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Anthony Lagina III, MD FACEPAssistant Professor of Emergency MedicineHyperbaric Medicine and Wound Care Clinic
Wayne State University/Detroit Receiving Hospital
Outline
IntroductionHistory and developmentPhysiology and theoryCurrent indications for treatmentFuture indications for treatment
Definition Hyperbaric Oxygen Therapy is the
administration of oxygen at pressure greater than sea level.Patient is placed in a chamber and pressurized
100% oxygen Room air with oxygen via a hood
HistoryFirst theories developed 300 years ago
Henshaw in 1662 Built the domicilium - metal chamber with a pair of large
organ bellows
"In times of good health this domicilium is proposed as a good expedient to help digestion, to promote insensible respiration, to facilitate breathing and expectoration and consequently, of excellent use for prevention of most affections of the lungs."(Henshaw, 1664)
“It seemed like a good idea”
HistoryFrance 1880s
Fashionable among the wealthy to increase the circulation to the
internal organs Fontaine 1877 - First mobile hyperbaric chamber
Early Chambers
The Steel Ball
HistoryCaisson Disease
First described in France during bridge building in 1840s
Symptoms = dizziness, coughing and joint pain with some deaths
HistoryThe Bends
Vernacular for Caisson diseaseCoined during Hudson Tunnel Project
in Brooklynn Named after ladies posture
Hyperbaric Chambers
Today
Portable Monoplace
Multiplace Chambers
Chamber Capability
-Maximum depth: 6 Atmospheres (165 FSW) -Maximum depth for administering 100% O2: 3 Atmospheres (66 FSW)
Ventilator support and cardiac monitoring for the critically ill patient
Not Hyperbaric Therapy!!!
TheoryComponents of dry Atmospheric Air
Nitrogen 78.084Oxygen 20.946Carbon Dioxide 0.033Argon 0.0934Other Gases
Neon, Helium, Krypton, Xenon, Hydrogen, Methane, Nitrous Oxide
The Ideal gas Law
PV=nRTPressure and volume are inversely proportionalPressure and moles of gas are directly related
Percentages of gases don’t change, the amount (moles) does
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Hyperoxygenation of tissuesMechanical Bubble CrunchingNeoangiogenesisBacteriocidal / Bacteriostatic EffectsPotent Vasoconstriction
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Hyperoxygenation of TissuesPlasma diffuses through tissue supplying
oxygen downstream from an occlusionHelps ischemic tissues meet metabolic
needs during the wound healing processIncreased breakdown of old boneForms new capillaries in wound areas
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Hyperoxygenation is a temporary measure maintaining tissue viability until corrective measures are implemented or new blood supply is established
Physiological Effects
Main Concept:Once the hemoglobin is saturated, in FiO2 can only affect the fraction of oxygen dissolved in the plasma.
* +/- one standard errorMean blood levels measured in 10 normal subjects
(modified from Saltzman, Smith et al, 1965)
Atmospheric Breathing FiO2 Theoretical Measured Measured Pressure (ATA) Gas (mmHg) Alveolar & Arterial Venous Arterial PO2 PO2 (mmHg) PO2 (mmHg) (mmHg) =====================================================================1.0 Air 160 110 89 +/- 3.2* 41 +/- .9*------------------------------------------------------------------------------------------------------1.0 100% O2 760 673 507 +/- 13.9 57 +/- 3.5------------------------------------------------------------------------------------------------------3.0 100% O2 2280 2193 1721 +/- 33.5 424 +/- 77.8---------------------------------------------------------------------------------------------------------
Oxygen solubilityHemoglobin oxygen content
sea level or at depth = 19.8 ml O2/ dl blood
Plasma oxygen content 0.0031 ml O2/ dl blood with air at sea level
2.1 ml O2/ dl blood 100% O2 at sea level
6.8 ml O2/ dl blood 100% O2 at 3 ATA
Body useHuman at rest = 6 ml O2/ dl blood
****Theoretically no Hb required for oxygenation of tissues at 3 ATA****
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Mechanical Bubble Crunching – Boyle’s Law:Oldest application of hyperbaric medicineHBO primary treatment in “bubble diseases”
Arterial gas embolusDecompression syndrome
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Mechanical Bubble Crunching – Boyle’s Law:Increases the “wash out” of gases other than
oxygenNitrogenCarbon Monoxide
Room air t1/2= 320 minutes
3 ATA t1/2= 23 minutes
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Neoangiogenesis (Neovascularization):Decreased oxygen tissue tensions stimulate
new vessel growth At the same time, underlying supporting
collagen needs oxygen to formCollagen deposition and the tensile strength
of wounds improve
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Bacteriocidal and Bacteriostatic Effects: leukocyte production of toxic radicals
(enhanced phagocytosis)Synergistic effect with aminoglycosides
