Adjunctive hyperbaric oxygen therapy reduces length of hospitalization in thermal burns

Is There a Place for Hyperbaric Oxygen Therapy?

Hyperbaric oxygen therapy (HBOT) involves treating patients by providing 100% oxygen through inhalation while inside a treatment pressurized chamber. The oxygen acts as a drug and the hyperbaric chamber as the dosing device. The effect of hyperbaric hyperoxia is dose dependent and, therefore, treatment depth and duration are important when considering its use. HBOT can either be the primary method of treatment or used adjunctively to medications or surgical techniques. The underpinning physiology is to bring oxygen-rich plasma to hypoxic tissue, preventing reperfusion injury, strengthening immune responsiveness, and encouraging new collagen deposition as well as endothelial cell formation.

Hyperbaric Oxygen and Mortality in Burns With Inhalation Injury: A Study of the National Burn Repository

Mortality in burn injury is primarily influenced by three factors: age, percent burn (%TBSA), and presence of inhalation injury. Numerous modalities have been tried in an attempt to treat those patients with burns and inhalation injury, including the use of hyperbaric oxygen (HBO). The aim of our study was to find the national prevalence of HBO for burns with inhalation injury, and whether HBO influenced mortality in these often severely injured patients. This retrospective study used the National Burn Repository (NBR) to identify hospital admissions of patients with both cutaneous burn and inhalation injuries. After applying exclusion criteria, a total of 13,044 patients were identified. Variables included in the multivariate regression analysis included age, sex, race, payer, mechanism of burn injury, TBSA group, total procedure number, mechanical ventilator days, and treatment with HBO. The main outcome variable was mortality. Of the 13,044 patients, 67 had HBO therapy. The HBO patients were older (mean age 51.7 vs 42.8 years, P < .001), but had smaller burns and thus a similar Baux score (66.6 vs 65.2, P = .661). The HBO patients had a higher mortality (29.9% vs 17.5%, P = .01). On multivariate regression analysis, HBO was an independent predictor of mortality (odds ratio = 2.484, P = .004). Other significant predictors of mortality included age, black race, Medicaid or uninsured patients, and %TBSA. The use of HBO for patients with burns and inhalation injury is uncommon in this database. It is unclear whether that reflects low prevalence or if individual centers do not all impute HBO into the NBR. For those patients in this database, HBO is an independent predictor of mortality. It can be difficult to determine the severity of inhalation injury in the NBR, so those patients receiving HBO could theoretically have more severe inhalation injury.

Hyperbaric Oxygen Therapy in Chronic Inflammatory Conditions of the Pouch

BACKGROUND

Pouchitis can be a chronic complication of ileal pouch-anal anastomosis. We aimed to determine the efficacy and safety of hyperbaric oxygen therapy (HBOT) for chronic antibiotic-refractory pouchitis (CARP) and other inflammatory conditions of the pouch.

METHODS

This was a retrospective case series of adults with inflammatory bowel disease (IBD) who underwent ileal pouch-anal anastomosis and then developed CARP and received HBOT between January 2015 and October 2019. A modified Pouchitis Disease Activity Index (mPDAI) score was used to quantify subjective symptoms (0-6) and endoscopic findings (0-6) before and after HBOT.

RESULTS

A total of 46 patients were included, with 23 (50.0%) being males with a mean age of 43.6 ± 12.9 years. The median number of HBOT sessions was 30 (range 10-60). There was a significant reduction in the mean mPDAI symptom subscore from 3.19 to 1.91 after HBOT (P < 0.05). The pre- and post-HBOT mean mPDAI endoscopy subscores for the afferent limb were 2.31 ± 1.84 and 0.85 ± 1.28 (P = 0.006); for the pouch body, 2.34 ± 1.37 and 1.29 ± 1.38 (P < 0.001); and for the cuff, 1.93 ± 1.11 and 0.63 ± 1.12 (P < 0.001), respectively. Transient side effects included ear barotrauma in 5 patients (10.9%) and hyperbaric myopic vision changes in 5 patients (10.9%).

CONCLUSIONS

Despite minor adverse events, HBOT was well tolerated in patients with CARP and significantly improved symptoms and endoscopic parameters.

