introduction to hyperbaric oxygen therapy · · types of chambers vary (multiplace vs. monoplace)...

2016 OPAM Mid-Year Educational Conference, Sponsored by AOCOPMSaturday, March 12, 2016

R-1

Mary Elizabeth Hanley DO

Fellowship Director

Undersea and Hyperbaric Medicine

Kent Hospital, Warwick, RI

Introduction toHyperbaric Oxygen

Therapy

Hyperbaric Medicine

Learning Objectives:

· Define Proposed Mechanisms of Action and BasicPhysiology of Hyperbaric Oxygen Therapy (HBOT)

· Review History of HBOT

· Describe Main Risks and Side Effects of HBOT

· Explain the Basics of Transcutaneous OxygenMeasurement (TCOM)

· Introduce Accepted Clinical Indications for HBOT

· Summarize the Current Lines of Research forFuture Applications of HBOT in Medicine

Wound Recovery & Hyperbaric Medicine Center – Kent Hospital 2010

Hyperbaric Medicine

General

Mechanism of Action

History of HBO

Risks & Side Effects

TCOM

Indications

Current Research

Nursingconsiderations


Hyperbaric Medicine

DefinitionMultiplace chamber Monoplace ChamberGeneral

Mechanism of Action 100% oxygen at pressure greater than oneatmosphere

History of HBO


TCOM

Indications

Current Research


· Administered by placing the entire patient

inside a pressure vessel (chamber)

· Treatment duration varies depending on

indication: Average 1.5 hours, DCS treatments 5+ hrs

· Treatment pressure varies: Avg. 2.0 -3.0 ATA

· Types of chambers vary (multiplace vs.monoplace)


Hyperbaric Medicine

DefinitionMultiplace chamberMonoplace ChamberGeneral

Mechanism of Action

History of HBO

· Chamber ispressurized with air

· Patients get 100% O2

in a hood


TCOM

Indications

Current Research



Hyperbaric Medicine

Definition Multiplace chamberMonoplace ChamberGeneral

The chambers are pressurized with 100% O2

Mechanism of Action

History of HBO


TCOM

Indications

Current Research


.



R-2

Hyperbaric Medicine

PhysicsMedicineGeneral

Mechanism of Action

· Ideal gas law:

Equation of the state of an ideal hypothetic gas witha fixed number of molecules.

History of HBO

Risks & Side EffectsTemperaturePV=nR

Absolutepressure Number

of moles

TCOM

PV=nRTIndications

Current Research Volume Constant


Combination of Boyle, Charles and Gay--Lussaclaws


Hyperbaric Medicine


Mechanism of ActionGay Lussac’s Law

Pressure and Temperature are directly proportionalHistory of HBO


TCOM

Indications

Current Research



Hyperbaric Medicine


Mechanism of ActionBoyle’s Law

History of HBO


TCOM

- Pressure and volume

inversely proportional

under constant

temperature

Indications

Current Research

- By increasing ambientpressure to 2 atm, thevolume decreases by 1/2Nursing

considerations


Hyperbaric Medicine


Mechanism of ActionBoyle’s Law

History of HBO


TCOM

Indications

Current Research



Hyperbaric Medicine


Mechanism of Action

History of HBO

Henry’s Law

At a given temperature, the amount of gasdissolved in solute is directly proportional tothe partial pressure of the gas


TCOMDoublepressureequilibrium

Lowpressureequilibrium

Indications

Current Research


LowConcentration

DoubleConcentration


Hyperbaric Medicine


Mechanism of Action

History of HBO

· Charles Law

At constant pressure, temperature and volumeare constant.


TCOM

Indications

Current Research




R-3

Hyperbaric Medicine


Mechanism of Action

History of HBO


TCOM

Conversion:Depth vs Pressure

P ATA= (Depth/33) + 1

D = (P ATA – 1) X 33

Atmospheric pressure:= 33 ft (sea water)

34 ft (fresh water)

10 mt (sea water)

14,965 psi

760 mmHg (Torr)

101,3 KPa

Indications

Current Research


.


