HBOT

HBOT

Hyperbaric Oxygen Therapy (HBOT) and Its Applications for Healing

by Stuart Weg, MD
Stuart Weg

Oxygen reveals itself as a fundamental component of life, not only by its physical presence in air and water, but in how this ubiquitous substance allows us to think about life. Though it is present all around us, oxygen has fascinating properties. This element is a vital part of life.  We take it in with every breath. At high concentrations it can be a lifesaving measure and certain conditions can be dramatically improved and sometimes healed.

From our perspectives as physicians at Patients Medical, it is fitting that oxygen carries with it properties to enhance healing, and the hope offered by this fundamental element is very real. Hyperbaric oxygen therapy (HBOT) can be an effective treatment option for a number of conditions ranging from autism to refractory osteomyelitis, and wound healing. Recognition of its potential continues to grow. We at Patients Medical have had excellent success with HBOT, and would like to share some of our findings about hyperbaric oxygen therapy with you.

Hyperbaric Oxygen—On a Historical Note

Hyperbaric oxygen therapy has long been used in the treatment of decompression sickness, also known as "the bends" or caisson disease, a sometimes fatal build-up of gases in the body experienced by divers, or by workers building submerged tunnels and bridge foundations. The rapid decompression a diver experiences when ascending from deep water too quickly causes gas bubbles to form in body tissues and blood. A hyperbaric oxygen chamber has saved lives by recompressing gas embolisms, allowing sufferers to normalize the critical balance of gas pressures in their bodies. In the controlled pressurized environment of the chamber patients can then slowly decompress, allowing tissue and blood gas pressures to gently equalize to normal atmospheric pressure.

Well before this clinically proven therapy relieved the suffering of deep sea divers, the potential for hyperbaric therapy was recognized, as early as 1662, with the construction of the first hyperbaric chamber in London, called the "Domicilium," for the treatment of several conditions, including inflammation, scurvy, and arthritis. The compression pressure of air in this device was likely too low to achieve clinical results, but the theory has proven beneficial. Hyperbaric therapy using oxygen was first recommended for treating bacterial infections in 1887.

An extensive amount of published research and clinical experience in this past decade has confirmed efficacy of HBOT for conditions well beyond that of an effective treatment for the "bends": healing wounds caused by diabetic foot ulcers, crush injuries, certain deep tissue and bone infections, and osteoradionecrosis. It has also shown significant promise in the treatment of other chronic conditions involving inflammation and hypoxia.

The Hyperbaric Oxygen Chamber—What's Going on in There

A patient treated in a hyperbaric oxygen chamber typically lies or sits comfortably while being administered 100% oxygen. Pressure within the chamber is slowly elevated above normal atmospheric pressure. Depending on the particular protocol and condition being treated, pressure is increased to at least the equivalent of 1.4 atmospheres, or to as much as 3 times normal atmospheric pressure. A monoplace hyperbaric oxygen chamber accommodates a single patient during treatment, while multiplace chambers accommodate multiple patients.

Also dependent on the particular condition and protocol, patients on average receive 30–40 treatments, with each treatment lasting 60-90 minutes. A protocol may start with two chamber sessions a day through an initial period, reducing the frequency to once a day through the duration of protocol. Other protocols call for treatments one to three times a week for 10 weeks. Benefits are frequently seen quite early in the protocol.

Under elevated pressures within the chamber, hemoglobin, the oxygen-carrying red blood cells, becomes saturated with oxygen. Oxygen, in addition, dissolves more readily in blood plasma, hyper-oxygenating the blood. Normally, 98% of oxygen in blood is carried by hemoglobin, the remaining 2% being dissolved in the blood plasma. While under hyperbaric pressures and breathing 100% oxygen, the individual's hemoglobin becomes saturated, while plasma oxygen levels also increase. This hyper-oxygenated condition, called hyperoxia, is sustained for as long as two to four hours after HBOT has ended. In wounds or injuries where normal blood flow is hindered, the increased oxygen tension in the plasma allows cells to receive oxygen, even in the absence of red blood cells. A number of beneficial processes result.

