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1. HYPERBARIC OXYGEN AND ITS USE IN MEDICAL CONDITIONS Dr. John Hughes, DO Regional Osteopathic Medical Education Conference February 1, 2018

2. OUTLINE • Definition • History • Physics • Physiology • Mechanism • FDA Approved • Off Label

3. HYPERBARIC OXYGEN THERAPY A medical treatment in which a patient breathes 100% oxygen under increased atmospheric pressure • “Hyper” – more • “Baric” – atmospheric pressure • Hyperoxygenation – “high dose”

4. HISTORY 1662 First documented use of compressed air by an English clergyman 1775 Discovery of oxygen 1800 Hyperbaric spas constructed throughout Europe “Air baths” 1834 Pulmonary disease treated with compressed air in France 1870 First mobile hyperbaric operating theater 1891 Introduction of hyperbarics to U.S. for “nervous disorders”

5. 1928 Largest hyperbaric chamber constructed for various maladies 1937 100% O2 first used in hyperbarics for decompression sickness 1938 Used for treatment of leprosy in Brazil 1938 Used in USA to treat experimental CO poisoning in animals 1950 Used by UK to enhance tumor radio-sensitivity 1959 Boerema proved life can be sustained in absence of blood flow HISTORY

6. HISTORY 1960s Effectiveness shown for stoke, MS, MLS, brain ischemia, CO poisoning, gas gangrene, etc 1970’s Majority of US hyperbaric chambers were military 1980 Hyperbaric community began to develop with various organizations and certifications 1991 The National Board of Diving and Hyperbaric Medical Technology (NBDHMT) formed 2002 International Hyperbaric Medical Association (IHMA) formed

7. PHYSICS Henry’s Law of Gas Solubility The solubility of a gas in a liquid is directly proportional to the partial pressure of the gas above the liquid. Increasing the atmospheric pressure increases the amount of gas that is dissolved into a fluid. (Oxygen → Blood Plasma) A B

8. Clinical Hyperbaric Pressures • 7 – 22 psi • 10 – 15 normal amount of oxygen • Bypasses body’s normal system of transporting oxygen What Gets Hyper-Oxygenated? • Blood Plasma • Cerebrospinal Fluid • Lymph Fluid PHYSIOLOGY

9. HIGH DOSE OXYGEN • Classified as drug by the FDA • Produces physiological changes in the body • Toxic at high doses – (oxygen toxicity) DX: • Disease or injury causing low oxygen levels/poor perfusion in the tissues Results: • Enhance and speeds up the body’s natural healing process

10. • Limits ischemic damage, cell death, inflammation • Promotes collagen synthesis (fibroblast stimulation) • Decreases lactate production and tissue acidosis • Aids in oxygen dependent killing of bacteria – WBC • Limits leukocyte adhesion and degranulation • Decreases tissue edema MECHANISM OF ACTION

11. • Stem Cell Mobilization • Causes mobilization of CD34+ progenitor cells from bone marrow • University of Pennsylvania study • Angiogenesis • Promotes neovascularization of poorly perfused tissue • Unique action MECHANISM OF ACTION



14. ANGIOGENESIS “Although there may be insufficient stimulus to initiate angiogenesis under normal conditions, by increasing the local oxygen delivery the oxygen gradient is magnified ….resulting in a stronger signal for the repair mechanism.”

15. FDA-APPROVED USES • DiabeticWounds* • Osteomyelitis* • Delayed Radiation Injuries(Soft tissue/bone)* • Compromised skin grafts/flaps* • Decompression sickness • Carbon monoxide poisoning • Intracranial abscess • Acute Arterial insufficiency • Thermal burns • Crush injuries, acute trauma • Necrotizing soft tissue infections • Exceptional blood loss anemia • Gas gangrene *Represent 95% of all hospital treatments


17. Patients with diabetic lower extremity ulcer Patient has failed a 30-day course of standard, conventional wound therapy Treatment Protocol – 2.4ATA/90 minute x 20-40 treatments adjunct to standard wound care DIABETES WOUNDS LOWER EXTREMITY

