Article – 1 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Local treatment of chronic wounds: in patients with peripheral vascular disease, chronic venous insufficiency, and diabetes.
Authors: Rüttermann M, Maier-Hasselmann A, Nink-Grebe B, Burckhardt M.
Digital Object Identifier (or PMID etc): PMID: 23413377
Keywords: Bandages/standards, Chronic Disease, Debridement/standards, Diabetic Foot/therapy, Germany, Negative-Pressure Wound Therapy/standards, Peripheral Vascular Diseases/therapy, Practice Guidelines as Topic, Skin/injuries, Venous Insufficiency/therapy, Wound Healing, Wounds and Injuries/therapy
Abstract: A chronic wound is defined as an area where the skin is not intact that fails to heal within eight weeks. Such wounds usually develop on the lower limbs as a complication of diabetes, venous insufficiency, or inadequate arterial perfusion. Most of the roughly 45,000 limb amputations performed in Germany each year are necessitated by non-healing chronic wounds. In the development of this S3 guideline, a systematic search was performed that yielded 4998 references including 38 randomized, controlled trials and 26 systematic reviews, which were used as the basis for the recommendations and statements made in the guideline. Twelve member societies of the umbrella Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF), as well as the German Association of Nursing Science (Deutsche Gesellschaft für Pflegewissenschaft, and patient representatives participated in the consensus rounds in which the guideline's recommendations and statements were agreed upon.
Results: This guideline contains seven evidence-based recommendations and 30 good clinical practice (GCP) recommendations. Evidence-based recommendations are given in favor of hydrogel, hyperbaric oxygenation, and integrated care, and against the use of medicinal honey and growth factors. Terms are defined precisely in order to ease communication and to specify what is meant by "wound debridement" (a procedure performed by a physician) as opposed to cleansing a wound. Under the premise of preventing pain, exudation, and maceration, local therapeutic agents can be chosen on the basis of the scientific evidence, the patient's preference, the physician's experience, and the wound situation. Costs should also be considered.
Conclusion: Scant evidence is available to answer many of the relevant questions about chronic wounds. There are valid data in support of hyperbaric oxygen and integrated care. More research is needed.
Source URL:
http://www.ncbi.nlm.nih.gov/pubmed/23413377
Full text URL:
http://dx.doi.org/10.3238/arztebl.2013.0025
Article – 2 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Salvage of the Problem Wound and Potential Amputation with Wound Care and Adjunctive Hyperbaric Oxygen Therapy: An Economic Analysis.
Authors: Cianci, PE; Petrone, G; Drager, S; Lueders, H; Lee, H; Shapiro, R
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: A carefully coordinated wound care program utilizing the specialties of infectious disease, vascular surgery, orthopedics, internal medicine, primary care, and hyperbaric oxygen therapy has resulted in a 92% overall salvage rate in a series of 39 patients with problem wounds of the lower extremity and/or limb-threatening lesions. This was accomplished economically when compared to the cost of primary amputation, rehabilitation, and long-term follow-up.
Conclusion: We recommend the aggressive team approach as a cost-effective method of dealing with otherwise refractory problem wounds of the lower extremity.
Article – 3 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: The outcome of chronic wounds following hyperbaric oxygen therapy: a prospective cohort study the first year interim report
Authors: Hawkins, GC; Bennett, MH; van der Hulst, AE
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: The treatment of chronic wounds is a major health cost. This study is an ongoing prospective cohort looking at the effects of hyperbaric oxygen therapy (HBOT) on the healing of chronic wounds. Data are being collected from patients presenting to hyperbaric facilities in Australia with chronic (greater than 3 months' duration) non-irradiated wounds, including details of aetiology, wound characteristics and possible predictors of wound healing. Participants are being enrolled whether or not a decision was made to treat with HBOT. Assessments are performed at the end of the course of HBOT and at one, six and 12 months after hyperbaric treatment. The aim is to quantify the proportion healed and to identify any significant predictors for wound healing.
Results: There are 110 participants included in this analysis with 88 receiving HBOT. Excluding the miscellaneous aetiologies, at the end of treatment 52.3% of patients had a 'good' outcome to the wound, increasing to 64.1%, 91.7% and 78.2% at one, six and 12 months respectively. Logistic regression for participants with diabetic wounds suggests that wound area, chronicity and transcutaneous oxygen readings on room air combine to produce a statistically significant model for prediction of wound healing at one month after treatment.
