Hyperbaric Oxygen Therapy

Abigail Schnieders, MD
Jeff Jorgensen, MD
May 29, 2013
To participate in audience interaction, type
web address into smartphone
Web address: respond.cc
Session: 39431
Historical Overview
 1600’s:
 Henshaw, a British clergyman, built a structure called the
domicilium which was a pressurized chamber
 1879
 Fontaine, a French surgeon, built a pressurized mobile
operating room
 1928
 Dr. Orville Cunningham, anesthesiologist - “steel ball
hospital” which was a 6 story hospital which could reach 3
atm of pressure
 This was deconstructed during WWII for scrap
 More recent work performed by the military
Henshaw IN, Simpson A. Compressed Air as a Therapeutic Agent in the Treatment of Consumption, Asthma, Chronic Bronchitis and Other Diseases. Edinburgh: Sutherland and
Knox; 1857.
Basics of HBOT
 Inhalation of pure 100% O2 under increased
atmospheric pressure
 Benefits:
 increase in the overall pressure to reduce the volume of
inert gas bubbles

Decompression illness
 Increase partial pressure of oxygen in tissues

Local wound healing
 Increased oxygen transport capacity

Carbon monoxide poisoning
Oxygen carrying capacity
 Increased oxygen transport capacity of the blood
 Under normal atm pressure, O2 transport limited by the
oxygen binding capacity of hemoglobin
 At normal atmospheric pressure, 97% of delivered
oxygen is hemoglobin bound
 3% dissolved in plasma
 Under hyperbaric conditions, arterial oxygen tensions
can exceed 2000mm Hg
 10-20 fold increase
What is the only absolute contraindication for
hyperbaric oxygen treatment?
A. Tumor Recurrence
B. Untreated Pneumothorax
C. Eustachian Tube Dysfunction
D. Anemia
What is the only absolute contraindication for
hyperbaric oxygen treatment?
A. Tumor Recurrence
B. Untreated Pneumothorax
C. Eustachian Tube Dysfunction
D. Anemia
Ideal Gas Laws
 Boyles law
 P1v1=p2v2
 As pressure increases, the volume of gas decreases
 Useful in decompression sickness

The volume of the concerning bubble decreases
 Problem - pneumothorax

Volume of gas trapped in lungs overexpands, causing a
tension type pneumothorax
Ideal Gas Laws
 Charles’ law
 ([p1v1]/T1 = [p2v2]T2)
 Explains increase in
temperature with
pressurization
Ideal Gas Laws
Henry’s law
 The amount of gas
dissolved within a liquid
is equal to the partial
pressure of the gas
exerted on the surface
 By increasing the atm
pressure, more O2 can
be dissolved into the
plasma
HBO
 Multiplace chambers
 Treat multiple patients
at the same time
 Allows for nursing staff
to monitor patient
 Patients breathe O2 via
a mask or close fitting
hood
 May be pressurized to 6
atm
Emi Latham MD. Emedicine. Hyperbaric Oxygen Therapy. Feb 2013
HBO
 Monoplace Chamber
 Compresses one person
at a time
 100% O2 is used to
pressurize the vessel
 Employees and
equipment remain
outside the chamber
 Typically only
pressurizes to 3 atm
Hyperbaric Oxygen
 Standardized amount of oxygen
 ATA
 Calculated from the percentage of oxygen in the gas
mixture multiplied by the pressure
 Pressure expressed in feet of seawater

1 atmosphere = 33 feet of seawater = 14.7 pounds per square
inch
Contraindications
Emi Latham MD. Emedicine. Hyperbaric Oxygen Therapy. Feb 2013
Contraindications
Emi Latham MD. Emedicine. Hyperbaric Oxygen Therapy. Feb 2013
Indications
 Decompression Sickness
 Gas Embolism
 Crush Injury
 Anaerobic Infections
 Osteomyelitis
 Chronic Wound
 Necrotizing Infections
 Osteoradionecrosis
Applications in Otolaryngology
 ORN
 Graft/flap viability
 Necrotizing Infections
 Chronic Wounds
 SSNHL
 Tinnitus
 Bells palsy
 Radiation sensitization
Which of the following mechanisms does not
account for the ability of HBOT to preserve
graft viability ?
A. Improved fibroblast function
and collagen synthesis
B. Closure of AV shunts
C. Reducing oxygen deficit
D. All of the above help preserve
graft viability
Which of the following mechanisms does not
account for the ability of HBOT to preserve
graft viability ?
A. Improved fibroblast function
and collagen synthesis
B. Closure of AV shunts
C. Reducing oxygen deficit
D. All of the above help preserve
graft viability
Compromised Graft/ Flaps
 Underlying pathophysiology of compromised graft is
hypoxia
 HBOT benefits by reducing O2 deficit
 Improved wound healing
 Fibroblast and collagen synthesis
 Angiogenesis
Compromised Grafts/Flaps
 Several controlled clinical trials show benefit for
HBOT in compromised grafts and flaps
 Greenwood et al 1973

