Textbook of Hyperbaric Medicine

Textbook of Hyperbaric Medicine

Kewal K. Jain Textbook of Hyperbaric Medicine Sixth Edition

Kewal K. Jain, MD Basel, Switzerland ISBN 978-3-319-47138-9 ISBN 978-3-319-47140-2 (ebook) DOI 10.1007/978-3-319-47140-2 Library of Congress Control Number: 2016953130 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

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

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 2003. 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.

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

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

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 2009 2015 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

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 2004 2008, 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

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 1999 2002. 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 2000. 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

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

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

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 1988. 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 1500. 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

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... 9 2 Physical, Physiological, and Biochemical Aspects of Hyperbaric Oxygenation... 11 Introduction... 11 Physical Basics... 11 Physiology of Oxygenation... 12 The Oxygen Pathway... 12 Ventilation Phase... 12 Transport Phase... 12 Shift of the Oxygen-Hemoglobin Dissociation Curve... 13 Delivery of Oxygen to the Tissues... 14 Oxygen Transfer at the Capillary Level... 14 Relation Between the Oxygen Transport and Utilization... 14 Oxygen Utilization in the Cell... 15 Effect of Blood Flow... 15 Effect of Oxygen-Hemoglobin Reaction on Transport of CO 2... 15 Autoregulation of the Intracellular po 2... 16 Hyperbaric Oxygenation... 16 Theoretical Considerations... 16 General Effects of HBO on the Healthy Human Body... 19 Biochemical Effects of HBO... 20 Effect of HBO on Enzymes... 20 Effect of HBO on the Nervous System... 20 Effect of HBO at Molecular Level... 21 Conclusion... 21 References... 21 3 Effects of Diving and High Pressure on the Human Body... 23 Physical Effects of Pressure... 23 Effects of Pressure on Various Systems of the Body... 23 Hematological and Biochemical Effects... 23 Effect on Ammonia Metabolism... 24 Effect on Blood Cells and Platelets... 24 xxi

xxii Contents Changes in the Respiratory System and Blood Gases... 24 Effects on the Cardiovascular System... 25 Changes in the Endocrine System... 25 Effect on the Skeletal System... 25 Effects of High-Pressure Environments on the Nervous System... 25 Damage to the Middle Ear and Inner Ear in Diving... 29 Vertigo and Diving... 30 Taste Sensation Under High Pressure... 30 Effect of High Pressure on Effect of Drugs... 30 Conclusion... 31 References... 31 4 Physical Exercise under Hyperbaric Conditions... 33 Introduction... 33 Exercise and Hypoxia... 34 Exercise in Hyperbaric Environments... 34 Exercise Under Hyperoxia... 35 Physical Exercise Under Hyperbaric Conditions... 35 General Effects... 35 Effect on Lactate Production and Clearance... 36 Effect of Exercise on Ammonia Metabolism... 37 Effect of HBO on Antioxidant Enzymes in Skeletal Muscle... 37 Effect of HBO on Blood Flow to the Muscles During Exercise... 37 Physical Exercise in Relation to Toxic Effects of HBO... 38 Conclusion... 38 References... 38 5 Hypoxia... 39 Introduction... 39 Pathophysiology of Hypoxia... 39 Hypoxia-Inducible Factor... 40 Hypoxia and Heat Shock Proteins... 40 Effect of Hypoxia on Cellular Metabolism... 40 Impact of Hypoxia on Various Body Systems... 41 Respiratory Function... 41 Cardiovascular System... 41 General Metabolic Effects... 41 Effects of Hypoxia on the Brain... 42 Role of HBO in the Treatment of Hypoxic States... 46 The Role of Nitric Oxide Synthase in the Effect of HBO in Hypoxia... 47 Possible Dangers of HBO in Hypoxic States... 47 References... 48 6 Oxygen Toxicity... 49 Introduction... 49 Pathophysiology of Oxygen Toxicity... 50 Free Radical Mechanisms... 50 Pathology of Oxygen Toxicity... 50 Pulmonary Oxygen Toxicity... 52 Normobaric vs. Hyperbaric Oxygen in Induction of Pulmonary Oxygen Toxicity... 53

