HBOT: Physician’s Guide
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Hyperbaric oxygen (HBOT) is the administration of 100% oxygen at higher than 1.4 atmospheres of pressures while the patient is fully enclosed in a hyperbaric chamber. This causes oxygen to dissolve into the plasma resulting in up to a 20 fold increase in arterial oxygen pressure. The length of treatment is usually 90 minutes and the number of treatments range from a few to over 40 depending on the protocol for the treating condition. Treatments are administered consecutively 5 days per week.
HBOT speeds the body’s natural ability to heal by increasing the blood supply (angiogenesis) and fighting infection through the following mechanisms: stem cell production, improved mitochondrial ATP generation, new blood vessel formation (angiogenesis) for improved wound and bone healing, and improved immune activity during chronic infections.
Safety of HBOT
Hyperbaric oxygen therapy is safe for all conditions except for untreated pneumothorax. (29) Certain chemotherapy drugs are contraindicated during HBOT treatment.
Efficacy of HBOT
HBOT has been studied in thousands of clinical, in vivo and in vitro studies and has been shown to be both safe and effective for dozens of disorders. The following section lists all the indications for HBOT, the insurance-reimbursed indications as well as citations of clinical studies for the most common indications.
The following is a list of diagnoses and conditions treated by hyperbarics that are typically covered by health insurance:
Conditions related to cancer treatments and radiation damage
Infections in tissue, muscle, bone or skin, and/or drug resistant infections
Sores and gangrene that will not heal or that are related to diabetes
Surgical sites with grafts or flaps
Bones and/or tissue that are difficult to heal
Acute severe problems from accidents (e.g. crushed leg, arm, fingers)
Rare conditions such as decompression sickness, anemia, burns, carbon monoxide poisoning, or emboli from air or gas
Swelling of the brain, cerebral edema
Medicare Approved Conditions for Hyperbarics:
- Acute carbon monoxide intoxication
- Decompression illness
- Gas embolism
- Gas gangrene
- Acute traumatic peripheral ischemia
- Crush injuries and suturing of severed limbs (limb reattachment)
- Progressive necrotizing infections (necrotizing fasciitis)
- Acute peripheral arterial insufficiency
- Treatment of compromised grafts and flaps
- Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management
- Osteoradionecrosis as an adjunct to conventional treatment
- Soft tissue radionecrosis as an adjunct to conventional treatment
- Cyanide poisoning
- Actinomycosis, only as an adjunct to conventional therpay when the disease process is refractory to antibiotics and surgical treatment
- Diabetic wounds of the lower extremities in patients who meet these three criteria:
- The patient has Type 1 or Type 2 diabetes and have a lower extremity wound that's due to diabetes
- The wound is classified as Wagner grade III or higher
- The patient has failed an adequate course of wound care therapy
Rationale of Hyperbarics for the following Medicare Approved Conditions:
Other Treatable Conditions currently in the investigational category:
Skin and other infections
Wounds not covered by Medicare
Sudden blindness or deafness
Eye conditions (such as macular edema)
Perineal Crohn's Disease
Sickle Cell Disease with Crisis
Peripheral Vascular Disease
Traumatic brain injury
Closed head injury
Spinal cord injury
Multiple Sclerosis (certain aspects)
Reflex Sympathetic Dystrophy and other neurological disorders
Chronic fatigue symptoms
Orthopedic problems-sprains/strains chronic or acute/fractures non-healing
Liver detoxification enhancement
Atmospheric vs. Hyperbaric oxygen therapy
Normally, when we consider the role of oxygen in medicine it is primarily for hypoxia due to cardiopulmonary indications, such as congestive heart failure, COPD, or pneumonia. Oxygen, carried by hemoglobin in red blood cells, is limited by how much it can increase tissue oxygenation due to rapid saturation of hemoglobin.
