Richa Wadhawan et al. / Journal of Science / Vol 4 / Issue 10 / 2014 /604-614.

e ISSN 2277 - 3290

Print ISSN 2277 - 3282

Journal of Science Dentistry

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HYPERBARIC OXYGEN THERAPY; UTILITY IN MEDICAL &

DENTAL FIELDS A REVIEW
* Richa Wadhawan1, Yehoshuva Reddy1, Kaushal Luthra1, Dharti Gajjar 2 and
Gaurav Solanki3
1
Institute of Dental Education & Advance Studies, Gwalior, India.
2
Pacific Dental College, Udaipur, Rajasthan, India.
3
Jodhpur Dental College General Hospital, Jodhpur, India.

ABSTRACT
Hyperbaric Medicine is the fascinating use of barometric pressure for delivering increased oxygen dissolved in
plasma to body tissues. It is increasingly being used in a number of areas of medical practice. It is an accepted adjunctive
therapy in conditions such as burns, crush injuries, head injuries, spinal cord injuries, reconstruction surgeries, Post
Traumatic Stress Disorder (PTSD) and High Altitude Cerebral Oedema (HACO), gas poisonings, gas gangrene, radiation
injuries, acute hearing loss various anaerobic and aerobic infections that are commonly encountered in combat. Patients who
have been suffering with non-healing ulcers, decubitus ulcers and all late sequelae of radiation therapy are also benefited with
HBO therapy. Therapy is given in special therapeutic chambers. In the sixties HBO went out of practice because of its use
without adequate scientific validation. Over the last two decades, animal studies, clinical trials and well-validated clinical
experience has proved efficacy of HBO in many indications and there is recently a renewed interest in this field all over the
world. With continuing growth all over the world Hyperbaric Medicine has found a distinct role in the modern era of
evidence-based medicine. This article aims to give a brief overview of the rationale, existing trends and applications of this
therapy.

Keywords Hyperbaric Oxygen Therapy, Crush Injuries, Wounds, Osteoradionecrosis, Mandibular Osteomyelitis etc.

INTRODUCTION
Oxygen is essential to any healing process.
Hyperbaric oxygen (HBO) therapy is a form of treatment
in which a patient breathes 100% oxygen at higher than
normal atmospheric pressure that is greater than 1
atmosphere absolute (ATA). Through HBO therapy, the
concentration of the oxygen dissolved in the bloodstream,
is thus raised many time above normal (up 2000 %).
Because of this high concentration of oxygen, HBO
therapy is used to accelerate the healing process after oral
surgery, plastic surgery, wound care, burn victims and
may neurologic, orthopaedic as well as emergency
conditions and degenerative diseases. In addition to the
blood, all the body fluids including lymph and cerebral-
spinal fluid are infused with healing benefits of this
molecular oxygen [1]. It can reach bone and tissue which
are not accessible to the red blood cells, enhance white
blood cell function and promote the formation of new
capillary and peripheral blood vessels This results in an
increased control of infections and faster healing in a
wide range of conditions. With HBO therapy, patients
have remained free from opportunistic infections,
experiencing relief from fatigue and maintain their body
weight. Long established as the primary therapy in the
treatment of medical disorders such as carbon monoxide
poisoning and gas gangrene, this therapy is now
increasingly being used on an adjunctive basis in the
management of a variety of disorders refractory to
standard medical and surgical care including cosmetic,
fitness and spa related therapeutic applications [2].

