Textbook of Hyperbaric Medicine

Transcription

1 Textbook of Hyperbaric Medicine

2 Kewal K. Jain Textbook of Hyperbaric Medicine Sixth Edition

3 Kewal K. Jain, MD Basel, Switzerland ISBN ISBN (ebook) DOI / Library of Congress Control Number: Springer International Publishing AG 2017 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

4 Foreword to the Third Edition Slowly but surely, hyperbaric medicine is becoming an established treatment modality for a variety of medical disorders, despite the rocky road that it has sometimes had to travel over the years. In some ways, I feel that the need for oxygen in medical treatments is akin to man s basic requirement for water and food, and I also think it is fair to say that the logic and utility of hyperbaric oxygen treatment now seem to be almost as undeniable as these basic requirements are. It is certainly the case that, from time immemorial, remedies learned by trial and error have been handed down through the generations with the result that many roots, berries, fruits, and leaves, as well as special waters containing minerals have been advocated throughout history for their curative powers. More recently, however, evidence-based medicine has come to the fore, demanding higher standards of evidence from basic and clinical/research trials and objective statistical results. One of the first instances of such objective studies in my lifetime was when Austin Bradford Hill and Richard Doll ( Doll 2003 ) convinced colleagues to allocate patients with pulmonary tuberculosis randomly to prove the efficacy of streptomycin, although their trial followed a tradition started 200 years earlier by Linde, who provided citrus fruits aboard some, but not all ships in the British Navy to test whether they would prevent scurvy ( Moberg and Chon 2000 ). By means of prospective trials, it has been found that various established therapies can be detrimental for some diseases, while being clearly beneficial for others. This is precisely the case with hyperbaric medicine now: while a hyperoxic environment for newborn babies can lead to retrolental fibroplasia with blindness, there is also convincing evidence that hyperbaric treatments provide clear benefits in diseases such as various neurological disorders, stroke, cerebral ischemia, and wound healing. And, of course, those of us who have worked in highaltitude environments know the very short time window during which the human brain can function in hypoxic conditions. It never ceases to astonish me what a wide range of effects (beneficial or toxic) a seemingly innocuous substance such as oxygen can have in various circumstances. By and large, the experts who have made such superb contributions to the Textbook of Hyperbaric Medicine are the world leaders in their fields. With their help, Dr. Jain has expanded his already outstanding book into a compendium of multiauthored chapters (containing over 2000 references) covering areas of medicine as disparate as wound healing, gastrointestinal disorders, trauma, and obstetrics. Of particular interest in this edition are the extensive discussions of cerebral circulation and its disorders, as well as of stroke, diving accidents, and neurosurgery. For an earlier edition, Dr. Jain enlisted a remarkable Foreword by Professor Edward Teller (see next page), who began by stating Hyperbaric medicine is new and controversial and that we live in an age that has the habit of treating progress with suspicion, and then went on to pose the question, But what is the innovator to do? He also raised the age-old problem of the ethics of the double-blind trial and cautioned us to be aware of the potential danger of highpressure treatment for too long a period, in the same way that drug treatments at too high dosages bear clear risks. The field of hyperbaric medicine has indeed been subject to an at times v

5 vi Foreword to the Third Edition intense debate, but much progress has been made since Professor Teller originally wrote his words (and will, I am sure, continue to be made in the future), on the basis of mutual respect, understanding, and cooperation, while also submitting beliefs to randomized trials. Professor Teller wrote then: It is not entirely impossible that, perhaps sometime in the next decade, professors of medicine will have difficulty in explaining why treatment with oxygen was not widely adopted much earlier. Reflecting today on these words by an elder statesman whose scientific observations went unheeded early on, we can safely conclude that the uphill battle for acceptance of hyperbaric oxygen as therapy now rests on a solid foundation. This solid foundation is described comprehensively and clearly within this outstanding text, in which the assembled experts provide a fair and balanced summary of the literature and evidence. And it also means that the decade of HBO to which Professor Teller indirectly referred has now come. James F. Toole, MD Teagle Professor of Neurology Director, Cerebrovascular Research Center Wake Forest University School of Medicine Winston-Salem, NC, USA References Doll R. The evolution of the controlled trial. The Eighteenth John P. McGovern Award Lecture, delivered at the Thirty-third meeting of the American Osler Society, Edinburgh, Scotland; 23 May Moberg CL, Chon ZA, editors. Launching the antibiotic era. Personal accounts of the discovery and use of the first antibiotics. New York: Rockefeller University Press; 1990.

