TABLE I. Disadvantages Patient isolated during treatment Higher capitalization requirements

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1 TABLE I MONOPLACE MULTIPLACE CHAMBERS Advantages Relatively low purchase price Greater working pressure Requires little space and relatively minor Constant patient attendance facility renovations. Ability to use a variety of electrically generated Modest program capitalization signals to the patient during therapy. Treatment protocol specific to patient/condition Entrance and exit capability of attendants during Modes staffing requirements therapy Patient does not wear mask/hood/head tent for Ability to conduct intensive care activities during oxygen delivery treatment Chamber is relatively mobile, for possible relocation Ability to manage complications such as No risk of iatrogenic DCS in patient or staff pneumothorax without releasing pressure. Add-on capability for ease of program expansion Disadvantages Patient isolated during treatment Higher capitalization requirements Inability to suction patient Major space requirements; basement/ground floor Limited pressure capability (3ATA); level limitations Pure oxygen environment; associated fire hazard Higher operating costs Inability to use certain diagnostic/therapeutic Larger and experienced staffing requirements Equipment transcutaneous oxygen assessment now Risk of decompression sickness in internal available (radiometer TCM 3) personnel Increased risk of complications from pneumothorax/ All patients on the same protocol tension pneumothorax and arterial air embolism Uncertain oxygen delivery tension at patient with developing during decompression face mask Severe maxillofacial/head & neck involvement

2 may make it difficult to effectively delivery oxygen Facility fire-associated decompression requirements Significant equipment maintenance and system Upkeep requirements TABLE II THE EFFECTS OF HYPERBARIC TREATMENTS OF CARDIOVASCULAR SYSTEM Heart Rate - Decreased Contractility - No effect Stoke volume - No Effect Cardiac Output - Decreased Blood Pressure - Possible minimal increase Systemic Vascular Resistance - After load increases - Arterial Vasoconstriction

3 TABLE III THE PRIMARY EFFECTS OF HYPERBARIC OXYGEN MECHNISM EFFECT CLINICAL UTILITY a) Hyper-oxygenation *Greater oxygen carrying capacity *Severe blood loss anemia (unable to carry oxygen) *Increased oxygen defusion in tissue *Crush injury, compartment syndrome fluid graft and flap salvage *Diffusion distance is proportional (decreased perfusion) to the square root of the dissolved *Edema (increased diffusion barrioer) oxygen b) Decrease Gas Bubble Size Boyles law: *Decompression sickness *Gas vol is inversely proportional to pressure *Hyperbaric diffusion gradient favors gas leaving the bubble and oxygen moving in. Oxygen in the bubble is metabolized *Law of La Place p-4t/r *Bubbles are unstable as they decrease in size *Air embolus syndrome

4 TABLE IV THE SECONDARY EFFECTS OF HYPERBARIC MEDICINE MECHANISM EFFECT CLINICAL APPLICATION Vasoconstriction * Decreased inflow into tissues * Crush injuries * Decreased edema * Acute burns * Compartment syndrome Angiogenesis * Increases O2 gradient between * Graft and flap salvage the wound and the surrounding * Osteo radionecrosis environment * Radiation endarteritis obliterans * Increase in fibroblast proliferation * Chronic wounds leads to an increase in collagen deposition and increase fibronectin, which aids in neovascularization Fibroblast Proliferation * Proliferation is oxygen dependent * Chronic wounds * Radiation induced injury Leukocyte Oxidative Killing * Oxygen free radicals increased * Necrotizing soft tissue infections * Anaerobe lack SOD to control * Chronic osteomyelitis the oxygen free radicals Toxin Inhibition * Decreases clostridial alpha toxins * Clostridial gas gangrene * Decreases cardio toxins Antibiotic Synergy * Oxyquinolones, amphotericin B * Sepsis and aminoglycosides use oxygen to * Necrotizing infections transport across cell membranes

5 TABLE V SIGNS AND SYMPTOMS OF OXYGEN TOXICITY CNS Nausea and vomiting Seizures Sweating Pallor Muscle twitching Anxiety / respiratory changes PULMONARY Dry cough Substernal chest pain Bronchitis Shortness of breath Pulmonary edema Pulmonary fibrosis Visual changes Tinnitus Hallucinations Vertigo Hiccups Decreases level of consciousness

