Elective Treatments

NHS England no longer commissions any elective HBOT treatments.

LHM continues to provide elective Hyperbaric Oxygen Therapy on an evaluative basis for internationally recognised indications.

Click on a condition to be taken to further information about it:

Soft Tissue Radiation Damage

Delayed radiation complications are typically seen six months or more after therapeutic radiation therapy. However, they can develop many years later. These complications result from scarring and narrowing of the blood vessels.

Hyperbaric oxygen is the only treatment that has been shown in clinical trials to reverse the damaging affects of radiation. It has been used successfully for years in the treatment of these injuries. This therapy causes more oxygen to reach these damaged areas. This allows the tissue to grow new blood vessels and heal.

Radiation damage can occur anywhere in the body. Hyperbaric therapy is often used in patients who have had radiation to the head and neck area. This is to either to heal a wound or in anticipation of dental extractions. This helps to prevent serious complications that can occur when surgery is performed in an area which has been radiated.

Similar radiation damage can occur anywhere in the body that radiotherapy has been used to fight cancer. Radiation to the urinary bladder can cause pain and bleeding, and is called hemorrhagic cystitis. Radiation proctitis can occur when there is radiation to the area of the bowels. This can cause bleeding, pain, diarrhea and in some instances a fistula. This is a small hole in the bowel which can not heal. Any area of soft tissue (skin or muscle) or bone that has radiation related injury may benefit from hyperbaric therapy. There is also new evidence to support the use of hyperbaric therapy in patients with side effects from brain radiation.

Radiation Proctitis

Radiation proctitis is a common unfortunate complication of radiation to lower abdomen and pelvis. It most commonly occurs after radiation treatment for cancers such as cervical cancer, prostate cancer, and colon cancer. Radiation proctitis involves the lower intestine, primarily the sigmoid colon and the rectum.

Radiation Treatment

This is a treatment that uses x-rays or gamma rays to treat cancer. Having this done on your pelvic (hip) area may damage your rectal tissues and blood vessels, causing proctitis. Proctitis caused by radiation may occur for a period of three months after your treatment. Chronic radiation proctitis (CRP) may occur months or years after your treatment.

Clinical Features

Early symptoms can develop during the first or second week of radiation therapy. Nausea and vomiting are seen with upper abdominal radiation therapy as opposed to pelvic radiation. Involvement of small intestine leads to abdominal cramps, nausea, and watery diarrhoea. Large intestinal irradiation leads to diarrhoea, tenesmus, mucoid rectal discharge, and rectal bleeding if ulceration is present. However, many patients remain symptom free even with mucosal ulceration.

The late symptoms appear at an interval range of 3 months to 10 years. The most common symptom with small intestinal radiation damage is colicky abdominal pain, nausea, vomiting, and small intestinal obstruction can also occur. If the ileum is extensively involved, malabsorption may be prominent. Patients with chronic radiation injury of rectum will have symptoms of proctitis, including tenesmus, mucoid rectal discharge, bleeding from rectum, constipation , loss of sphincter control and rarely fistulous tract into adjacent organs or bowel obstruction.

Treatment

High failure rates with conventional Treatment led to the use of HBO therapy, which has been shown in clinical trials to reverse the damaging effects of radiation. Chronic radiation complications result from scarring and narrowing of blood vessels within the area, which received the treatment. This therapy causes more oxygen to reach these damaged areas allowing tissue to grow new blood vessels and heal. It has been used successfully for years in the treatment of these injuries and others such as radiation enteritis and radiation cystitis.

References

  1. Hyperbaric Oxygen Treatment of chronic refractory radiation proctitis: randomised and controlled double-blind crossover trial with long-term follow-up.-R.Clarke Int.J. RADIATION oncology Bio.Phys., pp 1-10 ,2008
  2. Hyperbaric Oxygen Therapy for late radiation tissue injury (review)-Bennett MH, Feldmeier J. Cochrane Database of systematic reviews 2005, Issue 3

Osteoradionecrosis

Problem Wounds and Diabetic Foot Ulcers

At London Hyperbaric Medicine we have great experience in the assessment and treatment of non-healing (hypoxic) problem wounds as well as Diabetic Foot Ulcers which have not responded to standard care.

There is good evidence to suggest that Hyperbaric Oxygen Therapy may be of benefit to patients suffering from these and other related conditions.

A chronic (non-healing) wound or the so-called ‘problem wound’ is defined as any wound that fails to heal within a reasonable period of time by the use of conventional medical or surgical techniques.

This is a common condition that prompts multiple medical visits, prolonged hospitalisation, and fastidious nursing care. Non-healing wounds of the lower extremities are the most common although they may occur anywhere on the body.