6 Foreword to the First Edition Hyperbaric medicine is new and controversial. Indeed, since it is new, it must be controversial in an age that has the habit of treating progress with suspicion. But what is the innovator to do? If he applies a new and safe procedure to patients, and the procedure appears to be successful, his success might well be denigrated as anecdotal. Will he be allowed to run a double-blind experiment in which half of the patients are denied the benefits of what appears to be a cure? It is an age-old problem that has grown sharper in the course of time. Hyperbaric medicine grew out of the problems encountered by divers exposed to high pressures. The treatment of disturbances due to bubbles which develop during rapid decompression was the natural connection between high pressure and medicine. This limited application of a medical procedure is, of course, widely accepted. But its extension to counteract the damage due to the air bubbles resulting from other causes, such as those accidentally introduced during medical treatment, is less generally recognized. What is attempted in this book is a detailed and critical treatment of a large subject. If thorough discussion will lead to some consensus, the subject could grow very much larger. Indeed, oxygen, which in the form of hyperbaric oxygen (HBO) is called a drug, is the most natural of all drugs. The first problem we must face is the danger of high-pressure treatment used at excess pressure for too long a period, or in conjunction with the wrong kind of drug. Oxygen indeed has toxic effects. Furthermore, the delivery of the pressurized gas to the patient may be mishandled. A properly extensive discussion is devoted to such dangers, which are completely avoidable. Perhaps the most natural use of HBO is to counteract carbon monoxide poisoning. The best known effect of carbon monoxide is to replace oxygen by being more firmly bound to hemoglobin. But, of course, high-pressure oxygen can drive out the carbon monoxide and produce a cure in an understandable fashion. A little harder to grasp is why pure oxygen at two atmospheres of pressure (which is ten times as concentrated as the natural occurrence) should have any general uses. Indeed, under normal circumstances, the hemoglobin in arterial blood is 97 % saturated with oxygen. Are we exerting ourselves to supply the remaining 3 %? The answer, of course, is no. Oxygen is also soluble in blood. At two atmospheres of pressure, oxygen can be dissolved into the plasma at several times normal levels and can significantly improve tissue oxygenation. This is important because hemoglobin, while more eager to take up oxygen, is also more reluctant to part with it. The oxygen dissolved in the plasma, having a higher chemical potential, is pushed out from the capillaries and into the surrounding tissue. From there, it can spread small distances by diffusion. Even in the blood itself, the dissolved oxygen may help the white blood cells in their phagocytic activity. Bacteria themselves may react in a variety of ways. It appears that many can use oxygen at normal pressures, but are damaged by oxygen at higher pressures. In the case of anaerobic bacteria, oxygen can act in a powerful way to stop the infection. In combination with other methods, HBO clearly appears effective in cases of gangrene. vii

7 viii Foreword to the First Edition But more is involved than the straightforward destruction of the pathogen. The natural healing process may also be assisted by the presence of oxygen. This obviously should be the case when hyperbaric treatment counteracts on oxygen deficiency. Many injuries involve the destruction of capillaries, the means of delivering oxygen. Under such circumstances, healing is itself tied to revascularization of the damaged tissue. But growth of the requisite capillaries is in turn tied to the oxygen supply. This relationship can explain why in the case of many slow healing wounds, HBO seems to have a strong positive effect. Very much more can and should be done to extend the study of the speed of healing to the more normal cases. In the human body, 20 % of the oxygen consumption occurs in 3 % of the body mass: the brain. This is also the region most sensitive to a deficiency of oxygen, which can produce dramatic results. Indeed, surgical methods on the carotid artery are often used to relieve oxygen deficiency to the brain. It seems logical that in HBO we have a tool that can serve a similar purpose. This might be particularly important in the case of stroke, a high-ranking cause of death and disability. It is clearly worthwhile to explore whether and to what extent disability can be reduced or avoided by prompt use of hyperbaric treatment. If the blood supply to a small region of the brain is reduced, relief might come from the diffusion of oxygen into the ischemic region from neighboring capillaries. For all new medical techniques, scientific evidence is demanded. Yet medicine is still partly an art, as well as a dramatically advancing science. Therefore in the complicated questions of life, disease, and recovery, it is sometimes hard to distinguish between the fight against the causes of a disease and our efforts to aid toward the reassertion of overall health. There are good indications that HBO is helpful in many diseases, such as multiple sclerosis and osteomyelitis. One may mention these two applications because, in the former, earlier recognition of the disease made possible by the use of magnetic resonance imaging has made early treatment a better possibility and seems to have given a real chance for help from HBO. In the latter case, osteomyelitis, the location of the disease is the bone, where oxygen is usually not amply available. As members of the scientific community we are all naturally tempted to theorize, as long as a glimmer of a theory might be perceived. This book proceeds, however, along strictly step by step empirical lines. Case after case, the various pathologies are reviewed. In each situation, it is carefully stated to what extent the evidence merely indicates a conclusion and to what extent the conclusion can be proved. In the present stage of HBO, it is a certainty that there will be considerable criticism. On the other hand, those who disagree are likely at the same time to disagree among themselves. I believe that the result will be not only critical reflection, but also more experimentation, more reviews, more understanding, and more progress. It is not entirely impossible that, perhaps sometimes in the next decade, professors of medicine will have difficulty in explaining why the treatment with oxygen was not widely adopted much earlier. Edward Teller Formerly Director Emeritus Lawrence Livermore National Laboratories California & Senior Research Fellow Hoover Institution Stanford University, Stanford, CA, USA