18. DIABETES WOUNDS REFRACTORY OSTEOMYELITIS Pre-Hyperbaric Wound Partial Wound Closure 20 HBOT Tx 4Weeks Complication Resolved Full Healing 35 HBOT Tx 7Weeks

19. DIABETES WOUNDS EXPOSED TENDON After 10 Tx / 2 Weeks granulation tissue Required incision, drainage and debridement After 20 Tx / 4 Weeks After 35 Tx / 7 Weeks

20. DIABETES WOUNDS DIGITAL AMPUTATION InitialVisit After 10 Tx / 2 Weeks After 15 Tx / 3 Weeks After 30 Tx / 6 Weeks


22. DELAYED RADIATION INJURIES Soft tissue radiation injury – ulcers/non-healing wounds Osteoradionecrosis – mandibular Radiation cystitis Radiation proctitis Radiation enteritis • Symptoms may develop 3-24 months after radiation therapy • 5-10% of irradiated patients

23. VASCULAR INJURY • Injury to the underlying vasculature and arteriocapillary fibrosis • Tissue vascular density is greatly diminished • Loses ability to heal itself

24. Response to 20 treatments @ 1 ATA/90 min. with 100% O2 Response to 20 treatments @ 2.4 ATA/90 min. with 100% O2 ANGIOGENESIS IN IRRADIATED TISSUE

25. MANDIBULAR OSTEORADIONECROSIS InitialVisit – Bone Exposed After 10 Tx / 2 Weeks After 25 Tx – 5 Weeks After 40 Tx – 8Weeks New tissue over bone

26. DAMAGE TO OSTEOCYTES FROM RADIATION THERAPY Mandible has least redundant blood supply & muscle coverage <10% of patients receiving head & neck radiation therapy have complications: Weakens bone, predisposing to fracture Often painful, broken down mucosal coverage Decreases blood flow, difficult to fight infection

27. PATHOPHYSIOLOGY • Significant fibrotic changes in bone and marrow • Reduction in caliber and number of feeding vessels • Periosteal and mucosal damage  bone necrosis ORN X-ray – Mandible ORN Histology – Mandible

28. After 35 Tx / 7 WeeksAfter 20 Tx / 4 Weeks InitialVisit After 10Tx / 2WeeksRADIATION SOFT TISSUE NECROSIS

29. 2 months post-surgery After 20 Tx / 4 Weeks 10 days following spilt thickness graft STSG AFTER RADIATION NECROSIS


31. PROBLEM WOUND WITH SKIN GRAFT FAILURE 25 HBOT Tx / 5Weeks Split thickness graft placed -100% acceptance InitialVisit Diabetic patient, 6 month non-healing wound, one failed graft

32. InitialVisit After 30 Tx / 6 Weeks After 15 Tx / 3 WeeksAfter 10 Tx / 2 Weeks 3 Weeks post HBOT Final HBOTVisit DEGLOVING ACCIDENT – FAILED FLAP – LEFT DORSAL FOOT

33. After 10 Tx / 2 Weeks After 15 Tx / 3 Weeks InitialVisit SKIN NECROSIS – TOTAL KNEE REPLACEMENT

34. WHAT DOES HBOT BENEFIT? Any kind of injury or disease in which poor tissue perfusion is either causing or complicating the situation. • underlying vascular injury • edema/swelling • trauma

35. “OFF-LABEL” USES – WORLDWIDE • Orthopedic Injury/Post Surgery • Lyme Disease • Traumatic Brain Injury/PCS • Stroke – Ischemic • Cerebral Palsy • Autism • Bells Palsy • Crohn’s Disease/IBD • Chronic Fatigue Syndrome • CRPS/RSD • Diabetic Retinopathy • Post Surgery Recovery/Healing from laser or traditional types of cosmetic surgery • Arthritis (Osteo and Rheumatoid) • Macular Degeneration • Migraine and Cluster Headache • Multiple Sclerosis (Acute, Relapsing, Remitting, Chronic) • Osteonecrosis – Avascular, Aseptic, and Ischemic Bone Necrosis • Non-healing fractures – Non Union • Peripheral Neuropathy • Psoriasis • Lupus • Immune System Support • Cancer w/Keto