HBOT uses 100% oxygen in a pressurized chamber at 1.5 atm or greater, creating up to a 20-fold increase in oxygen delivery to cells. The key to the effects of hyperbaric oxygen is that it increases the amount of dissolved oxygen in plasma, which has several advantages for patients:
- Oxygen Delivery: Oxygen dissolved in plasma can be delivered to cells independently of oxygen dissociation factors required by hemoglobin such as 2,3- DPG, acidosis and elevated body temperature
- Oxygen Perfusion: dissolved oxygen allows for oxygen to be delivered to the microvasculature where red blood cells could not due to:
- Altered distensibility, making it useful for sickle cell anemia (1, 2)
- Blood rheology, improving oxygenation in the face of thromboemboic phenomenon
- Abnormal vasculature improving perfusion in patients with diabetes (3-6), cancer (7-11), cardiovascular disorders (12-14)
- Compromised perfusion: traumatic brain injury15, stroke16, CHF12-14
- Circulation: HBOT increases peripheral vascular dilation through nitric oxide production (4, 13, 14, 17)
- Stem Cells: Increases stem cell production through nitric oxide production (17)
- Immunity: Improves oxidative burst capacity, improving native anti-microbial function, particularly in chronic infections (Lyme’s disease18), and acute, aggressive infections (Necrotizing infections19-21)
- Improves natural killer cell activity against cancer cells22
- Potentiates oxidative effects of chemotherapy and radiation therapy and improves quality of life in cancer patients (7- 11)
- Wound Healing: (3-5, 8, 20, 21, 23, 24) :Improves fibroblast production23, angioneogenesis (6, 12)
- Sports Injuries: HBOT improves muscle recovery and reduces healing time (25)
- Neuro-Degenerative disorders: Improves ATP production in mitochondria which improves degenerative disorders: Autism (26, 27), Alzheimer’s, Muscular dystrophies (28)
1. Reynolds JD. Painful sickle cell crisis. Successful treatment with hyperbaric oxygen therapy.JAMA. Jun 21 1971;216(12):1977-1978.
2. Wallyn CR, Jampol LM, Goldberg MF, Zanetti CL. The use of hyperbaric oxygen therapy in the treatment of sickle cell hyphema. Invest Ophthalmol Vis Sci. Aug 1985;26(8):1155-1158.
3. Al-Waili NS, Butler GJ, Beale J, et al. Influences of hyperbaric oxygen on blood pressure, heart rate and blood glucose levels in patients with diabetes mellitus and hypertension. Arch Med Res.Nov 2006;37(8):991-997.
4. Chen SJ, Yu CT, Cheng YL, Yu SY, Lo HC. Effects of hyperbaric oxygen therapy on circulating interleukin-8, nitric oxide, and insulin-like growth factors in patients with type 2 diabetes mellitus.Clin Biochem. Jan 2007;40(1-2):30- 36.
5. Hinchliffe RJ, Valk GD, Apelqvist J, et al. A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev. May-Jun 2008;24 Suppl 1:S119-144.
6. Unfirer S, Kibel A, Drenjancevic-Peric I. The effect of hyperbaric oxygen therapy on blood vessel function in diabetes mellitus. Med Hypotheses. Nov 2008;71(5):776- 780.
7. Chen YC, Chen SY, Ho PS, et al. Apoptosis of T-leukemia and B-myeloma cancer cells induced by hyperbaric oxygen increased phosphorylation of p38 MAPK. Leuk Res. Jun 2007;31(6):805-815.
8. Dall'Era MA, Hampson NB, Hsi RA, Madsen B, Corman JM. Hyperbaric oxygen therapy for radiation induced proctopathy in men treated for prostate cancer. J Urol. Jul 2006;176(1):87-90./font>
9. Krahn MJ, Hagen NA. Analgesic effect of hyperbaric oxygen for pain caused by cancer treatment. J Palliat Care. Summer 1999;15(2):53-55.
10. Teas J, Cunningham JE, Cone L, et al. Can hyperbaric oxygen therapy reduce breast cancer treatment- related lymphedema? A pilot study. J Womens Health (Larchmt). Nov 2004;13(9):1008-1018.