8 Preface to the Sixth Edition A quarter of a century has passed since the first edition of the book was published. Apart from incorporating new advances since the fifth edition, there was a major reorganization of the book for the new publisher, Springer. Of the more than 2500 publications relevant to hyperbaric medicine published during that were reviewed, approximately 1300 have been selected and added to the bibliography which has been divided and appended at the end of each chapter. Several older references have been deleted, whereas others have been retained either for their historical interest or for research that has not been repeated. As in previous editions, proportionately more space has been devoted to disorders of the nervous system than other therapeutic areas. Nine chapters on new topics have been added to this edition, and two chapters from the first edition were deleted with incorporation of essential information into other chapters. With increasing application of biotechnologies to clinical medicine, applications in combination with hyperbaric oxygen have been explored, including a new chapter on personalized hyperbaric medicine. There is an increasing integration of multidisciplinary approaches in management of complex disorders, and the role of hyperbaric oxygen in these has been defined. Other new chapters include Nursing in a Hyperbaric Medical Facility, Hyperbaric Oxygen Therapy in Military Medicine, and Ethics, Standards and Quality Control in Practice of Hyperbaric Medicine. Finally, I would like to thank Gregory Sutorius, senior editor in Clinical Medicine at Springer, for his encouragement and oversight of this project. Diane Lamsback, developmental editor for Springer, has provided invaluable assistance in editing and managing this project. Basel, Switzerland ix

9 Preface to the Fifth Edition Almost 20 years have passed since the first edition of the Textbook of Hyperbaric Medicine was written, and since the publication of the fourth revised edition in 2004, there has been a considerable increase of research and development in applications of hyperbaric oxygen. Of the more than 1200 publications relevant to hyperbaric medicine during , approximately 300 have been selected and added to the list in this book, whilst a corresponding number of older references have been deleted to maintain the bibliography at 2000 entries. Several older publications have been retained for their historical interest, and some of these have indeed become classics. There is an ever increasing use of hyperbaric oxygen for neurological disorders. Other areas of expansion include applications in ophthalmology, and the chapter on this has been rewritten and expanded by Frank Butler and Heather Murphy-Lavoie. A new chapter by Alan Wyatt on the role of hyperbaric oxygen in organ transplantation has been added as well as a chapter on the treatment of chronic Lyme disease by William Fife and Caroline Fife. Multimodality treatment is required in some complex disorders, and hyperbaric oxygen has been combined with new advances in drug treatment and surgical procedures as well as with complementary medicine techniques such as acupuncture. As other new technologies such as those for manipulating stem cells develop, their interaction with hyperbaric oxygen is being studied. Hyperbaric oxygen may prove to be a useful adjunct to stem cell-based therapeutics and regenerative medicine. I would like to thank the editorial staff at Hogrefe & Huber Publishers, particularly the Publishing Manager, Robert Dimbleby, for their help and encouragement during this revision. Basel, Switzerland xi

10 Preface to the Fourth Edition The textbook has been revised in accordance with the progress made in hyperbaric medicine during the past 4 years. There were over 1000 publications relevant to hyperbaric medicine during Approximately 200 of these were selected and a corresponding number of older references were deleted to keep the total number of references in the bibliography to The number of clinical trials for various applications in hyperbaric oxygen therapy has increased. These are included wherever the published results are available. As personalized medicine is developing, it will be applied to hyperbaric oxygenation as well. It is already obvious that patients require an individualized approach in hyperbaric therapy protocols. The dose of oxygen, pressure, and duration of treatment need to be determined for each patient individually. It is difficult to reach any conclusions from clinical trials about a particular pressure of oxygen or even a range for a broad diagnostic category with many variants among patients that determine the response. Applications in neurological disorders are developing further and space devoted to this area has been increased. A new chapter by Neubauer and Harch has been added on the treatment of cerebral palsy with hyperbaric oxygenation. I wish to thank the publishing directors of Hogrefe Publishers and their Editor, Mr. Robert Dimbleby, for their help and encouragement throughout the period of revision. Basel, Switzerland xiii

11 Preface to the Third Edition Hyperbaric medicine continues to make progress. The textbook has been revised and expanded with inclusion of new contributors. We are fortunate to have an article from Prof. Hideyo Takahashi of Japan describing the state of development of hyperbaric oxygen therapy in Japan. As in the previous edition, objective judgment has been exercised in deciding to include various reports and studies on this subject. There are more than 200 publications every year on hyperbaric medicine, and all the publications cannot be included in references. The bibliography already contains more than 2000 entries. Most of the older references have been retained because of their historical value. Much of the original material still holds its value and has also been retained. Simply because no new work has been done in some areas does not mean that these indications for HBO are no longer valid. Research in hyperbaric medicine continues to be limited by lack of funding. However, the technique is available for clinical application in certain cases when the need arises and often a precedence in that area helps. Well-documented anecdotal reports have a teaching value, and this has been utilized in the textbook. This is particularly so in the case of emergency medicine and treatment of hypoxemic/ischemic encephalopathies, where it would be practically impossible to conduct controlled studies. Much of the expansion of hyperbaric oxygen therapy is in the area of neurological disorders, which is reflected in the increased number of chapters devoted to this area. This application of hyperbaric oxygen holds the greatest promise for the future for diseases of the nervous system. I wish to thank the publishing directors of Hogrefe & Huber and their Editor, Mr. Robert Dimbleby, for their help and encouragement throughout the period of preparation. Basel, Switzerland xv