Compromised Skin Grafts and Flaps

Compromised skin grafts and skin flaps represent a problem involving insufficient oxygen supply to tissue. Plastic surgeons use the grafts and flaps to repair serious injuries, and to close or cover wounds. Skin is taken from one part of the body and used to cover missing skin on another part. There are several types of skin grafts. They include full-thickness grafts, in which all of the skin layers are used, and split-thickness grafts, in which only the top layers and some of the deeper layers are used. There are also pedicle grafts, in which part of the skin remains attached to the donor site. This allows the old blood supply to remain intact while a new blood supply develops.

The problem is what to do when skin grafts appear to be compromised. A freshly applied split-thickness graft receives no oxygen until tiny blood vessels called capillaries can grow into it. Such capillary ingrowth normally takes place over a two to three day period. If this does not happen, it’s not likely that the graft will survive. Hyperbaric oxygen therapy improves the chances that a graft will succeed, both by supplying oxygen and by encouraging capillary growth.

Hyperoxygenation causes an increase in the effectiveness of the blood that reaches the graft through blood vessels. Hyperoxygenation increases the oxygen in the graft bed and wound margins up to 15 fold.

In many instances, HBOT is used only after a skin graft starts to fail. While HBOT can help save failing grafts, it can be even more effective when used before surgery to keep grafts from failing in the first place.

Hyperbaric oxygen also reduces edema and helps to limit the swelling of the graft or flap. Oxygen dissolved in plasma is also readily available to tissues and organs which can decrease damage from reperfusion injury.

HBOT’s effectiveness in supporting skin graft survival is supported by clinical research. The effectiveness of HBOT is shown in grafting, with a salvage rate of 75% for the HBOT group compared to 46% for the controls, with near 100% HBOT salvage when the patient is treated within 72 hours post-operatively.
The use of HBOT for the preparation of a base for skin grafting and the preservation of compromised skin grafts has also been documented as effective.

References:

  1. McFarlane RM, Wermuth RE. The use of hyperbaric oxygen to prevent necrosis in experimental pedicle flaps and composite skin grafts. Plast Reconstr Surg 1966;37:422-430.
  2. Tan CM, Im MJ, Myers RA, Hoopes JE. Effect of hyperbaric oxygen and hyperbaric air on survival of island skin flaps. Plast Reconstr Surg 1974;73:27-30.
  3. Zamboni WA. Applications of hyperbaric oxygen therapy in plastic surgery. In: Oriani G, Marroni A, Wattel F, eds. Handbook on Hyperbaric Oxygen Therapy. New York: Springer-Verlag, 1996.

Osteomyelitis

Osteomyelitis represents an inflammatory process with a bacterial infection involving bone.

The term “refractory osteomyelitis” refers to failure to heal or recurrence despite adequate surgical and antibiotic therapy.

A unique form of refractory osteomyelitis, “malignant otitis externa”, is a progressive and potentially fatal infection of the ear canal and base of the skull.

Hyperbaric oxygen is a useful adjunct to antibiotic therapy and, when feasible, surgical debridement.

Malignant Otitis Externa

This condition describes otitis externa (inflammation of the ear canal) which progresses to osteomielitis when infection spreads onto the skull base and petrous portion of the temporal bone.

It is most common in elderly diabetic or immunocompromised patients and is usually caused by Pseudomonas Aeruginosa.

Symptoms

Most commonly overwhelming constant deep otalgia (earache) and malodorous discharge from the ear. VII- XII cranial nerves palsies may occur and cause symptoms similar to those with a stroke- facial weakness, hearing loss, difficulties in swallowing and breathing, hoarseness and impaired speech.

Sometimes Malignant Otitis Externa may lead to meningitis, sigmoid sinus thrombosis, brain abscess and death.

This condition should be suspected in patients with granulation tissue at depth of ear canal which does not settle with the usual treatment. The diagnosis often is not considered until cranial nerve palsy has developed. Histological and microbiological examination of granulation tissue, and a high definition CT scan of the head are required to make a diagnosis.(1)

Treatment

Conventional treatment of MOE is with topical, oral and intravenous antibiotics and regular aural toilet by ENT (microscope guided suction of the ear canal. ) with application of topical AB and cauterisation/debridement of granulation tissues. The dose and duration of treatment is decided after discussion with microbiologist and by monitoring clinical response. Often therapy has to be continued for 6 weeks or more. Opiate analgesia often required to control the ear pain. Even with aggressive treatment there is still significant mortality.(1)

HBO application

Recent reports by Davis et al., with dual–modality therapy with antibiotics and Hyperbaric Oxygen Therapy show (HBO) improved success rate of upward of 90 to 100 % (2). Application of HBO has shown to reduce the swelling of damaged tissues, reverses tissue hypoxia, promotes new blood vessels formation hence improves blood supply and speeds up regeneration of tissues damaged by infection. It also enhances the therapeutic effect of antibiotics. Therefore adjuvant HBO therapy should be considered in advanced or recurrent cases of malignant otitis externa.

