Breathe new life into old wounds

Advertising Feature Breathe new life into old wounds If you have diabetes or have received radiation treatment, please retain this booklet for future reference. 1

Please visit our website www.hyperbarichealth.com to download a copy of this booklet as a PDF. Alternatively, call 1300 HYPERBARIC (1300 497 372) and we ll send a copy to you, a relative or a friend who may benefit from hyperbaric treatment. The body has a very complex system of healing. Among other things, it needs good building blocks for repair (e.g. good nutrition) and a good transport system to get the building blocks to the site of action (both large and small blood vessels). Hyperbaric Oxygen Therapy (HBOT) delivers very high concentrations of oxygen to the wound via the bloodstream, allowing it to kick start the healing process. While doing this, it also develops new small blood vessels in the tissues, healing the wound from within and keeping further wounds at bay. HBOT has proven particularly effective in helping people with diabetes who have long-term wounds, as well as helping people who are experiencing late effects of radiotherapy for cancer treatment. This booklet describes how HBOT is a proven medical treatment and can help breathe new life into old wounds. All Hyperbaric Health Facilities are ACHS Accredited and Department of Health Licenced Private Hospitals Hyperbaric Health has contracts with DVA and all major health funds Medicare patients are bulk billed Hyperbaric Health will assist in patient transport and accommodation where available 2

Speeding up the healing process from the inside out Hyperbaric ( hyper meaning over, and baric meaning pressure ) literally translates to over pressure. HBOT exposes the patient to higher than normal pressure while the patient breathes 100% oxygen. This can only be achieved in a pressurised vessel (hyperbaric chamber). Breathing pure oxygen while in a pressurised environment results in therapeutic effects for the patient. Hyperbaric treatments for wounds occur at pressures between 2.0 and 2.4 times the pressure at sea level. In real terms, this delivers up to 15 times the normal level of oxygen to the body; this can only be achieved in a hyperbaric chamber, and causes some important changes in the body. Figure 1. Difference in healing with normal versus diabetic tissue. Healthy wound HBOT has many benefits in wound healing, including the following: Overcomes areas of poor oxygenation This is particularly true for parts of the body that have poor small vessel circulation (such as in people with diabetes). Oxygen at higher concentrations can supply the most distant tissues (such as skin on the toes) with the vital building blocks required to help repair damage. In turn, this reduces the need for more radical treatment such as surgery and potentially amputation. Grows new small blood vessels in areas with poor small vessel circulation This process is called angioneogenesis (literally new blood vessel growth ) as shown in Figure 1. This takes between 15 and 40 treatments to work and new small blood vessels can be grown within tissues with degraded blood vessels. This is a particular problem for people with diabetes and people who have had radiotherapy for cancers. The former may develop wounds that do not heal, leading to amputations, while the latter can have problems such as bleeding bowels, bladders or a breakdown of normal tissues in the areas where they have received radiotherapy. Diabetic wound Migrating skin cells MFSCs = Multifunction stem cells Platelet Wound-induced hypoxia (low oxygen) Cell differentiation factors Epithelial cells Blood vessel growth factors Blood vessel growth factors Limited cell differentiation factors Macrophages (white blood cells) MFSCs homing to wound site Circulation Precursors of structural cells Blood vessel cell migration Angioneogenesis and wound healing Limited angioneogenesis and wound healing Impaired healing enzyme activation Improved by HBO therapy Macrophage function Limited MFSC homing MFSC mobilisation to circulation MFSCs Increased activation factors Increased activation of healing enzymes Bone marrow Decreased activation of healing enzymes Decreased activation factors MFSCs Impaired MFSC mobilisation to circulation 3

Fights infection Figure 2. The wound healing process. Infections are naturally attacked by the body s white blood cells that use chemicals to destroy bacteria and are rapidly broken down to limit the damage to normal tissues. Some of these chemicals are called reactive oxygen species and include chemicals such as hydrogen peroxide (H 2 O 2 ). For the white cells to work properly they need oxygen to convert into these natural antibiotics and the additional oxygen delivered by HBOT optimises this effect. High levels of oxygen can also deactivate some of the toxins that are produced by bacteria, particularly in gas gangrene, reducing the infection s ability to spread. In other words, ultra high levels of oxygen energise the body s natural immune system to better fight infection. Red blood cell Skin surface Wound Platelet Macrophage a Injury d Late inflammation (48 h) Collagen Neutrophils (white blood cells) Macrophages (white blood cells) Fibroblast Epidermis and dermis of skin Fibrin b Coagulation (clot forming) Neutrophils (white blood cells) c Early inflammation (24 h) Delivers building blocks for wound healing Wound healing is a complex process. It requires many cellular components to come together at the correct time in optimal amounts for a rapid, strong wound-healing response. Several stages of the wound-healing process require a good level of oxygen for cells to build the structure around which the wound can heal. In some conditions (such as diabetes or auto-immune diseases) the reduced delivery of oxygen creates a weak healing process scaffold which leads to recurrence of the wound or a wound that does not heal at all (see Figure 2). Conversely, an increased delivery of oxygen provides a strong healing scaffold and fights infection, resulting in complete and proper healing of the wound. e Proliferation (building tissue scaffolding 72 h) Oxygen dependent processes Enhances the delivery of stem cells f Remodelling (scar formation and strengthening weeks to months) Stem cells are generic cells that can change into specific cells that are needed in the body. The number of stem cells decreases with age but they are often required; in particular, for the process of wound healing. HBOT has been shown to greatly enhance the development and release of stem cells as well as their activation in wound healing. HBOT is only one form of treatment that can help in the treatment of long-term wounds and tissue damage secondary to radiotherapy. However, if you have had a wound for longer than 3 months it is unlikely that it is going to heal by itself; you may like to consider HBOT as an option for treatment. 4

