     Extremely important  is  its  stimulation  of  new  capillary and

     collagen formation in radiated tissue, normalising tissue  oxygen

     tensions  to  permit surgery, healing, and even bone grafting.[14

     15]

     Finally, it  increases  tissue  levels  of  superoxide dismutase,

     which counters the  formation  of  free  radicals  after  injury,

     resulting  in  better  tissue  survival.[16] This is particularly

     important in  cursh  injury,  replants,  and  grafts,  where free

     radical formation is responsible for reperfusion injury.[17]

     Although many doctors believe that good  research  on  hyperbaric

     oxygen  is  rare,  the  converse is true.[18-22] Over 3800 papers

     have been published on the topic despite the relative scarcity of

     chambers. The Undersea  Medical  Society  began investigating the

     claims being made for hyperbaric  oxygen  treatment  in  1977.  A

     committee  (which  I  chaired)  considered 64 different allegedly

     improved by treatment  with  hyperbaric  oxygen.  In most of them

     there was insufficient evidence to warrant its clinical use.

     In preparing out original report we consulted the largest private

     insurers in the United States, Blue Cross/Blue  Shield,  and  the

     Federal  Health  Care  Finances  Administration.  Since  then the

     report  has  been  continually   updated.   At  present  only  12

     conditions are approved by  the  society  for  reimbursement.[23]

     Since  1977  the number of clinical chambers in the United States

     has grown from 37 to nearly 300.

     For inclusion  on  the  approved  list  there  had  to  have been

     controlled studies or large clinical series indicating  not  only

     the  efficacy  but  also the cost effectiveness of treatment with

     hyperbaric oxygen. In disorders  for which prospective controlled

     trials were impossible or unavailable, evidence adduced  for  the

     efficacy of hyperbaric oxygen had to be at least as convincing as

     that  used to support reimbursement of other treatments routinely

     paid for the insurers.  The  five  major  British centres for the

     most part limit treatment to  those  disorders  on  the  approved

     list, despite there being no regulation to that effect.

     This  list  can  serve  only  as  a guide. Though quite useful in

     diabetic wounds, hyperbaric oxygen is only part of a program of

     total wound care. For  some  diabetic wounds hyperbaric oxygen is

     inappropriate if the large vessels distal to the trifurcation  at

     the  knee  are  occluded  or  severely stenotic. Crush injury and

     impending compartment syndrome need  to be treated immediately if

     any worthwhile result is to follow. Late  referral,  which  gives

     time  for  oedema,  reperfusion, and injury; free radical damage;

     and  the  no  reflow  phenomenon  to  do  their  work,  makes the

     treatment largely a waster of time and money. For  some  surgical

     patients  the  potential  dangers  of further trauma to the wound

     during transportation will militate against the use of hyperbaric

     oxygen. Experience has shown,  however, that patients with severe

     carbon monoxide poisoning can be  transported  safely  over  long

     distances in a properly equipped ambulance or helicopter.

     Before  transfer  a  critically  ill  patient  is contemplated it

     should be ascertained  that  the  receiving  chamber facility can

     deliver the necessary level of intensive care. Whenever  the  use

     of   hyperbaric  oxygen  is  considered,  consultation  with  the

     physician  in  charge  of   the  hyperbaric  oxygen  facility  is

     mandatory to ensure that referral is appropriate. The  timing  of

     hyperbaric  oxygen  in  relation  to  surgery  is also critically

     important. For example, in  necrotising fasciitis, surgery is the

     accepted primary treatment, with  hyperbaric  oxygen  used  as  a

     follow  up. With gas gangrene, however, the hyperbaric chamber is

     used before surgery (other than for fasciotomy). In the treatment

     of radionecrosis the patient should be  treated at least 20 to 30

     times in the chamber, to induce the formation of new capillaries,

     before  elective  surgery  is  performed  if  healing  is  to  be

     expected.

     NOTES

     [1] BMA Board  of  Science  and  Education.  Clinical  hyperbaric

     medicine facilities in the UK London: BMA, 1993.

     [2] Perrins DJD, Maudsley RH, Colwil MR, Slack WK, Thomas DA. OHP

     in the management of chronic osteomyelitis. In: Brown IW, Cox BG,

     eds.   Proceedings  of  the  third  international  conference  on

     hyperbaric  medicine.   Washington,   DC:   National  Academy  of

     Sciences, National Research  Council,  1966:578-89.  (Publication

     1404.)

     [3]  Thom  SR. Antagonism of carbon monoxide-mediated brain lipid

     peroxidation  by  hyperbaric   oxygen.   Toxicol  Appl  Pharmacol

     1990;105:340-4.

