Hyperbaric Medicine Past, Present, and Future

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


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


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****


Mechanical Bubble Crunching – Boyle’s Law:Oldest application of hyperbaric medicineHBO primary treatment in “bubble diseases”

Arterial gas embolusDecompression syndrome


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


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


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


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


Potent Vasoconstriction – continued:Reduces edema and oxygenation at the

same timeVasoconstriction peripheral vascular

resistance (PVR) and mean arterial pressure (MAP) afterload


Rationale for Hyperbaric Oxygen in Problem Wounds:Enhances fibroblast replication collagen synthesis neovascularization leukocyte bacteriocidal activity O2 tension greater capillary oxygen

diffusion distances

Anthony


Definitive treatment for:Arterial Gas Embolism (AGE)Decompression Sickness (DCS) Carbon Monoxide (CO) Poisoning


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


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!!!


Arterial Gas Embolism:Cause – Central Line

Placement.


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


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


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


Carbon Monoxide (CO) Poisoning – continued:Hyperbaric Oxygen:

Improvement in mitochondrial oxidative processes

Inhibition of lipid peroxidationImpairment of leukocyte adhesion to injured

microvasculature


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


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)


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


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


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


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


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


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.


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


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.


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


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.


Exceptional Blood Loss Anemia:Traumatic Amputation

Right Lower Leg.Patient would not accept

blood or blood products.Hgb – 2 gm/dlHct – 6%


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

Hyperbaric Medicine Past, Present, and Future

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