Conclusion: This ongoing cohort study suggests that HBOT is highly associated with the healing of chronic wounds in the patients in this study. The wound area at presentation, the duration of the wound and the transcutaneous oxygen pressure on air may predict the likelihood of a chronic wound in diabetic patients healing by one month after treatment.
Article – 4 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Use of transcutaneous pressure of oxygen in the evaluation of edematous wounds
Authors: Dooley, J; Schirmer, J; Slade, B; Folden, B
Digital Object Identifier (or PMID etc): PMID: 8931284
Keywords: Nil
Abstract: Transcutaneous pressure of oxygen (Ptco2) was measured in edematous wounds before and after a regimen of hyperbaric oxygen (HBO2) therapy, in patients breathing normobaric air (AIR), 100% normobaric oxygen (O2), and 100% O2 at 239 kPa (2.36 atm abs; HBO). Wounds also were scored for severity, including three ratings for periwound edema. Only during AIR was pre Ptc O2 of markedly edematous wounds significantly lower than that of moderately edematous and non-edematous wounds (P < 0.001). After HBO2 therapy, wound severity score and periwound edema rating decreased significantly (P < 0.001), and periwound edema ratings could no longer be distinguished by PtcO2. Although pre periwound PtcO2 measured during both O2 and HBO evaluations was significantly greater than that measured during AIR (P < 0.0001) and was positively correlated with subsequent change in wound severity (P < 0.05), regression analyses failed to yield a significant prediction equation.
Conclusion: The authors conclude: a) dramatically marked increases in PtcO2 of normally hypoxic (< 30 Torr O2) edematous wounds during O2 and HBO challenges demonstrate that periwound edema is an O2 diffusion barrier during normal conditions; b) HBO2 therapy significantly reduces periwound edema in markedly edematous wounds; c) despite significant correlations between pre-therapy periwound PtcO2 measured during O2 and HBO challenges and changes in wound severity, single PtcO2 measurements are not predictive of changes in periwound edema or overall wound severity.
Article – 5 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Productivity and acuity tool for wound care and hyperbaric medicine centers.
Authors: Larson-Lohr, V
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: The unique workload and patient acuity in wound care and hyperbaric centers leaves staffing to subjective interpretation; lack of objective data makes it difficult to determine department budgets and appropriate staffing patterns. To address these problems, an objective tool was developed to assess acuity and productivity in hyperbaric and wound care departments. Patient classifications were created to define acuity based on disease and associated procedures. A total of 38 distinct indicators were identified for wound care and 22 for hyperbaric oxygen therapy. Time studies were performed on identified tasks. All patients were scored and placed in acuity classes. The number of hours per patient day was calculated and multiplied by direct care hours to find number of full-time-equivalents (FTEs). The tool was tested for content validity and clinical applicability.
Conclusion: The tool was found to accurately reflect patient-care work and suitable as a benchmarking tool for use in monoplace hyperbaric and wound care centers.
Article – 6 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: UHMS position statement: topical oxygen for chronic wounds.
Authors: Feldmeier, JJ; Hopf, HW; Warriner III, RA; Fife, CE; Gesell, LB; Bennett, MH
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: A small body of literature has been published reporting the application of topical oxygen for chronic non-healing wounds . Frequently, and erroneously, this form of oxygen administration has been referred to as "topical hyperbaric oxygen therapy" or even more erroneously "hyperbaric oxygen therapy." The advocates of topical oxygen claim several advantages over systemic hyperbaric oxygen including decreased cost, increased safety, decreased complications and putative physiologic effects including decreased free radical formation and more efficient delivery of oxygen to the wound surface. With topical oxygen an airtight chamber or polyethylene bag is sealed around a limb or the trunk by either a constriction/tourniquet device or by tape and high flow (usually 10 liters per minute) oxygen is introduced into the bag and over the wound. Pressures just over 1.0 atmospheres absolute (atm abs) (typically 1.004 to 1.013 atm abs) are recommended because higher pressures could decrease arterial/capillary inflow. The premise for topical oxygen, the diffusion of oxygen into the wound adequate to enhance healing, is attractive (though not proven) and its delivery is certainly less complex and expensive than hyperbaric oxygen. When discussing the physiology of topical oxygen, its proponents frequently reference studies of systemic hyperbaric oxygen suggesting that mechanisms are equally applicable to both topical and systemic high pressure oxygen delivery. In fact, however, the two are very different. To date, mechanisms of action whereby topical oxygen might be effective have not been defined or substantiated. Conversely, cellular toxicities due to extended courses of topical oxygen have been reported, although, again these data are not conclusive, and no mechanism for toxicity has been examined scientifically. Generally, collagen production and fibroblast proliferation are considered evidence of improved healing, and these are both enhanced by hyperbaric oxygen therapy. Paradoxically, claims of decreased collagen production and fibroblast inhibition in wounds subjected to topical oxygen have been reported in studies of topical oxygen as a benefit of topical oxygen therapy. The literature on topical oxygen is mostly small case series or small controlled but not randomized trials. Moreover, the studies generally are not aimed at specific ulcer types, but rather at "chronic wounds." This non-specific approach is recognized as a major design flaw in any study of therapies designed to improve impaired wound healing. The only randomized trial for topical oxygen in diabetic foot ulcers actually showed a tendency toward impaired wound healing in the topical oxygen group. Contentions that topical oxygen is superior to hyperbaric oxygen are not proven. There are potentially plausible mechanisms that support both possibly beneficial and detrimental effects of topical oxygen therapy, and thus well designed and executed basic science research and clinical trials are clearly needed. There is some ongoing research in regard to the role of topical oxygen at established wound laboratories.