Hyperbaric Medicine


Mechanism of Action PAO2 = FiO2 * (PB-47) – PaCO2/R

History of HBO

Alveolar PAO2 at60 fsw (FiO2 100%)~ 2041 mmHg


TCOM

Indications

Current Research


· Reverses Hypoxia

· Alters Ischemic Effect

· Influences Vascular Reactivity

· Reduces Edema

· Modulates Nitric Oxide Production

· Modifies Growth Factor Expression and Cytokine

Levels and Receptors

· Adjusts Cellular Ion Exchange


Hyperbaric Medicine


Mechanism of Action

· Promotes Cellular Proliferation: Proliferation and

function of leukocytes, fibroblasts, keratinocytes requires adequate O2

History of HBO· Accelerates Collagen Production: Collagen secretion from

fibroblasts is rate limited by O2

Risks & Side Effects · Stimulates Capillary budding, Neovascularization

TCOM

Indications

Current Research


· Promotes WBC Microbial Oxidative killing

· Increases select Abx membrane crossing

· Deactivates Clostridial toxins – Direct

Anaerobicidal

· Modulates Immune System Response

· Enhances Oxygen Radical scavengers and

decreases ischemia-reperfusion injury.


Hyperbaric Medicine

General

Mechanism of Action

History of HBO


TCOM

Indications

· 1662 – British physician, Henshaw, used achamber fitted with a large pair of organ bellows,so that air could either be compressed into thechamber or extracted from it· Increased pressures for acute diseases

· Reduced pressures for chronic diseases.

· 1775 – Oxygen discovered

· 1870 – Alphonse Jaminet: Caisson disease –Construction of St. Louis & Brooklyn bridges

Current Research



Hyperbaric Medicine

General Paul Bert

Mechanism of Action

History of HBO


Proposed thefundamentals ofHyperbaricMedicine

TCOM

Indications

Current Research


“Under the effect of inhalation of pureoxygen, the gases contained in the veins andthe right heart diminished, thendisappeared...”

La Pression Barométrique, 1878


Hyperbaric Medicine

General

Mechanism of Action

History of HBO


TCOM

Indications

Current Research


· 1889 – Moir usedhyperbaric therapy to treatworkers building railroadtunnels underneath theHudson River. Reducedmortality rate ofdecompression sicknessfrom 25% to only 1.6% peryear.

· 1926 -- Six--story “steelball

hospital” built in Cleveland,Ohio. The facility wascapable of treating patientsin 72 rooms over 12 floorsat pressures of 3 atmabsolute. Dismantled forscrap metal .



R-4

Hyperbaric Medicine

General

Mechanism of Action

History of HBO

Risks & Side Effect

TCOM

Indications

Current Research


· Barotrauma· Ears, sinus, teeth

· Upper respiratory congestion

· Ear clearing techniques: yawning,swallowing, jaw movements, etc.

· Tension Pneumothorax

· Breath--holding or coughingspasms,

insufficient exhalation· Lung blebs or expulsion barriers

· Changes in visual acuity

· Transient myopia

· Oxygen toxicity

· Lungs and CNSWound Recovery & Hyperbaric Medicine Center – Kent Hospital 2010

Hyperbaric Medicine

General

Mechanism of Action

History of HBO


TCOM

Indications

Current Research


Absolute

· Untreated Pneumothorax

· Bleomycin (Lung)

· Adriamycin (Cardiac)

Relative

· Upper Respiratory Infections

· Seizure Disorders

· Emphysema with CO2 Retention

· High Fevers

· History of Spontaneous Pneumothorax

· History of < 6 months Thoracic Surgery

· History of Surgery for Otosclerosis

· Viral Infections?

.


Hyperbaric Medicine

General

Mechanism of Action

History of HBO

Trans--Cutaneous O2 MeasurementAlgorithm

· Measures O2 concentration for extremities

and wound areas

· Electrode with heat element and O2 sensor

attached to skinRisks & Side Effects

TCOM

Indications

· Non--invasive diagnostic tool to assess

patients’ ability to heal. O2 challenge test is agood indicator of response to HBO.

Current Research



Hyperbaric Medicine

Trans--Cutaneous O2 MeasurementAlgorithmGeneral

Mechanism of ActionWoundHypoxia <40mmHg

History of HBO


Sea Level O2

Challenge

TCOM

Indications Exceed 50mmHg <50mmHgFails to reach45-50mmHG

Current Research


HBO Candidate Repeat at 2 ATA,>200

Revascularize

(+) (-)

.


