Objectives What to Know About HBO (Hyperbaric Oxygen Therapy) Presented by Catherine Rogers, APN, BC, CWCN, CWS, FACCWS Advanced Practice Nurse/Program Manager SwedishAmerican Health System Rockford, IL Wound Care and Hyperbaric Clinics Upon completion, the participant will: State at least two conditions for hyperbaric oxygen treatment, Recall a minimum of 3 safety issues that must be addressed prior to treatment, Describe what the patient experiences during each treatment, Cite one benefit of HBO for diabetic foot ulcers. What is HBO? Hyperbaric oxygen therapy is the breathing of oxygen molecules under pressure. What HBO is not: breathing in air or O2 by nasal cannula or topically applied O2 to an extremity A Brief History of HBO Studies as far back at 1660 s Research in the 1960 s Dr. Boerema Research in 1977 Dr s Hunt and Davis pioneered studies in hypoxia, hyperoxia and wound healing Best known for treatment of divers suffering from the bends How HBO affects the body Transport of O2 via the blood by Binding to hemoglobin Dissolved in plasma HBO is able to Increase the amount of O2 dissolved in plasma How HBO affects the body Physics that apply to hyperbaric oxygen Increases the distance that dissolved oxygen can diffuse in the tissues Increases PO2 levels Gas laws that apply to hyperbaric oxygen Boyles Henry s 1
How HBO affects the body In some indications for HBO therapy there is tissue/bone infection- Oxygen tension is increased and O2 molecules can reach leukocytes Produces oxygen radicals which are bactericidal on anaerobic bacteria In some indications for HBO therapy the patient has a wound- Wounds have a zone of hypoxia The periwound area is usually malperfused Cellular energy and metabolism Antibacterial effect Regeneration of tissue Cellular energy and metabolism Improved local tissue oxygen levels Improved cell energy use/formation Decreased local tissue edema Nitric oxide production Antibacterial effect Improved leukocyte-bacterial-killing Increased effectiveness of antibiotics Regenerating wound tissue effects Enhanced uptake of growth factors Promotion of collagen deposits Promotes extracellular matrix Promotes angiogenesis Use of HBO today Regulation and Reimbursement: UHMS Undersea and Hyperbaric Medical Society CMS/LCD HBO is a modality in which the entire body is exposed to O2 under increased atmospheric pressure the patient is in a pressure chamber breathing 100% O2 at greater than one atmosphere pressure. 2
Use of HBO today Decompression illness, gas embolism Carbon monoxide or cyanide poisoning Blood loss anemia Acute thermal burns Clostridia myonecrosis Preservation of compromised skin grafts/flaps Crush injury, compartment syndrome Osteoradionecrosis Soft tissue radionecrosis Refractory osteomyelitis Typical clinic examples/set ups Monoplace chambers Multiplace Chambers Training/education requirements Physician role Safety Director Staff role Emergency procedures/equipment Examples of monoplace chambers Examples of multiplace chambers Indications for use Contraindications Pre-treatment testing Ears Lungs Arterial tests Physician exam Hypoglycemic issues Prostheses Claustrophobia issues 3
Indications for use CMS approved diagnosis Acute applications Chronic applications Off-label uses/non covered diagnosis The diagnosis is appropriate, but is the patient appropriate? If indicated, document hypoxia Are there any absolute contraindications? What about relative contraindications? Patient Selection for HBO therapy Documenting tissue hypoxia Obtain a baseline TcPo2 test Normal values > 50mmHg A low result indicates hypoxia Test results <40mmHg in non-diabetic <50mmHg in diabetic patients indicate patient is candidate Absolute contraindications Untreated pneumothorax Current administration of chemotherapy or amiodarone Administration of bleomycin within the last 12 months Pregnancy in non-life threatening conditions Terminal patients Relative contraindications Patient ability to understand and communicate problems Risk of middle ear trauma Risk of pulmonary trauma Risk of CHF, implanted device Potential for oxygen toxicity Other potentials Any absolute contraindications will eliminate patient from being a candidate for HBO therapy Any relative contraindication needs to be investigated and managed if possible 4
Next, the patient goes through an orientation: Teach and demonstrate ability to clear ears Understand treatment expectations Signing consent forms Assignment of treatment times Expectations of on-time arrival Review of safety issues Safety Issues Codes, standards and guidelines specific to HBO ASME ASME/PVHO-1 ASME/PVHO-2 NFPA 99 FDA CGA UHMS OSHA Fire Safety and Fire/Safety/Disaster Management Plan Safety Issues Prohibits flammable gases and liquids, vapors, polyester fabrics, lotions, oils, etc Postings within the clinic prohibit: Personal warming devices Cell phones and pagers Sparking toys Personal entertainment devices What to wear? What to do? How long will it take? How will it feel? What to wear? Changing rooms 100% cotton gowns, sheets If you weren t born with it, it doesn t go into the chamber No makeup, hairspray What to do? Most chambers today have television/dvd options Piped in music Sleep Make faces and enjoy the down time 5
How long will it take? Treatment plans are developed based on the reason HBO is needed: Some treatments may be completed once per day, 5 days a week, 90 minutes at pressure, Other treatment plans require twice a day up to 120 minutes at pressure, In general, most often the patient can be in and out in 120 minutes (2 hours). How will it feel? How do you do in small spaces? Have you been in a plane? Have you ever been diving? The treatment is complete Upon leaving the chamber Check the ears Check vitals Check the blood sugar Completion of HBO treatments How do we know when treatments are completed? Most reimbursement is based on 20 treatments Baseline TcPo2 tests provide before HBO measure of hypoxia Follow up TcPo2 tests provide evidence of effectiveness of HBO treatments/failure of treatments Patient ability to continue tolerating treatments/overall health Resolution of infection Filling in of wound bed/advancing epithelial tissue Compliance issues Case Studies Diabetic Foot Ulcers Osteomyelitis Case Studies Others Carbon monoxide poisoning Necrotizing infections Radiation latent affects Compromised flaps/grafts 6
References Will be provided October 2008 ISAPN Conference Rogers: HBO 37 7