12 Preface to the Second Edition A great deal of progress has taken place in Hyperbaric Medicine since the publication of the first edition. This has necessitated a thorough revision of the book and inclusion of new contributors. Some of the outdated references were removed and new ones have been added, bringing the total about 1800 entries. I have tried to keep my judgment objective, and this is helped by the fact that I have no involvement in the political and financial aspects of hyperbaric medicine. In spite of this critical revision and corrections, I am pleased to state that a great deal of the old stuff still holds its value. Use of hyperbaric oxygen therapy in neurological disorders continues to expand and required a chapter on neurosurgery, for which I was fortunate to have the collaboration of Dr. Michael Sukoff of the United States, who has done much of the pioneer work in this field. The chapter on pediatric surgery by Prof. Baydin from Russia is a useful new addition. With the inclusion of unpublished work on the role of neuropeptides in oxygen therapy (Prof. G.T. Ni) from China, the book is now truly international. I wish to thank the publishing directors of Hogrefe & Huber Publishers for their help and encouragement throughout the period of revision. Countless other colleagues also helped and their names are too numerous to list here. Basel, Switzerland xvii

13 Preface to the First Edition This book goes considerably beyond the scope of the Handbook of Hyperbaric Oxygen Therapy, which was written by me and published by Springer Verlag in In addition, with the many rapid developments in this field, the Handbook has already become remarkably outdated. Our use of the word textbook in the title of the present work is in keeping with the increasing worldwide recognition of this branch of medicine and the need for a definite and inclusive source covering this body of knowledge, as it exists today. In practice hyperbaric medicine of course involves mostly the use of hyperbaric oxygen, i.e., oxygen under pressure greater than atmospheric. As a result, this field overlaps with diving medicine in the areas of The effect of high pressure on the human body Physical exercise under hyperbaric environments Air embolism Decompression sickness I have made no attempt to intrude any further into diving medicine, as there are several excellent textbooks on that subject. In addition, the use of normobaric oxygen has been discussed elsewhere in a 1989 title by, Oxygen in Physiology and Medicine. I have written this current work in a textbook style, and there is more discussion on the pathophysiology of diseases and the rational basis of hyperbaric oxygen than in the Handbook. Extensive and up-to-date references have been assembled as an integral part of this project, and these total about The highlights of this present effort are the newly documented effectiveness of hyperbaric oxygen therapy in the rehabilitation of stroke patients and the validation of these gains via the iofetamine scan technique. This same method has also been used to document the improvement in multiple sclerosis patients undergoing hyperbaric oxygen therapy. In the preparation of this work, I was considerably aided by the capable and cooperative management effort provided by the two directors of the Hogrefe & Huber publishing company. The execution of a project involving this degree of both scope and detail is certainly an exercise in teamwork between author and publisher, and it was a pleasure to have shaped the production in a creative and timely manner. Basel, Switzerland xix

14 Contents Part I Basic Aspects 1 The History of Hyperbaric Medicine... 3 Hyperbaric Therapy and Diving Medicine... 3 The Development of Hyperbaric Air Therapy... 4 The Development of Hyperbaric Oxygen Therapy... 7 References Physical, Physiological, and Biochemical Aspects of Hyperbaric Oxygenation Introduction Physical Basics Physiology of Oxygenation The Oxygen Pathway Ventilation Phase Transport Phase Shift of the Oxygen-Hemoglobin Dissociation Curve Delivery of Oxygen to the Tissues Oxygen Transfer at the Capillary Level Relation Between the Oxygen Transport and Utilization Oxygen Utilization in the Cell Effect of Blood Flow Effect of Oxygen-Hemoglobin Reaction on Transport of CO Autoregulation of the Intracellular po Hyperbaric Oxygenation Theoretical Considerations General Effects of HBO on the Healthy Human Body Biochemical Effects of HBO Effect of HBO on Enzymes Effect of HBO on the Nervous System Effect of HBO at Molecular Level Conclusion References Effects of Diving and High Pressure on the Human Body Physical Effects of Pressure Effects of Pressure on Various Systems of the Body Hematological and Biochemical Effects Effect on Ammonia Metabolism Effect on Blood Cells and Platelets xxi

15 xxii Contents Changes in the Respiratory System and Blood Gases Effects on the Cardiovascular System Changes in the Endocrine System Effect on the Skeletal System Effects of High-Pressure Environments on the Nervous System Damage to the Middle Ear and Inner Ear in Diving Vertigo and Diving Taste Sensation Under High Pressure Effect of High Pressure on Effect of Drugs Conclusion References Physical Exercise under Hyperbaric Conditions Introduction Exercise and Hypoxia Exercise in Hyperbaric Environments Exercise Under Hyperoxia Physical Exercise Under Hyperbaric Conditions General Effects Effect on Lactate Production and Clearance Effect of Exercise on Ammonia Metabolism Effect of HBO on Antioxidant Enzymes in Skeletal Muscle Effect of HBO on Blood Flow to the Muscles During Exercise Physical Exercise in Relation to Toxic Effects of HBO Conclusion References Hypoxia Introduction Pathophysiology of Hypoxia Hypoxia-Inducible Factor Hypoxia and Heat Shock Proteins Effect of Hypoxia on Cellular Metabolism Impact of Hypoxia on Various Body Systems Respiratory Function Cardiovascular System General Metabolic Effects Effects of Hypoxia on the Brain Role of HBO in the Treatment of Hypoxic States The Role of Nitric Oxide Synthase in the Effect of HBO in Hypoxia Possible Dangers of HBO in Hypoxic States References Oxygen Toxicity Introduction Pathophysiology of Oxygen Toxicity Free Radical Mechanisms Pathology of Oxygen Toxicity Pulmonary Oxygen Toxicity Normobaric vs. Hyperbaric Oxygen in Induction of Pulmonary Oxygen Toxicity... 53