HBOT is a single treatment with many actions Several conditions are treated with HBOT but it is most commonly used to treat long-term (chronic) wounds and secondary tissue damage sustained from receiving radiotherapy for cancer. Long-term (chronic) wounds These are wounds that have existed for longer than 3 months and are unlikely to heal by themselves. The longer the wound exists, the less likely it is to heal with repeated dressings. This leads to a repetitive, ongoing, expensive and uncomfortable cycle of dressings and interventions for complications (such as infections) that can continue for years. HBOT seeks to end that cycle through gentle healing. The longer the wound exists, the less likely it is to heal with repeated dressings Many long-term wounds often have an underlying low oxygen concentration (called hypoxia) that prevents them from healing. Hypoxia has been measured directly in the laboratory and can be measured with a skin probe called a trans-cutaneous oxygen measurement probe (TCOM). The TCOM measures the amount of oxygen being delivered to the skin (which is where the wound occurs) by placing stick-on cups on the patient s skin (the procedure is non-invasive). HBOT delivers oxygen to the wound, allowing it to kick start the healing process by promoting the development of new small blood vessels. With this approach, the wound can be healed and further wounds can be kept at bay. HBOT is by no means the only available treatment for long-term wounds and assessment of the large blood vessels by a vascular laboratory in conjunction with a vascular surgeon is recommended. Proper dressings and management of other medical issues (such as good diabetes control, good nutrition and adequate vitamin and mineral intake) all contribute to wound healing in addition to HBOT. Radiation tissue injury When people have radiotherapy for cancer treatment, damage invariably occurs to normal tissues around the area being irradiated. This occurs because the field being irradiated is slightly larger than the actual cancer (to make sure all cancer cells are irradiated) and some radiation must pass through normal tissues in order to reach the tumour. This has two effects: There can be acute (early) radiation damage such as swelling and sunburn effects, for example on skin There can be late-onset radiation damage. This occurs 12 18 months after radiotherapy and is due to damage of the small blood vessels. HBOT can help in both cases with reduction of swelling (increase in size) and inflammation (the redness) in the early stages, but is much more effective in the treatment of late-onset radiation effects. This is particularly evident in people who develop dental cavities (holes in their teeth) secondary to radiation therapy of the head and neck, who require removal of the teeth. For people with cancers of the head and neck, removal of radiationdamaged teeth can lead to exposure of the mandible (jaw-bone) and breakdown of both the soft tissues of the gums and the bone itself. This can require extensive reconstructive surgery that, because it is in an irradiated field with poor blood flow, can lead to further wound breakdown and further surgery. 5

HBOT is also helpful for people who have undergone radiotherapy to the pelvis for prostate or gynaecological cancers and developed injuries to other pelvic organs (such as the bladder and bowel). In the pelvis, the lining of the bladder and lower bowel can become damaged by radiotherapy, leading to bladder and bowel frequency (frequent visits to the toilet), bleeding (with multiple transfusions) and considerable pain and discomfort. These effects do not occur in all people who have radiotherapy and depend on the type and total amount of radiotherapy that each person receives. HBOT can end the potentially destructive downward spiral of damage to irradiated tissues, surgical operations in the irradiated field, followed by non-healing of the surgical wound. It s all about ending the cycle. Figure 3. The downward spiral of chronic wounds. non healing wound Giving the body building blocks to repair itself The body has a very complex system of healing. You need good building blocks for repair, (e.g. good nutrition), a good transport system (both large and small blood vessels), a good ability to fight infection and a good cellular system to put it all together. In several medical conditions, some (or all) of these items are missing or compromised. The problem with this is that the wound stalls in its healing process and patients can end up in a dysfunctional downward spiral. Without intervention, this downward spiral continues until the patient follows one of two pathways: a poor outcome (such as amputation in the case of a person with a diabetic foot ulcer) OR develop an overwhelming problem (such as an infection), requiring time in hospital. repeated expensive wound dressings repeated visits to the doctor HBOT is an effective, minimally invasive way of ending the wound cycle and making a definite move toward a normal healing process repeated admissions to hospital Ask your doctor whether your wound is suitable for HBOT 6