Post irradiated reconstruction of head and neck
 Perrins et al 1967

Effects on survival of STSG
 Current standard for compromised grafts and flaps
includes twice daily treatment until graft appears
viable, then once daily until healed
 Cost effectiveness of HBOT vs flap
Greenwood TW, Gilchrist AG. Hyperbaric oxygen and wound healing in post-irradiation head and neck surgery. Br J Surg. May 1973;60(5):394-7
Compromised Grafts/Flaps
 Cochrane Review 2011: HBOT for treating acute
surgical wounds
 3 RCT reviewed comparing HBOT with other
interventions
 Lack of strong evidence to support the use of HBOT for
grafts/ flaps

Small trials suggested some benefit on the outcomes of skin
grafting, but these were at risk of bias
Eskes Anne. Cochrane Database of Systematic Reviews. Hyperbaric Oxygen Therapy for treating acute surgical and traumatic wounds. 2011
24 hours post-operatively, a patient who has undergone
myofasciocutaneous free flap reconstruction of a soft tissue defect
of the cheek demonstrates ischemic changes. What is your next
step?
A. Heparin drip
B. Immediate referral for HBOT
C. Emergent take back for
exploration of anastamosis
D. Post patient for another free
flap reconstruction the
following day
24 hours post-operatively, a patient who has undergone
myofasciocutaneous free flap reconstruction of a soft tissue defect
of the cheek demonstrates ischemic changes. What is your next
step?
A. Heparin drip
B. Immediate referral for HBOT
C. Emergent take back for
exploration of anastamosis
D. Post patient for another free
flap reconstruction the
following day
What is the Overall Mortality Rate for
Necrotizing Soft Tissue Infections of the Head
and Neck?
A. 1%
B. 15%
C. 20%
D. 30%
What is the Overall Mortality Rate for
Necrotizing Soft Tissue Infections of the Head
and Neck?
A. 1%
B. 15%
C. 20%
D. 30%
Necrotizing Soft Tissue Infections
 Pathophysiology:
 Local tissue hypoxia and secondary occlusive
endarteritis leads to tissue death and spread of infection
 Intravascular sequestration of leukocytes is mediated by
toxins from organisms
 Facultative organisms consume remaining O2
 Promotion of anaerobic bacteria
Necrotizing Soft Tissue Infection
 Wide surgical debridement and aggressive antibiotic
therapy
 HBOT can be an adjunctive therapy
 Toxic to anaerobic bacteria
 Improves PMN function and bacterial clearance
 Decreased neutrophil adherence
 Clostridial myonecrosis – stops production of alpha
toxins
 May facilitate antibiotic penetration

Particularly in cephalosporins, sulfonamides, aminoglycosides
Necrotizing Soft Tissue Infections
 Initial treatment performed twice daily treatments for
90 minutes each in coordination with surgical
debridement
 2.0-2.5 ATA
 Number of treatments related to clinical response
 Reduction in mortality
 34% vs 11.9%
 38% vs 12.5%
Gozal D, Ziser A, Shupak A, et al. Necrotizing fasciitis. Arch Surg. Feb 1986;121(2):233-5. [Medline].
Riseman JA, Zamboni WA, Curtis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery. Nov
1990;108(5):847-50
Necrotizing Soft Tissue Infections
 Retrospective review 2012
 University of Pennsylvania
 80 cases from 2005-2009
 Looked at in-hospital mortality and amputation rates
 mortality rate