36. QUALITY OF HEALING • Promotes greater tissue strength • More rapid tissue growth & covering larger areas • Resulting tissue integrity is stronger • Enhances the growth of new blood vessels

37. SPORTS INJURIES • Reduces swelling • Blunts the inflammatory process • Improves range of motion earlier/ PT • Increases and enhances tissue growth – fibroblast and osteoblast proliferation • Improves Bone Regeneration-Faster and Stronger Fracture Repair • Non-Union fracture, complicated Fractures, AVN

38. CASE STUDY • Injured on January 5th 2009 • Shearing fracture, surgically repaired • High risk for Non-Union • “Season Ending” • Started HBO January 7th 2009 • 30 tx over 6 week period • Cleared to ski March 3rd 2009 “Fastest healing I’ve ever seen in a injury this significant” -Orthopedic Surgeon

39. WIDELY USED IN PROFESSIONAL SPORTS Twelve NFL teams own chambers • “Ward using hyperbaric chamber to accelerate recovery” USAToday • “Football superstarTerrell Owens used hyperbaric oxygen therapy to hasten his recovery from an ankle injury so that he could play in the Super Bowl.” Fox Sports • Cincinnati Bengals defensive tackle Bryan Robinson says “hyperbaric oxygen therapy was the catalyst in getting a nagging ankle injury to heal.” Cincinnati Inquirer • “Linebacker Kevin Burnett credits hyperbaric oxygen therapy for helping him get back onto the playing field quickly after surgery to repair cartilage damage in his knee.” Dallas Cowboys Official Weekly

40. China: HBOT is included as a routine therapy in sports medicine; there are now over 4000 facilities. HBOT IN SPORTS AROUND THE WORD Portable hyperbaric chamber at Olympic Track and Field venue: 2012 – London

41. LYME DISEASE • Fastest growing vector-borne infectious disease in the US • Reported annual cases increased nearly 25-fold since1982 • No tests available to prove that the organism is eradicated or that the patient is cured

42. “THE GREAT IMITATOR” • 5 subspecies of borrelia burgdorferi, over 100 strains in the us, and 300 strains worldwide • Evades the immune system and antibiotic therapy, leading to chronic infection • The Elisa screening test is unreliable • Symptoms can be easily mistaken for other illnesses

43. MECHANISM OF TREATMENT • Lyme disease is known as “anaerobic”: it cannot exist in oxygen • Reduces harmful bacteria • Herxheimer response, which includes symptoms such as fever, chills, headache, flushing, and more • Endotoxins that are released as the harmful bacteria dies • Lasts only a few hours to days

44. TRAUMATIC BRAIN INJURY • Inflammatory reaction resulting from tissue injury: • Edema • Reduced blood flow • Reduced oxygen • Excitatory amino acids • Free radical damage • Lipid peroxidation • Cell death

45. RESULTS OF LSU PILOT TRIAL In one month of HBOT = Significant improvement in symptoms • 15 point increase in full scale IQ • Significant increase in cognition • 30% decrease in PTSD; 8/14 no longer met criteria for PTSD • 51% reduction in depression • 38% reduction in anxiety • PBNR (cog., phys., emot.) +33- 90% Harch, et al. J Neurotrauma, 2012:29(1):168-185.

46. HBOT AND THE BRAIN • Induces neuroplasticity • Increases tissue oxygenation • Generates new capillary networks • Restores blood supple • Increases stem cells in the blood

47. HBOT AND ADULT STEM CELLS • 2 hours = 3x amount of stem cells circulating stem cells in your blood • 20 sessions = 800% more stem cells circulating stem cells in your blood • Migrate to damaged tissues and help them regenerate • Essential to healing nerve and brain tissue

48. RECAP 100% oxygen under increased atmospheric pressure In use since the 1800’s Henry’s Law of Gas Solubility Oxygen → Plasma Considered a drug Reduces inflammation Mobilizes stem cells Increases angiogenesis Promotes greater tissue strength Enhances the growth of new blood vessels


50. Treats traumatic brain injury (TBI) patients by combining regenerative therapies: HBOT, stem cells, PRP, and nutritional therapies. Treats chronic pain and major medical problems using natural and alternative medicine whenever possible.