North Carolina Hyperbarics treats a variety of medical indications approved and mandated by Medicare guidelines. These guidelines have been studied and proven to show the most beneficial outcome for patients with the referenced diagnosis below. With each diagnosis the protocol and length of treatment will differ. Each protocol will be set forth by the rendering/treating physician.
ROUTINE COVERED INDICATIONS
Portions of content in the following descriptions are provided courtesy of the Undersea & Hyperbaric Medical Society (UHMS) with their permission, and are copyright protected. For a complete description of indications, as they appear on the Undersea & Hyperbaric Medical Society website, please visit www.uhms.org.
Enhancement of Healing in Selected Problem Wounds
Problem wounds are those which fail to respond to established medical and surgical management. Such wounds usually develop in compromised hosts with multiple local and systemic factors contributing to inhibition of tissue repair. These include diabetic feet, compromised amputation sites, non-healing traumatic wounds, and vascular insufficiency ulcers (ulcers with poor circulation). All share the common problem of tissue hypoxia (low tissue oxygen level, usually related to impaired circulation). The elevation in tissue oxygen which occurs in the hyperbaric chamber induces significant changes in the wound repair process that promote healing. When hyperbaric treatment is used in conjunction with standard wound care, improved results have been demonstrated in the healing of difficult or limb threatening wounds as compared to routine wound care alone.insufficiency
Delayed Radiation Injury (Soft Tissue and Bony Necrosis)
Radiation side effects are generally divided into two categories. First, there are those that happen during or just after the treatment, called acute reactions. Second, there are those that happen months or even years after the treatment, called chronic complications. The acute side effects almost always resolve with time and are treated in such a way as to address the patient’s symptoms. Unfortunately, chronic complications often may not get better with time and are likely to get worse. Almost all chronic radiation complications result from scarring and narrowing of the blood vessels within the area which has received the treatment. Chronic radiation damage is called “osteoradionecrosis” when the bone is damaged and “soft tissue radionecrosis” if it is muscle, skin or internal organs which have been damaged by radiation. The high dose oxygen provided in the hyperbaric chamber is carried in the patient’s circulation to the site of injury to be available for repair of the damage done by the narrowing and scarring of the blood vessels.
Bone infections can be hard to treat because there are limited blood vessels in the bone, and antimicrobials do not penetrate the bone very well. Chronic refractory osteomyelitis (CROM) is a bone infection that has not responded to conventional therapy, such as antimicrobials and surgical debridement, after a six-week course of treatment. Adjunctive hyperbaric oxygen is an AHA Class II recommendation in the management of CROM.
These chronic bone infections can occur in pediatric patients as well as adult patients, and they are often associated with other local or systemic problems. Patients who are immunosuppressed or have other co-morbidities such as diabetes are more likely to develop CROM. In
instances where the osteomyelitis is associated with a very high rate of morbidity and mortality, such as the spine, skull, or sternum, initiation of adjunctive hyperbaric oxygen earlier than (6) six weeks may be of benefit.
The most common presentation for CROM is in long bones after trauma, and in diabetic foot ulcers (DFU). In the DFU, about 20% of patients that are referred to a wound center will have osteomyelitis. If they do not respond to a course of conventional care, then patients should be referred for adjunctive hyperbaric oxygen therapy as part of a multi-disciplinary approach. This is an AHA Class I recommendation.
