Clinical Indications for Hyperbaric Oxygen Therapy in 2011 Part 1
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1 Clinical Indications for Hyperbaric Oxygen Therapy in 2011 Part 1 Med LtCol Peter GERMONPRE Centre for Hyperbaric Oxygen Therapy Military Hospital Brussels
2 What is HBO therapy? Breathing oxygen under pressure for therapeutical purposes Increase of oxygen transport Increase of oxygen delivery Oxygen as a drug Indications, dose, side effects
3 How to administer HBO? Monoplace hyperbaric chambers
4 How to administer HBO? Monoplace hyperbaric chambers Multiplace hyperbaric chambers
5 How to administer HBO? Monoplace hyperbaric chambers Multiplace hyperbaric chambers Pressure of at least 2 ATA Duration of at least 60 minutes of O 2
6 How to administer HBO? Pressure of at least 2 ATA Duration of at least 60 minutes of O2 Topical application of oxygen is NOT HBO Therapy!
7 Effects of breathing oxygen at pressure Increase of P (alv( alv) ) O 2 Increase of P (art) O 2 Increase of P (ven) O 2 Hemoglobin saturation in venous blood = 100%
8 Oxygen transport in blood Ca(O 2 ) = (Hb( x SaO 2 x 1.34) + (PaO 2 x 0.003)
9 Oxygen transport in blood Hb dissociation curve (Barcroft) Ca(O 2 ) = (Hb( x SaO 2 x 1.34) + (PaO 2 x 0.003)
10 Oxygen transport in blood Physiological O 2 consumption
11 Boerema 1959 Life without blood?
12 Life without blood!
13 Hyperbaric Oxygen Therapy
14 Effects of hyperbaric hyperoxia Increased O 2 transport in blood
15 Effects of hyperbaric hyperoxia Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law)
16 Effects of hyperbaric hyperoxia Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Volume (liters) 12 Variations in volume ,33 2,5 2 1,67 1,43 1,25 1, Pressure (ATA)
17 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases
18 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases po 2 (cap) 40mmHg Krogh s Capillary Model
19 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases po 2 (cap) 40mmHg Krogh s Capillary Model
20 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases po 2 (cap) 40mmHg Krogh s Capillary Model
21 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases po 2 (cap) 40mmHg Krogh s Capillary Model
22 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases po 2 (cap) 300mmHg Krogh s Capillary Model
23 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases po 2 (cap) 300mmHg Krogh s Capillary Model
24 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases po 2 (cap) 300mmHg Krogh s Capillary Model
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27 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases Anti-infectious infectious defense mechanisms Direct (anaerobic( bacteria) Indirect (white blood cell function,, ATB)
28 Effects of hyperbaric O 2
29 Effects of hyperbaric O 2 Infection rate in 153 operative surgical patients at high risk for infection - correlation with SC po2 (FiO2 = 0.5) Greif R et al. NEJM 20;342(3): Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Roseau E Presse Med 29(12): Peritoneal infections: preventive effect of perioperative supplemental oxygen administration Hopf HW et al Arch Surg 132(9): Wound tissue oxygen tension predicts the risk of wound infection in surgical patients Johnson et al. Ann Surg 1991
30 Effects of hyperbaric O 2
31 Effects of hyperbaric O 2 Increased O 2 transport in blood Pressure effect (Boyle( Boyle-Mariotte s law) Diffusion distance of oxygen increases Anti-infectious infectious defense mechanisms Direct (anaerobic( bacteria Indirect (white blood cell function,, ATB) Stimulation of granulation tissue
32 Oxygen as a drug : Indications Any disease where oxygen (maybe) plays a role? Any disease where no other good treatment is available? A therapy in search of diseases (Chest,, 1987)
33 Evidence Based Medicine Level I evidence Multiple RCTs of good quality: prospective,, placebo controlled Level II III IV evidence Small RCTs without placebo Retrospective studies with patients as their own historical controls Retrospective studies, uncontrolled Case series Animal studies
34 HBO Therapy Indication 1. Is there a (local( or generalised) lack of oxygen? 2. Does this hypoxia cause or aggravate the disease? 3. Can HBO improve tissue oxygenation? 4. Is there evidence that improving tissue oxygenation improves the disease? 5. Is there a good risk-benefit ratio for this particular patient?