Hyperbaric Medicine

General

Mechanism of Action

History of HBO


TCOM

FDA ApprovedIndications

Indications

Current Research



Main MenuHyperbaric Medicine

DecompressionSickness

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries

Arterial Insufficiency

Severe Anemia

Intracranial Abscess

Necrotizing Fasciitis

RefractoryOsteomyelitis

Delayed RadiationInjury

Compromisedgrafts andflapsAcuteThermal BurnInjuries



R-5



Air or Gas Embolism

Decompression sickness

- Caisson disease or “the bends” --

CO Poisoning

Under pressure,Nitrogen is forcedin solution in theblood

Gas Gangrene

Crush Injuries


Attributed to formation ofnitrogen bubbles in the bodyon decompression

Severe Anemia

Intracranial AbscessAlso occurs in miners andastronauts



DelayedRadiationInjury





Physics - Pressure

Air or Gas Embolism 1 Sq. in. 1 Sq. in.

Top of Atmosphere

CO Poisoning

Gas Gangrene

Crush Injuries Atmosphere


Severe Anemia7.35 lbs at 18.000 ft.

Intracranial Abscess1Sq. in.

Necrotizing Fasciitis 14.7 lbspsi

33 FSWRefractoryOsteomyelitis


14.7 lbs 29.4 lbs

Compromisedgrafts andflaps Weight of Air and WaterAcuteThermal BurnInjuries



DecompressionSickness Patent Foramen ovale

Air or Gas Embolism

CO Poisoning

Gas Gangrene

·Pressure in the right sideis lower·Paradoxical embolization

Crush Injuries


Severe Anemia








DecompressionSickness Gases in Environmental Medicine

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia


· Metabolic

– Oxygen (O2)

– Carbon dioxide(CO2)

– Water vapor (H2O)

– Nitric oxide (NO)

– Carbon monoxide

· Metabolically inert (but notphysiologically so)

– Nitrogen (N2)

– Helium (He)

– Hydrogen (H2)

– Argon (Ar)

– Neon (Ne)

Necrotizing Fasciitis (CO)




· Diving gas mixes

– Air

– Nitrox

– Heliox



DecompressionSickness DiveTables

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries

· First developed in1915· Limits for safe

diving to prevent

nitrogen bubbleformationArterial Insufficiency

Severe Anemia








DecompressionSickness Decompression Sickness

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries

Experimental models in rabbits and dogsshowing the bubble contents in the bloodstream, synovial fluid and connective tissue


Severe Anemia








R-6


DecompressionSickness Mechanism of Injury

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia

BubblesIntracranial Abscess




· Vascular occlusion· Mechanical disruption of

tissue· Endothelial disruption

· Leukocyte activation,

adhesion· Platelet deposition

· Fibrin clot formation

· Ischemia-reperfusion

injuryCompromisedgrafts andflapsAcuteThermal BurnInjuries

.




Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia





Compromisedgrafts andflaps

Arterial Gas Embolism

Occurs when vascular wallis disrupted, as in:

· Rapid ascent (breath

holding, COPD)

· Trauma

· Iatrogenic

(nonsurgical) --Pulmonaryoverexpansion duringmechanical ventilation

· Iatrogenic (surgery,

opening of centralvenous catheters

AcuteThermal BurnInjuries



DecompressionSickness Treatment

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia






.




Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


· Carbon monoxide poisoning is the leadingcause of injury and death by poisoning in theworld

· Affinity of CO for hemoglobin (formingcarboxyhemoglobin) is 220 times higher thanfor oxygen

Severe Anemia





HBO causescarboxyhemoglobindissociation to occurfaster than pure oxygenat sea level pressure.






Air or Gas Embolism

CO Poisoning

Gas Gangrene

· Risk of developing neurologic sequelae including:cognitive defects, memory loss, dementia,parkinsonism, paralysis, chorea, cortical blindness,personality changes and peripheral neuropathy

Crush Injuries


· Delayed sequelae occur 2--40 days after poisoning· Incidence of sequelae is 25--50% higher after

severe poisoningSevere Anemia

COIntracranial Abscess



Chemical asfixiantto all ironcontaining proteins)- Myoglobin




.




Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia

Clostridial Myonecrosis

· Prompt recognition is important

· Mortality rates of 11--52%

· HBO: Diffused oxygen raises capillary pO2

levels at the wound site, stimulates capillarybudding and granulation of new, healthytissue






· Large grampositive bacilli· Anaerobic

· Spore bearing

· Battle casualtiesor agriculturalaccidents




R-7



Air or Gas Embolism

62 y.o male crane operator, non--diabetic, non--smoker3 days shoulder pain and feverColonoscopy 3 days prior for Rectal CaCO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia









Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia



Shoulder filmshowed gas inthe soft tissues

of the chest



Compromised graftsand flaps

5 treatments total 3of them within thefirst 24 hours aftersurgical debridement


.




Air or Gas

Embolism CO

Poisoning

Gas GangreneCrush Injuries


Severe Anemia




Crush Injuries

· Reduces infection and wound dehiscenceand improves healing

· Improves oxygenation to hypoperfused tissue

· Causes arterial hyperoxia generatingvasoconstriction and decreased edemaformation· Also, intermittent pressure stimulates

circulation and reduces edema· Early use of HBO may reduce compartment

pressures enough to avoid fasciotomyDelayedRadiationInjury


.



DecompressionSickness Acute Peripheral Arterial Insufficiency

Air or Gas

Embolism CO

Poisoning Gas

Gangrene Crush

InjuriesArterial Insufficiency

Severe Anemia






· Reduction of the oxygen supply to the involvedarea

· Retention of CO2 and other byproducts of tissuemetabolism

· Infection, non--healing wounds, or both can result· Swelling increases the distance that O2 must

diffuse from the capillary to supply the injuredtissue

· Edema causes collapse of capillaries andworsens ischemia

· Compartment syndrome may resultAcuteThermal BurnInjuries



DecompressionSickness HBO in Acute Peripheral Arterial Insufficiency

· Hyperoxygenation of the tissues· Increases peripheral vascular resistance: ↓ edema

· No risk of vasoconstriction ischemia due to ↑ O2 content· Protects tissues from reperfusion injury: ↑ Scavengers· Angioneogenesis: Endothelial Progenitor Cells

Air or Gas

Embolism CO

Poisoning Gas

Gangrene Crush

InjuriesArterial Insufficiency

Severe Anemia









Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries

· 20% mortality reduced to 2% when combined withfine needle aspiration· Antibiotics do not penetrate the abscess

· Direct killing of anaerobic bacteria· Controls brain damage and edema due to hyperbaric

CNS vasoconstriction

· Improved recovery time


Severe Anemia






.



R-8



Air or Gas Embolism

CO Poisoning

Gas Gangrene

Necrotizing Fasciitis and Fournier’s Gangrene

· The addition of HBOT to surgical and antibiotictreatment reduced mortality versus surgery

and antibiotics aloneCrush Injuries


Severe Anemia



Refractory

Osteomyelitis

Delayed Radiation

InjuryCompromised grafts

and flaps

Acute Thermal Burn

Injuries .




Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries

· Similar mechanism

· Better perfusion in poorly vascularized tissues·Augments the efficacy of bacterial killing by certain antibiotics

(aminoglycosides, vancomycin, quinolones and certain

sulfonamides)

· Improves osteoclast and osteoblast function


Severe Anemia






HBO is astandardadjunctivetherapy alongwith surgicaldebridementand IVantibiotics


.



DecompressionSickness Delayed Radiation Injury

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries

· Interstitial Fibrosis

· Endarteritis obliterans: occluded capillaries

· High turnover tissues are more affected: Bone marrow, GI

and urinary tracts (Radiation Proctitis/Cystitis)· Soft tissue complications: Non--healing, infection, dehiscence


Severe Anemia









DecompressionSickness Osteoradionecrosis of the jaw

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia






.




Air or Gas Embolism

53 year old, bilateral quadricep rupture post tendon repair.Myocutaneous left knee flap at risk.

