Wound Management Using Hyperbaric Oxygen Therapy (HBOT)
Dr Kim Soo Joang, Principal Resident Physician, Hyperbaric and Diving Medicine Centre, Singapore General Hospital
IntroductionHyperbaric Centre

Hyperbaric Oxygen Therapy (HBOT) is not a new treatment modality and has been around for more than half a century. In Singapore, the first hyperbaric chamber can be traced back to the Singapore General Hospital, in the 70’s, where it was used by the Orthopaedic Department. However, this was transferred to the Singapore Navy where the bulk of hyperbaric medical work was carried out by the Republic of Singapore Navy until recently. Whilst the application of Hyperbaric Oxygen Therapy in the management of decompression illness is well established, its application for other clinical conditions is less well known. Currently, there are 13 accepted indications for Hyperbaric Oxygen Therapy supported by good evidence.
Indications for Hyperbaric Oxygen Therapy

Approved uses as recommended by the Undersea and Hyperbaric Medical Society. (Hyperbaric Oxygen 2003, Indications and Results. The Hyperbaric Oxygen Therapy Committee Report)
1) Air or gas embolism
2) Carbon monoxide poisoning
3) Clostridial myositis and myonecrosis (Gas gangrene)
4) Crush injury, compartment syndrome and other acute ischaemias
5) Decompression sickness
6) Enhancement of healing in selected problem wounds
7) Exceptional anaemia
8) Intracranial abscess
9) Necrotising soft tissue infections
10) Osteomyelitis (Refractory)
11) Delayed radiation injury (soft tissue and bony necrosis)
12) Skin grafts and flaps
13) Thermal burns

One of the most common indications in clinical practice is enhancement of wound healing in selected problem wounds.

Effective problem wound management requires an integrated multidisciplinary team approach. Hyperbaric Medicine is one important component of this team. When used appropriately, Hyperbaric Oxygen Therapy can be an effective adjunctive therapy for problem wounds.
Hyperbaric Oxygen TherapyWhat is Hyperbaric Oxygen Therapy?

It is a form of therapy where patients breathe 100% oxygen intermittently at pressures greater than sea level. In order to receive oxygen at these pressures, patients will need to be pressurized in a specially designed and built vessel. These vessels can accommodate one or more patients. The vessel is usually compressed with air and the patient breathes 100% oxygen via a transparent hood or mask. Some one-man chambers are compressed with 100% oxygen. By breathing oxygen at high pressures, a large amount of oxygen is carried dissolved in the plasma.

Topical Hyperbaric Oxygen Therapy where oxygen is delivered directly to a wound is not considered Hyperbaric Oxygen Therapy.
How Does Hyperbaric Oxygen Help in Wound Healing?

Wounds without adequate tissue oxygen levels will not heal. Hyperbaric Oxygen Therapy when used appropriately can reverse tissue hypoxia so that wound healing can proceed.

Hyperbaric oxygen therapy has been shown to have the following effects:

• Stimulation of angiogenesis
• Enhancement of fibroblast replication and collagen synthesis
• Enhancement of epithelialization
• Reduction of local oedema
• Improved leukocyte killing
• Direct toxic effects on anaerobic bacteria
• Suppression of bacterial toxin production
• Synergism with certain antibiotics
• Prevention of leukocyte mediated post-ischaemic reperfusion injury

For Hyperbaric Oxygen Therapy to be effective there must be adequate blood flow to the wound. Without adequate blood flow, the oxygen carried in the blood and plasma will not be able to reach the site where it is needed most and in some cases revascularization procedures may be required first.
Who Can Benefit From Hyperbaric Oxygen Therapy?

Patients with the following types of wounds may benefit from Hyperbaric Oxygen Therapy:

1) Diabetic lower extremity wounds - failure to heal or improve with conventional management.
2) Venous stasis ulcers – failure to heal or improve with adequate control of oedema.
3) Late radiation injury – wounds that fail to heal or improve with conventional management.
4) Arterial insufficiency ulcers – failure to heal or improve despite maximum revascularisation.
5) Any wound that has failed to heal with conventional management where hypoxia is a contributing factor.

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Patients with problem wounds will undergo a non-invasive test called Transcutaneous Oximetry. This test measures the transcutaneous oxygen tension at the level of the skin and is an indirect measurement of microcirculatory blood flow. A baseline measurement is taken on room air and another while breathing 100% oxygen at sea level.

Patients who have reversible periwound hypoxia are suitable candidates for HBOT. If perfusion is too poor, referral to vascular team is warranted. Patients can be reassessed after vascular intervention if any.

Before a patient is selected for Hyperbaric Oxygen Therapy, an assessment is made to determine the patient’s fitness for exposure to high ambient pressure and high oxygen concentration.

Malignant ulcers are generally not accepted for Hyperbaric Oxygen Therapy.

When skin grafts and flaps are used to cover problem wounds, Hyperbaric Oxygen Therapy can be beneficial in support of compromised skin grafts and flaps.
What is Treatment Like?

Problem wounds usually require 20 to 30 treatment sessions or more depending on response. Each treatment session lasts about 2 hours and the treatment pressure is between 2 to 3 ATA (equivalent to 10 to 20 metres underwater).

The actual treatment can be divided into 3 phases – compression, maintenance of pressure and decompression.

Compression
During this phase, the pressure in the chamber is increased slowly to the treatment depth. There will be a sensation of fullness in the ears similar to that felt during take off and landing in an airplane. Equalization techniques are taught. Patients will feel warm during this phase.

Maintenance of pressure
Once the depth is reached, patients can relax and read a book, or watch a program on the in chamber entertainment system, while breathing oxygen in a transparent hood or mask.

Decompression
Once treatment is completed, patients will be decompressed back to sea level. Again, there will be a sensation of fullness in the ears. It is a normal sensation which will resolve spontaneously. Patients will feel cold during this phase.

Contraindications
The only true absolute contraindication to HBOT is an untreated pneumothorax. Once treated, the patient can proceed with HBOT. Prior exposure to Bleomycin is not compatible with HBOT.

Complications associated with HBOT
• Barotrauma
- Middle ear
- Tooth
- Sinus
- Pulmonary
• Oxygen toxicity
• Temporary worsening of myopia

Serious complications are extremely rare. The most common complaint is ear pain which can easily be managed with no serious consequences.

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For more information, please visit our website:
http://www.sgh.com.sg/MedicalSpecialtiesnServices/SpecialistCentres/HDM/

References

1. Hyperbaric Oxygen 2003. Indications and Results. The Hyperbaric Oxygen Therapy Committee Report. Pg 41 – 55. Enhancement of Healing in selected problem wounds. Robert A. Warriner III and Harriet W. Hopf.
2. Wound Care Practice. Paul J. Sheffield, Ph.D., Adrianne P.S. Smith, M.D., Caroline E. Fife, M.D. Pg 661-684. Hyperbaric Oxygen Therapy Applications in Wound Care. Caroline E. Fife.


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