16% in HBO group vs 19% in non-HBO group


P =0.77
Amputation rate
 17% vs 25%
 P=0.46
Massey et al. Hyperbaric oxygen therapy in necrotizing soft tissue infection. Jour Surg Res 177:1”146-151
A patient presents after undergoing primary chemoRT for a T3 scca of the
oral cavity with the following seen on panorex. He notes that a local
dentist pulled a tooth several months ago. What is the likely diagnosis?
A. Tumor recurrence
B. Osteoradionecrosis
C. Osteitis obliterans
D. Paget’s disease
A patient presents after undergoing primary chemoRT for a T3 scca of
the oral cavity with the following seen on panorex. He notes that a local
dentist pulled a tooth several months ago. What is the likely diagnosis?
A. Tumor recurrence
B. Osteoradionecrosis
C. Osteitis obliterans
D. Paget’s disease
Osteoradionecrosis
 Late complication of radiation exposure
 Irradiated bone becomes devitalized
 Bone is exposed through mucosa and persists as a nonhealing wound for >3 months
ORN
 First recognized by Ewing in 1926
 “radiation osteitis”
 Described as a combination of radiation, trauma and
infection
 More recently, evidence has shown that microorganisms play a role as surface contaminants and are
not the true etiological factors
Osteoradionecrosis of the mandible is associated with which of the
following?
A. >60 Gy
B. Large area of radiated tissue
C. Odontogenic and periodontal
disease
D. All of the above
Osteoradionecrosis of the mandible is associated with which of the
following?
A. >60 Gy
B. Large area of radiated tissue
C. Odontogenic and periodontal
disease
D. All of the above
ORN
 Typically associated with >60Gy
 No conclusive evidence to suggest increased incidence
with combined chemo-RT
 IMRT: rates of ORN ~6%

Older techniques ~5-15%
 Presentation ranges from superficial, slowly
progressive erosion to pathologic fracture
 pain, fever, drainage
AS Jacobsen et al. Oral Oncology 46 (2010) 795-801
ORN
 Early onset
 <2 years after completion of RT
 Related to doses higher than 70 Gy
 Late onset
 Thought to arise from trauma in a chronically hypoxic
tissue environment
ORN
ORN: pathogenesis
 1983 – Marx
 Proposed that radiation therapy induces an endarteritis
 Tissue hypoxia, hypocellularity and hypovascularity
 Tissue breakdown and chronic non healing wounds
 1990 – Bras
 Studied resection specimens ORN vs non-ORN
 Histopathologic findings suggested radiation induced
obliteration of inferior alveolar artery
Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983; 41:283-8
Bras J de Jonge HK. OSte4oradionecrosis of the mandible: pathogenmesis. Am J Otolaryng 1990; 11:244-50.
ORN: pathogenesis
 Newer theory - suppresion of osteoclast related bone
turnover is the initial event
 Supported by bisphosphonate induced osteonecrosis
 “Fibro-atrophic theory”
 Fibroblast population undergoes cellular depletion in
response to radiation exposure
Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983; 41:283-8
Bras J de Jonge HK. OSte4oradionecrosis of the mandible: pathogenmesis. Am J Otolaryng 1990; 11:244-50.
Marx Staging
 Most widely used for classifying ORN
 Based on response to treatment
 Patients are advanced until the ORN is resolved
Marx Staging
 Stage I
 Primary HBO therapy

30 dives, followed by re-evaluation and staging
 If clinical improvement, the patient completes a full course 60 dives
 If no clinical improvement, patient is deemed a non-responder and advanced to stage II
 Stage II
 Combination of tran-oral debridement or sequestrectomy with primary mucosal repair
followed by 20 dives