Post antibiotic effect is prolonged with tobramycin against Pseudomonas aeruginosa
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Potent Vasoconstriction:Hyperoxia constricts normal blood arterioles
and venulesIschemic blood vessels do not constrict thus
allowing tissue oxygen increasesDespite blood flow, tissue oxygen due
to high PaO2
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Potent Vasoconstriction – continued:Reduces edema and oxygenation at the
same timeVasoconstriction peripheral vascular
resistance (PVR) and mean arterial pressure (MAP) afterload
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Rationale for Hyperbaric Oxygen in Problem Wounds:Enhances fibroblast replication collagen synthesis neovascularization leukocyte bacteriocidal activity O2 tension greater capillary oxygen
diffusion distances
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Definitive treatment for:Arterial Gas Embolism (AGE)Decompression Sickness (DCS) Carbon Monoxide (CO) Poisoning
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Additional Clinical IndicationsGas GangreneCrush InjuryProblem WoundsIntracranial AbscessIdiopathic Sudden
Sensorineural Hearing Loss-2011
Exceptional Blood Loss Anemia
Necrotizing InfectionsOsteomyelitis
(Refractory)Late Effects of
RadiationSkin GraftsThermal BurnsCentral Retinal Artery
occlusion
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Air or Gas Embolism:Occurs when gas bubbles enter directly into
the arteries or veinsPulmonary Barotrauma (overinflation)
breath-holding on ascentMechanical ventilation
Blast injury, penetrating chest trauma, chest tube placement and bronchoscopy
Things residents do!!!
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Arterial Gas Embolism:Cause – Central Line
Placement.
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Cerebral Air Gas Embolism (CAGE) – from lung biopsy procedure
Hyperbaric Treatment Protocol
Arterial Gas Embolism
Diving Related IatrogenicCAUSE
Dive HistoryACLS Measures
Chest X-rayIV Fluids
U.S.N. Treatment Table 6History- Central Line Placement
Chest X-rayIV Fluids
ACLS Measures
SymptomsResolved ?Yes No
Compress to 6 ATAPatient on 50/50 Nitrox
Consider extensions at 2.8 ATAOr 1.9 ATA as needed.Finish out on Table 6
Symptoms Resolved?Yes
CompleteTable 6a
No
to Table 6
CO Poisoning
Most common fatal poison in USA/France40,000 seek medical attention500+ die of unintentional exposureInhalation or methylene chloride exposure
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Carbon Monoxide (CO) Poisoning:Carbon Monoxide (CO) exposure leads to hypoxic
stress mediated by an elevated carboxyhemoglobin (COHb) level
Two (2) organ systems most susceptible to injury from CO Cardiovascular Central nervous systems
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Carbon Monoxide (CO) Poisoning – continued:Hyperbaric oxygen
causes COHb dissociation at levels greater than at sea level
pathophysiological events associated with central nervous system (CNS) injuries mediated by CO
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Carbon Monoxide (CO) Poisoning – continued:Hyperbaric Oxygen:
Improvement in mitochondrial oxidative processes
Inhibition of lipid peroxidationImpairment of leukocyte adhesion to injured
microvasculature
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Decompression Sickness (DCS):Decompression sickness (the bends)
The generation of bubbles of inert gas in the tissues and / or blood in volumes sufficient to interfere with organ function.
Rapid decompression during ascent from diving, flying or in a hyperbaric chamber
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Decompression Sickness:Clinical Manifestations:
Type I, Pain OnlyJoint PainCutaneous Eruptions (Skin Bends).
Type II Neurological Dysfunction
Both Central and Peripheral Nervous SystemsCardiorespiratory SymptomsPulmonary Edema (Chokes)
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Decompression Sickness:Clinical Diagnosis:
History of Dive, Altitude or Hyperbaric Exposure. Manifestations most commonly include: paresthesias, hypersthesia, joint
pain, skin rash and malaise. More serious signs and symptoms include:
Motor Weakness, ataxia, dyspnea, urethral and anal sphincter dysfunction, shock, and death
Hyperbaric Treatment Protocol
Decompression SicknessHistory of dive (s) > 30 FSW Yes
Signs and SymptomsOnset of musculoskeletal pain.
Cutaneous manifestations.Central or peripheral neurological
deficits.Cardiopulmonary symptoms.
No
Yes
Monitor Vital signs100 % oxygen by mask
Complete history of dive (s).Neurological examination.
Physical examination.STAT Chest x-ray.
ECG.Labs.
IV Fluids.
Institute U.S. NavyTreatment Table 6
Symptoms Resolved ?Yes
No
Consider extensionsat 2.8 ATA and / or
1.9 ATA
Follow-upNeurology Consult.Residual symptoms-Retreat @ 2.4 ATA
Or U.S. Navy Table 6After 4-8 hour interval.