Corresponding Author- Richa Wadhawan Email- richawadhawan@gmail.com

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Mechanism of Action
The mechanism of action of hyperbaric oxygen
therapy is twofold physical and physiological. The
physical effect is exerted due to increased dissolution of
oxygen in the plasma by virtue of Henrys Law leading to
improvement in the cellular oxygen supply by raising the
tissue-cellular diffusion gradient. This has found utility in
hypoxia in a variety of settings as in regional hypoxia in
compromised surgical grafts, osteoradionecrosis, problem
wounds and crush injuries as well as in global hypoxia in
carbon monoxide and cyanide poisoning [3]. Among the
physiological effects, HBO therapy combats anaerobic
infections due to production of free radicals and direct
inhibition of the clostridial alpha toxin. It also indirectly
acts against aerobic infection by helping in the oxidative
burst. Further, HBO produces vasoconstriction through a
Nitric Oxide Synthase (NOS) mediated response, hence
reducing oedema, helps in the formation of the collagen
matrix that assists wound healing and angiogenesis and
prevents free radical injury through inhibition of ICAM1
and CD18. These mechanisms make HBO therapy to be
useful in indications such as mixed infections, clostridial
myonecrosis, necrotising soft tissue infections and
refractory osteomyelitis. Further, latest studies are
elaborating ever new mechanisms of action of HBO
therapy. It is emerging that HBO therapy increases the
number of stem cells in the human body, upregulate
expression of antioxidant and cytoprotective genes and
provides neuroprotection in the setting of cerebral
ischaemia through modulation of various molecular
markers 2 such as MMP9, HIF 1a, Superoxide Dismutase,
Nogo e A and others [4].
Most of the benefits of HBO are explained by
the simple physical relationships determining gas
concentration, volume, and pressure. HBO is most
commonly used under conditions of tissue hypoxia or to
treat decompression sickness or gas embolism, in which
gas bubbles obstruct blood flow. Increased oxygen
delivery Henry's Law states that the amount of an ideal
gas dissolved in solution is directly proportional to its
partial pressure. Thus, the dissolved plasma oxygen
concentration of 0.3 ml/dl at sea level (1.0 atm) increases
to 1.5 ml/dl upon administration of 100 percent oxygen,
while HBO delivered at 3.0 atm yields a dissolved oxygen
content of 6 ml/dl.
The latter figure is sufficient to meet resting
tissue oxygen extraction requirements irrespective of the
adequacy of the hemoglobin-bound oxygen pool. The
ability of HBO to augment oxygen content and
independently meet resting tissue oxygen requirements
has led to its use in conditions of compromised oxygen
delivery, such as profound anemia, carbon monoxide
(CO) poisoning, and both acute and chronic ischemia.
Reduction of gas bubble size The use of HBO therapy
for decompression illness is based upon Boyle's Law,
since the volume of nitrogen bubbles is inversely related
to the pressure exerted upon it. At 3.0 atm, bubble volume
decreases by approximately two-thirds. Further bubble
dissolution is accomplished by the replacement of inert
nitrogen within the bubbles with oxygen, which is then
rapidly metabolized by tissues [5].
How HBO therapy Works
The usual arterial partial pressure of O2 is 100
mm Hg, Hb is 95% saturated and 100 ml of blood carries
19 ml of O2 in combination with Hb and 0.32 ml
dissolved in plasma. If the inspired O2 concentration is
increased to 100% O2 combined with Hb can increase to a
maximum of 20 ml when the Hb is 100% saturated and
the amount of O2 dissolved in plasma may increase to
2.09 ml. During HBO in addition to the Hb which is
100% saturated the amount of O2 carried in solution will
increase to 4.4 ml% at a pressure of 2 ATA to 6.8 ml % at
3 ATA which is almost sufficient to supply the resting
total oxygen requirement of many tissues without a
contribution from oxygen bound to haemoglobin. It is this
increased oxygen in plasma which is responsible for most
of the beneficial effects of hyperbaric oxygen. Increased
pressure by its direct mechanical effect reduces bubble
size in conditions such as air embolism and
decompression sickness [6].
Hyperoxygenation causes immune stimulation
by restoring WBC function, enhanced phagocytic
capabilities and neutrophil mediated killing of bacteria.
HBO2 accelerates neo-vascularization in hypoxic areas by
augmentation of fibroblastic activity which further
promotes capillary growth. HBO causes vasoconstriction
in normal tissues but with an overall increased delivery of
oxygen due to the hyperoxygenation. This is the basis of
use in reducing edema and tissue swelling. In cerebral
edema this helps to reduce edema while maintaining
hyperoxia. It also reduces the adherence of white cells to
capillary walls and is useful in acute brain and spinal cord
injury. HBO therapy is bactericidal for anaerobic
organisms such as Clostridia welchii, and also inhibits the
growth of aerobic carboxyhaemoglobin from 4 to 5 hours
in subjects breathing room air to 20 minutes or less and is
the treatment of choice in carbonmonoxide (CO), smoke
inhalations and acute cyanide poisoning [7].
Therapeutic Effects of HBO [8-10]
Hyperoxygenation
It causes (i) Immune stimulation by restoring
WBC function and enhancing their phagocytic
capabilities and (ii) Neo-vascularization in hypoxic areas
by augmenting fibroblastic activity and capillary growth.
This is useful in radiation tissue damage and other
problem wounds.
Vasoconstriction
It reduces edema and tissue swelling while
ensuring adequate oxygen delivery and is thus useful in
acute trauma wounds and burns.
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Bactericidal
For anaerobic organisms & inhibits growth of
aerobic bacteria at pressures > 1.3 ATA. It inhibits
production of alpha-toxin by C Welchii and is synergistic
with aminoglycosides and quinolones. Thus it is
lifesaving in gas gangrene and severe necrotising
infections.
Reduces Half-Life of Carboxyhaemoglobin
From 4 to 5 hours to 20 minutes or less and is the
treatment of choice for carbon monoxide poisoning in fire
victims.
Mechanical Effects
Direct benefit of increased pressure helps
reduces bubble size in air embolism and decompression