References:

  1. Key Topics in Otolaryngology- N J Roland, R D R McRae,A W McCombe
  2. Essential Otolaryngology Head & neck surgery,8th edition- K J Lee.
  3. Value of Hyperbaric oxygen in bacterial and fungal malignant external otitis treatment.W Narozny, J Kuczkowski..Eur Arch Otorhinolaryngology (2006)
  4. Adjuvant hyperbaric oxygenin malignant external otitis- Davis JC, Gates GA, Davis MG Jr, Mader JT, Dinesman A. Arch Otol Head Neck surg.1992

Acute Soft Tissue Ischaemia

Hyperbaric oxygen (HBO) is used as an adjunct for the management of crush injuries, compartment syndromes and other acute traumatic peripheral ischemias. The rationale for using HBO is to counteract tissue hypoxia and the consequences of hypoxia that arise secondary to trauma.

Severe Haemorrhagic Anaemia

In most situations where there is severe blood loss, patients will receive blood product transfusions. If it is a planned procedure this can be autologus blood donation by the patient prior to the procedure or if in the emergency situation by donor blood transfusion. In rare situations, such as when the patient will not receive blood products for religious reasons, HBO can be used as a supportive therapy until there has been sufficient red cell regeneration. In these situations there has been enough blood loss that respiratory requirements cannot be met.

Under normobaric conditions most of the oxygen available for tissue use is bound to haemoglobin molecules and in arterial blood the haemoglobin is approximately 98% saturated. In the hyperbaric environment, as well as the haemoglobin being saturated, there is a high concentration of oxygen dissolved in the plasma. Various animal studies have shown that there is an improved survival in animals with haemorrhagic shock treated with HBO compared to control groups. There was limited human experience until 1987 when it was reported on a case series of 26 patients, these patients had blood loss of over 50% and without receiving any blood products had a survival of 70%.

Hyperbaric oxygen treatments need to be repeated until there is sufficient improvement in the haematocrit and haemoglobin to meet the patient’s oxygen requirements. HBO treatments are given with increasing lengths of air breaks between treatments, treatments are for one hour per exposure, normobaric oxygen is given between treatments but with appropriate air breaks to avoid pulmonary oxygen toxicity.

Selected Sports Injuries

Information for Healthcare professionals

Hyperbaric Oxygen Therapy should be considered an important adjunctive therapy in the management of acute trauma, which is often seen in sports injuries.

Trauma is a multi disciplinary medical problem as it could affect many different systems of the body. Trauma, direct or indirect, in turn, can be classified as either minor (contusions, ligament injuries, etc) or major (fractures, spinal injuries, severe contusions, crush injuries – compartment syndrome, burns, etc).

Hyperbaric Oxygen Therapy increases the Oxygen delivery to the tissues

HBO reduces swelling and pain:

  • Prevents Hypoxia of the traumatized tissues
  • Speeds up the healing of tissues, ligaments and fractured bones
  • Reduces scar tissue formation and damage
  • Helps return players to the game sooner

Ischaemia and oedema are parts of a vicious cycle where hypoxia is the major component in the changes that affect the injured tissues. Oedema (swelling) of the tissues will compound the problem created by hypoxia as it increases the diffusion distance from the capillaries to the cell.

This also affects the microcirculation that further impedes oxygenation in already compromised tissue.

As the partial pressure of inspired oxygen increases, the oxygen dissolved in the plasma increases proportionately. This dissolved oxygen is sufficient to oxygenate tissues without haemoglobin bound oxygen. This is where the oxygen under pressure proves its benefits (Henry’s Law). Traumatized tissue’s auto regulatory mechanism increases blood flow to compensate for hypoxia. In a damaged microcirculation this mechanism causes undesirable swelling.

The increases in the oxygen carrying capacity of the plasma appear to have 2 important effects.

  1. In-spite of the impaired microcirculation, the plasma carries sufficient amounts of oxygen to avoid problems associated with hypoxia.
  2. Reduction of oedema through vasoconstriction. Oxygen under pressure causes a 20% reduction in the blood flow. Oedema is reduced at the same time as microcirculation improves. This enhances re-absorption of fluid and a further reduction of swelling.

The important part of treatment and rehabilitation of any injury is physical therapy with the associated application of Hyperbaric Oxygen Therapy using various protocols according to the type and origin of the injury.

In conclusion, data from many studies suggest that treatment should be instituted within the first 24-48 hours. Some studies indicate the first 12 hours are very important and it appears as if best results are obtained if the injury should is actively treated early on. The treatment protocol used by London Hyperbaric and Wound Healing Centre is our standard LHM 14m (2.4 ATA for 90 minutes) and at this pressure there is enough oxygen dissolved in the plasma to gain maximum benefit with minimal risk of toxic or side effects.