35 Undersea and Hyperbaric Medical Society, Air or Gas Embolism 2. Carbon Monoxide Poisoning (incl. CO Poisoning Complicated by Cyanide Poisoning) 3. Clostridial Myositis and Myonecrosis (Gas Gangrene) 4. Crush Injury, Compartment Syndrome and other Acute Traumatic Ischemias 5. Decompression Sickness 6. Arterial Insufficiencies (Central Retinal Artery Occlusion, Enhancement of Healing In Selected Problem Wounds) 7. Severe Anemia 8. Intracranial Abscess 9. Necrotizing Soft Tissue Infections 10. Osteomyelitis (Refractory) 11. Delayed Radiation Injury (Soft Tissue and Bony Necrosis) 12. Compromised Grafts and Flaps 13. Acute Thermal Burn Injury
36
37 Military indications (Ref RTG-192 NATO Working Group) Decompression Sickness - Air embolism Crush injury Carbon Monoxide Poisoning Acoustic (noise)) trauma Burns Anaerobic soft tissue infections
38 Air embolism
39 Air embolism
40 Air embolism
41 Air embolism
42 Air embolism
43 Crush injury
44 CO Poisoning
45 Anaerobic infections Animal studies Amsterdam Experience
46 Burns 3 Depth degrees of cutaneous burn Increasing burn depth over 24 hours Jackson concept of 3 zones
47 Burns 3 Depth degrees of cutaneous burn
48 Burns 3 Depth degrees of cutaneous burn Increasing burn depth over 24 hours Jackson concept of 3 zones
49 Burns 3 Depth degrees of cutaneous burn Increasing burn depth over 24 hours Jackson concept of 3 zones
50 Experimental evidence Animal litterature CHBO Study on rats 2000 CHBO Study 2 on rats
51 Experimental evidence
52 Experimental evidence
53 Experimental evidence Animal litterature Study on rats 2000 Study 2 on rats Why not done? Clinical human RCTs lacking Optimal environment HBO and ICU lacking
54 Acoustic Trauma Frequent, both in military and in civilian youth Impulse noise vs longer exposure Emergency treatment with HBO & corticosteroids = promising RCTs lacking Comparison to hearing before trauma? Early (>36hr) treatment necessary
55 Acoustic Trauma Lafere et al. DHM Belgian soldiers with acute impulse noise (gunshot) acoustic trauma
56 Acoustic Trauma Lafere et al. DHM 2010
57 Dangers of HBO therapy Transportation Compression Stay at Depth Decompression
58 Dangers of HBO therapy Haemodynamically unstable patients should not be moved! Barotrauma of the ears Common (10-20%) Preventable Rarely serious Hyperoxic seizures Seldom (1 in treatments) Unpredictable (but...) No sequelae
59 Dangers of HBO therapy Uncontrolled use Diseases with large impact of QoL For which there is no cure For which evaluation of effects is mainly subjective Gives HBO a a bad name Examples... Multiple Sclerosis Chronic Fatigue Autism Cerebral Palsy Never say never......but: proof must be given
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62 And even Interest in HBOT by the equine industry is due to its ascribed beneficial effects on the healing of lower limb wounds, which remain a major health problem to man and horses worldwide. Slow healing wounds or those that fail to heal can result in prolonged hospitalisation, numerous surgical interventions and time consuming wound care. Slow healing is particularly inconvenient and challenging for high performance human and equine athletes.
63 And even Interest in HBOT by the equine industry is due to its ascribed beneficial effects on the healing of lower limb wounds, which remain a major health problem to man and horses worldwide. Slow healing wounds or those that fail to heal can result in prolonged hospitalisation, numerous surgical interventions and time consuming wound care. Slow healing is particularly inconvenient and challenging for high performance human and equine athletes.
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