illnesses.
Reactivates
Sleeping cells in the penumbra region around
central dead neuronal tissue. This is the basis of its use in
neurological conditions. It also reduces adherence of
WBCs to capillary walls and maybe useful in acute brain
and spinal cord injury.
Beneficial Effects of HBO
Following are some of the reasons that HBO is gaining
acceptance rapidly the world over.
Safe therapy with very few and minor side
effects. Addition of HBO obviates the need for frequent
surgical procedures, promotes healing and early
mobilization of the patient. Reduces length of
hospitalization and thereby overall treatment and
rehabilitation costs. Only treatment available in some
indications. Emerging role in indications which have
lifetime disabilities [11].
Method of Administration
HBO therapy can be given in a Monoplace
chamber in which a single patient is placed in a chamber
which is then pressurized with 100% oxygen. Monoplace
chambers are used to treat stable patients with chronic
medical conditions. Or it can be given in a Multiplace
chamber where many patients can be treated at the same
time.
These chambers are used for acute problems and
also for critically ill patients who require a medical
attendant within the chamber. These chambers are
pressurised with compressed air and the patient breathes
100% oxygen at that pressure through special masks or
oxygen hoods. The treatment control panel controls the
therapy and monitors the patient during the treatment.
Most therapy is given at 2 or 3 ATA and the average
duration of therapy is 60 to 90 minutes. Number of
therapies may vary from 3-5 for acute conditions to 50-60
for radiation illnesses [12]. HBO therapy is relaxing and
painless. The patient lies on a bed enclosed in a clear
plastic chamber. The patient and therapist can see one
another and communicate through an intercom. The
pressure is set to the prescribed level and the chamber is
filled with oxygen. The patient will experience a slight
sensation of pressure, like that felt in the descent of an
airplane. Each session lasts for up to 90 minutes. For
comfort, the patient can watch television or listen to the
radio during treatment. The individual requirements of the
patient dictate the number of hyperbaric oxygen
treatments necessary. For example, treatment for acute
carbon monoxide poisoning or bloodless surgery may
require only one treatment, while wound healing may
require 30-40 treatments. The patients response to
hyperbaric treatment ultimately affects the exact number
of treatments. The Hyperbaric Treatment Centers
medical team will work closely with the referring
physician to design an individually tailored plan to meet
each patients specific needs. Physicians receive complete
documentation and notification of progress. Most
insurance companies, including Medicare, cover at least a
portion of the costs of hyperbaric therapy [13].
Indications for HBO Therapy
These indications are supported with peer
reviewed proof of efficacy and early referral is essential.
Non-healing ulcers, problem wounds, compromised skin
grafts and flaps These wounds have the underlying
problem of tissue hypoxia, with oxygen tension usually
below 20 mmHg, and therefore more prone to infection.
The elevation of oxygen tension by hyperbaric oxygen
therapy has powerful effects on wound dynamics, by both
enhancing leukocyte bactericidal activity and promoting
the fibroblast-collagen support needed for
neovascularization [14].
HBO Therapy in Air Embolism and Decompression
Sickness
Air embolism may be caused by sudden
decompression or ascent in diving, trauma like head and
neck injuries, high altitude accidents or may be iatrogenic
during a diagnostic or surgical procedure. Air emboli may
lodge distally in the smaller arteries and arterioles of brain
and obstruct the flow of blood resulting in ischemia,
hypoxia and cerebral edema. The bubble may also act as a
foreign body and start a number of chemical reactions.
HBO therapy has been used to treat divers suffering from
air embolism or bubbles within the blood stream since
the late 1960s. [15]. Embolisms can also occur during
surgery. HBO compresses the bubbles to between 1/3 and
1/6 the original size, re-establishing uninterrupted
circulation. In many cases, the success of HBO depends
on rapid diagnosis and treatment. Decompression
Sickness (DCS) is caused by rapid reduction of
environmental pressure, which may cause formation of
bubbles from inert gases (mainly nitrogen) in the body
tissues. Also humoral agents may be released from tissues
secondary to trauma caused by expanding gas resulting in
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blood sludging. It may occur in divers, workers in
compressed air tunnels or rapid ascent by an aviator
(altitude DCS). HBO is the first line of treatment in these
conditions and helps by compression of bubbles by
increased pressure and improves the diffusion of nitrogen
from bubbles due to concentration gradient between
bubble and surrounding tissues. HBO induced
vasoconstriction inhibits air embolus redistribution and
decreases cerebral edema. High O2 counteracts the
ischemic and hypoxic effects of vascular obstruction. It
also reduces blood sludging and improves WBC function
[16].
Bloodless Surgery
HBO may also be used prior to and following
bloodless surgery to maximize the oxygen carrying
capabilities of the blood. Patients who opt for bloodless
medicine and surgery do not wish to receive blood
transfusions to replace blood lost during surgery. Oxygen
is normally carried throughout the body in the red blood
cells, which can only be replaced via a transfusion. The
high pressure of the HBO chamber forces oxygen into the
plasma, or fluid component of the blood. This enables
oxygen levels in the body to be maintained even when red
blood cells are in short supply [17].
Hyperbaric Oxygen Therapy in Smoke Inhalation and
Carbon Monoxide Poisoning
Smoke inhalation involves multiple toxicities,
pulmonary insufficiency and thermal and chemical
injuries. CO intoxication is the most immediate life-
threatening disorder in such cases causing hypoxia
resulting from displacement of oxygen from hemoglobin.
CO poisoning involves most parts of the body but the
areas most affected are those with high blood flow and