16 Contents xxiii Oxygen-Induced Retinopathy Factors That Enhance Oxygen Toxicity Central Nervous System Oxygen Toxicity Ammonia and Amino Acids Biomarkers of Oxygen Neurotoxicity Neuropathology of Oxygen Toxicity Manifestations of CNS Oxygen Toxicity Clinical Monitoring for Oxygen Toxicity Protection Against Oxygen Toxicity Extension of Oxygen Tolerance Conclusion and Directions for Future Research References Hyperbaric Chambers: Equipment, Technique, and Safety Introduction Monoplace Chambers Multiplace Chambers Multiplace Chambers for the Critical Care Department Surgery in the Multiplace Chamber Mobile Multiplace Hyperbaric Chambers Hyperbaric Chambers for Diving Medicine Hyperbaric Chambers for Animal Research Selection of a Hyperbaric Chamber Technique of Hyperbaric Oxygenation Ancillary Equipment Oxygen Masks and Hoods Respirators and Ventilators Diagnostic Equipment ECG and EEG Transcutaneous Oxygen Tension Glucose-Monitoring Devices Use of Miscellaneous Medical Devices in the Hyperbaric Chamber Cardiopulmonary Resuscitation Use of Defibrillators in Hyperbaric Chambers Pleural Suction Drainage Endotracheal Tubes Care of Tracheotomy Continuous Bladder Irrigation and HBO Transdermal Patches for Drug Delivery and Hyperbaric Chamber Implanted Devices in Patients Monitoring of Patients in the Hyperbaric Chamber Safety in the Hyperbaric Chamber Operational Safety Masks and Breathing Control System Fire Safety in the Chamber Use of Portable Hyperbaric Chambers in Patient s Rooms Regulatory Issues Relevant to Hyperbaric Medicine Staffing of Hyperbaric Facilities Conclusion References... 77

17 xxiv Contents 8 Indications, Contraindications, and Complications of HBO Therapy Indications Contraindications Complications of Hyperbaric Oxygenation Middle Ear Barotrauma Ophthalmological Complications of HBO Pulmonary Complications of HBO Oxygen Seizures Decompression Sickness Genetic Effects Claustrophobia Anxiety Reactions Coincidental Medical Events in the Hyperbaric Chamber Precautions in Selection of Patients for HBO Treatment Conclusion References Drug Interactions with Hyperbaric Oxygenation Oxygen as a Drug Drug Drug Interactions Interactions of HBO with Other Drugs Interaction of HBO with Antimicrobials Carbapenem Antibiotics Aminoglycoside Antibiotics Sulfonamides Interaction of HBO with Anticancer Agents Interaction of HBO with Cardiovascular Drugs Adrenomimetic, Adrenolytic, and Ganglion-Blocking Agents Digitalis/Digoxin Antianginal Drugs Heparin Interaction of HBO with Drugs Acting on the CNS Anesthetics CNS Stimulants Ethanol Narcotic Analgesics Pentobarbital Scopolamine Interaction of HBO with Miscellaneous Drugs Practical Considerations of Drug Administration During HBO Therapy Drugs that Enhance Oxygen Toxicity Drugs that Protect Against Oxygen Toxicity Conclusion References Neurophysiologic SPECT Brain Function Imaging and Hyperbaric Oxygen Therapy J. Michael Uszler Introduction Case Studies Conclusion Suggested Reading... 96

18 Contents xxv Part II Clinical Applications 11 Decompression Sickness Philip B. James and Introduction Pathophysiology Gas Formation Pulmonary Changes Bubble-Induced CNS Injury Changes in Blood Dysbaric Osteonecrosis Role of Free Radicals Clinical Features Decompression Sickness in Diving Altitude Decompression Sickness Ocular Complications of DCS Ultrasonic Detection of Bubbles Diagnosis Blood Examination Ultrasound Monitoring of Bubbles Bone Scanning X-Rays Retinal Angiography Imaging Electrophysiological Studies Neuropsychological Assessment Treatment Emergency Management and Evaluation Recompression and HBO Treatment Management of Altitude Decompression Sickness Management of Neurological Manifestations of Decompression Sickness Monoplace vs. Multiplace Chambers Use of Oxygen vs. Other Gas Mixtures Drugs Importance of Early Treatment Delayed Treatment Treatment of Residual Neurological Injury and SPECT Brain Imaging in Type II DCS Risk Factors for DCS Preventive Measures for DCS Prognosis of DCS Conclusion References Cerebral Air Embolism Introduction Causes Mechanisms Pathophysiology of Cerebral air Embolism Clinical Features Diagnosis Treatment