Conclusion: Neither CMS nor other third party payors recognize or reimburse for topical oxygen. Therefore, the policy of the Undersea and Hyperbaric Medical Society in regard to topical oxygen is stated as follows: 1. Topical oxygen should not be termed hyperbaric oxygen since doing so either intentionally or unintentionally suggests that topical oxygen treatment is equivalent or even identical to hyperbaric oxygen. Published documents reporting experience with topical oxygen should clearly state that topical oxygen not hyperbaric oxygen is being employed. 2. Mechanisms of action or clinical study results for hyperbaric oxygen cannot and should not be co-opted to support topical oxygen since hyperbaric oxygen therapy and topical oxygen have different routes and probably efficiencies of entry into the wound and their physiology and biochemistry are necessarily different. 3. The application of topical oxygen cannot be recommended outside of a clinical trial at this time based on the volume and quality of scientific supporting evidence available, nor does the Society recommend third party payor reimbursement. 4. Before topical oxygen can be recommended as therapy for non-healing wounds, its application should be subjected to the same intense scientific scrutiny to which systemic hyperbaric oxygen has been held.
Article – 7 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Transcutaneous oximetry, problem wounds and hyperbaric oxygen therapy
Authors: Smart, DR; Bennett, MH; Mitchell, SJ
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: Transcutaneous oximetry measurement (TCOM) is the process of measuring the partial pressure of tissue oxygen (PtcO2) via a heated electrode placed upon the skin. We aim to describe the use of TCOM to define tissue hypoxia and normal ranges for PtcO2, and correlate TCOM with clinical outcomes for wounds treated with hyperbaric oxygen therapy (HBOT). A structured literature search covering the past 25 years was performed using the MeSH terms: blood gas monitoring; transcutaneous; wound healing; peripheral vascular disease; diabetes; and hyperbaric oxygenation. We critically appraised all relevant papers and, using our synthesis of the data, present our recommendations for the use of TCOM in the assessment of problem wounds for HBOT, and for further research.
Results: Normal chest PtcO2 is 60-70 mmHg, which is similar to limb values. TCOM values do not change significantly with age in healthy individuals but limb values are reduced in diabetes, peripheral vascular disease and in limb elevation. TCOM has been validated in predicting wound healing, and successful vascular reconstruction and amputation level, as well as in confirmation of the need for amputation. TCOM is a more effective marker of disease than Doppler assessment or ankle-brachial indices. Thirty-eight studies since 1982 suggest that hypoxia is defined as PtcO2 = 10-40 mmHg. A single critical value for tissue viability has not been determined. PtcO2 increases with increasing partial pressure of inspired oxygen (PIO2), and is markedly elevated during HBOT. TCOM values progressively increase during a course of HBOT. While low PtcO2 values breathing air confirm wound hypoxia, they did not predict outcome with HBOT. Breathing 100% oxygen at ambient pressure is somewhat predictive of outcome — if wound PtcO2 less than 35 mmHg, 41% fail to heal; while a PtcO2 greater than 200 mmHg breathing hyperbaric oxygen is the best single discriminator between success and failure of HBOT (74% reliable). Using the available data, we suggest clinical guidelines.