oxygen requirement like brain and heart. When a patient
inhales a lethal amount of carbon monoxide, the CO
migrates directly into the tissues where it attached to and
alters proteins. These alterations do not become toxic
until the tissues have an inadequate supply of oxygen.
Administering oxygen at normal atmospheric pressure
does not terminate this process. However, HBO therapy at
pressures greater than 2 atmospheres stops cell
deterioration. HBO causes immediate saturation of
plasma with enough oxygen to sustain life and to
counteract tissue hypoxia in spite of high levels of COHb.
It causes a rapid reduction of CO in the blood and from
cytochrome oxidase and restores its function. It also
reduces cerebral edema and brain lipid peroxidation
caused by CO [18].
Osteomyelitis
Chronic bone infections that resist treatment
carry high medical costs over the years. In combination
with a comprehensive regimen of cleansing, isolation of
infection, bone and muscle grafting and antibiotics, HBO
can speed the healing process and may also reduce the
likelihood of re-infection.
In chronic osteomyelitis refractory to the
antibiotics and conventional treatment, the primary
problem is an interface or barrier between the infection
and the host. This barrier may be necrotic bone,
suppuration, avascular scar or other oxygen barriers that
preclude leucocyte, immunoprotein or antibiotic entry
into the infection focus [19].
HBO enhances permeation of the barrier by host
factors and antibiotics. HBO drives the host factors of
leucocytic killing and osteoclastic resorption to occur.
Periodic elevation of bone and oxygen tension from
hypoxic levels to normal or supranormal levels promotes
fibroblastic division, collagen production. Intermittent
oxygen tensions of 30-40 mm Hg are necessary for
neovascularisation in an ischaemic environment.
Osteoclastic resorption of the microscopic residuals of the
dead, infected bone (microscopic surgical debridement)
may be the crucial factor in eliminating the osteomyelitis
focus and thereby prevent recurrences. The osteoclast has
a metabolic activity approximately 100 times greater than
that of the osteocyte; hence its function is highly oxygen
dependent. The osteoclast function is stimulated by HBO
as demonstrated in rabbit models. Aminoglycoside
transfer across the bacterial cell wall is oxygen -
dependent and in a hypoxic environment, is enhanced by
HBO therapy [20]. The surgical removal of all avascular
tissue, necrotic bone and sinus tract is essential for
treatment success. This is easy to practice where the
interface between the dead / infected bone and the viable
bone is clearly defined. However, such debridement is not
without disfigurement, if facial bones are affected or
when the osteomyelitis is of diffuse type. For these types
of cases, HBO can obviate the need of such surgery and is
the ideal adjunct to conventional treatment. Even if the
patient of mandibular osteomyelitis has undergone
disfiguring surgery, HBO is ideal to prepare a well
vascularised tissue bed for reconstructive surgery. Further
in the post-operative period HBO helps in faster healing
and integration of the graft. Osteomyelitis causes low
oxygen tension in infected bones. Studies show that
elevating the oxygen tensions in affected bones and the
surrounding tissues helps speed healing. HBO provides
adequate oxygen for fibroblast activity, augments certain
antibiotics (aminoglycosides, vancomycin, quinolones
and certain sulfonamides), and prevents
polymorphonuclear leukocytes from adhering to damaged
blood vessel linings [21].
Radio Necrosis
HBO therapy represents a new approach to the
treatment of wounds caused by radiation therapy.
Radiation burns differ considerably from normal wounds.
When the body is wounded, the blood flowing from all
directions is cut off abruptly, therefore creating a sudden
drop in oxygen pressure and sending a message to the
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brain to send all the infection fighters and healing agents.
In the case of radiation therapy, the pinpoint center of the
area being treated receives the greatest amount of
damage, while the perimeter receives the least. Since the
radiation damage is gradual, the oxygen pressure does not
drop abruptly and the brain does not receive the message
to send infection fighting and healing agents. When the
oxygen pressure is increased by over 10 times during
HBO therapy, the brain can then recognize a sudden
decline in pressure at the wound site, triggering the
healing process. This provides new hope for patients
suffering from radiation wounds that are incapable of
healing.
Radiotherapy is used in treating malignant
tumors in the head and neck region, and can result in a
hypoxic, hypocellular, hypovascular environment which
causes injury to surrounding normal tissue. The use of
HBO therapy in improving wound healing is based on the
principle that delivery of oxygen is an essential process
when considering tissue & bone repair [22].
Although HBO therapy is widely applied, its
mechanism of action is still poorly understood, and there
is controversy over its clinical use. This literature review
found that experimental research involving HBO therapy
is scarce, and there is a lack of randomized controlled
clinical trials.
The review concludes that more research, both
clinical and experimental, is necessary before solid
conclusions can be drawn regarding the use of HBO
therapy in the management of radiation-induced injury to
the head and neck region. The beneficial effects of HBO
result from an improved vascular supply, increased
oxygen tension at the tissues. Adequate tissue oxygen
tension also facilitates fibroblast proliferation, new
capillary formation, osteogenesis and optimal
polymorphonuclear leukocyte function [23].
Soft-Tissue Infections
HBO has also been proven to fight infection
from bacteria that need oxygen to survive. Although it
may seem that raising oxygen levels would promote the
growth of these bacteria, the reverse is true. Simply
stated, white blood cells kill bacteria with an explosion
of oxygen. When oxygen levels are lower than normal
due to poor circulation, white blood cells are not strong
enough to produce this explosion. HBO not only restores
oxygen to the normal level, but super charges these