Contents xxiii Oxygen-Induced Retinopathy... 53 Factors That Enhance Oxygen Toxicity... 53 Central Nervous System Oxygen Toxicity... 54 Ammonia and Amino Acids... 56 Biomarkers of Oxygen Neurotoxicity... 56 Neuropathology of Oxygen Toxicity... 56 Manifestations of CNS Oxygen Toxicity... 57 Clinical Monitoring for Oxygen Toxicity... 57 Protection Against Oxygen Toxicity... 57 Extension of Oxygen Tolerance... 59 Conclusion and Directions for Future Research... 59 References... 60 7 Hyperbaric Chambers: Equipment, Technique, and Safety... 61 Introduction... 61 Monoplace Chambers... 61 Multiplace Chambers... 62 Multiplace Chambers for the Critical Care Department... 64 Surgery in the Multiplace Chamber... 65 Mobile Multiplace Hyperbaric Chambers... 65 Hyperbaric Chambers for Diving Medicine... 66 Hyperbaric Chambers for Animal Research... 66 Selection of a Hyperbaric Chamber... 68 Technique of Hyperbaric Oxygenation... 68 Ancillary Equipment... 70 Oxygen Masks and Hoods... 70 Respirators and Ventilators... 70 Diagnostic Equipment... 71 ECG and EEG... 71 Transcutaneous Oxygen Tension... 71 Glucose-Monitoring Devices... 71 Use of Miscellaneous Medical Devices in the Hyperbaric Chamber... 72 Cardiopulmonary Resuscitation... 72 Use of Defibrillators in Hyperbaric Chambers... 72 Pleural Suction Drainage... 72 Endotracheal Tubes... 72 Care of Tracheotomy... 72 Continuous Bladder Irrigation and HBO... 72 Transdermal Patches for Drug Delivery and Hyperbaric Chamber... 73 Implanted Devices in Patients... 73 Monitoring of Patients in the Hyperbaric Chamber... 73 Safety in the Hyperbaric Chamber... 74 Operational Safety... 74 Masks and Breathing Control System... 74 Fire Safety in the Chamber... 74 Use of Portable Hyperbaric Chambers in Patient s Rooms... 76 Regulatory Issues Relevant to Hyperbaric Medicine... 76 Staffing of Hyperbaric Facilities... 77 Conclusion... 77 References... 77

xxiv Contents 8 Indications, Contraindications, and Complications of HBO Therapy... 79 Indications... 79 Contraindications... 79 Complications of Hyperbaric Oxygenation... 81 Middle Ear Barotrauma... 81 Ophthalmological Complications of HBO... 82 Pulmonary Complications of HBO... 82 Oxygen Seizures... 82 Decompression Sickness... 83 Genetic Effects... 83 Claustrophobia... 83 Anxiety Reactions... 83 Coincidental Medical Events in the Hyperbaric Chamber... 84 Precautions in Selection of Patients for HBO Treatment... 84 Conclusion... 84 References... 84 9 Drug Interactions with Hyperbaric Oxygenation... 85 Oxygen as a Drug... 85 Drug Drug Interactions... 85 Interactions of HBO with Other Drugs... 85 Interaction of HBO with Antimicrobials... 86 Carbapenem Antibiotics... 86 Aminoglycoside Antibiotics... 86 Sulfonamides... 86 Interaction of HBO with Anticancer Agents... 86 Interaction of HBO with Cardiovascular Drugs... 86 Adrenomimetic, Adrenolytic, and Ganglion-Blocking Agents... 86 Digitalis/Digoxin... 87 Antianginal Drugs... 87 Heparin... 87 Interaction of HBO with Drugs Acting on the CNS... 87 Anesthetics... 87 CNS Stimulants... 87 Ethanol... 87 Narcotic Analgesics... 87 Pentobarbital... 87 Scopolamine... 87 Interaction of HBO with Miscellaneous Drugs... 88 Practical Considerations of Drug Administration During HBO Therapy... 88 Drugs that Enhance Oxygen Toxicity... 88 Drugs that Protect Against Oxygen Toxicity... 88 Conclusion... 89 References... 89 10 Neurophysiologic SPECT Brain Function Imaging and Hyperbaric Oxygen Therapy... 91 J. Michael Uszler Introduction... 91 Case Studies... 93 Conclusion... 94 Suggested Reading... 96