The History and Development of Hyperbaric Oxygenation (HBO) in Thermal Burn Injury

Background and Objectives: Hyperbaric oxygenation (HBO) denotes breathing of 100% oxygen under elevated ambient pressure. Since the initiation of HBO for burns in 1965, abundant experimental and clinical work has been done. Despite many undisputedly positive and only a few controversial results on the efficacy of adjunctive HBO for burn injury, the method has not yet been established in clinical routine. Materials and Methods: We did a retrospective analysis of the literature according to PRISMA-guidelines, from the very beginning of HBO for burns up to present, trying to elucidate the question why HBO is still sidelined in the treatment of burn injury. Results: Forty-seven publications (32 animal experiments, four trials in human volunteers and 11 clinical studies) fulfilled the inclusion criteria. Except four investigators who found little or no beneficial action, all were able to demonstrate positive effects of HBO, most of them describing less edema, improved healing, less infection or bacterial growth and most recently, reduction of post-burn pain. Secondary enlargement of burn was prevented, as microvascular perfusion could be preserved, and cells were kept viable. The application of HBO, however, concerning pressure, duration, frequency and number of treatment sessions, varied considerably. Authors of large clinical studies underscored the intricate measures required when administering HBO in severe burns. Conclusions: HBO unquestionably has a positive impact on the pathophysiological mechanisms, and hence on the healing and course of burns. The few negative results are most likely due to peculiarities in the administration of HBO and possibly also to interactions when delivering the treatment to severely ill patients. Well-designed studies are needed to definitively assess its clinical value as an adjunctive treatment focusing on relevant outcome criteria such as wound healing time, complications, length of hospital stay, mortality and scar quality, while also defining optimal HBO dosage and timing.

The role of hyperbaric oxygen therapy in trauma

This review explains the method of action of hyperbaric oxygenation (HBO) therapy and examines the evidence for its use in trauma. Methods of delivery, complications and contra-indications are discussed. It is acknowledged that there are few controlled trials which evaluate the efficacy of HBO in this indication; supporting evidence for its efficacy is mainly in the form of case reports, or by implication from laboratory and animal work. Lack of evidence may not equate to lack of efficacy, but may reflect the difficulties in coordinating clinical trials involving critically ill patients and a complex treatment modality, the availability of which is not widespread. The adjunctive use of HBO has shown promising results in the treatment of crush injury. Consideration of tissue pathophysiology suggests that such an approach may also offer improved outcomes in the broader spectrum of trauma scenarios involving marginally viable tissues with compromised perfusion.

Hyperbaric oxygen in the management of chronic wounds

This article reviews the role that hyperbaric oxygen therapy (HBOT) plays in the field of wound healing. HBOT, although not seen as a common method of wound management in the UK, can perhaps offer another avenue to managing recalcitrant wounds. In order for the healing of chronic wounds to progress, the practitioner must address all the factors impeding the healing process, one of which is oxygenation. HBOT is thought to improve many aspects of poor healing by supplying high levels of oxygen at normal atmospheric pressure. It has been suggested that increasing the availability of oxygen does not necessarily stimulate the healing process, but that perhaps the pressure at which the oxygen is delivered is the responsible stimulus.

Hyperbaric oxygen in trauma and surgical emergencies

Hyperbaric oxygen therapy (HBO), that is the administration of 100% oxygen delivered under pressure, has a beneficial effect in several surgical conditions. Its use has been assessed and audited and its pharmacological effects demonstrated. It is appropriate for use in several acute surgical conditions as evidence-based therapy. These are: Gas Gangrene Crush Injuries, Compartment Syndromes & Acute Traumatic Ischaemias Enhancement of Healing in Selected Problem Wounds Exceptional Blood loss Anaemia Necrotising Soft Tissue Infections Compromised Skin Grafts & Flaps Thermal Burns HBO therapy suffers from previous inappropriate use, lack of knowledge, and scarce hyperbaric facilities. Hyperbaric therapy, when properly supervised by a physician trained in its use, working closely with a surgeon, and ethically used for appropriate indications, can be a useful adjunct to surgical practice. Military surgeons may be in a situation in which they can utilize HBO in acute surgical conditions and trauma. They are urged to identify HBO facilities, both fixed and portable, and to establish communication with hyperbaric therapy colleagues.