cells by delivering oxygen under greater than normal
pressure. Necrotizing infections like crepitant anaerobic
cellulitis, progressive bacterial gangrene, necrotizing
fasciitis and nonclostridial myonecrosis cause hypoxia in
surrounding tissues, impair neutrophil activity and thus
anaerobic bacteria proliferate. The infection also triggers
occlusive endarteritis. It is well documented that death
rates are lower among patients with necrotizing infection
who receive HBO treatments plus standard therapy
(debridement and antibiotics) and they require fewer
debridement [24].
Tissue Flaps and Grafts
Most tissue flaps and grafts heal readily without
HBO. However, when a flap has lost oxygen and is in
danger of becoming unsalvageable, HBO can often
sustain the flap until the blood flow can be restored. HBO
therapy can also significantly increase new capillary
growth following surgery.
When the wound bed in skin grafts and flaps
does not have enough oxygen supplied to it, the skin graft
will at least partially fail. Common causes are previous
radiation to the wound area, diabetes, and certain
infections. Factors such as age, nutritional status, smoking
etc, also result in an unpredictable pattern of blood flow
to the skin. Partial or complete failure of the wound
reconstruction is very difficult for a patient and also very
expensive. HBO is well recognized for its role in assisting
in the preparation and salvage of skin grafts and
compromised flaps [25].
Diabetic Ulcers
HBO therapys role in stimulating capillary
growth and increasing the white blood cells capacity to
kill bacteria make it an effective aid in the treatment of
diabetic ulcers and other hard-to-heal wounds. Diabetics
are especially susceptible to these ulcers due to poor
circulation, low oxygen levels in the blood stream and
rigidity of the blood cells. In addition to increasing the
amount of oxygen carried to tissues, HBO therapy also
increases glucose and reduces lactose levels, making
blood cells more flexible. This allows blood vessels in the
bodys extremities. Wound care strategies, which include
hyperbaric therapy, have been proved to be cost effective
with reduced amputations thereby vastly improving the
quality of life for these patients [26].
Gas Gangrene
This familiar disease, caused by loss of blood
supply, produces dead tissue accompanied by gas bubbles
infected by bacteria that thrive in the absence of oxygen.
These bacteria produce deadly toxins that rapidly multiply
within the tissues of the body. Before HBO therapy, the
only way to save a patient with gas gangrene from rapid
death was to surgically remove the infected area by
amputation or disfiguration. HBO inhibits the production
of these poisonous toxins, stabilizes the patient, controls
the infection and reduces the need for immediate surgery
[27].
Compartment Syndrome
The use of HBO for the Skeletal Muscle
Compartment Syndrome is indicated in severe pain,
marked swelling, tenseness of the muscle compartment,
Neuropathy, myelopathy, and/or encephalopathy and
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skeletal-muscle compartment pressure measurements
greater than 40 mmHg in the uncompromised host. Rising
serial compartment pressure measurements as values
approach 30-40 mmHg in mildly compromised host
(diabetic, peripheral vascular disease, collagen vascular
disease, etc.) and 20-30 mmHg in hypotensive patients
will benefit from HBO therapy [28].
HBO in Wounds Healing
HBO therapy can play a significant role when
combined with conventional therapy in the following
types of wounds
1. Problem Wounds These fail to respond to
established medical and surgical management for more
than 30 days.
2. Vascular Insufficiency Ulcers HBO is
recommended in selected wounds, which do not heal
despite maximum revascularization. Additionally for
preparation of a granulating bed for skin grafting in areas
with poor circulation such as venous ulcers [29].
3. Infective Wounds Clostridial Myositis &
Myonecrosis (Gas Gangrene) Clostridium bacteria are
anaerobic, and their replication, migration and exotoxin
production is inhibited on exposure to high oxygen during
HBO therapy. It is well established that addition of HBO
helps in these gravely ill patients saves life and possibly
limb amputation [30].
4. Traumatic Crush Injury When body tissues are
severely traumatized such as in accidents, falls and
gunshot wounds, the rate of complications such as
infection, non-healing of fractures and amputations range
up to 50%. As an adjunct to orthopedic surgery and
antibiotics, HBO therapy can significantly decrease costs
and complications. A number of factors contribute to
tissue death due to traumatic crush injury. Although a
surgeon can repair large blood vessels, crushed micro-
vessels (capillaries) cannot be mended. In addition, the
affected area may swell, limiting circulation even further.
As the oxygen level drops in the tissue, the cells lose their
consistency and their ability to regenerate. HBO sends
oxygen to greater volumes of tissue, promoting new cell
growth. It is vital that crush injury patients receive HBO
therapy early, perhaps even before surgery is scheduled
[31].
5. Thermal Burns The burn wound is a complex and
dynamic pathophysiologic process characterized by a
zone of coagulation, surrounded by a region of stasis,
bounded by an area of hyperemia. Adjunctive HBO
therapy has been shown to limit the progression of the
burn injury, reduce swelling, reduce the need for surgery,
diminish lung damage, shorten the hospitalization and
result in significant overall cost savings. These benefits
are more apparent if therapy is initiated within 6-24 hours
of the burn injury. Indications for HBO therapy include
deep second-degree and third-degree burns that involve
greater than 20% of the total body surface area and less
extensive burns that involve the face, hands or groin area
[32].
HBO in Oncology & Radiation Tissue Damage
Patients, who have received 2,000 to 5,000 rads
or more, may have difficulties with any subsequent
surgical healing. The primary mechanism of late radiation
tissue complications is endarteritis (progressive loss of the
microvasculature) resulting in tissue hypoxia, death and
necrosis. Conventional treatment is often frustrating.