Consult DAN / NEDU
Navy Treatment Table 7
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Crush Injuries and Compartment Syndromes:Crush injuries are directly associated with
traumaSkeletal muscle compartment syndromes
arise from ischemia, venous outflow obstruction, exertion, external compression as well as trauma
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Crush Injuries and Compartment Syndromes:Management of the most severe cases always
involves surgeryStudies show statistically significant reductions in loss
of muscle function, metabolites associated with muscle injury, edema and muscle necrosis with HBO
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Crush Injuries, Compartment Syndromes and Other ATPI’s:Hyperbaric oxygen should also be considered
for several conditions with related pathophysiologyBurnsThreatened flaps, graft and re-implantation Frost bite
Hyperbaric Treatment Protocol
Crush Injury / Acute Peripheral IschemiaThreatened Extremity
Elevated Compartment PressuresClinical signs and symptoms of
Compartment Syndrome
Yes No
Acute traumatic thrombotic orEmbolic extremity injury.
Elevated compartment pressures.History
Physical ExaminationLabs
X-raysCompartment manography
Wound photographyTranscutaneous oxygen
assessment
Institute Non-Healing Wound Table2.4 ATA TID x 24 hours
2.4 ATA after first 24 hours.QD when clinical indicators permit.
Follow-up
Wound PhotographyTranscutaneous Oxygen
Assessment
TreatmentThreshold
3-12treatments
Clinical evaluation.Surgical Consultation.
If extremity is threatened.
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Crush Injuries and Compartment Syndromes:Criteria for Using HBO in Crush Injury:
Objective criteria coupled with an accepted orthopedic grading system (Gustilo Classification)
Ability of the host to respond to the injuryMangled Extremity Severity ScoreEarly decision to treat before irreversible changes
due to edema and ischemia occur
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Crush Injuries and Compartment Syndromes:Stages of Compartment Syndromes:
Suspected: HBO is not required Impending: Signs of compartment syndrome are
present. If fasciotomy is not required, HBO is indicated.
Established: After surgery, HBO should be used to reduce the morbidity if significant residual injury from the compartment syndrome remains.
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Crush Injuries and Compartment Syndromes:Utilization Considerations.
Treatment Schedules and Peer Review:Early HBO therapy, preferably within 4-6
hours from injury for greatest benefitTreatment schedules need to be based
upon the suspected pathophysiology
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Exceptional Blood Loss Anemia.Rationale: Patients who have a marked loss of red
blood cell mass by hemorrhage, hemolysis, or aplasia run the risk of lacking adequate oxygen carrying capacity by the blood. The more quickly the severe anemia develops, the less tolerant the patient may be of the insult.
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Exceptional Blood Loss Anemia:Traumatic Amputation
Right Lower Leg.Patient would not accept
blood or blood products.Hgb – 2 gm/dlHct – 6%
Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen
Exceptional Blood Loss AnemiaThe Role of Hyperbaric Oxygen Therapy.
Two organs at risk: heart and brain.Corrects accumulating oxygen debt in
patients who cannot receive or refuse transfusion.
On the HorizonAcute Cerebral EdemaCerebral Palsy Stroke Traumatic brain injury Postoperative intracranial
aneurysm
Frost BiteAcute OsteomyelitisChronic non-healing
woundsCrohn's DiseaseNear Drowning/Hanging Perinatal Hypoxia
Complications Of HBO• Middle ear barotrauma• Sinus squeeze• Ocular effects• Confinement anxiety• Oxygen toxicity - pulmonary and CNS• Paradoxically lowers blood sugar in diabetics• Hemodynamic instability in critically ill patients• Lowers seizure threshold
Contraindications
Absolute ContraindicationsUntreated PneumothoraxBleomycin –cardiotoxicityCisplatin- delayed wound healingDisulfiram- blocks superoxide dimutase (SOD)
ContraindicationsRelative ContraindicationsURICOPD with bullous emphysema or CO2 retentionClaustrophobiaSeizuresEar or sinus surgery or recent thoracic surgeryOptic neuritisPacemakers (verify for pressure tolerance)PregnancyCongenital Spherocytosis
Chamber HazardsFire
~50 fatalities to date from fireAll occurred when FiO2 >27%
UNDERSEA AND HYPERBARIC MEDICAL SOCIETYCHAMBER EXPERIENCE AND MISHAP DATABASE REPORT FOR 1923 – 1998 David A. Desautels, MPA, RRT, CHT
Chamber HazardsWoman, horse killed in hyperbaric
chamber explosion. By Jeff Weiner, The Orlando Sentinel staff Fri, 02/10/2012 - 5:18pm
DefinitiveAir/Gas EmbolusDecompression SyndromeCO poisoning
•Adjunctive•Crush Injury/Compartment syndrome•Exceptional Blood Loss Anemia•Necrotizing Infections•Gas Gangrene•Thermal Burns