Contents xxv Part II Clinical Applications 11 Decompression Sickness... 101 Philip B. James and Introduction... 101 Pathophysiology... 102 Gas Formation... 102 Pulmonary Changes... 104 Bubble-Induced CNS Injury... 104 Changes in Blood... 105 Dysbaric Osteonecrosis... 106 Role of Free Radicals... 106 Clinical Features... 106 Decompression Sickness in Diving... 106 Altitude Decompression Sickness... 107 Ocular Complications of DCS... 108 Ultrasonic Detection of Bubbles... 109 Diagnosis... 109 Blood Examination... 109 Ultrasound Monitoring of Bubbles... 110 Bone Scanning... 110 X-Rays... 110 Retinal Angiography... 110 Imaging... 110 Electrophysiological Studies... 110 Neuropsychological Assessment... 110 Treatment... 110 Emergency Management and Evaluation... 110 Recompression and HBO Treatment... 111 Management of Altitude Decompression Sickness... 111 Management of Neurological Manifestations of Decompression Sickness... 114 Monoplace vs. Multiplace Chambers... 115 Use of Oxygen vs. Other Gas Mixtures... 115 Drugs... 116 Importance of Early Treatment... 117 Delayed Treatment... 117 Treatment of Residual Neurological Injury and SPECT Brain Imaging in Type II DCS... 117 Risk Factors for DCS... 117 Preventive Measures for DCS... 118 Prognosis of DCS... 118 Conclusion... 118 References... 119 12 Cerebral Air Embolism... 121 Introduction... 121 Causes... 121 Mechanisms... 122 Pathophysiology of Cerebral air Embolism... 122 Clinical Features... 123 Diagnosis... 123 Treatment... 123

xxvi Contents Clinical Applications of HBO for Air Embolism... 124 Ancillary Treatments... 126 Antiplatelet Drugs... 126 Steroids... 126 Hemodilution... 126 Control of Seizures... 126 Measures to Improve Cerebral Metabolism... 126 Hyperbaric Treatment in Special Situations... 126 Cerebral Edema... 126 Cardiovascular Surgery... 126 Neurosurgery... 127 Pulmonary Barotrauma... 127 Air Embolism During Invasive Medical Procedures... 127 Cerebral Air Embolism During Obstetrical Procedures... 127 Cerebral Air Embolism in Endoscopic Retrograde Cholangiopancreatography... 128 Cerebral Embolism Due to Hydrogen Peroxide Poisoning... 128 Relapse Following Spontaneous Recovery... 128 Delayed Treatment... 129 Conclusion... 129 References... 129 13 Carbon Monoxide and Other Tissue Poisons... 131 Classification of Tissue Poisons... 131 Carbon Monoxide Poisoning... 131 Historical Aspects of CO Poisoning... 131 Biochemical and Physical Aspects of CO... 131 CO Body Stores... 132 Biochemical Effects of CO on Living Organisms... 132 Inhibition of the Utilization of Oxygen by CO... 132 Epidemiology of CO Poisoning... 133 Causes of CO Poisoning... 134 Sources of CO Poisoning... 134 Pathophysiology of CO Poisoning... 134 CO Binding to Myoglobin... 134 CO-Induced Hypoxia... 135 Effects of CO on Various Systems of the Body... 135 Cardiovascular System... 135 Hemorheological Effects of CO... 136 Effect of CO on Blood Lactate... 136 Effect of CO on the Lungs... 136 Exercise Capacity... 136 Sleep... 136 Effect on Pregnancy... 136 Musculoskeletal System... 136 Skin... 136 Gastrointestinal System... 137 Effects on the Peripheral Nervous System... 137 Effects on the Visual System... 137 Effect on the Auditory System... 137 Effect on the Central Nervous System... 137 Clinical Features of CO Poisoning... 138 Neuropsychological Sequelae of CO Poisoning... 138