HBO is the only treatment available for these conditions
and helps reduce morbidity, disfiguring sequelae and
further need for corrective surgery. HBO is also being
evaluated for its role in enhancing radiosenstivity in
selected head and neck tumors [33].
Late Radiation Induced Tissue Damage
HBO raises tissue pO2 to within the normal
range initiating cellular and vascular repair mechanisms.
It stimulates angiogenesis, increases neovascularization,
fibroblast and osteoblast proliferation and collagen
formation in hypovascular, irradiated tissues - skin,
mucosa and bone. It thus helps in re-epithelialization of
ulcers and creation of a vascular bed to support grafts and
pedicle flaps. HBO is also bactericidal for certain
anaerobes, bacteriostatic for certain species of escherichia
and increases the rate of killing of bacteria by phagocytes
thus helping immune suppressed patients. Common
indications are osteoradionecrosis, soft tissue necrosis,
radiation cystitis, proctitis enteritis, vesicocutaneous
fistula; radiation induced optic neuropathy, retinopathy,
CNS damage etc [34].
Adjunctive to Therapeutic Radiation
In an irradiated field, endarteritis, tissue hypoxia
and tissue fibrosis occur leading to increased post-
operative complications like wound infections, dehiscence
and delayed healing. Implantation of metal prostheses into
irradiated tissue as restorative surgery give higher failure
rate. Pre and post-operative HBO enhances the quality of
irradiated tissues to allow them to better withstand
surgical insults. HBO stimulates bone formation, turnover
and bone maturation. It significantly reduces the risk of
osteo-radionecrosis and implants failure. Prophylactic
HBO is used for tooth extraction or surgery in previously
irradiated tissue and prevention of osseo integrated
implant failures [35].
HBO as Radiosensitiser
The oxygen tension inside a tumor can be as low
as 8 mmHg. It drops lower as the tumor enlarges and may
drop to zero in the necrotic center of the tumor. Hypoxia
increases the resistance of cancer to radiotherapy. With
oxygen tension at zero, the amount of radiation required
to be effective is three times that required with normal
oxygen tension. When irradiation is done immediately
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after HBO therapy, the well- oxygenated cells will be
damaged lethally.
The effect of HBO in enhancing radiosensitivity
is most pronounced in head and neck tumors. HBO can be
combined with other radiosensitivity enhancers too.
Indications are Neuroblastomas mainly Glioblastoma
Multiforme and Astrocytoma and also re-irradiation of
squamous cell carcinoma head and neck [36].
HBO Therapy in Sudden Hearing Loss
Sudden hearing loss is a sensorineural hearing
impairment, which develops over a period of few hours to
a few days and with no recognized causes at the time of
onset - cochlear ischemia is a frequent etiology. Studies
have shown that cochlear activity is sensitive to constant
supply of oxygen and the performance of the auditory
system can be improved by intense application of oxygen
along with vasodilators and anti-inflammatory drugs. The
beneficial effects of HBO on sudden sensorineural
hearing loss are probably achieved by an increase in the
distribution of O2 dissolved per volume unit of blood
circulating through the regions affected by the lack of
oxygen. Increase oxygen in the peri and endolymph helps
in the recovery of inner ear function. HBO also improves
haemorrheology and contributes to improved
microcirculation. It lowers hematocrit, blood viscosity
and improves erythrocyte elasticity [37].
HBO Therapy in Exceptional Blood Loss (Anemia)
If a patient has lost sufficient red cell mass to
compromise respiratory requirements and will not receive
transfusions because of medical or religious reasons, the
intermittent use of HBO therapy as short term
management will supply enough oxygen to support the
basic metabolic needs of the body until red blood cells are
restored.The following guidelines are recommended when
using HBO in such indications mean blood pressure
below 60 mm Hg, or requirement for vasopressors;
altered mental status; myocardial ischemia by clinical or
ECG criteria; ischemic bowel or severe lactic acidosis
[38].
Rationale for HBO Therapy in the Treatment of
Neurological Illnesses
The rationale of use of HBO in neurological
indications is based on the finding in SPECT studies that
around the central area of neuronal death is the penumbra
peri-infarct zone having hibernating/idling or sleeping
neurons and gliosis (dead neurons) on CT scans may
actually be viable tissue for years following the insult.
HBO delivers high oxygen to these sleeping cells and
reactivates them. It also reduces edemas and reverses the
reduced flexibility of erythrocytes. This is the basis of its
use in acute stroke, post-traumatic brain injuries and
cerebral palsy. Evidence based neurorehabilitation as a
science is yet evolving, available treatment methods are
not adequate and few centers have opportunity to explore
the role of a range of modalities in these patients. After
reviewing international and national experience a possible
inference is that there appears evidence of a physiological
basis and a possible role of Hyperbaric Oxygen in
management of well-defined ischemic and anoxic
neurological illnesses [39].
Mechanism of Action
The possible mechanism of action of HBO in
neurological disorders is relief of hypoxia, improvement
of microcirculation and cerebral metabolism, reduced
cerebral edema by vasoconstrictive effect, increases the
permeability of the blood-brain barrier and preservation
of partially damaged tissue and prevention of further
progression of secondary effects of cerebral lesions [40].
Indications for HBOT in Neurological Illnesses
Cerebrovascular Accidents (Stroke)
The reported rate of improvement is 40% to
100%, which is much higher than the natural rate of
recovery. It shows a striking reduction in spasticity
possibly due to improved function of neurons in affected
areas or the brain and secondly to rise of PO2 in the
spastic inactive and hypoxic muscle. Additionally there is
an improvement in the cognitive and mental performance.
The major criticism is that none of the reported studies are
random controlled [41].
Acute Traumatic Brain Injuries
