I usually order HBOt as a last resort for patients who have had systematic workup and treatment for peripheral vascular disease but still has an ischemic nonhealing wound. Sure, sometimes anecdotally I feel as if I am helping the patient but sometimes not despite appropriate measure to treat the patient. There is literature on HBOt but not many prospective double blinded randomized controlled trials. A good study would be a significant undertaking. Is there any good evidence based approach to HBOt or are we just practicing voodoo medicine?

Great topic and widely debated. One of the key references that I use in EBM is www.cochrane.org. Their summary findings on HBO are as follows: "We found some evidence that people with diabetic foot ulcers are less likely to have a major amputation if they receive hyperbaric oxygen therapy. This is based on three randomised trials with a limited number of patients. Further research is needed."

This finding confirms for me the role of HBO and further helps emphasize that one key element in achieving success with HBO is selecting the right patients for treatment...

I agree with with Dr. Steinberg. The right patient for treatment. I use transcutaneous oximetry testing as a predictor of wound healing and response to hyperbaric oxygen. We have healed many patients with hyperbaric oxygen therapy as an adjunct to good local wound care including KCI wound vac , debridments. Without tcom evaluation you're wasting some patients time and health care dollars.

The Judy Dan Wound Centre ion North York General Hospital just started
a RCT for HBOt. It looks good and is well powered. Check it out.

http://www.ontariowoundcare.com/research.html

It would be interesting to attempt serial testing with hyperspectral imaging pre, during, and post HBO therapy to establish if there is significant increase in tissue perfusion following HBO therapy, and if so, if those increases remain following completion of the dives.

Here in México, HBOt has been used with really doubtful results, patients going into the hyperbaric chamber breath 100% oxygen which would increase tissue oxygenation also via normal circulatory system, and what we have observed is that doing this under normo baric conditions also helps increase TcPo2 levels on periwound skin, so we have tried some trials on normobaric oxygen breathing intermitently during the day, to improve healing, of course with previous TcPo2 lectures that would help. discarding extreme ischemia.  The fact is also that HBOt is expensive going here in México from 80 to 100 usdlls, per session and having to go daily would take to bankrupt any patient of ours, so with oxygen inhalation you could save a lot.

 

 

 

 

 

TcPo2 measuring

I don´t agree with Hector, the failure in Mexico in the lack of multidisciplinary management of these patient and unfair competition.  Very important is to ignore the advanced wound therapy, the basic pathology and the lifestyle.  If normobaric oxygen helps, HBOT reduces the healing time always , I repeat, with multidisciplinary management.

Quite sure, Maria I surely agree that multidisciplinary management is basic.  Here in our clinic we give our patients advanced wound healing, vascular atention and metabolic control, the failure of HBOT I would applied it as a cost effective failure and of little benefit in those patients with levels of less than 30mmHg of TCPO2 in their feet, this is my personal experience... I am quite sure the HBOT is helpful for many other situations.

 

This presents as a perplexing issue, as to the validity of HBOT in the management of not only ischemia, but with DFU and Osteomyelitis.  In order to understand the mechanism of healing, you have to understand WHY HBOT works....

 

HBOT (100% oxygen under pressure) is designed to increase the blood supply of oxygen by increasing the hematocrit.  By increasing the Hct and the effect of oxygen causing vasodilitation, you get the expected results that we see in daiily practice.

 

I have made it a point to order HBOT on each and every osteomyelitis patient, diabetic foot seen post-surgically and patients with PAD as frequently as ordering Xrays on post-operative bunionectomy patients.  This modality has become a very powerful tool in the arsenal of those of us that treat and work in diabetic limb salvage clinics and centers.

 

I agree with Dr. Steinberg's analysis of the Cochrane study, but there are also many useful sites that educate patients regarding HBOT:

 

Undersea & Hyperbaric Medical Society www.uhms.org

 

American College of Hyperbaric Medicine www.hyperbaricmedicine.org

 

Hyperbaric Medicine Today www.hbomedtoday.com

 

I respectfully disagree with George and others here.

 

I think we should use these advanced wound care modalities, ie. HBOT and Wound VAC, more proactively, rather than as "the last resort."

 

In terms of clinical evidence, we do already have AHA level 1 evidence that "HBOT increases the chance of wound healing, thus reduces the rate of major leg amputations (per the Cochrane review summary)." 

 

I also want to add the CADTH data. CADTH is basically the Canadian version of FDA. Their 2007 report on HBOT indicated that, when properly used, HBOT heals more DM foot ulcer, reduce the amputation rates, increase the Quality-of-Life Years, and reduce the total cost of treatment (by avoiding major leg amputations). 

 

As a wound care physician, my goal is to "save the limb." In order to do that, I believe we have to be proactive about which useful modality to offer, and when. 