Conclusion: TCOM is useful to identify patients with problem wounds who may respond to HBOT. Poor quality of the available clinical studies limits the interpretation of the available evidence. A large, multicentre prospective study is required that correlates TCOM using a standard protocol with initial wound grades and clinical outcomes.
Article – 8 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Effects of hyperbaric oxygen therapy on experimental burn wound healing in rats: a randomized controlled study.
Authors: Bilic, I; Petri, NM; Bezic, J; Alfirevic, D; Modun, D; Capkun, V; Bota, B
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: A body of data supports the efficacy of hyperbaric oxygen (HBO2) therapy in the treatment of thermal burns, but the role of HBO2 in the treatment of burn injury remains a subject of controversy. The aim of this study was to evaluate possible positive effects of HBO2 on the experimental burn wound healing. Deep second degree burns were produced on the depilated backs of 70 male Wistar rats using a validated burn protocol. The animals were assigned randomly to one of two groups: 35 to the control group, which was treated with silver sulphadiazine and placebo gas, and 35 to the experimental group, which was treated with silver sulphadiazine and HBO2. The main outcome measure was wound healing, characterized by formation of post-burn edema, neoangiogenesis, number of regeneratory active follicles, necrosis staging, margination of leukocytes, and time of epithelization. A significant reduction of the post-burn edema after treatment with HBO2 (p = 0.009) was found. HBO2 had a beneficial effect on neoangiogenesis (p = 0.009). The number of preserved regeneratory active follicles was significantly higher (p = 0.009) and epithelial regeneration was more rapid in the experimental group (p = 0.048). There were no significant differences for margination of leukocytes (p = 0.55) or necrosis staging (p = 1.00).
Conclusion: These data further support earlier conclusions that HBO2 is beneficial in the healing of burn wounds.
Article – 9 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Maintenance of negative-pressure wound therapy while undergoing hyperbaric oxygen therapy.
Authors: Chong, SJ; Kwan, TM; Weihao, L; Joang, KS; Rick, SC
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: Both negative wound pressure therapy (NPWT) and hyperbaric oxygen therapy (HBOT) are useful modalities in the treatment of problem wounds. However, none of the commercially available portable negative-pressure devices have been certified safe for use in a recompression chamber. Thus, the NPWT device is removed while the patient undergoes HBOT. The purpose of this study is to demonstrate that wound negative pressure can be effectively and safely maintained during HBOT. In a small, prospective, randomised crossover trial, we used commonly available clinical materials to connect the NPWT suction tubing to the negative suction generating device in the hyperbaric chamber. Six patients each underwent one HBOT session with continuous NPWT and one HBOT session without concurrent NPWT. We assessed the patient's pain score, the amount of exudate aspirated by the NPWT during HBOT, and the appearance of the wound dressing after each session was assessed in a blinded manner.
Results: There were no differences in pain scores between the two HBOT sessions. The amount of exudate aspirated during HBOT with NPWT ranged from 5 to 12 ml. Five of the six patients had a better appearance scoring of their dressing when NPWT was maintained during HBOT (P = 0.006).
Conclusion: We successfully demonstrated a simple design that allows the maintenance of NPWT during HBOT without causing additional pain, and with continued extraction of exudate. The maintenance of NPWT during HBOT also allowed the dressing to be maintained undisturbed.
Article – 10 - HBOT+ Selected problem wounds (inc. diabetic wounds)
Title: Hyperbaric oxygen therapy and promoting neurological recovery following nerve trauma.
Authors: Nazario, J; Kuffler, DP
Digital Object Identifier (or PMID etc): Nil
Keywords: Nil
Abstract: There is a constant search for new techniques that induce more extensive and rapid wound healing. Hyperbaric oxygen therapy (HBO2T) involves placing a patient in a sealed chamber and elevating its pressure several-fold above ambient air pressure while the patient breathes 100% oxygen. HBO2T induces a number of physiological actions, and which wounds are selected for HBO2T depends on the specific actions of HBO2T relative to the wound's healing requirements. Although nerve traumas are not yet indicated for HBO2T, there are many animal and clinical examples showing the benefits of HBO2T in inducing neurological recovery following nerve trauma. This review examines the general mechanisms required to induce wound healing and the actions of HBO2T which meet these requirements. It then examines the requirements for inducing axon regeneration and how many are met by HBO2T. Finally, we discuss anecdotal evidence that HBO2T enhances the rate and extent of axon regeneration in both animal models and clinically.
Conclusion: We conclude that HBO2T triggers most of the mechanisms required to induce axon regeneration.