If healing progresses, patient completes a total of 60 dives
If wound break down, patient is deemed a nonresponder and advanced to stage III
 Stage III
 Definitive surgical debridement of all diseased bone, primary mucosal closure and
external fixation followed by 20 dives
 10 weeks after debridement, staged reconstruction performed with non-vascularized bone
 Additional post-op 10 dives
 Automatically includes patients with pathologic fracture, oro-cutaneous fistula or
radiographic evidence of bony resorption
ORN: staging
 Kagan and Schwartz
 More recent clinical staging system
 Classification based on clinical and radiographic findings
 Treatment determined based on stage
 Stage I
 Minimal soft tissue ulceration and limited exposed cortical bone
 Treated conservatively
 Stage II
 Localized involvement of mandibular cortex and underlying medullary bone
 II a – minimal soft tissue ulceration
 II b – presence of oro-cutaneous fistula or soft tissue necrosis
 Majority resolve with conservative management
 Stage III
 Full thickness involvement of the bone, including the inferior border\
 Full thickness fracture
 All require surgical intervention, including bone/ soft tissue replacement
The patient mentioned previously (image below) would be staged and
treated how (according to the Marx classification)?
A. Stage I – no intervention
necessary
B. Stage II – no intervention
necessary
C. Stage III – MMF followed by
10 treatments of HBO
D. Stage III – definitive surgical
debridement followed by
primary closure, HBOT, with
staged reconstruction
The patient mentioned previously (image below) would be staged and
treated how (according to the Marx classification)?
A. Stage I – no intervention
necessary
B. Stage II – no intervention
necessary
C. Stage III – MMF followed by 10
treatments of HBO
D. Stage III – definitive surgical
debridement followed by
primary closure, HBOT, with
staged reconstruction
Marx protocol - criticism
 Determining disease stage based on response to
treatment rather than clinical and imaging findings
 Does not account for reconstruction of defects with
vascularized tissue
 2003 – Gal et al



30 patients with Marx stage III who were treated with radical
resection and RFFF with no peri-operative HBO
Reported a 97% success rate
Concluded that in advanced disease, HBO may delay more
definitive therapy
 Utility of HBOT in advanced stages of ORN
Marx protocol: Dental Extraction
 Stage I ORN/Extraction
 Patients with exposed bone who have no serious manifestations of
those in Stage III. Begin with 30 HBO2 treatments with no
debridement or only minor bony debridement. If patient progresses,
give 10 additional HBO2 treatments.
 Stage II ORN
 If not progressing, Stage II patients should receive surgical
debridement and 30 HBO2 treatments followed by 10 postoperative treatments. Surgery for Stage II patients must maintain
mandibular continuity.
 Stage III ORN
 If mandibular continuity is not achieved, Stage III patients are entered
into a reconstructive protocol where a mandibular resection if followed
by a planned reconstruction. All necrotic bone must be surgically
eradicated. Stage III patients receive 30 HBO2 treatments prior to
resection followed by 10 post-resection treatments.
ORN: contemporary staging
 Stage I
 Localized bone resorption with mucosal dehiscence
 Conservative thearpy



Local wound care, HBOT with 20 dives, abx
Additional 10 dives if definitive improvememt
Poor response = debridement + additional HBOT
 Stage II
 Cortical and medullary bone resorption with moderate mucosal breakdown
 Antibiotics, debridement, and HBO (20 + 10)
 If failure to respond – repeat debridement and possible flap reconstruction
 Stage III
 Full thickness devitalization of bone with resorption of inferior border of
mandible; or pathologic fracture
 Debridement and immediate reconstruction with free tissue transfer
 No HBOT
AS Jacobsen et al. Paradigm shifts in the manamgement of osteoradionecrosis of the mandible. Oral Oncology 46 (2010) 795-801
ORN
 Prevention
 Prophylactic oral care prior to and during RT
 Optimally remove all diseased teeth 21 days prior to
intiating RT
 Monthly dental checkups for 6 months after completion
of RT
 Dental extraction more than 4 months after
completion should be treated with HBO
Osteoradionecrosis: therapy
 Cornerstone of therapy is to begin and complete
HBOT prior to any surgical intervention and
resume as soon as possible after surgery
 Prevention is key
Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. May 1983;41(5):283-8. [Medline].
Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg. Jun 1983;41(6):351-7
Feldmeier JJ, Hampson NB. A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: an
evidence based approach. Undersea Hyperb Med. Spring 2002;29(1):4-30
HBO: Carcinogenesis
 Potential for promoting tumor growth due to angiogenic
effect
 Refuted by several studies
 Marx et al
 No evidence of increased likelihood of tumor recurrence or second
tumor development
 Feldmeier et al
 Consensus 2001


No enhancement of tumor growth
Potential decrease in growth rate and metastasis rates
 Literature review showing that malignant angiogenesis
follows a different pathway than angiogenesis related to
wound healing
 Significant differences in growth and inhibition factors
Feldmeier J, Carl U, Hartmann K, et al. Hyperbaric oxygen: does it promote growth or recurrence of malignancy?. Undersea Hyperb Med. Spring 2003;30(1):1-18
HBO: Carcinogenesis
 Chong et al 2004
 Animal model of prostate cancer
 No increase in proliferative index and no increase in tumor
vascularity
 Lin et al
 Retrospective review of 22 patients who underwent salvage
surgery for recurrent head and neck cancer after failing
primary radiation