Contents xxvii Clinical Diagnosis of CO Poisoning... 140 Pitfalls in the Clinical Diagnosis of CO Poisoning... 140 Occult CO Poisoning... 140 Laboratory Diagnosis of CO Poisoning... 140 Brain Imaging Studies... 141 General Management of CO Poisoning... 142 Rationale for Oxygen Therapy (NBO or HBO ) for CO Poisoning... 143 Experimental Evidence... 144 Clinical Use of HBO in CO Poisoning... 144 Clinical Trials of HBO in CO Poisoning... 145 HBO for CO Intoxication Secondary to Methylene Chloride Poisoning... 148 Treatment of CO Poisoning in Pregnancy... 148 Treatment of Smoke Inhalation... 149 Prevention and Treatment of Late Sequelae of CO Poisoning... 149 Controversies in the Use of HBO for CO Poisoning... 149 Cyanide Poisoning... 150 Pathophysiology... 150 Clinical Features of Cyanide Poisoning... 150 Laboratory Diagnosis... 150 Treatment... 150 Rationale for Use of HBO in Cyanide Poisoning... 150 Hydrogen Sulfide Poisoning... 150 Carbon Tetrachloride Poisoning... 151 Methemoglobinemias... 151 Treatment... 151 Miscellaneous Poisons... 152 Organophosphorus Compounds... 152 Conclusions: Poisoning Other Than with CO... 152 References... 152 14 HBO Therapy in Infections... 155 Introduction... 155 Host Defense Mechanisms Against Infection... 155 Impairment by Anoxia... 155 Oxygen as an Antibiotic... 155 HBO as an Adjuvant to Antibiotics... 157 HBO in the Treatment of Infections... 157 HBO in the Treatment of Soft Tissue Infections... 158 Crepitant Anaerobic Cellulitis... 158 Progressive Bacterial Gangrene... 158 Necrotizing Fasciitis... 158 Nonclostridial Myonecrosis... 159 Fournier s Gangrene... 159 Gas Gangrene... 160 Fungal Infection... 163 HBO in the Management of AIDS... 164 Miscellaneous Infections... 164 Osteomyelitis... 165 Management of Osteomyelitis... 166 HBO Treatment of Osteomyelitis... 167 Clinical Results of HBO Treatment in Osteomyelitis... 168 Osteomyelitis of the Jaw... 168 Osteomyelitis of the Sternum... 168

xxviii Contents Malignant Otitis Externa... 168 References... 169 15 Hyperbaric Oxygen Therapy and Chronic Lyme Disease: The Controversy and the Evidence... 171 Caroline E. Fife and Kristen A. Eckert Introduction to Lyme Disease vs. Chronic Lyme Disease : A Brief Overview... 171 Chronic Lyme Disease... 173 HBOT for Lyme Disease and CLD... 174 Rationale for Using HBOT... 174 The Need for a HBOT Medical Registry... 179 Conclusion... 179 References... 180 16 HBO Therapy in Wound Healing, Plastic Surgery, and Dermatology... 183 Introduction... 183 Wound Healing... 184 Role of Oxygen in Wound Healing... 184 Pathophysiology of Nonhealing Wounds... 184 Wound Healing Enhancement by Oxygen... 185 Clinical Applications... 187 Role of HBO in Nonhealing Wounds and Ulcers... 189 Ulcers Due to Arterial Insufficiency... 189 Diabetic Ulcers... 190 Clinical Use of HBO in Diabetic Foot... 191 Guideline for the Use of HBO in the Treatment of Diabetic Foot Ulcers... 192 Venous Ulcers... 193 Decubitus Ulcers... 195 Infected Wounds... 195 Frostbite... 195 Spider Bite... 196 HBO for Inflammatory Bowel Disease... 197 HBO as an Aid to the Survival of Skin Flaps and Free Skin Grafts... 197 Basic Considerations... 197 Animal Experimental Studies... 198 Comparison and Combination of HBO with Other Methods for Enhancing Flap Survival... 199 Clinical Applications... 199 Conclusion... 200 HBO as an Adjunct in the Treatment of Thermal Burns... 200 Basic Considerations... 200 Experimental Studies... 201 Clinical Applications... 201 Conclusion... 202 Applications of HBO in Dermatology... 202 Necrobiosis Lipoidica Diabeticorum... 202 Pyoderma Gangrenosum... 202 Purpura Fulminans... 203 Toxic Epidermal Necrolysis... 203 Psoriasis... 203 Scleroderma... 203 References... 204

