What are the benefits of hyperbaric oxygen therapy (HBOT) in wound care?

Benefits of Hyperbaric Oxygen Therapy in Wound Care

Hyperbaric oxygen therapy (HBOT) may be considered as an adjunctive therapy for nonhealing diabetic foot ulcers after revascularization, but has limited evidence supporting its use for other wound types. 1

Mechanism of Action

HBOT works through several physiological mechanisms that can benefit wound healing:

• Increases tissue oxygen tension to levels that support wound healing
• Enhances angiogenesis and collagen deposition
• Improves leukocyte killing ability against bacteria
• Inhibits toxin formation in anaerobic bacteria
• Promotes stem cell release from bone marrow via nitric oxide pathways 2, 3

Evidence-Based Benefits by Wound Type

Diabetic Foot Ulcers (DFUs)

• Strongest evidence base for HBOT use in wound care
• May reduce major amputation rates in patients with diabetic foot ulcers 1
• May improve wound healing rates at 12 months in selected patients 1
• Most beneficial in neuro-ischemic or ischemic diabetic foot ulcers where standard care has failed 1

Other Wound Types

• Limited evidence for venous ulcers, arterial ulcers, and pressure ulcers 4
• One small trial showed reduction in ulcer area at 6 weeks for venous ulcers, but no significant long-term benefit 4
• Insufficient evidence to recommend routine use for non-diabetic wounds 1

Patient Selection Criteria

HBOT is most likely to benefit patients with:

• Nonhealing diabetic foot ulcers after revascularization 1
• Wounds with hypoxic or ischemic components 1
• Wounds that have failed standard care approaches 1

Clinical Implementation

HBOT protocol typically involves:

• Breathing 100% oxygen at pressurized atmosphere of 2-2.4 ATA
• Sessions lasting 60-90 minutes
• Multiple sessions (average 48, range 20-68) 5
• Treatment course of several weeks to months

Limitations and Considerations

• Accessibility issues: Limited availability of hyperbaric facilities
• Cost concerns: Expensive therapy with variable insurance coverage
• Time commitment: Requires multiple sessions over extended periods
• Patient suitability: Not all patients are candidates due to contraindications
• Contraindications: Severe heart failure (NYHA class IV), recent cardiac arrest, severe respiratory compromise 6

Current Guideline Recommendations

1. American College of Cardiology/American Heart Association (2024):

   • May be considered as adjunctive therapy to revascularization for wound healing in CLTI and diabetic foot ulcers
   • Evidence rated as Class IIb (weak recommendation), Level B-NR (moderate-quality evidence) 1

2. International Working Group on the Diabetic Foot (2023):

   • Conditionally recommends HBOT for neuro-ischemic or ischemic diabetic foot ulcers where standard care has failed
   • Low certainty of evidence 1

3. American Diabetes Association (2023):

   • Notes limited benefit in healing DFUs in the absence of ischemia and/or infection
   • May provide some benefit in prevention of amputation in selected chronic neuroischemic ulcers 1

Clinical Pearls

• Early referral for HBOT (within 6 weeks of wound onset) may result in faster healing compared to late referrals (>18 months) 5
• HBOT should be used as an adjunct to, not a replacement for, standard wound care
• Patient selection is critical - not all chronic wounds will benefit from HBOT
• Regular reassessment of wound healing progress is essential to determine continued need for therapy

HBOT remains a treatment option with moderate evidence supporting its use in specific wound types, particularly diabetic foot ulcers that have failed standard care approaches.