11. Teguh DN, Levendag PC, Noever I, et al. Early hyperbaric oxygen therapy for reducing radiotherapy side effects: early results of a randomized trial in oropharyngeal and nasopharyngeal cancer. Int J Radiat Oncol Biol Phys. Nov 1 2009;75 (3):711-716.
12. Bartorelli AL. Hyperoxemic perfusion for treatment of reperfusion microvascular ischemia in patients with myocardial infarction. Am J Cardiovasc Drugs. 2003;3 (4):253-263.
13. Cabigas BP, Su J, Hutchins W, et al. Hyperoxic and hyperbaric-induced cardioprotection: role of nitric oxide synthase 3. Cardiovasc Res. Oct 1 2006;72(1):143- 151.
14. Yogaratnam JZ, Laden G, Guvendik L, Cowen M, Cale A, Griffin S. Pharmacological preconditioning with hyperbaric oxygen: can this therapy attenuate myocardial ischemic reperfusion injury and induce myocardial protection via nitric oxide? J Surg Res. Sep 2008;149(1):155-164.
15. Shi XY, Tang ZQ, Xiong B, et al. Cerebral perfusion SPECT imaging for assessment of the effect of hyperbaric oxygen therapy on patients with postbrain injury neural status. Chin J Traumatol. Dec 2003;6(6):346-349.
16. Kidd PM. Integrated brain restoration after ischemic stroke--medical management, risk factors, nutrients, and other interventions for managing inflammation and enhancing brain plasticity. Altern Med Rev. Mar 2009;14(1):14-35.
17. Thom SR, Bhopale VM, Velazquez OC, Goldstein LJ, Thom LH, Buerk DG. Stem cell mobilization by hyperbaric oxygen. Am J Physiol Heart Circ Physiol. Apr 2006;290 (4):H1378-1386.
18. Taylor RS, Simpson IN. Review of treatment options for lyme borreliosis. J Chemother. Sep 2005;17 Suppl 2:3-16.
19. Korhonen K. Hyperbaric oxygen therapy in acute necrotizing infections. With a special reference to the effects on tissue gas tensions. Ann Chir Gynaecol. 2000;89 Suppl 214:7-36.
20. Hirn M. Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis. A clinical and experimental study. Eur J Surg Suppl. 1993(570):1- 36.
21. Holland JA, Hill GB, Wolfe WG, Osterhout S, Saltzman HA, Brown IW, Jr. Experimental and clinical experience with hyperbaric oxygen in the treatment of clostridial myonecrosis. Surgery.Jan 1975;77(1):75-85.
22. De Ridder M, Van Esch G, Engels B, Verovski V, Storme G. Hypoxic tumor cell radiosensitization: role of the iNOS/NO pathway. Bull Cancer. Mar 2008;95(3):282- 291.
23. Niinikoski JH. Clinical hyperbaric oxygen therapy, wound perfusion, and transcutaneous oximetry. World J Surg. Mar 2004;28(3):307-311.
24. Thom SR. Oxidative stress is fundamental to hyperbaric oxygen therapy. J Appl Physiol. Mar 2009;106(3):988-995.
25. Staples J, Clement D. Hyperbaric oxygen chambers and the treatment of sports injuries.Sports Med. Oct 1996;22(4):219-227.
26. Rossignol DA, Rossignol LW, James SJ, Melnyk S, Mumper E. The effects of hyperbaric oxygen therapy on oxidative stress, inflammation, and symptoms in children with autism: an open-label pilot study. BMC Pediatr. 2007;7:36.
27. Rossignol DA, Rossignol LW, Smith S, et al. Hyperbaric treatment for children with autism: a multicenter, randomized, double-blind, controlled trial. BMC Pediatr. 2009;9:21.
28. Peach G. Hyperbaric oxygen and the reflex sympathetic dystrophy syndrome: a case report.Undersea Hyperb Med. Dec 1995;22(4):407-408.
29. Toklu AS, Korpinar S, Erelel M, Uzun G, Yildiz S. Are pulmonary bleb and bullae a contraindication for hyperbaric oxygen treatment? Respir Med. Aug 2008;102(8):1145- 1147.