HBO causes reduction of CBF thus reducing
intracranial tension yet providing concomitant high doses
of oxygen to the brain. It interrupts the cycle of ischemia,
hypoxia, edema and enzymatic derangements. There is
improved aerobic metabolism, reduction in lactate levels,
increase in creatinine phosphate and ATP levels.
Elevation of partial pressure of oxygen increases the
diffusion distance, and O2 delivery in abnormal areas is
enhanced. However there has to be a responsive cerebral
circulation. It is contraindicated when a stage of
vasomotor paralysis has developed, and must not have
fixed and dilated pupils. Most favourable results are
obtained in patients in mid-level Glasgow Coma scales.
Spinal Cord Injury
There is evidence that it is useful in spinal cord
traumas especially if administered within the first 4 hours
and for subsequent rehabilitation of spinal damage
patients.
Cerebral Palsy
Evidence now shows that HBO therapy may
dramatically improve some CP symptoms spasticity,
vision, hearing, and speech. However improvement, if
any, will vary from patient to patient. More oxygen may
help many children with cerebral palsy, but it is NOT a
cure. It is simply a way of ensuring the most complete
recovery possible and must be combined with other
therapies [42].
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Bells palsy
Steroids and surgical decompression are the only
treatment used currently but results are inconclusive as to
their benefit. HBO added to other treatment increases the
efficacy of the treatment and reduces the period needed
for restoration of complete function of the damaged nerve
[43].
Toxic Effects/Complications
When used in standard protocols of pressures
that do not exceed 3 ATA (300 kPa) and the length of
treatment is less than 120 minutes, hyperbaric oxygen
therapy is safe.
Ear Barotrauma
This is the most common side effect of HBOT.
Ear barotrauma is a condition of discomfort in the ear
caused by pressure differences between the inside and the
outside of the eardrum. This may be caused by an upper
respiratory infection, nasal congestion, or immature or
deformed eustachian tubes. Usually, the discomfort is
temporary and can be resolved by equalizing the pressure
in the ears. Children can be taught to clear (pop) their ears
by drinking water, chewing gum, yawning or simply by
blowing pressure into the nose while pinching it shut.
Decongestants or nasal sprays may be used, if necessary.
If a patient is unable to equalize their ear pressure, the
chamber pressure will be reduced until their ear
discomfort subsides. Rarely, some patients may have to
stop treatment and get evaluated by an ENT specialist for
possible ear tube placement. Also, a device, called the Ear
Popper that helps in relieving the discomfort of sinus
pressure [44].
Sinus Pain
This is the second most common HBOT
complication and usually occurs in patients with upper
respiratory tract infections or allergic rhinitis. Usually a
program of decongestant nasal spray, antihistamines,
and/or steroid spray just prior to compression allows
therapy to continue.
Ocular Changes
Transient reversible myopia, retrolental
fibroplasia and vision changes can be caused or worsened
by hyperbaric therapy. It is always temporary and
resolves after discontinuing treatment. Do not get new
prescription glasses while receiving treatment.
Acceleration of growth in existing cataracts is seen rarely
in the elderly.
Oxygen Toxicity
Pulmonary and neuralgic manifestations (Paul
Bert effect) of excessive oxygen are often cited as major
concerns. Oxygen tolerance limits that avoid these
manifestations are well defined for continuous exposures
in normal people. Toxicity is not produced by daily
exposures to oxygen at below 2.0 ATA for up to 2 hours
per day. The protocol for most of the diagnoses addressed
by clinician is 1.5 ATA for 1 hour a day. Oxygen toxicity
can be prevented in most tissues by using five minutes air
in the chamber for every 30 minutes of oxygen. This
allows antioxidants to deal with free oxygen radicals
formed during the hyperoxic period [45].
Oxygen Seizures
Incidence of seizures is very rare and occurs only
about once in over 200,000 treatments. Seizures have
never been reported in treatments at less than 2.0 ATA for
1 hour or less. These are usually seen in persons with a
known seizure disorder.
Fire
Theoretically there is an increased risk of fire
due to the enriched oxygen atmosphere inside of a tank.
Since this chamber used by this clinic delivers oxygen
through a mask system, the risk of fire is greatly reduced.
Further, these risks are minimized by eliminating fire
causing materials from the tank during treatment. No
pocket warmers, lighters, or cell phones should ever be
carried inside the chambers. Under certain conditions,
battery operated devices may or may not be allowed. Fire
is a realistic hazard but preventable by strict safety
procedures and the patient may be claustrophobic.
Claustrophobia
Due to the confining nature of this treatment,
confinement anxiety may occur. If signs of this are seen,
therapy may be discontinued until this problem is
resolved. In an emergency it takes two minutes to
decompress the chamber. The chamber door cannot be
opened until it is totally decompressed [46].
Pulmonary Barotrauma
Pulmonary barotrauma is a condition that rarely
happens at the end of a therapy session, during
decompression. This can be caused by the patient holding
their breath during decompression or by certain lung
diseases. Lung diseases that can cause an increased risk of
pulmonary barotrauma include those in which there is
obstruction to gas flow, such as asthma that has not
responded fully to treatment and lung scarring or
inflammation (such as sarcoidosis, eosinophilic
granuloma, or interstitial fibrosis).
More rarely, a patient might experience a
spontaneous pneumothorax. This occurs when an existing
abnormality of the lung ruptures and allows air to leak
between the lung tissue and the chest wall making it
difficult to expand the lung and breathe. These are very
dangerous and require emergency care. Fortunately this
complication has never been seen in mild hyperbaric
treatments [47].
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CONTRAINDICATIONS [48-50] Since cancers both thrive in blood rich

