Hyperbaric Oxygen Therapy. William Tettelbach, MD, FACP, CWS Intermountain Healthcare Salt Lake City, Utah
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1 Hyperbaric Oxygen Therapy William Tettelbach, MD, FACP, CWS Intermountain Healthcare Salt Lake City, Utah
2 Hyperbaric Oxygen Indications Undersea and Hyperbaric Medical Society ( FDA accepts the UHMS indications; Chambers are devices, not drugs (exception: IDE for investigation of HBO2 for traumatic brain injury)
3 Hyperbaric Oxygen Therapy (HBO2) 1. Definition 2. Physiology 3. Indications 4. Clinical Examples
4 Hyperbaric Oxygen Therapy Definition: Inhalation of 100% oxygen while pressurized to greater than 1.4 atm abs (sea level = 1 atm abs) (1 ATA = 33 FSW)
5 Hyperbaric Oxygen Physiology 1. Bubble volume reduction 2. Blood/tissue PO 2 3. Gas washout (eg: N 2, CO) 4. Vasoconstriction 5. Neovascularization 6. WBC oxidative killing 7. Modulation ischemia/reperfusion 8. Growth factor receptors and VEGF 9. Reduces circulating inflammatory cytokines 10. Mobilizes stem/progenitor cells that accelerate healing
6 Bubble Reduction
7 PO2 of Blood and Tissue PaO 2 = mmhg Subcutaneous and muscle PO 2 = 500 mmhg (Boerema - Life without blood; 1960)
8 Variable effect (retina, brain) Decreases edema Vasoconstriction
9 Collagen Neovascularization (Hypoxic Wounds) Vascular density # Growth factor receptors VEGF Circulating stem cells Synergy with PDGF
10 One HBO2 exposure increases PDGFR expression in culture No HBO2 PDGFR + HBO2 Courtesy Dr. Reenstra
11 One HBO2 exposure increases PDGFR expression in vivo Before HBO2 24 hrs after HBO2 Courtesy Dr. Reenstra
12 WBC function and immune modulation Enhanced PMN leukocyte & osteoclast killing O2 tension Supra-oxide Immune modulation Inhibits anaerobes and their toxins
13 HBO2 Indications 1. Gas embolism 2. Carbon monoxide poisoning 3. Clostridial myonecrosis (gas gangrene) 4. Crush injury/traumatic ischemia 5. Decompression sickness 6. Problem ischemic wounds 7. Exceptional blood loss (anemia)
14 HBO2 Indications 8. Osteomyelitis (refractory) 9. Radiation tissue damage (osteoradionecrosis) 10. Skin grafts and flaps (compromised) 11. Thermal burns 12. Intracranial abscess 13. Acute central retinal arterial occlusion 14. Idiopathic sudden sensorineural hearing loss UHMS 2013
15 Typical HBO2 Treatment 2.0 to 2.4 atm abs (atmospheres absolute) Multiplace - IMC Monoplace - LDSH minutes Once or twice per day
16 Case: Necrotizing Fasciitis 17 y/o male, previously healthy Spontaneous necrotizing fasciitis (GAS) of right chest wall, right axillary and right arm, no break in skin Rapidly progressive infection, septic, transferred to LDSH Initial surgery, prior to HBO2
17 Case: Necrotizing Fasciitis Multiple surgeries to debride necrotic tissue, ICU support Six hyperbaric oxygen sessions Discharged home in good condition Two months later, incisions well healed After 6 daily HBO2 sessions
18 Clostridial Gas Gangrene 36 y/o female, pustule from unknown source UMC - OR x 3 for Clostridial nec fasc and gangrene Worsened with WBC to 44k and chest wall involvement Transferred to IMC for HBO2
19 Clostridial Gas Gangrene 20 HBO2 Tx Nutrition Vitamin D deficiency Tx 6 more surgeries with flaps and grafts Durable favorable outcome
20 Compromised surgical flap 48 y/o female ; Prophylactic bilateral mastectomies (+ BRCA) with tissue expander reconstruction. Type 1 DM, peripheral neuropathy, hypothyroidism, hyperlipidemia, progressive LE muscle weakness (undiagnosed), anxiety, depression. Nonsmoker.
21 Compromised surgical flap 27 HBO2 sessions: After 17 Tx, OR for debridement, expander exchange, latissimus pedical flaps. Also received Trental & Vitamin D.
22 Traumatic ischemia 23 y/o male, work-related, high pressure paint sprayer injection One week post-op, worse, OR and HBO2.
23 Traumatic ischemia 12 HBO2 Tx, OR for flap Vitamin D Tx, Smoking cessation Favorable outcome
24 Crush and ischemia 5 y/o who had intentional binding of feet. Toe amputations One week later referred for HBO2 from PCMC.
25 Crush and ischemia 8 HBO2 Tx; transported from PCMC M-W-F Wound Care with sedation M-W-F Bilateral tympanostomy tubes Grafts and complete healing
26 Post-Op ischemia and compartment syndrome 37 y/o male s/p mitral valve repair with postop arterial ischemia; revascularized; compartment syndrome; non-viable muscle; BKA considered.
27 Post-Op ischemia and compartment syndrome 23 HBO2 Tx at IMC: chest tube, VAC; transferred to o/p HBO2 at UVMC (near home): Neuropathy with foot drop and sensory problems.
28 Compromised grafts/flaps 4 yr old child, dog bite to nose HBO2 started after replantation
29 Iatrogenic Cerebral Gas Embolism 65 y/o female, cardiac ischemia, at cath: bradycardia, acute ST, mental status change hemiparesis, aphasia. CT intracerebral gas.
30 5 HBO2 Tx Acute Gas Embolism Lidocaine, IV drip for cerebral protection Outcome: Post HBO2 #1 weak RUE, RLE. Aphasia resolving Neuro exam plateaued after the 4 th HBO2 After 5 th HBO2, Persistent RUE and RLE weakness ; cerebellar abnormalities
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