Some facts about wounds The number of people with long-term wounds (more than 3 months duration) in Australia is estimated to be approximately 200,000 people 1 The rate of lower limb wounds in diabetics is estimated at 1.9% at any one time 2 The overall lifetime chance of a person with diabetes developing a leg wound is up to 25% 3 Between 76 and 85% of amputations in people with diabetes begin as an ulcer 4,5 The chance of requiring further amputation (either on the same leg or the other leg) after an amputation is between 30 and 50% 6 Some facts about post-radiotherapy damage Damage can start between 12 and 18 months after radiotherapy Infection, surgery or trauma can accelerate the breakdown of bone and soft tissue in an irradiated area Re-operating in an irradiated area can precipitate further damage and a cycle of operations and re-operations Diabetes mellitus is the most common cause of non-traumatic amputations in Australia 2 References 1. Elephant In The Room: Wound Awareness Campaign 2010. Australian Wound Management Association. www.elephantintheroom.com.au. Viewed 17 October 2010. 2. Australian Institute of Health and Welfare. Diabetes: Australian facts 2008. Canberra: Australian Government, Australian Institute of Health and Welfare, 2008. 3. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293 (2): 217 28. 4. Ulbrecht JS, Cavanagh PR, Caputo GM. Foot problems in diabetes: an overview. Clin Infect Dis 2004; 39 (Suppl. 2): S73 82. 5. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G et al. The global burden of diabetic foot disease. Lancet 2005; 366 (9498): 1719 24. 6. Ollendorf DA, Kotsanos JG, Wishner WJ et al. Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Diabetes Care 1998; 21(8): 1240 5. 7

Treating people from age 1 to 100+ Breathing oxygen is indistinguishable from breathing air. As the pressure gently changes patients will need to clear their ears just as you may do occasionally on a plane. HBOT is a very safe treatment. We regularly treat people aged in their 90s. Children can also be safely treated in a hyperbaric chamber. There are two main types of chambers: multiplace chambers monoplace chambers. 8

Multiplace chambers Multiplace chambers are large metal chambers that can treat a number of people simultaneously (hence multi place). Patients enter the chamber via a door that creates a pressure seal and they sit or lie down (depending on the condition and type of chamber). A trained hyperbaric nurse is always present within the chamber during the treatment. While they are being treated, patients can read a book and breathe normally. It s just like going for a ride in a plane. In these chambers pressure is delivered with air but the patients inside breathe 100% oxygen either though a fitted mask or a hood. This effect is the same as breathing normally if the chamber was pressurised with 100% oxygen. To increase safety the chamber is filled with air and 100% oxygen is only delivered to the hood or mask. The treatment lasts approximately 2 hours (the actual treatment time at pressure is 90 minutes but an additional 30 minutes is allowed for getting the chamber to pressure). Monoplace chambers Monoplace chambers are single-person chambers that are generally smaller than multiplace chambers. They are usually made of acrylic (a very strong clear plastic) and are pressurised with pure oxygen (i.e. patients generally don t have to wear a mask or hood). Patients lie on a trolley and slide into the chamber. Patients can see around themselves quite clearly (a bit like a tunnel in a large aquarium where you can look at the fish swimming around you) and normally there are video screens so patients can watch their favourite movie or television show while undergoing treatment. Advantages of the monoplace chambers are a slightly faster treatment time and treatment can be based around the patient s schedule as there is no need to wait for other patients to start treatment. Both chamber types give the same treatment and the type of chamber patients will have depends on the facilities at the Hyperbaric Health Wound Centre that is closest to them. 9