 

I remember the days when we used to "withhold" wound VAC therapy saying, "oh, it is for the last resort" when VAC just came out on the market about 10 years ago. I don't think any reasonable clinician thinks that way anymore.

 

It's too bad that there is still a lot of prejudice of HBOT that exists among clinicians and the patients. It is really an useful and minimally invasive treatment, and I believe HBOT is truly under-utilized treatment to this day.

 

Kazu Suzuki

Los Angeles, CA

 

===============================

This summary is based on a health technology assessment available from CADTH’s web site (www.cadth.ca): 

Hailey D, Jacobs P, Perry DC, Chuck A, Morrison A, Boudreau R. Adjunctive Hyperbaric Oxygen Therapy for Diabetic Foot Ulcer: An Economic Analysis. 

 

1. Adjunctive HBOT for DFU is more 

effective than standard care alone. The 

proportion of major LEAs can decrease from 

32% among patients receiving standard care 

to 11% among those receiving adjunctive 

HBOT. There was a decrease in the 

proportion of unhealed wounds with HBOT; 

the reverse was true for minor LEAs. 

 

2. HBOT for DFU is cost-effective compared 

with standard care. The 12-year cost for a 

patient receiving HBOT was C$40,695 

compared to C$49,786 for standard care 

alone, with an associated increase of          

0.63 quality-adjusted life years (QALYs) 

(3.01 QALYs for standard care versus       

3.64 QALYs for those receiving HBOT). 

I truly agree with Kazu. It is a matter of using the right tools in our armamentarium at the right time. Peter Sheehan taught us that with his study, showing that if we were not getting 50% healing of a wound within 4 weeks we needed to switch to the more advanced technologies: KCI's VAC, Apligraf, HBO2, etc. in order to kickstart the healing.

Tye, I challenge you to remember the wounds that you saw at the Texas Diabetes Institute under Dr. Steinberg, Harkless and even myself occasionally who received these treatments and whose limbs were salvaged. It is a matter of the right treatment at the right time for the right wound.

I just thought of one other thing that I wanted to mention, speaking of using the correct treatment on the right wound at just the right time. I've mentioned this from time to time and so you may have heard me say it.

While I was in Des Moines, on the staff at a Curative Wound Care Center, a good friend of mine who was an MD family practice physician called and asked if I could take over the care of a patient of his who he had been treating for a toe ulceration. He had been treating it with Regranex without success.

I agreed and when the patient arrived I was shocked to find a patient with a desicated, gangrenous digit. I called my friend and assured him that while Regranex was an excellent product, it couldn't be expected to bring Lazarus back from the grave!

Right product for the right wound at the right time. We can't doom a great product/technology by using it incorrectly, spreading that word and I feel that sometimes that is what people do.

FYI,

UHMS (Undersea and Hyperbaric Medical Society) is the US-based, international medical society that is the primary source of diving and hyperbaric medicine. It is a non-profit organization.

www.uhms.org

Here's the list of "official" HBO indications based on the UHMS committee review. As far as I know, the wound indications are the most used indications for HBOT in the US.




======================================================

The latest guideline, including the clinical evidence reviews, can be purchased here:

http://underseaandh960.corecommerce.com/Hyperbaric-Oxygen-Therapy-Indications-p25.html

 

Here is my brief write-up on HBOT, titled

"A Guide to Hyperbaric Oxygen Therapy For Diabetic Foot Wounds,"

...edited by Dr. John Steinberg. 

It describes the rationale of why HBOT needs to be a part of your wound care regimen:

http://www.podiatrytoday.com/article/8026

=========================================
Monoplace (single person) chamber on left 
-- this particular unit is used by the professional soccer team in Tokyo for sports medicine indication.

Multiplace (multiple people) chamber on right
-- this one is in Tokyo Medical and Dental University
 

I believe that if you check, the HCT does not go up with HBO, but that the effective number does go up, due to the O2 bound to plasma.

I would like to add to Dr. Miller's comment.

SPP (Skin Perfusion Pressure) does not change with HBO, since SPP measures the perfusion (flow rate of red blood cells, specifically).

TCOM, or Trans-Cutaneous Oxymetry, which uses a heating sensor that measures the oxygen permeated through the skin. TCOM value does go up with HBO, as HBOT increases the oxygen concentration within the plasma, up to 10 fold.

Some of the hyperbaric clinics do perform "oxygen challenge" to do a litmus test of "if the patient responds to the HBOT or not." I personally don't believe in performing this "challenge" test, as I fear that we may be excluding the patients who may benefit from HBOT.

Dr. Robert Warriner has an excellent HBOT lecture on the PRESENT website. If you are interested in HBOT, I urge every resident to review his lecture.

 

VIEW LECTURE