more indications than many doctors realise. (Editorial)
Subjects: Hyperbaric oxygenation_Therapeutic
Reference #: A14393718
Full Text COPYRIGHT British Medical Association
More indications than many doctors
Many British doctors are
ignorant of the indications for hyperbaric oxygen and sceptical of its
benefits, according to a recent survey of hyperbaric oxygen facilities.
The survey, by the BMA's Board of Science and Education, concluded that
given the present level of use then provision was sufficient, although
doctors may be underusing the treatment. They need to know for which
conditions hyperbaric oxygen works and refer accordingly. The telephone
advisory service, run by the Institute of Naval Medicine at Gosport (similiar
to the National Poisons Unit help line), should be better known.
Treatment with hyperbaric
oxygen was introduced as an adjunct to cardiovascular surgery before
cardiopulmonary bypass techniques and deep hypotheria became available.
But when surgery in a hyperbaric chamber was no longer necessary most of
the original researchers stopped studying it. Britain helped to pioneer
the use of hyperbaric oxygen to treat carbon monoxide poisoning,
refractory osteomyelitis, and compromised skin grafts. But with no
formal training programmes and little funding, the treatment now
attracts little attention in Britian.
When administered at
pressures greater than one atmosphere, oxygen can assume properties more
akin to a drug than a simple support for metabolism. In carbon monoxide
poisoning, for example, it stops lipid peroxidation, which spares
neuronal cell membranes. It reduces odema by about 50% in post
ischaemic muscle through preserving adenosine triphosphate. In acute
burns it reduces fluid requirements by 35% in the first 24 hours, thus
reducing oedema.[5-8] It reduces white cell adhesion to capillary walls
after ischaemic or traumatic insult, mitigating the no reflow
phenomenon. Red cell flexibility is doubled in about 15
treatments. White cell killing of aerobic bacteria and some fungi is
greatly enhanced at high oxygen pressures, facilitating control of
osteomyelitis and reducing the number of operations and mortality in
necrotising fasciitis. Extremely important is its stimulation of new
capillary and collagen formation in radiated tissue, normalising tissue
oxygen tensions to permit surgery, healing, and even bone grafting.[14
Finally, it increases tissue
levels of superoxide dismutase, which counters the formation of free
radicals after injury, resulting in better tissue survival. This is
particularly important in crush injury, replants, and grafts, where free
radical formation is responsible for reperfusion injury.
Although many doctors
believe that good research on hyperbaric oxygen is rare, the converse is
true.[18-22] Over 3800 papers have been published on the topic despite
the relative scarcity of chambers. The Undersea Medical Society began
investigating the claims being made for hyperbaric oxygen treatment in
1977. A committee (which I chaired) considered 64 different allegedly
improved by treatment with hyperbaric oxygen. In most of them there was
insufficient evidence to warrant its clinical use. In preparing out
original report we consulted the largest private insurers in the United
States, Blue Cross/Blue Shield, and the Federal Health Care Finances
Administration. Since then the report has been continually updated. At
present only 12 conditions are approved by the society for
reimbursement. Since 1977 the number of clinical chambers in the
United States has grown from 37 to nearly 300.
For inclusion on the
approved list there had to have been controlled studies or large
clinical series indicating not only the efficacy but also the cost
effectiveness of treatment with hyperbaric oxygen. In disorders for
which prospective controlled trials were impossible or unavailable,
evidence adduced for the efficacy of hyperbaric oxygen had to be at
least as convincing as that used to support reimbursement of other
treatments routinely paid for the insurers. The five major British
centres for the most part limit treatment to those disorders on the
approved list, despite there being no regulation to that effect.
This list can serve only as
a guide. Though quite useful in diabetic wounds, hyperbaric oxygen is
only part of a programme of total wound care. For some diabetic wounds
hyperbaric oxygen is inappropriate if the large vessels distal to the
trifurcation at the knee are occluded or severely stenotic. Crush injury
and impending compartment syndrome need to be treated immediately if any
worthwhile result is to follow. Late referral, which gives time for
oedema, reperfusion, and injury; free radical damage; and the no reflow
phenomenon to do their work, makes the treatment largely a waster of
time and money. For some surgical patients the potential dangers of
further trauma to the wound during transportation will militate against
the use of hyperbaric oxygen.
Experience has shown,
however, that patients with severe carbon monoxide poisoning can be
transported safely over long distances in a properly equipped ambulance
Before transfer a critically
ill patient is contemplated it should be ascertained that the receiving
chamber facility can deliver the necessary level of intensive care.
Whenever the use of hyperbaric oxygen is considered, consultation with
the physician in charge of the hyperbaric oxygen facility is mandatory
to ensure that referral is appropriate. The timing of hyperbaric oxygen
in relation to surgery is also critically important. For example, in
necrotising fasciitis, surgery is the accepted primary treatment, with
hyperbaric oxygen used as a follow up. With gas gangrene, however, the
hyperbaric chamber is used before surgery (other than for fasciotomy).
