Plan. What is HBO?How is it administered?What does it do for the diabetic wound?What is the evidence for it?A plan of care. Hyperbaric Oxygen Treatment is breathing 100% oxygen at an ambient pressure greater than 1 atmosphere absolute. It is not:Breathing 100% oxygen at normobaric pressureTopical application of hyperbaric oxygen to a limb.
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1. Hyperbaric Oxygen Treatment for Diabetic Foot Wounds Dr David Wilkinson
Hyperbaric Medicine Unit
Royal Adelaide Hospital
2. Plan What is HBO?
How is it administered?
What does it do for the diabetic wound?
What is the evidence for it?
A plan of care
3. What is HBO?
4. Hyperbaric Chambers Multiplace
Accommodate several people
Compress on air
Staff present inside chamber
Compress with oxygen
5. HBO treatment profile Compression of the chamber to 2.0 – 2.8 atmospheres over 5 minutes
Equalise middle ear
Breathe oxygen for 60 - 90 minutes
Decompress to 1 atmosphere over 15 – 30 minutes
7. How does HBO work? HBO effect Physical
Arterial oxygen partial pressure 1000-1800 mmHg
10-20 times usual pressure
Oxygen will diffuse 3-4 times further
Improved oxygenation ? improved cell function
Hyperoxygenated for 2 hours out of 24
Relative hypoxia for 22 hours
High oxygen pressure leads to changes in cell function
Hypoxia and erythropoietin release in the kidney and chemoreceptor activity in the aortic arch and carotid body
8. HBO effect Biochemical
Oxygen acts as a signal messenger for cell function
Fibroblast proliferation and collagen formation
Endothelial “budding” and angiogenesis
Functional receptor changes on Neutrophil
9. Theory of Wound Healing Identify hypoxia as a cause of non-healing
Fibroblast function poor with PtcO2 < 40mmHg
Neutrophil function poor with PtcO2 < 30mmHg
Administer HBO2 if indicated
Transcutaneous Oximetry (PtcO2)
10. Transcutaneous Oximetry PtcO2 prospectively used to predict healing of limb wound
Bunt, Ann Vasc Surg, 1996
PtcO2 a better predictor of healing than Doppler arterial pressures and ABI
Padberg, J Surg Res, 1996
PtcO2 predicts likely response to HBO
Smith, Wound Rep Reg, 1996
11. Published evidence
12. Diabetic problem wounds RCT
Doctor, J Postgrad Med 1992
Faglia, Diabetes Care 1996
Abidia, Eur J Endovasc Surg 2003
Kessler, Diabetes Care 2003
13. Medicare Review Medicare Services Advisory Committee
Supporting Committee reporting to MSAC
Review of Hyperbaric Oxygen Therapy
14. Medicare Review Pooled results from diabetic studies
17. Medicare Review MSAC recommended that public funding for hyperbaric oxygen therapy should be supported for HBOT administered for the following indications:
“Diabetic wounds including diabetic gangrene and diabetic foot ulcers. There is evidence that HBOT is effective in promoting wound healing, and reducing the length of hospital stays and the likelihood of major amputations in patients with diabetic wounds. There may also be cost savings associated with treatment benefits.”
18. Cochrane Review Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric oxygen therapy for chronic wounds (Cochrane Review). In: The Cochrane Library, Issue 2, 2004.
“In people with foot ulcers due to diabetes, HBOT significantly reduced the risk of major amputation and may improve the chances of healing at 1 year”
May be justified where HBOT facilities available
Need ecomonic evaluation
Need appropriately powered trial of high methodological rigour
19. A plan of care Persons with diabetes require a systematic, integrated, multidisciplinary assessment
HBO may be indicated if local tissue hypoxia is thought to be involved
Any vascular surgery for large vessels is first
To identify likely benefit
Assimilate HBO treatment into care plan
20- 30 sessions
20. Summary HBO is a relatively safe, validated therapy
It does take time – 30 daily sessions
It works best in tissues that are hypoxic to some degree
Enhanced cell function (fibroblasts, angiogenesis)
Angiogenesis means the benefits of HBO will carry over for several months
We have a cheerful, committed team to facilitate the course of treatment
It is approved by Medicare
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