Contents xxix 17 HBO Therapy in the Management of Radionecrosis... 207 Intoduction... 207 Radiation Physics... 207 Unit of Radiation... 207 Radiation Biology... 208 Radiation Pathology... 208 Clinicopathological Correlations... 208 Effect of Radiation on Blood Vessels... 208 Effect on Soft Tissues... 208 Radiation Effects on the Nervous System... 208 Radiation Effects on the Bone... 209 HBO Therapy for Radionecrosis... 209 Effect of HBO on Radiation Damage to Skin and Mucous Membranes... 209 Rationale for Clinical Application... 209 Management of Osteoradionecrosis... 210 Basic Studies... 210 Osteoradionecrosis of the Mandible... 211 Osteonecrosis of the Temporal Bone... 212 Osteoradionecrosis of the Chest Wall... 212 Osteoradionecrosis of the Vertebrae... 212 Management of Radionecrosis of CNS... 212 Management of Radionecrosis of Soft Tissues... 214 Effect of HBO on Cancer Recurrence... 216 Conclusion... 217 References... 217 18 The Use of HBO in Treating Neurological Disorders... 221 Introduction... 221 Effect of HBO on Cerebral Metabolism... 221 Effect of HBO on Cerebral Blood Flow... 222 Effect of HBO on the Blood Brain Barrier... 224 Effect of HBO on Oxygen Tension in the Cerebrospinal fluid... 224 Rationale for the Use of HBO in Neurological Disorders... 225 Cerebral Hypoxia... 225 Cerebral Edema... 225 Role of HBO in Neuroprotection... 226 Indications for the Use of HBO in Neurological Disorders... 228 Clinical Neurological Assessment of Response to HBO... 229 Comatose Patients... 229 Paraplegics... 229 Hemiplegics (Stroke Patients)... 230 Diagnostic Procedures Used for Assessing the Effect of HBO... 230 Electrophysiological Studies... 230 Cerebral Blood Flow... 231 Computerized Tomography... 232 Magnetic Resonance Imaging... 232 Positron Emission Tomography... 233 Single Photon Emission Computed Tomography... 233 References... 234

xxx Contents 19 Role of Hyperbaric Oxygenation in the Management of Stroke... 237 Introduction... 237 Epidemiology of Stroke... 238 Risk Factors for Stroke... 238 Pathophysiology of Stroke... 239 Causes of Stroke... 239 Changes in the Brain During Ischemic Stroke... 240 Clinicopathological Correlations... 240 Structure of a Cerebral Infarct... 240 Cerebral Metabolism in Ischemia... 242 Molecular Mechanism in the Pathogenesis of Stroke... 244 Gene Expression in Response to Cerebral Ischemia... 244 Induction of Heat Shock Proteins... 244 Role of Cytokines and Adhesion Molecules in Stroke... 244 DNA Damage and Repair in Cerebral Ischemia... 244 Role of Neurotrophic Factors... 244 Classification of Ischemic Cerebrovascular Disease... 245 Recovery from Stroke... 245 Complications of Stroke... 246 Sequelae of Stroke... 246 Vascular Dementia... 247 Diagnosis of Stroke... 247 Stroke Scales... 248 Barthel Index... 248 Rankin Scale... 248 National Institutes of Health Stroke Scale... 248 Unified Neurological Stroke Scale... 248 Canadian Neurological Scale... 249 Evaluation of Various Scales... 249 An Overview of the Conventional Management of Stroke... 249 Acute Ischemic Stroke... 249 Neuroprotectives... 250 Management of the Chronic Poststroke Stage... 252 Management of Spasticity... 252 Role of HBO in the Management of Acute Stroke... 253 HBO in Relation to Cerebral Ischemia and Free Radicals... 254 Animal Experiments... 254 Neuroprotective Effect of HBO Preconditioning... 257 Review of Clinical Studies... 258 HBO as a Supplement to Rehabilitation of Stroke Patients... 262 Conclusions of the Effects of HBO in Stroke Patients... 265 Future Prospects... 266 References... 266 20 HBO Therapy in Global Cerebral Ischemia/Anoxia and Coma... 269 Paul G. Harch Introduction... 269 Pathophysiology... 270 Rational Basis of HBO Therapy... 271 Review of Animal Experimental Studies... 298 Review of Human Clinical Studies... 300 Case Studies... 304