In the treatment of radionecrosis the patient should be treated at least
20 to 30 times in the chamber, to induce the formation of new
capillaries, before elective surgery is performed if healing is to be
 BMA Board of Science and
Education. Clinical hyperbaric medicine facilities in the UK London: BMA,
 Perrins DJD, Maudsley RH, Colwil MR, Slack WK, Thomas DA. OHP in the
management of chronic osteomyelitis. In: Brown IW, Cox BG, eds.
Proceedings of the third international conference on hyperbaric
medicine. Washington, DC: National Academy of Sciences, National
Research Council, 1966:578-89. (Publication 1404.)
 Thom SR. Antagonism of carbon monoxide-mediated brain lipid
peroxidation by hyperbaric oxygen. Toxicol Appl Pharmacol
 Nylander G, Lewis D, Nordstrom H, Larsson J. Metabolic effects of
hyperbaric oxygen in post-ischemic muscle. Plast Reconstr Surg
 Cianci P, Leuders HW, Lee H, Shapiro RL, Sexton J, Williams C, et
al. Adjunctive hyperbaric oxygen therapy reduced length of
hospitalisation in thermal burns. J Burn Care Rehabil 1989;19:432-5.
 Nylander G, Nordstrom H, Eriksson E. Effects of hyperbaric oxygen on
oedema formation after a scald burn. Burns 1984;10:193-6.
 Stewart RJ, Yamaguchi YT, Cianci PA, Knost PM, Samadani S, Mason SW
et al.The effects of hyperbaric oxygen on adenosine triphosphate in
thermally injured skin. Surgical Forum 1988;39:87-90.
 Wells CH, Hinton JG. Effects of hyperbaric oxygen on post-bur plasma
extravasation. In: Davis JC, Hunt TK (eds). Hyperbaric oxygen therapy.
Bethesda, Maryland: Undersea Medical Society, 1977:259-65.
 Zamboni WA, Roth AC, Russell RC, Graham B, Suchy H, Kucan JO.
Morphological analysis of the microcirculation during reperfusion of
ischemic skeletal muscle and the effect of hyperbaric oxygen. Plast
Reconstr Surg 1993;1110-23.
 Mathieu D, Coget J, Vinckier F, Saulnier A, Durocher ET, Wattel F.
Red blood cell deformability and hyperbaric oxygen. Med Subaquatique
 Mader JT, Brown GL, Gluckian JC, Wells CH, Reinarz JA. A mechanism
for the amelioration by hyperbaric oxygen of experimental staphylococcal
osteomyelitis in rabbits. J Infect Dis 1980;142:915-22.
 Davis JC, Heckman JD, DeLee JC, Buckwold FJ. Chronic non-hematogenous
osteomyelitis treated with adjuvant hyperbaric oxygen. J Bone Joint Surg
 Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS.
Hyperbaric oxygen therapy for necrotising fasciitis reduced mortality
and the need for debridements. Surgery 1990;108:847-50.
 Marx RE, Johnson RP. Problem wounds in oral and maxillofacial
surgery: the role of hyperbaric oxygen. In: Davis JC, Hunt TK, eds.
Problem wounds: the role of oxygen. New York: Elsevier Science
 Marx RE, Johnson RP, Kline SN. Prevention of osteroradionecrosis: a
randomised prospective clinical trial of hyperbaric oxygen versus
penicillin . J Am Dent Assoc 1985;111:490-554.
 Kaelin CM, Im MJ, Myers RA, Manson PN, Hoopes JE. The effects of
hyperbaric oxygen on free flaps in rats. Arch Surg 1990;125:607-9.
 Manson PN, Anthenelli RN, Im MJ, Bulkley GB, Hoopes JE. The role of
oxygen-free radicals in ischemic tissue injury in island skin flaps. Ann
 Davis JC. Hyperbaric oxygen therapy. Intensive Care Med
 Goulon M, Barois A, Rapin M, Nouilhat F, Grosbuis S, LaBrousse J.
Intoxication oxycarbonee et anoxie aigue par inhalation de gaz de
charbon et hydrocarbures. Am Intern Med 1969;120: 335-49.
 Hart GB, Lamb RC, Strauss MB. Gas gangrene 1: a collective review.
J Trauma 1983;23:991-5.
 Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s. Cleve
Clin J Med 1992;59: 517-28.
 Strauss MB, Hargens AR, Gershuni DH, Greenberg DA, Crenshaw AG,
Hart GB, et al. Reduction of skeletal muscle necrosis using intermittent
hyperbaric oxygen in the model compartment syndrome. J Bone Joint Surg
 Thom SR. Hyperbaric oxygen therapy: a committee report. Bethesda:
Undersea Hyperbaric and Medical Society, 1992.