What is the role of Hyperbaric Oxygen Therapy (HBOT) in wound healing?

Hyperbaric Oxygen Therapy for Wound Healing

Hyperbaric oxygen therapy (HBOT) should not be routinely used for diabetic foot ulcers, as evidence does not consistently support its effectiveness for improving wound healing or reducing amputations compared to comprehensive standard wound care alone.

Current Evidence on HBOT for Wound Healing

Diabetic Foot Ulcers

The most recent guidelines provide limited support for HBOT in specific wound healing scenarios:

• The International Working Group on the Diabetic Foot (IWGDF 2023) conditionally recommends HBOT only as an adjunct therapy in neuro-ischemic or ischemic diabetes-related foot ulcers where standard care has failed and where resources already exist to support this intervention 1.

• However, multiple high-quality studies and guidelines indicate that HBOT has mixed or inconclusive evidence supporting its use:

  • The 2023 American Diabetes Association (ADA) Standards of Care notes that recent studies have shown no benefit in healing diabetic foot ulcers in the absence of ischemia and/or infection 1.
  • The 2022 ADA Standards of Care states that HBOT does not have a significant effect on health-related quality of life in patients with diabetic foot ulcers 1.
  • The Dutch DAMOCLES trial demonstrated that HBOT in patients with diabetes and ischemic wounds did not significantly improve complete wound healing and limb salvage 1.

Patient Selection Considerations

For the limited scenarios where HBOT might be considered:

• Patient factors that may indicate potential benefit:

  • Neuro-ischemic or ischemic diabetic foot ulcers that have failed standard care 1
  • Patients who can commit to weeks of intense treatment 1
  • Patients who live in close proximity to established hyperbaric units 1

• Contraindications and precautions:

  • Acute decompensated heart failure (NYHA class IV) 2
  • Recent cardiac arrest 2
  • Severe hemodynamic instability 2
  • Severe respiratory compromise 2
  • History of spontaneous pneumothorax or bullous lung disease 2
  • COPD with CO2 retention 2
  • Uncontrolled seizure disorders 2

Alternative Oxygen Therapies

Topical oxygen therapy (TOT) has emerged as a potentially more promising alternative:

• Recent high-quality RCTs and systematic reviews support TOT's efficacy in healing chronic diabetic foot ulcers at 12 weeks 1.
• TOT provides for home-based therapy rather than requiring daily visits to specialized centers 1.
• High participation rates with few reported adverse events make TOT an attractive option for advanced wound care 1.

Implementation Considerations

If HBOT is being considered despite limited evidence:

• HBOT should only be performed in facilities specifically designed and equipped for critically ill patients 2.
• Staff should have appropriate training to manage potential complications 2.
• A typical protocol involves treatment under 2.5 absolute atmospheric pressure for 120 minutes, 5 days a week for 4 consecutive weeks 3.

Common Pitfalls to Avoid

1. Overreliance on HBOT: Expecting HBOT to be effective for all types of wounds despite evidence showing limited efficacy.

2. Delaying standard care: HBOT should never delay appropriate standard wound care including debridement, infection control, and vascular assessment.

3. Ignoring contraindications: Failing to screen for conditions that increase risk during HBOT, such as untreated pneumothorax or severe heart failure.

4. Cost-effectiveness concerns: HBOT requires significant resources and may not be cost-effective compared to other interventions.

5. Neglecting follow-up: Even when HBOT is used, continued wound monitoring and standard care remain essential.

In conclusion, while HBOT may have limited applications in specific wound healing scenarios, the current evidence does not support its routine use for diabetic foot ulcers. Clinicians should focus primarily on comprehensive standard wound care and consider topical oxygen therapy as a potentially more accessible and effective alternative.