11 had necrosis and underwent HBOT
 9/11 had local failure
11 did not
 4/11 demonstrated recurrence
 Potential for enhanced recurrence of primary tumors
 Very small numbers and poorly matched controls
HBOT: enhanced radiosensitivity?
 Cochrane review 2012
 HBOT may improve the ability of radiotherapy to kill
hypoxic cancer cells
 19 trials with total of 2286 patients
 Head and Neck
 Effect varied with different fractionation methods
 Concluded that more data would be necessary to
determine if there is an effect on overall mortality
Bennett, Michael. Hyperbaric oxygenation for tumor sensitization to radiotherapy. Cochrane Database of Systematic Reviews. 2012
Sudden SNHL
 Inner ear hypoxia
 Cochrane review 2012
 Reviewed 7 trials
 No significant chance of 50% increase in PTA
 Significant chance of 25% increase in PTA

RR 1.39 CI (1.05-1.84) p = 0.02
 Absolute improvement in PTA of 15.6 dB
 CI (1.5-29.8) p=0.03
 Small studies of poor quality, clinical significance
undetermined
 1.5-2.5 ATA for 90 minutes daily for 15-20 treatments
Bennett MH, Kertesz T, Perleth M, Yeung P, Lehm JP. Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. Oct 17
2012;10:CD004739
.
Complications of HBO
 Barotrauma
 Middle ear




Autoinflation techniques
Afrin
PE tubes
Wait for URI resolution
 Sinus
 Afrin
 Nasal steroids
 antihistamines
Complications of HBO
 Barotrauma
 Dental

Replacement of filling or crown may allow trapped air to
escape
 Pulmonary



Increase decompression time
Avoid breath holding
High index of suspicion for pneumothorax
Complications of HBO
 Round or Oval Window blowout
 Immediate deafness
 Nystagmus/ vertigo
 Visual change
 Progressive myopia
 Cataracts (may only influence cataract formation after
prolonged treatments >100)
Complications of HBO
 Oxygen toxicity
 Seizures


Treatment is removal from O2 source
Periodic “air breaks” where patients breathe room air
Cost of HBOT
 Undersea and Hyperbaric Medical Society
 List of approved diagnoses for reimbursement
 14 approved by medicare
 Average hospital charge
 1,800 for 90 minutes
Summary
 Basic principles for HBOT
 Early determination for HBOT
 Classification of ORN of the mandible
 Other indications for HBOT in the head and neck
 Counsel patients regarding potential complications
References
 Henshaw IN, Simpson A. Compressed Air as a Therapeutic Agent in the Treatment of








Consumption, Asthma, Chronic Bronchitis and Other Diseases. Edinburgh: Sutherland and
Knox; 1857.
Emi Latham MD. Emedicine. Hyperbaric Oxygen Therapy. Feb 2013
Greenwood TW, Gilchrist AG. Hyperbaric oxygen and wound healing in post-irradiation head
and neck surgery. Br J Surg. May 1973;60(5):394-7
Eskes Anne. Cochrane Database of Systematic Reviews. Hyperbaric Oxygen Therapy for
treating acute surgical and traumatic wounds. 2011
Gozal D, Ziser A, Shupak A, et al. Necrotizing fasciitis. Arch Surg. Feb 1986;121(2):233-5.
[Medline].
Riseman JA, Zamboni WA, Curtis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis
reduces mortality and the need for debridements. Surgery. Nov 1990;108(5):847-50
Feldmeier J, Carl U, Hartmann K, et al. Hyperbaric oxygen: does it promote growth or
recurrence of malignancy?. Undersea Hyperb Med. Spring 2003;30(1):1-18
Bennett MH, Kertesz T, Perleth M, Yeung P, Lehm JP. Hyperbaric oxygen for idiopathic sudden
sensorineural hearing loss and tinnitus. Cochrane Database Syst Rev. Oct 17 2012;10:CD004739.
Bennett, Michael. Hyperbaric oxygenation for tumor sensitization to radiotherapy. Cochrane Database of Systematic Reviews. 2012