     [4] Nylander G,  Lewis  D,  Nordstrom  H,  Larsson  J.  Metabolic

     effects  of  hyperbaric  oxygen  in  post-ischemic  muscle. Plast

     Reconstr Surg 1987;79:91-6.

     [5] Cianci P, Leuders HW,  Lee  H, Shapiro RL, Sexton J, Williams

     C, et al. Adjunctive hyperbaric oxygen therapy reduced length  of

     hospitalization   in   thermal   burns.   J   Burn  Care  Rehabil

     1989;19:432-5.

     [6] Nylander G, Nordstrom  H,  Eriksson  E. Effects of hyperbaric

     oxygen  on  oedema  formation   after   a   scald   burn.   Burns

     1984;10:193-6.

     [7]  Stewart  RJ,  Yamaguchi YT, Cianci PA, Knost PM, Samadani S,

     Mason SW et  al.The  effects  of  hyperbaric  oxygen on adenosine

     triphosphate  in   thermally   injured   skin.   Surgical   Forum

     1988;39:87-90.

     [8] Wells CH, Hinton JG. Effects of hyperbaric oxygen on post-bur

     plasma  extravasation.  In:  Davis  JC, Hunt TK (eds). Hyperbaric

     oxygen therapy.  Bethesda,  Maryland:  Undersea  Medical Society,

     1977:259-65.

     [9] Zamboni WA, Roth AC, Russell RC, Graham B, Suchy H, Kucan JO.

     Morphological analysis of the microcirculation during reperfusion

     of ischemic skeletal muscle and the effect of hyperbaric  oxygen.

     Plast Reconstr Surg 1993;1110-23.

     [10]  Mathieu  D,  Coget  J, Vinckier F, Saulnier A, Durocher ET,

     Wattel F. Red blood cell deformability and hyperbaric oxygen. Med

     Subaquatique Hyperbar 1984;3:100-4.

     [11] Mader JT, Brown  GL,  Gluckian  JC,  Wells CH, Reinarz JA. A

     mechanism  for  the  amelioration   by   hyperbaric   oxygen   of

     experimental  staphylococcal  osteomyelitis  in rabbits. J Infect

     Dis 1980;142:915-22.

     [12]  Davis  JC,  Heckman  JD,  DeLee  JC,  Buckwold  FJ. Chronic

     non-hematogenous osteomyelitis treated with  adjuvant  hyperbaric

     oxygen. J Bone Joint Surg [Am] 1986;68:1210-7.

     [13] Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross

     DS.  Hyperbaric  oxygen therapy for necrotising fasciitis reduced

     mortality and the need for debridements. Surgery 1990;108:847-50.

     [14]  Marx  RE,   Johnson   RP.   Problem   wounds  in  oral  and

     maxillofacial surgery: the role of hyperbaric oxygen.  In:  Davis

     JC,  Hunt  TK, eds. Problem wounds: the role of oxygen. New York:

     Elsevier Science Publishing, 1988:65-125.

     [15]   Marx   RE,   Johnson   RP,   Kline   SN.   Prevention   of

     osteroradionecrosis: a randomised  prospective  clinical trial of

     hyperbaric  oxygen  versus  penicillin  .   J   Am   Dent   Assoc

     1985;111:490-554.

     [16]  Kaelin  CM,  Im  MJ,  Myers  RA,  Manson PN, Hoopes JE. The

     effects of hyperbaric oxygen  on  free  flaps  in rats. Arch Surg

     1990;125:607-9.

     [17] Manson PN, Anthenelli RN, Im MJ, Bulkley GB, Hoopes JE.  The

     role  of oxygen-free radicals in ischemic tissue injury in island

     skin flaps. Ann Surg 1983;198:87-90.

     [18] Davis  JC.  Hyperbaric  oxygen  therapy.  Intensive Care Med

     1989;4:55-7.

     [19] Goulon M,  Barois  A,  Rapin  M,  Nouilhat  F,  Grosbuis  S,

     LaBrousse   J.  Intoxication  oxycarbonee  et  anoxie  aigue  par

     inhalation de gaz  de  charbon  et  hydrocarbures.  Am Intern Med

     1969;120: 335-49.

     [20] Hart GB, Lamb RC, Strauss MB. Gas gangrene 1:  a  collective

     review. J Trauma 1983;23:991-5.

     [21] Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s.

     Cleve Clin J Med 1992;59: 517-28.

     [22]  Strauss MB, Hargens AR, Gershuni DH, Greenberg DA, Crenshaw

     AG, Hart GB, et al.  Reduction  of skeletal muscle necrosis using

     intermittent hyperbaric oxygen in the model compartment syndrome.

     J Bone Joint Surg [Am] 1983;65:65-62.

     [23] Thom SR. Hyperbaric  oxygen  therapy:  a  committee  report.

     Bethesda: Undersea Hyperbaric and Medical Society, 1992.