From the Guidelines
Hyperbaric oxygen therapy is conditionally recommended for treating peripheral necrosis, particularly in cases of compromised tissue viability, as it may improve wound healing and reduce ulcer area, although the evidence is limited and the certainty of evidence is low. The use of hyperbaric oxygen therapy involves breathing 100% oxygen at a pressurized atmosphere of 2ATA or above, which increases the partial pressure of oxygen in hypoxic or ischemic tissues, promoting angiogenesis, collagen deposition, and epithelialization 1.
Key Considerations
- The majority of studies on hyperbaric oxygen therapy were at high risk of bias, although one good quality study showed evidence of benefit on critical outcomes of healing and time to healing 1.
- People with diabetes require assessment for suitability for hyperbaric oxygen therapy, and those with general frailty and comorbid conditions may have to be excluded from this treatment modality due to increased risks of adverse events 1.
- The balance of effects will likely favor the use of hyperbaric oxygen over standard of care alone, although hyperbaric oxygen therapy requires large costs and may not be cost-effective in all settings 1.
Treatment Protocol
- The standard treatment protocol involves sessions at 2.0-2.5 atmospheres absolute (ATA) for 90-120 minutes, typically administered 5-6 days per week for 20-40 sessions, depending on clinical response.
- Patients should be monitored for improvement in tissue perfusion, reduction in necrotic tissue, and signs of new granulation tissue formation.
Potential Side Effects
- Potential side effects include barotrauma to the ears or sinuses, temporary nearsightedness, claustrophobia, and rarely oxygen toxicity.
- HBOT should be used as part of a comprehensive treatment approach that includes appropriate wound care, infection control, and management of underlying conditions like diabetes or vascular disease 1.
From the Research
Relationship Between Hyperbaric Oxygen Therapy and Peripheral Necrosis
- Hyperbaric oxygen therapy potentially can provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma 2.
- In patients with crush injury or early compartment syndrome, hyperbaric oxygen therapy may reduce the penumbra of cells at risk for delayed necrosis and secondary ischemia 2.
- Hyperbaric oxygen therapy uses high pressures to saturate hemoglobin and dissolve oxygen into blood plasma to create a hyperoxemic environment to nourish and reverse local tissue injury caused by ischemia and hypoxemia 3.
- Hyperbaric oxygen therapy has been shown to be effective in treating avascular necrosis (AVN) of the femoral head and femoral condyle, with prevention of disease progression observed in a single centre retrospective study 4.
Mechanism of Action
- Hyperbaric oxygen therapy increases tissue oxygenation in both healthy tissue and in the vicinity of infected tissue, which may be of significance in preventing the extension of invading microorganisms 5.
- The hyper-oxygenated tissue zone surrounding the infected area may play a role in preventing the extension of invading microorganisms 5.
- Topical oxygen therapy, which avoids the issues associated with hyperbaric oxygen therapy, has shown promise in wound healing for patients with peripheral arterial disease, with a reduction in wound area observed in 66% of patients 6.
Clinical Applications
- Hyperbaric oxygen therapy is a Medicare-approved treatment for chronic nonhealing wounds and radiation necrosis 3.
- Hyperbaric oxygen therapy has been used to treat Clostridial gas gangrene and perineal necrotizing fasciitis, with improved patient survival and reduced mortality rates observed 5.
- Hyperbaric oxygen therapy may have a significant role in the treatment of femoral avascular necrosis, with prevention of disease progression observed in a single centre retrospective study 4.