Hyperbaric medicine

1. Ian Gawthrope
SCGH Registrar Teaching 2017
Hyperbaric medicine

2. 2
Fremantle Hyperbaric Unit

3. Fiona Stanley Hyperbaric Unit

4. Multiplace chambers

5. Monoplace chambers

6. Critical care patients

7. Registrars!

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History of Hyperbaric Medicine
1928 Cunningham built a 64 foot diameter steel
hyperbaric ball with five floors at Cleveland Ohio
USA
Patients lived inside chamber at 2ATA
Scrapped for metal
during World War II

12. Hyperbaric Medicine Unit

14. Mild Hyperbaric

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http://www.naturalhealthperth.com/hyperbaric-therapy.html

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17. Burns received when his hair caught fire from fireworks
during the making of a Pepsi commercial in 1984. Treated
with HBO and eventually bought his own chamber.
Michael Jackson and HBO

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Mechanisms of action
Pharmacological effect In vitro Animal models Clinical findings
Bubble size reduction Boyle’s law (ca. 1662) (Waite et al. 1967)
Gas washout (Haldane 1922) (Peterson and Stewart 1970)
(Jay et al. 1995) (Myers et al. 19484)
(Vorosmarti et al. 1978)
Upregulation of growth
factors and GF receptors
(Feng et al. 1998) (Sheikh et al. 2000)
(Bonomo et al. 1998)
Inhibition of neutrophil
adhesion
(Thom 2004) (Thom 2004) (Boykin and Baylis 2007)
Inhibition of infection (Kaye 1967)
(Hohn et al. 1976)
(Mader et al. 1980) (Kaye 1967)
(Hohn et al. 1976)
(Wilkinson and Doolette 2004)
(Roje et al. 2008)
Modulation of inflammation (Thom 2004) (Thom 2004) (Buras at al. 2006)
(Zhang et al. 2008)
(Yogaratnam et al. 2000)
Alex et al. 2005)
Reduction of ischaemia-
reperfusion injury
(Takahashi et al. 1992)
(Strauss et al. 1983)
(Zamboni et al. 1993)
(Buras et al. 2000)
(Mazariegos et al. 1999)
(Dekleva et al. 2004)
Neovascularisation (Sander et al. 2009)
(Hopf et al. 2005) (Marx et al. 1990)
(Marx 2008)
Osteogenesis (Sawai et al. 1996) (Johnsson et al.
1999) (Sever et al. 2010)
(Marx 2008)
Angiogenesis (Sander et al. 2009) (Hopf et al.
2005) (Hunt and Pai 1972)
(Marx 2008) (Hammarlund and
Sunberg 1994)
Stem cell growth and release (Milovanova et al. 2009) (Thom et al. 2011)

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HBO - MECHANISMS OF ACTION

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Recognised Indications for Hyperbaric Oxygen
• Dysbaric (Bubble) Injury
• Decompression Illness
• Acute Ischaemic Conditions
• Compromised Flaps and Grafts
• Crush Injury
• Compartment Syndrome
• Reperfusion Injury
• Infective Conditions
• Necrotising Fasciitis
• Malignant Otitis Externa
• Refractory Osteomyelitis
• Refractory Mycoses

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Recognised Indications for Hyperbaric Oxygen
• Delayed Radiation Injury
• Osteoradionecrosis
• Soft Tissue Radionecrosis
• Problem Wounds
• Diabetic Ulcers
• Venous Ulcers
• Decubitus Ulcers
• Frostbite
• Toxic Gas Poisoning
• Carbon Monoxide

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Absolute contraindications
• Untreated pneumothorax
• Acute severe bronchospasm
• Concomitant treatment with Doxorubicin
• Cardiac toxicity – 87% mortality in rats when chemotherapeutic
agent combined with HBO
• Previous treatment with Bleomycin
• Reports of elevation in FiO2 intraoperatively causing interstitial
pneumonitis even if Bleomycin therapy had ceased years before.
• Probably overstated risk.
• Safe administration of hyperbaric oxygen after bleomycin: a case series of 15 patients.
Undersea Hyperb Med. 2012 Sep-Oct;39(5):873-9. Torp KD1, Carraway MS, Ott MC, Stolp BW,
Moon RE, Piantadosi CA, Freiberger JJ.

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Relative contraindications
• Concomitant treatment with Cis-Platinum
• HBO increases cytotoxic effect of drug in tissues and impedes wound healing.
• Concomitant treatment with Disulfiram (Antabuse)
• Blocks the production of superoxide dismutase which may increase the risk of oxygen toxicity
• Seizure disorders
• Lowered seizure threshold may increase risk of oxygen toxicity seizures
• COPD with CO2 retention
• Loss of hypoxic drive
• Upper respiratory tract infections and sinusitis
• Risk of barotrauma
• Claustrophobia and anxiety/mental illness
• Consider use of benzodiazepines
• Heart failure
• Risk of pulmonary oedema due to reduction in cardiac output
• Bullous lung disease
• Pregnancy

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Complications
• Barotrauma (2-4% of treatments)
• Middle ear, sinus squeeze
• Oxygen toxicity seizures
• Pulmonary oxygen toxicity
• Rare with routine daily exposures
• Temporary worsening of short-
sightedness
• Worsening of known cataracts
• Fire

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Barotrauma
• Most common side effect of HBOT
• Incidence of middle ear barotrauma ~ 2%
• Pseudoephedrine has been demonstrated to
be effective in preventing barotitis media
• Brown M et al. Pseudoephedrine for the prevention of barotitis media: a controlled clinical trial in underwater divers. Ann
Emerg Med. 1992;21:849-852
• Sinus squeeze second most complication
• Decongestant/steroid nasal sprays
• Serous otitis media can develop
• Evidence to suggest HBO might cause a reversible derangement in middle ear chemoreceptor reflex arcs that regulate
middle ear aeration
• Typanometry may be helpful to predict
Eustachian tube dysfunction
• Tympanostomy tubes may be required