Medicare recognised treatments HBOT is recognised as an effective treatment by Medicare and, for common conditions, Medicare and health funds will pay for the treatment as a legitimate effective treatment. Hyperbaric Health facilities charge a very small facility fee (for lunch or afternoon tea after the treatment) but the assessment, management by specialist doctors and treatment itself do not cost the patient any money. Hyperbaric Health bulk bills and has no-gap arrangements with most of the major private health funds and the Department of Veterans Affairs. The conditions that are paid for by Medicare include: treatment for soft tissue and bone radionecrosis (damage due to radiotherapy both as a preventative measure and as treatment) hypoxic (low oxygen) and chronic (long term) wounds gas gangrene and necrotising infections decompression illness (the bends) arterial gas embolism (AGE). Other conditions have recognised HBOT as a valid treatment but currently Medicare will only fund the conditions above. Recognised indications for Hyperbaric Oxygen Therapy This list is based on the best evidence currently available and is by no means exhaustive. It is based on the Australian and New Zealand Hyperbaric Medicine Group (ANZHMG) list of indications for treatment. Diabetic wounds* Problem wounds* Late radiotherapy tissue injury* Infective conditions Acute ischaemic conditions Decompression illness (DCI)* Toxic gas poisoning Ocular ischaemic pathology Adjuvant to radiotherapy Miscellaneous ulcers, post-surgical wounds, gangrene chronic ischaemic wounds, post surgical problem wounds, venous ulcers prophylaxis and management of bony and soft tissue radionecrosis including radiation proctitis, radiation cystitis, maxillofacial bony and soft tissue necrosis necrotising infections*, refractory osteomyelitis, malignant otitis externa compromised flaps and grafts, crush injury, compartment syndrome, reperfusion injury, idiopathic sudden sensorineural hearing loss, avascular necrosis decompression sickness, cerebral arterial gas embolism including iatrogenic injury carbon monoxide poisoning cystoid macular oedema, retinal artery or vein occlusion adjunct to radiotherapy for solid tumours thermal burns, frostbite The ANZHMG, a sub-committee of the South Pacific Underwater Medicine Society (SPUMS), review evidence and recommend conditions for which HBOT may be employed biennially. Hyperbaric Health, as policy, uses the ANZHMG Indications. *Indications funded by Medicare 10

HBOT is a non-invasive medical treatment involving breathing 100% oxygen while inside a pressurised hyperbaric chamber. HBOT increases oxygen delivery to tissues higher than is otherwise possible. To find out if you would benefit from HBOT please complete this form in consultation with your doctor and contact your nearest Hyperbaric Health Wound Centre. If you have more than one specialist please photocopy this referral and take it to all your doctors. Referral form For urgent referrals please contact your nearest facility listed below. Patient name: Address: Date of birth: (dd-mm-yy) Private referral Please tick indication for hyperbaric oxygen therapy (HBOT) Daytime telephone: Medicare referral Problem wounds Diabetic Non Diabetic Late radiation tissue injury Infective conditions Soft tissue Prophylaxis Suspected organism: Bone Established disease Acute ischaemic conditions Decompression illness (DCI) Toxic gas poisoning Compromised flaps/grafts Crush injury/compartment syndrome Reperfusion injury Avascular necrosis Sudden sensorineural hearing loss Please phone the nearest facility Please phone the nearest facility Ocular ischaemic pathology Retinal artery/vein occlusion Adjuvant to radiotherapy Please discuss with facility prior to referral Miscellaneous Thermal burns Frostbite Background medical history Please include as much information as possible and attach extra sheets and test results to this referral sheet Referring doctor: Address: Telephone: Medicare provider number: Melbourne Located at St. John of God Hospital Gibb Street, Berwick VIC 3806 berwick@hyperbarichealth.com Ph: (03) 9707 1420 Fax: (03) 9707 1860 Located at Brunswick Private Hospital 82 Moreland Avenue, Brunswick VIC 3056 brunswick@hyperbarichealth.com Ph: (03) 9383 6505 Fax: (03) 8587 2489 Sydney Suite 3, Ground Floor, 46 50 Kent Road, Mascot NSW 2020 sydney@hyperbarichealth.com Ph: (02) 9578 0000 Fax: (02) 9578 0050 Perth Opening in 2011 Located at St. John of God Hospital Subiaco WA 6008 perth@hyperbarichealth.com New Zealand Quay Park Medical Centre 68 Beach Road, Auckland 1010 auckland@hyperbarichealth.com Ph: (09) 919 2340 Fax: (09) 919 2341 11

Do you or someone you care for have a wound or injury that is: having trouble healing or due to diabetes complications or due to radiation treatment or causing ongoing pain? Hyperbaric Oxygen Therapy may help. Speak to your doctor, call 1300 HYPERBARIC (1300 497 372) or visit www.hyperbarichealth.com for more information or to download a copy of this booklet as a pdf. Call us on our national free call number 1300 HYPERBARIC (1300 497 372) or call the Hyperbaric Health Wound Centre closest to you: Hyperbaric Health 2010. Berwick St. John of God Hospital Gibb Street, Berwick VIC 3806 berwick@hyperbarichealth.com Ph: (03) 9707 1420 Perth Opening in 2011 St. John of God Hospital Subiaco WA 6008 perth@hyperbarichealth.com Brunswick Brunswick Private Hospital 82 Moreland Avenue, Brunswick VIC 3056 brunswick@hyperbarichealth.com Ph: (03) 9383 6505 New Zealand Quay Park Medical Centre 68 Beach Road, Auckland 1010 auckland@hyperbarichealth.com Ph: (09) 919 2340 Sydney Suite 3, Ground Floor 46 50 Kent Road, Mascot NSW 2020 sydney@hyperbarichealth.com Ph: (02) 9578 0000