Contents xxxi Patient 1: HBO Treatment for Coma Due to Traumatic Brain Injury... 304 Patient 2: Near Drowning, Chronic Phase... 307 Patient 3: Near Drowning, Chronic Phase... 308 Patient 4: Battered Child Syndrome... 309 Conclusion... 311 References... 314 21 HBO Therapy in Neurosurgery... 321 Introduction... 321 Role of HBO in the Management of Traumatic Brain Injury: TBI... 321 Mechanism of Action of HBO in TBI... 322 Effect of HBO on ICP in Acute TBI... 322 Effect of HBO Therapy in Chronic Sequelae of TBI... 323 Experimental and Clinical Studies of HBO in TBI... 323 Controlled Clinical Trials of HBO for TBI... 325 Use of HBO for TBI in Clinical Practice... 326 Conclusions... 326 Role of HBO in the Management of Spinal Cord Injury... 326 Effects of Spinal Cord Injury... 327 Rationale of the Use of HBO in SCI... 327 Animal Experimental Studies of HBO in SCI... 327 Clinical Studies of HBO in SCI... 328 Role of HBO in Rehabilitation of SCI Patients... 329 Role of HBO in Compressive and Ischemic Lesions of the Spinal Cord... 329 Conclusions About Use of HBO in SCI... 330 HBO as an Adjunct to Radiotherapy of Brain Tumors... 330 Role of HBO in the Management of CNS Infections... 331 Role of HBO in Cerebrovascular Surgery... 332 Neuroprotection During Neurosurgery... 337 Conclusion... 337 References... 338 22 Oxygen Treatment for Multiple Sclerosis Patients... 341 Philip B. James Introduction... 341 Pathophysiology... 342 Rationale for Hyperbaric Oxygen Treatment... 342 Clinical Trials of HBO in Multiple Sclerosis... 345 Conclusion... 349 References... 349 23 HBO in the Management of Cerebral Palsy... 351 Paul G. Harch Introduction: Causes of Cerebral Palsy... 351 Oxygen Therapy in the Neonatal Period... 351 Treatment of Cerebral Palsy with HBO... 353 Published Clinical Trials... 354 The United States Army Study on Adjunctive HBO Treatment of Children with Cerebral Anoxic Injury... 355 The New Delhi Study of HBOT in CP... 356 Unpublished Studies... 356 The Cornell Study... 356 Comparative Effectiveness Studies... 356

xxxii Contents Recent Studies (Since 2007)... 357 Side Effects... 357 Case Reports... 358 Patient 1: Cerebral Palsy... 358 Patient 2: Cerebral Palsy... 359 Conclusions... 361 References... 363 24 HBO Therapy in Miscellaneous Neurological Disorders... 365 Introduction... 365 HBO in the Treatment of Benign Intracranial Hypertension... 365 Peripheral Neuropathy... 366 HBO for the Treatment of Peripheral Neuropathic Pain... 366 HBO for Treatment of Drug-Induced Neuropathy... 366 HBO for the Treatment of Trigeminal Neuralgia... 367 HBO in Susac s Syndrome... 367 Cerebral Malaria... 367 Vascular Headaches... 367 Rationale for the Use of HBO in Vascular Headaches... 367 Current Status of Use of HBO in Vascular Headaches... 368 HBO for Autism Spectrum Disorder... 368 Neurological Disorders in Which HBO Has Not Been Found to Be Useful... 368 Dementia Due to Degenerative Disorders of the Brain... 368 HBO in the Management of Neuromuscular Disorders... 369 References... 370 25 HBO Therapy in Cardiovascular Diseases... 371 Introduction... 371 Pathophysiology... 371 Risk Factors... 371 Hypoxia, Hyperoxia, and Atherosclerosis... 371 Hyperbaric Oxygenation in Cardiology... 372 Effect of Hypoxia, Hyperoxia, and Hyperbaric Environments on Cardiovascular Function... 372 Metabolic Effects of HBO on the Heart... 372 Role of HBO in Experimental Myocardial Infarction... 373 Clinical Applications of HBO in Cardiology... 373 Acute Myocardial Infarction... 373 Combination of HBO and Thrombolysis... 376 Chronic Ischemic Heart Disease (Angina Pectoris)... 376 Cardiac Arrhythmias... 377 Heart Failure... 377 Cardiac Resuscitation... 377 HBO as an Adjunct to Cardiac Surgery... 377 Experimental Studies... 377 Human Cardiac Surgery... 378 Protective Effect of HBO Preconditioning in Cardiac Surgery... 379 CNS Complications of Cardiac Surgery... 379 HBO in Preventive Cardiology... 380 Prevention and Rehabilitation of Coronary Artery Disease... 380 Physical Training of Patients with Chronic Myocardial Insufficiency... 380 Conclusion and Comments... 380