19 xxvi Contents Clinical Applications of HBO for Air Embolism Ancillary Treatments Antiplatelet Drugs Steroids Hemodilution Control of Seizures Measures to Improve Cerebral Metabolism Hyperbaric Treatment in Special Situations Cerebral Edema Cardiovascular Surgery Neurosurgery Pulmonary Barotrauma Air Embolism During Invasive Medical Procedures Cerebral Air Embolism During Obstetrical Procedures Cerebral Air Embolism in Endoscopic Retrograde Cholangiopancreatography Cerebral Embolism Due to Hydrogen Peroxide Poisoning Relapse Following Spontaneous Recovery Delayed Treatment Conclusion References Carbon Monoxide and Other Tissue Poisons Classification of Tissue Poisons Carbon Monoxide Poisoning Historical Aspects of CO Poisoning Biochemical and Physical Aspects of CO CO Body Stores Biochemical Effects of CO on Living Organisms Inhibition of the Utilization of Oxygen by CO Epidemiology of CO Poisoning Causes of CO Poisoning Sources of CO Poisoning Pathophysiology of CO Poisoning CO Binding to Myoglobin CO-Induced Hypoxia Effects of CO on Various Systems of the Body Cardiovascular System Hemorheological Effects of CO Effect of CO on Blood Lactate Effect of CO on the Lungs Exercise Capacity Sleep Effect on Pregnancy Musculoskeletal System Skin Gastrointestinal System Effects on the Peripheral Nervous System Effects on the Visual System Effect on the Auditory System Effect on the Central Nervous System Clinical Features of CO Poisoning Neuropsychological Sequelae of CO Poisoning

20 Contents xxvii Clinical Diagnosis of CO Poisoning Pitfalls in the Clinical Diagnosis of CO Poisoning Occult CO Poisoning Laboratory Diagnosis of CO Poisoning Brain Imaging Studies General Management of CO Poisoning Rationale for Oxygen Therapy (NBO or HBO ) for CO Poisoning Experimental Evidence Clinical Use of HBO in CO Poisoning Clinical Trials of HBO in CO Poisoning HBO for CO Intoxication Secondary to Methylene Chloride Poisoning Treatment of CO Poisoning in Pregnancy Treatment of Smoke Inhalation Prevention and Treatment of Late Sequelae of CO Poisoning Controversies in the Use of HBO for CO Poisoning Cyanide Poisoning Pathophysiology Clinical Features of Cyanide Poisoning Laboratory Diagnosis Treatment Rationale for Use of HBO in Cyanide Poisoning Hydrogen Sulfide Poisoning Carbon Tetrachloride Poisoning Methemoglobinemias Treatment Miscellaneous Poisons Organophosphorus Compounds Conclusions: Poisoning Other Than with CO References HBO Therapy in Infections Introduction Host Defense Mechanisms Against Infection Impairment by Anoxia Oxygen as an Antibiotic HBO as an Adjuvant to Antibiotics HBO in the Treatment of Infections HBO in the Treatment of Soft Tissue Infections Crepitant Anaerobic Cellulitis Progressive Bacterial Gangrene Necrotizing Fasciitis Nonclostridial Myonecrosis Fournier s Gangrene Gas Gangrene Fungal Infection HBO in the Management of AIDS Miscellaneous Infections Osteomyelitis Management of Osteomyelitis HBO Treatment of Osteomyelitis Clinical Results of HBO Treatment in Osteomyelitis Osteomyelitis of the Jaw Osteomyelitis of the Sternum

21 xxviii Contents Malignant Otitis Externa References Hyperbaric Oxygen Therapy and Chronic Lyme Disease: The Controversy and the Evidence Caroline E. Fife and Kristen A. Eckert Introduction to Lyme Disease vs. Chronic Lyme Disease : A Brief Overview Chronic Lyme Disease HBOT for Lyme Disease and CLD Rationale for Using HBOT The Need for a HBOT Medical Registry Conclusion References HBO Therapy in Wound Healing, Plastic Surgery, and Dermatology Introduction Wound Healing Role of Oxygen in Wound Healing Pathophysiology of Nonhealing Wounds Wound Healing Enhancement by Oxygen Clinical Applications Role of HBO in Nonhealing Wounds and Ulcers Ulcers Due to Arterial Insufficiency Diabetic Ulcers Clinical Use of HBO in Diabetic Foot Guideline for the Use of HBO in the Treatment of Diabetic Foot Ulcers Venous Ulcers Decubitus Ulcers Infected Wounds Frostbite Spider Bite HBO for Inflammatory Bowel Disease HBO as an Aid to the Survival of Skin Flaps and Free Skin Grafts Basic Considerations Animal Experimental Studies Comparison and Combination of HBO with Other Methods for Enhancing Flap Survival Clinical Applications Conclusion HBO as an Adjunct in the Treatment of Thermal Burns Basic Considerations Experimental Studies Clinical Applications Conclusion Applications of HBO in Dermatology Necrobiosis Lipoidica Diabeticorum Pyoderma Gangrenosum Purpura Fulminans Toxic Epidermal Necrolysis Psoriasis Scleroderma References