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Oxygen toxicity seizures
• Incidence 1 in 1650 patient treatments
• Banham. Oxygen toxicity seizures: 20 years' experience from a single hyperbaric unit. DHM 2011;41:202-10
• Seizures are generalized tonic-clonic
resolving without residual effects when
oxygen removed
• Mechanism poorly understood
• Air breaks are thought to reduce the risk

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Progressive myopia
• Lenticular in origin
• Due to changes in the refractive index of
the lens
• Evanger K et al. Myopic shift during Hyperbaric Oxygenation attributed to lens index changes. Optom Vis Sci. 2015;
92(11): 1076-84.
• Usually fully reversible within 4-8 weeks
• Isolated case reports of worsening of
known cataracts
• Development of new cataracts very rare
and usually only in patients receiving >150
treatments
• Palmquist et al. Nuclear cataract and myopia during hyperbaric oxygen therapy. Br J Opthal. 1984;68:113-117.

28. Fire risk!

32. Fiona Stanley Hyperbaric Unit
Patient Treatment Statistics: 1 July 2015 -
30 June 2016 - 163 patients

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Fiona Stanley Hyperbaric Unit
DCI treated fiscal yearly since Nov 1989 at FH and FSH HMU’s

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http://en.wikipedia.org/wiki/Radiation_therapy
Delayed Radiation Injury

35. The Role of HBO in Delayed Radiation Injury
Lag phase
Angiogenic
phase
Plateau
phase

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HBO and Delayed Radiation Injury

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Soft tissue radionecrosis
• Wound spontaneously broke down 20
years after radiotherapy
• Wound healed after 30 HBO and
wound care

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HBO in Wound Healing

39. Treatment tables

40. Decompression Illness

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Definition
• Decompression illness arises in
compressed gas divers, aviators, and
astronauts when bubbles form in blood
and / or in tissues, during or after a
decrease in environmental pressure

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The Gas Law’s
• Boyle’s law: The volume of a gas is inversely
proportional to the pressure provided the
temperature and mass are constant
• Henry’s law: The amount of any given gas that will
dissolve in a liquid at a given temperature is a
function of the partial pressure of that gas in
contact with the liquid.

43. History of DCI
• First noted in Caisson workers around
1845 - “Caisson’s Disease”
• Term “Bends” adopted during
construction of Brooklyn Bridge in
reference to “Grecian Bend” of women
• In 1889 25% of workers on Hudson
river tunnel died of DCI. A
recompression chamber reduced this
to 1.7%

44. Mechanisms of
bubble
formation

45. Two mechanisms of bubble formation
BUBBLE FORMATION
Dissolved gas Pulmonary barotrauma

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Pulmonary barotrauma
Divers ascend head first
CAGE is primary concern

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Arterial bubbles and the brain
Muth CM, Shank ES. New Eng J Med 2000;347:476-82
WBCs

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Presentation of CAGE
• Rapid onset of neurological symptoms
– often immediately at surface
– unconsciousness in 50%
– hemiparesis, monoparesis, sensory changes, visual change,
dysphasia, disorientation, dissociation

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Natural history of CAGE
• 5 - 10% die early
• 30% static
• 60% spontaneous recovery
• clinical correlate of bubble redistribution
• 50% of those recovering suffer progressive
relapse
• clinical correlate of inflammatory events

51. Two mechanisms of bubble formation
BUBBLE FORMATION
Dissolved gas Pulmonary barotrauma

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Symptoms of DCI
Symptom % of patients Symptom % of patients
Pain 67 Dyspnoea 13
Fatigue 54 Itch 10
Tingling 46 Visual disturbance 8
Headache 46 Rash 7
Numbness 35 Loss of consciousness 5
Weakness 26 Cough 3
Cognitive difficulty 25 Urinary dysfunction 1
Dizziness 20 Other 13
Ataxia 17

54. Two mechanisms of bubble formation –
with a twist!
BUBBLE FORMATION
Dissolved gas Pulmonary barotrauma
Venous blood Arterial bloodTissues
Patent foramen ovale + other shunts

56. Treatment tables for DCI

57. Treatment tables for DCI

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Case History 1
• 27 year old male
• Recreational diver
• Spear fishing on surface supply hookah
• 15 metres depth for 15 mins
• Rapid ascent whilst reloading spear gun
– Loss of buoyancy
• Two further attempts with rapid ascents!

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Case History 1
• Third uncontrolled ascent – on surface
confused, with blurred vision and felt
unable to move limbs
• Rescued to the boat
• Kept supine
• Transferred to Busselton ED

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Case History 1
• In ED – no neurological symptoms and
felt well
• Complained of chest pain – CT Thorax
was normal
• Creatinine 120
• Self discharged

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Case History 1
• Returned 9 hours later
• Diffuse abdominal pain
• Lactate 10.8
• Treated with IV fluids and oxygen after
consulting Hyperbaric team
• Lactate normalised
• Creatinine 987

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Case History 1
• Transferred to Fremantle Hospital
• Diagnosed with ATN
• High fractional urinary excretion of 5.5%
• Elevated LDH 468 (125-250)
• MAG3 scan in keeping with ATN
• No myglobinuria, CK 893 – Rhabdomyolysis induced
ATN unlikely

64. Case History 1
Creatinine peaked at 1210

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Case History 1
• Treated with daily Hyperbaric oxygen for
seven days
• Creatinine normalised
• Returned to diving
• Full recovery

66. Questions?