Skin Grafts & Flaps (Compromised)
Reconstructing complex wounds is accomplished by shifting or transferring tissues to the wound from a different part of the body. A “skin graft” is the transfer of a portion of the skin (without its blood supply) to a wound. A “flap” consists of one or more tissue component including skin, deeper tissues, muscle and bone. Flaps are transferred with either their own, original blood supply (pedicle flap) or with detached blood vessels which are attached at the site of the wound (free flap). Skin grafts survive as oxygen and nutrients diffuse into them from the underlying wound bed. Long-term survival depends on a new blood supply forming from the wound to the graft. When the wound bed does not have enough oxygen supplied to it, the skin graft will at least partially fail. Common causes for this are previous radiation to the wound area, diabetes mellitus, and certain infections. In these situations, the availability of
oxygen in the wound bed can be increased with hyperbaric oxygen therapy in preparation for skin grafting. Additionally, hyperbaric oxygen therapy can be used after skin grafting to increase the amount of the graft that will survive in the compromised settings. Flaps also require oxygen and nutrients to survive. The outer, visible portion (usually skin) is furthest from the source of blood supply for the flap. This is the area most likely to be compromised by inadequate oxygen. Factors such as age, nutritional status, smoking, and previous radiation result in an unpredictable pattern of blood flow to the skin. If a flap is found to have less than adequate oxygen after it has been transferred, hyperbaric oxygen can help minimize the amount of tissue which does not survive and also reduces the need for repeat flap procedures. Hyperbaric oxygen can help by assisting in the preparation and salvage of skin grafts and compromised flaps.
Necrotizing Soft Tissue Infections
A number of types of infections of soft tissue may benefit from adjunct treatment with hyperbaric oxygen and are included in the category of “necrotizing soft tissue infections.” Names of such clinical syndromes include crepitant anaerobic cellulitis, progressive bacterial gangrene, necrotizing fasciitis, and nonclostridial myonecrosis. Gas gangrene (clostridial myositis and myonecrosis) is a separate entity. Necrotizing soft tissue infections themselves may induce conditions adverse to control of the infection by normal host defense mechanisms. The infections commonly lower tissue oxygen levels, impairing the ability of the white blood cells (neutrophils) to fight infection. Toxins
produced by bacteria involved may also inhibit neutrophil activity. The primary treatments for necrotizing soft tissue infection are surgical excision of infected tissue and administration of appropriate antibiotics. Hyperbaric oxygen may be beneficial in several ways. Some of the bacteria involved in necrotizing soft tissue infections are “anaerobic,” growing most rapidly in a low oxygen environment. In the hyperbaric chamber, tissue oxygen levels may be raised sufficiently to inhibit bacterial growth. In addition, hyperbaric oxygen treatment may enhance the ability of neutrophils to kill bacteria, by a number of different mechanisms.
Clostridal Myositis and Myonecrosis (Gas Gangrene)
Clostridial myositis and myonecrosis is an acute, rapidly progressive infection of the soft tissues commonly known as “gas gangrene.” The infection is caused by one of several bacteria in the group known as “clostridium.” Clostridium bacteria are “anaerobic,” meaning that they prefer
low oxygen concentrations to grow. If clostridium are exposed to high amounts of oxygen, their replication, migration, and exotoxin production can be inhibited. This is the rationale for the use of hyperbaric oxygen in the treatment of gas gangren.
Crush Injury, Compartment Syndrome, and
other Acute Traumatic Ischemias
Crush injuries occur when body tissues are severely traumatized such as in motor vehicle accidents, falls, and gun shot wounds. These injuries frequently occur in the extremities. When used as an adjunct to orthopedic surgery and antibiotics, hyperbaric oxygen therapy
shows promise as a way to decrease complications from severe crush injuries. Hyperbaric oxygen treatments increase oxygen delivery to the injured tissues, reduces swelling and provides an improved environment for healing and fighting infection.
Air or Gas Embolism
Air or gas embolism occurs when gas bubbles enter arteries, veins and/or capillaries. This results in reduced blood flow and poor oxygen delivery to the areas supplied by the affected circulation. Hyperbaric oxygen has been shown to reduce the size of
bubbles obstructing circulation. The increased pressure in the hyperbaric chamber reduces bubble size and drives the remaining gas into physical solution, while the high oxygen pressure washes out inert gas from the bubble. When bubbles are smaller or resolved, blood flow resumes.