Upper respiratory Infections environments and may be suppressed in high oxygen
These conditions can make it difficult for the environments, cancer and HBO poses a dilemma since
patient to clear their ears, which can result in what may be HBO both increases blood flow via angiogenesis and also
termed sinus squeeze. raises oxygen levels.

High Fevers History of Spontaneous Pneumothorax

In most cases the fever should be lowered before
hyperbaric oxygen treatment begins.
History of Thoracic (Chest) Surgery
This is rarely a problem and usually not
considered a contraindication. However, there is concern
that air may be trapped in lesions that were created by
surgical scarring. These conditions need to be evaluated
prior to considering HBO therapy.
Malignant Disease
Severe chronic obstructive pulmonary disease
(COPD) with CO2 retention or bullous emphysema. This
condition can lead to pneumothorax during HBO
treatment.
Other
Severe cardiomyopathy or decompensated
congestive heart failure (CHF), Poorly controlled seizure
disorders, History of optic neuritis, History of
reconstructive ear surgery etc.

Figure 1. An Multiplace Clinical Hyperbaric Chamber

Courtsey Methods in medicine. Hyperbaric oxygen therapy in the battlefield. Medical journal armed for cesindia.
2013; 69 94 - 96.

CONCLUSION familiarize themselves with recent evidence on this mode

Hyperbaric medicine is poised at an exciting era
of revival. The role of hyperbaric oxygen therapy is
scientifically established in certain well defined
conditions and the hyperbaric chamber is now an integral
part of hospital services. Doctors in all fields must
of therapy, so that their patients are not denied the gains
of this modern treatment. Cost analysis has shown that the
addition of hyperbaric oxygen to conventional treatment
results in significant cost savings due to lesser stay in
hospital and shorter course of illness.

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