22 Contents xxix 17 HBO Therapy in the Management of Radionecrosis Intoduction Radiation Physics Unit of Radiation Radiation Biology Radiation Pathology Clinicopathological Correlations Effect of Radiation on Blood Vessels Effect on Soft Tissues Radiation Effects on the Nervous System Radiation Effects on the Bone HBO Therapy for Radionecrosis Effect of HBO on Radiation Damage to Skin and Mucous Membranes Rationale for Clinical Application Management of Osteoradionecrosis Basic Studies Osteoradionecrosis of the Mandible Osteonecrosis of the Temporal Bone Osteoradionecrosis of the Chest Wall Osteoradionecrosis of the Vertebrae Management of Radionecrosis of CNS Management of Radionecrosis of Soft Tissues Effect of HBO on Cancer Recurrence Conclusion References The Use of HBO in Treating Neurological Disorders Introduction Effect of HBO on Cerebral Metabolism Effect of HBO on Cerebral Blood Flow Effect of HBO on the Blood Brain Barrier Effect of HBO on Oxygen Tension in the Cerebrospinal fluid Rationale for the Use of HBO in Neurological Disorders Cerebral Hypoxia Cerebral Edema Role of HBO in Neuroprotection Indications for the Use of HBO in Neurological Disorders Clinical Neurological Assessment of Response to HBO Comatose Patients Paraplegics Hemiplegics (Stroke Patients) Diagnostic Procedures Used for Assessing the Effect of HBO Electrophysiological Studies Cerebral Blood Flow Computerized Tomography Magnetic Resonance Imaging Positron Emission Tomography Single Photon Emission Computed Tomography References

23 xxx Contents 19 Role of Hyperbaric Oxygenation in the Management of Stroke Introduction Epidemiology of Stroke Risk Factors for Stroke Pathophysiology of Stroke Causes of Stroke Changes in the Brain During Ischemic Stroke Clinicopathological Correlations Structure of a Cerebral Infarct Cerebral Metabolism in Ischemia Molecular Mechanism in the Pathogenesis of Stroke Gene Expression in Response to Cerebral Ischemia Induction of Heat Shock Proteins Role of Cytokines and Adhesion Molecules in Stroke DNA Damage and Repair in Cerebral Ischemia Role of Neurotrophic Factors Classification of Ischemic Cerebrovascular Disease Recovery from Stroke Complications of Stroke Sequelae of Stroke Vascular Dementia Diagnosis of Stroke Stroke Scales Barthel Index Rankin Scale National Institutes of Health Stroke Scale Unified Neurological Stroke Scale Canadian Neurological Scale Evaluation of Various Scales An Overview of the Conventional Management of Stroke Acute Ischemic Stroke Neuroprotectives Management of the Chronic Poststroke Stage Management of Spasticity Role of HBO in the Management of Acute Stroke HBO in Relation to Cerebral Ischemia and Free Radicals Animal Experiments Neuroprotective Effect of HBO Preconditioning Review of Clinical Studies HBO as a Supplement to Rehabilitation of Stroke Patients Conclusions of the Effects of HBO in Stroke Patients Future Prospects References HBO Therapy in Global Cerebral Ischemia/Anoxia and Coma Paul G. Harch Introduction Pathophysiology Rational Basis of HBO Therapy Review of Animal Experimental Studies Review of Human Clinical Studies Case Studies

24 Contents xxxi Patient 1: HBO Treatment for Coma Due to Traumatic Brain Injury Patient 2: Near Drowning, Chronic Phase Patient 3: Near Drowning, Chronic Phase Patient 4: Battered Child Syndrome Conclusion References HBO Therapy in Neurosurgery Introduction Role of HBO in the Management of Traumatic Brain Injury: TBI Mechanism of Action of HBO in TBI Effect of HBO on ICP in Acute TBI Effect of HBO Therapy in Chronic Sequelae of TBI Experimental and Clinical Studies of HBO in TBI Controlled Clinical Trials of HBO for TBI Use of HBO for TBI in Clinical Practice Conclusions Role of HBO in the Management of Spinal Cord Injury Effects of Spinal Cord Injury Rationale of the Use of HBO in SCI Animal Experimental Studies of HBO in SCI Clinical Studies of HBO in SCI Role of HBO in Rehabilitation of SCI Patients Role of HBO in Compressive and Ischemic Lesions of the Spinal Cord Conclusions About Use of HBO in SCI HBO as an Adjunct to Radiotherapy of Brain Tumors Role of HBO in the Management of CNS Infections Role of HBO in Cerebrovascular Surgery Neuroprotection During Neurosurgery Conclusion References Oxygen Treatment for Multiple Sclerosis Patients Philip B. James Introduction Pathophysiology Rationale for Hyperbaric Oxygen Treatment Clinical Trials of HBO in Multiple Sclerosis Conclusion References HBO in the Management of Cerebral Palsy Paul G. Harch Introduction: Causes of Cerebral Palsy Oxygen Therapy in the Neonatal Period Treatment of Cerebral Palsy with HBO Published Clinical Trials The United States Army Study on Adjunctive HBO Treatment of Children with Cerebral Anoxic Injury The New Delhi Study of HBOT in CP Unpublished Studies The Cornell Study Comparative Effectiveness Studies