When scuba diving, additional oxygen and nitrogen dissolve in body tissues. The additional oxygen is consumed by the tissues, but the excess nitrogen must be washed out by the blood during decompression. During or after ascent this excess nitrogen gas can form bubbles in the tissues, analogous to the carbon dioxide bubbles that form when a carbonated beverage container is opened. These bubbles may then cause symptoms that are referred to as decompression
sickness (“DCS” or “the bends”). Trapping of gas within the lungs during ascent, either because the lung is diseased or because of breath-holding, can cause bubbles to be forced into the bloodstream (“arterial gas embolism” or “AGE”), where they can block the flow of blood or damage the lining of blood vessels supplying critical organs such as the brain. The success of hyperbaric oxygen treatment for DCS or AGE has borne the test of time, and continues to be the standard of care for the treatment of these disorders.
Carbon Monoxide Poisoning
Carbon monoxide (CO) is a colorless, odorless gas produced as a byproduct of combustion. Poisoning occurs by inhalation, either accidentally or intentionally (suicide attempt.) Oxygen, and especially hyperbaric oxygen,
accelerates the clearance of CO from the body, thereby restoring oxygen delivery to sensitive tissues such as brain and heart.
Carbon Monoxide Poisoning Complicated by Cyanide Poisoning
Cyanide poisoning occurs when cyanide, commonly present in smoke from fires and in industrial chemicals, is ingested or inhaled. Frequently, victims of smoke inhalation develop carbon monoxide
poisoning and cyanide poisoning simultaneously. The hyperbaric oxygen therapy used to treat carbon monoxide poisoning may also reduce the toxicity of cyanide and augment the benefit of antidote treatment.
Thermal burn injuries, if not fatal, can cause disastrous long-term physical and emotional disability for the survivor. Especially in closed space fires, thermal and smoke damage to the lungs can occur, requiring in some cases intubation and use of a mechanical ventilator. Burn injuries characteristically progress to become deeper and more extensive with time. In more severe and/or extensive burns (deep second, third, and fourth degree burns,) multiple aggressive surgeries are generally
necessary to excise the burned tissue and later perform skin grafts to cover these areas. Adjunctive hyperbaric oxygen therapy has been shown to limit the progression of the burn injury, reduce swelling, reduce the need for surgery, diminish lung damage, shorten the hospitalization, and result in significant overall cost savings. Best results are realized when hyperbaric oxygen therapy is used as an integral part of an aggressive multidisciplinary approach to the management of this potentially fatal injury.
Abscess formation in the brain can be a devastating complication of sinus infections or bone infections (osteomyelitis) of the skull. Occasionally, abscesses are seeded from infection occurring in other parts of the body. Brain abscesses are frequently multiple. One of the problems in treatment of brain abscesses relates to the fact that surgical drainage of their contents is often required for cure. Unfortunately, normal brain tissue surrounding the abscess may be unavoidably damaged by such surgery. Fine needle aspiration of the abscesses is being performed with greater frequency to avoid this problem. Antibiotics may not penetrate well into
the brain abscesses. Furthermore, white blood cells, which kill infecting bacteria, may not have enough oxygen to effectively eliminate the infection when functioning deep in the abscess at a distance from their normal blood supply. White blood cells require a minimum level of oxygen to kill bacteria. Most intracranial abscesses are caused by anaerobic bacteria (bacteria that function optimally in low oxygen concentrations). Hyperbaric oxygen raises the environmental oxygen level in the region of the abscess, exposing the bacteria to levels which may inhibit or kill them, as well as providing sufficient oxygen for white blood cells to exercise their killing power.
Exceptional Blood Loss (Severe Anemia)
For purpose of consideration of the use of hyperbaric oxygen therapy, exceptional blood-loss anemia (severe anemia) is by definition loss of enough red blood cell mass to compromise sufficient oxygen delivery to
tissue in patients who cannot be transfused for medical or religious reasons. As hyperbaric oxygen (or for that matter normobaric oxygen) administered for long periods can become toxic, intermittent administration of hyperbaric oxygen is essential.