The hyper-oxygenation of blood initiates several natural healing processes, such as fibroblast proliferation, collagen synthesis, and angiogenesis. A reduction in immune cell signaling and inflammatory cytokine signaling occurs, with a concurrent reduction in inflammation. Wound healing is promoted by HBOT through improved red blood cell deformability and flow, the reduction of edema, and neovascularization (growth of new blood vessels where they may not otherwise occur). A high level of evidence exists to show HBOT significantly reduces the risk of amputations due to diabetic foot ulcers. Benefits are seen in the treatment of other non-healing wounds as a result of trauma or radionecrosis (tissue destruction due to radiant energy exposure).

HBOT and Diabetic Wound Healing

Hyperbaric oxygen has been shown to aid in the healing of diabetic foot ulcers.

In the disease progression of diabetic foot ulcers, expression of stromal cell-derived factor (SDF-1α) is suppressed and inhibited from providing a homing signal which directs EPC to the wound. An exogenous application of SDF-1α to the wound enhances the homing signal, allowing progenitor cells to congregate and stabilize the ulcer. HBOT enhances mobilization of EPC and acts synergistically with SDF-1α homing EPC to the wound, by promoting neovascularization, and wound healing.

HBOT and Radiotherapy Healing

Radiation therapy is used in a variety of cancer treatments, and carries the risk of harming adjoining soft tissues and bone. Symptoms may not surface for months after initial radiation therapy, and can be difficult to diagnose and treat. Hyperbaric oxygen therapy has been shown to be an effective treatment for radiation colitis, a condition which can develop from six months to five years after radiotherapy in the pelvic region. Though some patients heal spontaneously following radiation therapy to the pelvis, the disease may progresses to chronic bleeding and/or stricture and fistula formation. Medical therapy is often unsuccessful, and surgery is eventually required—HBOT is a promising alternative.

In radiation-induced colitis, inflammatory cells infiltrate the affected tissues in a well-coordinated inflammation response to injury. Circulating leukocytes are captured on vascular endothelium by adhesion molecules before migrating through vessel walls to radiation-damaged tissues. Reactive metabolites produced by activated leukocytes can do further damage to tissues, potentially inducing colonic ulcers. Chronic radiation-induced colitis is evident as persistent and progressive degradation in intestinal tissues that tend not to heal once damage has been done. HBOT is an effective treatment in some patients by supplying an oxygen gradient in hypoxic tissues promoting angiogenesis and increasing the blood supply to ischemic tissues. Hyperbaric oxygen therapy has provided an alternative treatment to quality-of-life changing colostomy.

HBOT and Bone Healing

Osteoradionecrosis is the non-infection-induced degeneration of previously irradiated bone, most commonly occurring as a result of secondary trauma to the bone. Radiation-damaged blood vessels, often a dose-dependant result of head or neck irradiation, leave bone susceptible to poor blood supply and incomplete healing in the event of later surgery or trauma. Osteoradionecrosis is most often induced by secondary trauma in injury, or as a result of non-healing dental surgery or tooth extractions. Hyperbaric oxygen therapy has been used as an adjunct treatment with antibiotics prior to tooth extraction when the patient was at risk due to previous radiation treatments.

HBOT aids in this pre-treatment through neovascularization, promoting fibroblast proliferation, capillary formation, and collagen formation in bone and soft tissue. The oxygen treatment is continued after extraction to reduce the risk of osteoradionecrosis. HBOT has been used following reconstructive surgery to aid in tissue and bone healing, and has been seen to promote bone nodule formation, calcium deposition, mineralization, and alkaline phosphatase activity in bone repair and regeneration in in-vitro studies.

Refractory osteomyelitis is another troublesome bone condition that responds well to HBOT. In this, case bone degenerates through bacterial infection. Microbes that prefer low oxygen environments (anaerobes) are killed directly by the increased levels of oxygen in hyperbaric oxygen treatments. A separate pathway to kill oxygen-loving microbes (aerobes) involves polymorphonuclear leukocytes enlisted through the immune response and facilitated by high oxygen concentrations. As an adjunctive therapy with the administration of antibiotics, HBOT is an effective treatment for refractory osteomyelitis.

HBOT, Brain Injury, Inflammation, and Autism Spectrum Disorders

Case reports of the treatment of injured military personnel are showing the potential use of HBOT in the treatment of mild traumatic brain injury (mTBI), and the inflammation associated with mTBI. Two U.S. airmen injured in a blast from an improvised explosive device (IED) experienced sleep disturbances, headaches, and irritability, as well as memory and cognitive difficulties that became progressively worse over the six months following their injuries.