Contents xxxiii HBO in Shock... 380 Pathophysiology of Shock... 380 Oxygen Delivery by Blood... 380 Traumatic and Hypovolemic Shock... 381 Cardiogenic Shock... 381 Peripheral Vascular Disease... 381 Causes... 381 Symptoms and Signs... 382 Pathophysiology of Limb Ischemia... 382 Biochemical Changes in Skeletal Muscle in Ischemia and Response to Exercise... 382 Clinical and Laboratory Assessment of Patients with Peripheral Vascular Disease... 383 General Management of PVD Patients... 384 Drug Therapy... 384 Exercise Therapy... 384 Surgery... 384 Role of HBO in the Management of Peripheral Vascular Disease... 385 Role of HBO in Miscellaneous Arteriopathies... 389 HBO as an Adjunct to Peripheral Vascular Surgery... 389 Conclusions Regarding the Role of HBO in Peripheral Vascular Disease... 390 References... 390 26 HBO Therapy in Hematology and Immunology... 393 Introduction... 393 Effect of HBO on Red Blood Cells... 393 Deformability... 393 Oxygen Exchange... 394 Structure and Biochemistry... 395 Effect of HBO on Stored Blood... 395 Hemoglobin... 395 Erythropoiesis... 396 Effect of HBO on Hemorheology in Human Patients... 396 Effect of HBO on Leukocytes... 396 Effect of HBO on Platelets and Coagulation... 396 Effect of HBO on Stem Cells... 396 Effect of HBO Treatment on the Immune System... 397 Effect of HBO Treatment on Plasma and Blood Volume... 398 The Use of HBO in Conjunction with Oxygen Carriers... 399 Clinical Applications of HBO in Disorders of the Blood... 399 Hypovolemia and Acute Anemia Due to Blood Loss... 399 Hemolytic Anemia... 400 Potential Benefits of HBO in Cerebrovascular Diseases Due to Blood Disorders... 400 Contraindication: Congenital Spherocytosis... 400 References... 401 27 HBO Therapy in Gastroenterology... 403 Introduction... 403 HBO in Peptic Ulceration... 403 Pathophysiology and Rationale of HBO Therapy... 403 Experimental Studies in Animals... 404

xxxiv Contents Clinical Assessment of HBO in Gastric and Duodenal Ulcer Patients... 404 HBO in the Treatment of Intestinal Obstruction... 404 Basic Considerations and Rationale of HBO Therapy... 404 Experimental Studies in Animals... 405 HBO Therapy in Adynamic Ileus... 406 HBO in Adhesive Intestinal Obstruction... 406 Methods... 407 HBO in Chronic Idiopathic Intestinal Pseudo-obstruction... 407 HBO in Inflammatory Bowel Disease... 407 Ulcerative Colitis and Crohn s Disease... 407 Mechanism of Effectiveness of HBO in Ulcerative Colitis... 408 HBO in Infections of the Gastrointestinal Tract... 408 Toxic Megacolon... 408 Pseudomembranous Colitis... 409 Necrotizing Enterocolitis... 409 Radiation Enterocolitis... 409 HBO in Pneumatosis Intestinalis... 409 Pathophysiology of Pneumatosis Cystoides Intestinalis... 409 Rationale for HBO Therapy... 410 Clinical Experience... 410 HBO in Ischemic Disorders of the Intestine... 410 Use of Hyperbaric Therapy in Removal of Entrapped Intestinal Balloons... 411 HBO in Acute Pancreatitis... 411 Animal Experimental Studies of HBO in Acute Pancreatitis... 411 Clinical Applications of HBO in Acute Pancreatitis... 411 HBO in Diseases of the Liver... 412 Effect of HBO on the Normal Liver... 412 Effect of HBO on Experimentally Induced Hepatic Disorders in Animals... 412 Clinical Applications... 412 Conclusions Regarding the Use of HBO in Gastroenterology... 413 References... 414 28 HBO and Endocrinology... 417 Introduction... 417 Thyroid Glands... 417 Glucocorticoid Receptors... 417 Adrenocortical Function... 417 Epinephrine/Norepinephrine... 418 Prostaglandins... 418 Testosterone... 418 Clinical Applications... 419 Thyroid Disease... 419 Diabetes Mellitus... 419 Conclusion... 420 References... 420 29 HBO and Pulmonary Disorders... 423 Introduction... 423 Effects of HBO on Lungs... 423 Arterial and Pulmonary Arterial Hemodynamics... 423 Lung Mechanics and Pulmonary Gas Exchange... 424 Pulmonary Oxygen Toxicity... 424