6 TABLE VI CONTRA-INDICATIONS TO HYPERBARIC OXYGEN CONDITION Claustrophobia Pneumothorax History of spontaneous pheumothorax COPD RATIONIAL Anxiety Gas Emblioli, pneumomediastinum Pneumoperoinium Tension pneumothorax Subcutaneous emphysema Pneumocystic carini pneumonia Seizure disorders Increased lung bleb incidence pneumothorax Increased oxygen intolerance Increased risk of seizures Pregnancy* Upper respiratory infection Hyperthermia Hereditary spherocytosis Questionable fetal teratogen Barotrauma to sinus/ear/lung Decreased threshold for oxygen induced seizures Increased hemolysis

7 TABLE VI CONTRA-INDICATIONS TO HYPERBARIC OXYGEN CONDITION Optic neuritis Malignant tumors Acidosis Drugs cisplatinum RATIONIAL Questionable increases optic nerve pathology Questionable increased vascularity for tumors Decreased threshold for oxygen seizures Decreased wound healing - Doxyrubison Increased free oxygen radicals - Belomyocin Pulmonary fibrosis leading to pneumothorax - Steroid Decreased threshold for oxygen seizure - Alcohol Dehydration increases risk of decompression sickness - Aromatic hydrocarbons Spontaneous combustion - Disulfram Inhibits superoxide desmutase - Nicotine Decreases seizure threshold In pregnancy hyperbaric oxygen may be required in cases of carbon monoxide poisoning, cerebral gas embolus, decompression sickness, or clostridial myonecrosis.

8 TABLE VII ORGANS AFFECTED BY BAROTRAUMA ORGAN PATHOLOGY PRESENTATION Sinuses *Congestion / occlusion *Pain, bloody discharge Middle ear *Eustachian tube is occluded *Edema, rupture or retraction failure to equalize pressure of tympanic membrane within the middle ear space *Hemorrhage External ear *Wax build-up or *Pain, bleeding ear plugs occludes canal Inner ear *Oval or round window rupture *Atxia, vertigo, tinnitus, hearing loss GI Tract *Gas in bowels *Vomiting, nausea distention on ascent *Flatulancecolicky pain Teeth *Infected or restored teeth *Tooth pain may harbor gas *Tooth implosion or explosion Gas Embolus *Emergent decompression with *Sudden decrease level of consciousness blocked glottis/extremely rare hemiplegia, blown pupil

9 TABLE VIII THE TEED SCALE Middle-ear barotrauma of descent Grade 0 Grade I Symptoms without signs Injection of the tympanic membrane, especially along the handle of the malleus Grade II Injection plus slight hemorrhage within the substance of the tympanic membrane Grade III Grade IV Gross hemorrhage within the substance of the tympanic membrane Free blood in the middle ear as evidenced by blueness and bluging Grade V Perforation of the tympanic membrane

10 TABLE IX CLINICAL APPLICATION OF HYPERBARIC OXYGEN STANDARD OF CARE Carbon monoxide poisoning Cerebral arterial gas embolus Decompression sickness Osteo radionecrosis Clostriadial gas gangrene ADJUNCTIVE Radiation tissue damage Osteo radionecrosis prophylaxis Acute ischemia / crush injuries Necrotizing infections Acute exceptional blood loss Acute thermal burns Compromised skin grafts or flaps Selected problem wounds Refractory osteomyelitis

11 Treatment protocols may vary to a limited degree between institutions. Appendix I gives a useful guideline for treatment regimens for various conditions. APPENDIX I TREATMENT PROTOCOL GUIDELINES *2.0ATA O2 X 90 MINS *Wound healing *Compromised skin grafts/flaps *Thermal burns *Osteomyelitis *Crush injury/compartment syndrome *Mucormycosis

12 TREATMENT PROTOCOL GUIDELINES 2.0ATA O2 X 90 MINS. c 10 MIN. AIR BREAK (HIGH SEIZURE RISK) *Wound Healing *Compromised skin graft/flaps *Thermal burns *Osteomyelitis *Crush injury / compartment syndrome *Mucormycosis

13 TREATMENT OF PROTOCOLL GUIDELINES 2.5ATA O2 X 90 MINS *Non-clostridial gas gangrene *Necrotizing infections *Osteomyelitis (E. coli or pseudomonas isolated) *Late radiation tissue injury (ORN; STRN) 3.0ATA O2 X 90 MINS *Carbon monoxide poisoning *Clostridial gas gangrene