An assessment of skills, such as reaction times and mathematical processing according to a standard neuropsychological assessment measurement, showed marked improvement in all areas of testing, as well as improvements in sleep disturbances, headaches, and irritability following completion of hyperbaric oxygen therapy. Repeat neuropsychological testing confirmed the improvement.

Autism spectrum disorders (ASD) are characterized by impairment in a range of communication and social interaction skills. Lack of eye contact, lack of language, repetitive and self-stimulatory behaviors, as well as decreased sensory perception or hyper-sensitivity to stimuli are common symptoms. HBOT has been successfully used to improve performance in ASD children in a number of areas of impairment: language, social interaction, and cognitive awareness.

Inflammation, cerebral hypoperfusion (poor cerebral circulation), and immune dysfunction are discussed as possible causes of autism and related disorders. As a marker of inflammation, C-reactive protein levels decreased in response to oxygen therapy. HBOT suppresses stimulus-induced pro-inflammatory cytokine production. The pro-inflammatory cytokine tumor necrosis factor-alpha (TNF-α) has been found to be elevated in the cerebrospinal fluid of autistic children.

Other Promising Applications

Case studies of children with fetal alcohol syndrome (FAS) and cerebral palsy (CP) have shown improvements with hyperbaric oxygen in learning, memory, attention and problem solving after treatment in the case of FAS, and motor function in CP.

Hyperbaric oxygen therapy for Lyme disease is another emergent application. Chronic Lyme disease symptoms have been successfully treated with HBOT, although little published research is available to describe the use of hyperbaric oxygen for this indication. Lyme disease is a complex pathology easily treated with antibiotics early in the infection. However, early detection is not always possible, and co-infections are common, complicating diagnosis and treatment once the infection becomes systemic. Care needs be taken in obtaining a good diagnosis. Joint pain, fatigue, and neurological symptoms are common, and have responded well to HBOT in clinical experience.

HBOT Contraindications

There are a few contraindications to hyperbaric oxygen therapy. The absolute contraindications include history of untreated pneumothorax, and a history of treatment with bleomycin, cisplatin, disulfiram, doxorubicin, and sulfamylon. Bleomycin is a mixture of glycoprotein antibiotics derived from Streptomyces and is used to inhibit the spread of malignant cells. Cisplatin is a chemotherapy agent. HBOT treatment should not be undertaken for an extended period of time after treatment with either drug. Treatment may be considered after discontinuation of the other drugs listed.

Relative contraindications for HBOT include asthma, claustrophobia, congenital spherocytosis, COPD, Eustachian tube dysfunction, high fever, pacemaker, epidural pain pump, pregnancy, upper respiratory infection (URI), or history of seizures. Some of the potential side effects include seizures, pulmonary toxicity including hemorrhage and edema, barotraumas to sinuses or ear, progression of cataracts, and myopia which is usually reversible.

Other potential side effects include headaches, vomiting, and fatigue. Most complications are avoided when pressures are less than 3 atmospheres and the treatment duration is less than 120 minutes.

Summary

Hyper-oxygenation of the blood and tissues through hyperbaric oxygen therapy acts through multiple modes of actions to positively affect healing and oxygenation of hypoxic tissues in a non-invasive intervention. HBOT is known to stimulate progenitor cells, effecting repair and regeneration of both hard and soft tissues. Infections in deep tissues and bone benefit from hyperbaric oxygen therapy through direct antibiotic action, or synergistically with other standard treatments. Inflammatory factors are suppressed with oxygen treatments aiding in the healing processes.

Research continues in a number of areas where HBOT shows promise, including stroke, brain injury, and neurological conditions. A patient giving consideration to hyperbaric oxygen therapy as an avenue of relief from any of the conditions mentioned above should have a thorough history and physical examination by a qualified physician trained in hyperbaric medicine, to assess the risks and benefits that this potentially powerful therapy may offer them. Our record of success at Patients Medical is greatly encouraging, and we are pleased to offer our patients hyperbaric oxygen therapy using state-of-the-art equipment in a comfortable, pleasant clinical setting.


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