25 xxxii Contents Recent Studies (Since 2007) Side Effects Case Reports Patient 1: Cerebral Palsy Patient 2: Cerebral Palsy Conclusions References HBO Therapy in Miscellaneous Neurological Disorders Introduction HBO in the Treatment of Benign Intracranial Hypertension Peripheral Neuropathy HBO for the Treatment of Peripheral Neuropathic Pain HBO for Treatment of Drug-Induced Neuropathy HBO for the Treatment of Trigeminal Neuralgia HBO in Susac s Syndrome Cerebral Malaria Vascular Headaches Rationale for the Use of HBO in Vascular Headaches Current Status of Use of HBO in Vascular Headaches HBO for Autism Spectrum Disorder Neurological Disorders in Which HBO Has Not Been Found to Be Useful Dementia Due to Degenerative Disorders of the Brain HBO in the Management of Neuromuscular Disorders References HBO Therapy in Cardiovascular Diseases Introduction Pathophysiology Risk Factors Hypoxia, Hyperoxia, and Atherosclerosis Hyperbaric Oxygenation in Cardiology Effect of Hypoxia, Hyperoxia, and Hyperbaric Environments on Cardiovascular Function Metabolic Effects of HBO on the Heart Role of HBO in Experimental Myocardial Infarction Clinical Applications of HBO in Cardiology Acute Myocardial Infarction Combination of HBO and Thrombolysis Chronic Ischemic Heart Disease (Angina Pectoris) Cardiac Arrhythmias Heart Failure Cardiac Resuscitation HBO as an Adjunct to Cardiac Surgery Experimental Studies Human Cardiac Surgery Protective Effect of HBO Preconditioning in Cardiac Surgery CNS Complications of Cardiac Surgery HBO in Preventive Cardiology Prevention and Rehabilitation of Coronary Artery Disease Physical Training of Patients with Chronic Myocardial Insufficiency Conclusion and Comments

26 Contents xxxiii HBO in Shock Pathophysiology of Shock Oxygen Delivery by Blood Traumatic and Hypovolemic Shock Cardiogenic Shock Peripheral Vascular Disease Causes Symptoms and Signs Pathophysiology of Limb Ischemia Biochemical Changes in Skeletal Muscle in Ischemia and Response to Exercise Clinical and Laboratory Assessment of Patients with Peripheral Vascular Disease General Management of PVD Patients Drug Therapy Exercise Therapy Surgery Role of HBO in the Management of Peripheral Vascular Disease Role of HBO in Miscellaneous Arteriopathies HBO as an Adjunct to Peripheral Vascular Surgery Conclusions Regarding the Role of HBO in Peripheral Vascular Disease References HBO Therapy in Hematology and Immunology Introduction Effect of HBO on Red Blood Cells Deformability Oxygen Exchange Structure and Biochemistry Effect of HBO on Stored Blood Hemoglobin Erythropoiesis Effect of HBO on Hemorheology in Human Patients Effect of HBO on Leukocytes Effect of HBO on Platelets and Coagulation Effect of HBO on Stem Cells Effect of HBO Treatment on the Immune System Effect of HBO Treatment on Plasma and Blood Volume The Use of HBO in Conjunction with Oxygen Carriers Clinical Applications of HBO in Disorders of the Blood Hypovolemia and Acute Anemia Due to Blood Loss Hemolytic Anemia Potential Benefits of HBO in Cerebrovascular Diseases Due to Blood Disorders Contraindication: Congenital Spherocytosis References HBO Therapy in Gastroenterology Introduction HBO in Peptic Ulceration Pathophysiology and Rationale of HBO Therapy Experimental Studies in Animals

27 xxxiv Contents Clinical Assessment of HBO in Gastric and Duodenal Ulcer Patients HBO in the Treatment of Intestinal Obstruction Basic Considerations and Rationale of HBO Therapy Experimental Studies in Animals HBO Therapy in Adynamic Ileus HBO in Adhesive Intestinal Obstruction Methods HBO in Chronic Idiopathic Intestinal Pseudo-obstruction HBO in Inflammatory Bowel Disease Ulcerative Colitis and Crohn s Disease Mechanism of Effectiveness of HBO in Ulcerative Colitis HBO in Infections of the Gastrointestinal Tract Toxic Megacolon Pseudomembranous Colitis Necrotizing Enterocolitis Radiation Enterocolitis HBO in Pneumatosis Intestinalis Pathophysiology of Pneumatosis Cystoides Intestinalis Rationale for HBO Therapy Clinical Experience HBO in Ischemic Disorders of the Intestine Use of Hyperbaric Therapy in Removal of Entrapped Intestinal Balloons HBO in Acute Pancreatitis Animal Experimental Studies of HBO in Acute Pancreatitis Clinical Applications of HBO in Acute Pancreatitis HBO in Diseases of the Liver Effect of HBO on the Normal Liver Effect of HBO on Experimentally Induced Hepatic Disorders in Animals Clinical Applications Conclusions Regarding the Use of HBO in Gastroenterology References HBO and Endocrinology Introduction Thyroid Glands Glucocorticoid Receptors Adrenocortical Function Epinephrine/Norepinephrine Prostaglandins Testosterone Clinical Applications Thyroid Disease Diabetes Mellitus Conclusion References HBO and Pulmonary Disorders Introduction Effects of HBO on Lungs Arterial and Pulmonary Arterial Hemodynamics Lung Mechanics and Pulmonary Gas Exchange Pulmonary Oxygen Toxicity