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia








DecompressionSickness Split Thickness Skin Graft

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia

IntracranialAbscess







R-9


DecompressionSickness HBOT #9

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia

IntracranialAbscess







DecompressionSickness HBOT #18. Eschar debridement

Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia

IntracranialAbscess








Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia

IntracranialAbscess







DecompressionSickness Diabetic Lower Extremity Wounds

Air or Gas Embolism

CO Poisoning · DM ulcers lead to 1/2 of all amputations

· HBO is an American Heart Association Class I therapyGas Gangrene

Crush Injuries Selection Criteria


Severe Anemia

· Type I or type II diabetes and has a lower extremity wound· Wagner grade III or higher· Failed an adequate course of standard wound therapy· Good control of Diabetes









Air or Gas Embolism

62 yo F Diabetic S/P CVA, Right hemiplegia with pressure ulcer todorsum of foot, exposed necrotic tendon post debridement.

TCOM showed hypoxia with excellent response to the O2 challengeCO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia









Air or Gas Embolism

62 yo F Diabetic S/P CVA, Right hemiplegia with pressure ulcer todorsum of foot, exposed necrotic tendon post debridement.

TCOM showed hypoxia with excellent response to the O2 challengeCO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia








R-10



Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia

IntracranialAbscess





.




Air or Gas Embolism

CO Poisoning

Gas Gangrene

Crush Injuries


Severe Anemia




· HBO limits the progression of the burn injury· Decreases swelling· Reduces the need for surgery· Diminishes lung damage from smoke

inhalation· Shortens the hospitalization and results in

significant overall cost savings· These benefits are more apparent if therapy is

initiated within 6--24 hours of the burn injury



.


Hyperbaric Medicine

General

Mechanism of Action

History of HBO


TCOM

Indications

Bisphosphonate-associated Osteonecrosis

of the jaw

Current Research



Hyperbaric Medicine

General

Mechanism of Action

History of HBO


TCOM

Indications

Current Research

· Closed Head Injury

· Traumatic Brain Injury

· Cerebral Palsy

· Multiple Sclerosis

· Stroke

· Spinal Cord Injury

· Myocardial Infarction

· Chronic Lyme Disease



Hyperbaric Medicine

General

Mechanism of Action

History of HBO


TCOM

Indications

This is NOT Hyperbaric Oxygen Therapy

Current Research


.


Hyperbaric Medicine

General

Inpatient HBO IssuesMechanism of Action

History of HBO


TCOM

Indications

Current Research


· Emergent vs. non - emergent

· Scheduling – time/meals

· Inpatients transported via ambulance

/arrangements

· Premedication

· Treatments are daily M--F (except for

emergent diagnosis)

· Length of treatments

· Communication with the unit (ie: change of

status)



R-11

Hyperbaric Medicine

General What happens on arrival at HBO?Mechanism of Action

History of HBO


TCOM

Indications

Current Research


· Change into 100% cotton garments

· Safety guidelines and checks

· Vitals taken pre and post treatment

· Blood sugar taken on all diabetics

– Treated if blood sugar low

· External devices disconnected (i.e. VAC)

· Dressings left intact

· Entertainment - DVD, VCR


Hyperbaric Medicine

General Chamber SafetyMechanism of Action

History of HBO


TCOM

Indications

Current Research


· No powder, lotions, cologne or deodorantsbefore treatment

· Nothing into the chamber with patient excepteye glasses

· 100% cotton garments and linen· No hearing aides, dentures or jewelry· No smoking materials

· No paper products of any type - use plastictape on dressings

· No electronic devices· No petroleum based products or dressings

· Adult diapers are allowed


Hyperbaric Medicine

General Diabetic PatientsMechanism of Action

History of HBO


TCOM

Indications

Current Research


· Diabetics need to eat prior to treatments

· Normal medication schedule unless changedby MD (may adjust insulin coverage)

· Contact HBO staff if blood sugars high/low

· Blood sugars can drop > 50 mg/dl duringHBO

· Blood sugar preferably > 120 mg/dl prior totreatment

· Patients given juice prior to/during treatment

if needed to maintain glucose level based onhistory in chamber

· Communication is key


Hyperbaric Medicine

General

Mechanism of Action

Is patient a candidate forOutpatient HBO?

History of HBO


TCOM

Indications

Current Research


· Approved indication (most treated outpatient)

· Insurance authorization

· Medicare vs. Commercial

· Co--pays

· Schedule time

· Transportation arrangements

· RIDE program, ADA, EDS

· Where are they going?


Hyperbaric Medicine


introduction to hyperbaric oxygen therapy · · types of chambers vary (multiplace vs. monoplace)...

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