Hyperbaric oxygen therapy for deep second degree burns: an experimental study in the guinea pig

Most previous animal studies reporting improved epithelialisation and healing of burn wounds under hyperbaric oxygen (HBO) did not include the conventional treatment with topical antibiotics as part of the protocol, and did not compare the effectiveness of HBO therapy with that of normobaric 100% oxygen (NO). The purpose of our study was to compare the results of combined treatment with HBO + silver sulfadiazine (SS) and those of treatment with NO + SS or SS alone. Deep second degree burns were produced on the depilated backs of 54 guinea pigs using a validated burn protocol. The animals were assigned to three treatment groups: HBO + SS, NO + SS, and SS. Dressings were changed daily. HBO was administered at 2 atmospheres absolute (ATA) for 90 min BID, and NO for 90 min BID. The parameters compared among the groups were laser Doppler flowmetry, and burn wound contracture and re-epithelialisation data derived from computerised planimetry of photographs of the wound. No differences in laser Doppler flowmetry results or the magnitude of contracture were found between the groups. Significantly increased re-epithelialisation was observed under NO + SS starting 10 days after the burn (P = 0.02, ANOVA). This significance stems from the difference between the HBO + SS and NO + SS groups (Tukey test). These data indicate that excessively high levels of tissue PO2 might compromise burn healing, and explain our results. A further study comparing combined treatment using a milder HBO protocol + SS and NO + SS is indicated in the search for the optimal HBO regimen.

Hyperbaric oxygen therapy and piracetam decrease the early extension of deep partial-thickness burns

During the first 24 h, a progression of the burn wound in histological depth or extension is often noted. This can only partially be prevented by the routinely used protocols of fluid resuscitation and burn wound dressing. In a rat model of 5% TBSA burn, hyperbaric oxygen therapy (HBOT) and piracetam were evaluated for their ability to further prevent this early deepening of the burn wound. After infliction of the burn wound, the animals were treated with an accepted basic burn wound treatment consisting of mafenide 10% solution humid dressings. They were then randomized into three groups: a control group (n = 10), receiving no other treatment, a HBOT group (n = 17), receiving 60 min of HBOT (203 kPa) twice daily, and a piracetam group (n = 19), receiving piracetam (200 mg/kg IM) twice daily. On the third day of treatment, the entire burn wound was exised and examined histologically. It was found that both HBOT and piracetam had statistically significant effects on the preservation of epidermal basal membrane (P < 0.001 and P < 0.01, respectively). HBOT, but not piracetam, further had significant effects on the destruction of skin appendages (P < or = 0.05 and P > 0.05, respectively) and on the degree of subepidermal inflammation, as measured by leucocyte infiltration (P < 0.001 and P > 0.05, respectively). Furthermore, the HBOT group showed significantly less leucocyte infiltration than the piracetam group (P < 0.01). It was concluded that, although the clinical importance of the small effects on skin appendage and basal membrane preservation may be questionable, the effect on subepidermal leucocyte infiltration is striking and warrants further investigation of the anti-inflammatory effects of HBOT and possibly piracetam.

Hyperbaric oxygen therapy in wound management

Hyperbaric oxygen therapy is emerging as a possible treatment in wound management. It may be delivered systemically or topically. A review of the literature is undertaken to establish the extent of the research base of this practice.

Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns: a review

Hyperbaric oxygen therapy provided in specially designed pressure chambers is currently the treatment of choice for decompression sickness, arterial gas embolism, and serious carbon monoxide poisoning. It is an important adjunct in the treatment of gas gangrene, chronic osteomyelitis, radiation injury, and indolent wounds. The potential benefit in the treatment of thermal burns is not well appreciated. Hyperbaric oxygen therapy may significantly reduce morbidity, mortality, and cost of care. The application of this technology based on the demonstrated beneficial effects on the pathophysiology of the burn wound merits consideration in selected patients.

Topical hyperbaric therapy for problem skin wounds

BACKGROUND

Hyperbaric oxygen remains the sole treatment capable of inducing growth of new blood vessels. However, systemic hyperbaric oxygen therapy risks central nervous system and pulmonary toxicity.

OBJECTIVE

To describe topical hyperbaric oxygen therapy for the treatment of recalcitrant open wounds.

METHODS

Topical and systemic hyperbaric oxygen treatments are described and contrasted from one another. Applications of topical hyperbaric oxygen therapy are described.

CONCLUSION

Topical hyperbaric oxygen therapy is useful only for open wounds. The advantages of topical hyperbaric oxygen therapy include low cost, the lack of systemic oxygen toxicity, and effectiveness, allowing this treatment to be prescribed for many patients early in the course of their disease rather than as a last resort.

Burn wound healing: James Ellsworth Laing memorial essay for 1991

This essay has concentrated on the basic processes, clinical techniques involved in burn wound healing and how the two relate to each other. The achievement of early, sound, durable burn wound healing is one of the fundamental aims of burn care in order to minimize subsequent morbidity and mortality. It must be remembered that all patients with burns are individuals. There is no standard way to treat a burn and treatment must be tailored to suit the needs and requirements of both the patient and the burn wound. Burn wound healing is not the specific domain of any one specialist. It requires input from all disciplines and can be best achieved by the burn team approach.