HBOT & Performance

Jay Campbell

Oxygen:

Overlooked and underutilized, Oxygen is the most important nutrient!

We can live for weeks, even months without food, days without water yet only minutes without oxygen. While we all know this fact, the use and importance of oxygen as a nutrient seems to have slipped our consciousness. Maybe because we breath about 23,000x per day we simply take this notion for granted. Well if you are reading this article It is very likely I know a few things about you. I know that health optimization and biohacking must be one of your priorities. I know that you are at least as interested in pushing your bodies level of performance as you are in pushing the boundaries of longevity and I believe if this assumption is correct, you will be amazed at what role oxygen plays in these processes.

Health and adaptation

We have all heard of the concept: Survival of the fittest. When people first hear this concept, many associate fittest with strongest. Fight or flight…. He who can get away fastest or fight the hardest wins. Well it is not that simple. What was actually meant by the term fittest was most able to adapt. The person who can adapt to an ever-changing environment around them is most likely to survive. This means that our health, our performance and ultimately our quality of life is directly related to our ability to teach our body how to adapt to our world. The term hormesis has been used in our circles to describe this phenomenon. Continuous exposure to some degree of stress, enough to create a healing response from the body, ultimately leading us toward improved recovery ad performance but not so much to break us down and hinder those abilities. Almost all our health optimization strategies are based on this premise.

Deficiency and Toxicity

While this is an absolute oversimplification of how our bodies work, I think it helps to understand that the root of virtually all disease and dysfunction can be reduced to toxicity and deficiency. Even more so, that any degree of toxicity or deficiency will limit our ability to adapt. This does not only include foods and vitamins. We can be toxic and deficient in our chemistry ( the things we put in our body i.e. food, vitamins, alcohol, medications etc), but we can also be toxic and deficient with regard to our physical bodies ( what we do with our bodies i.e. exercise, postures, positions, etc) and emotionally as well (what we think about i.e. jealousy, fear, anger etc.) A goal of purity and sufficiency in what we put in our bodies, what we do to our bodies and even in our daily thoughts will all lead to improved health. We are designed to have optimal health and performance in our life. If we are expressing anything less than optimal health we are either toxic (we have too much of something our body needs to get rid of) or we are deficient (we are missing something our body requires to perform optimally) If we view each of our health journeys through this lens, deviations from optimal health become very obvious and a plan we each need to work toward peak performance starts to lay itself out. As you begin to understand the role oxygen plays in our body, we can begin to appreciate its role in helping our body detoxify as well as the massive consequences that arise when we become even mildly let alone moderately oxygen deficient.

Oxygen as a nutrient

A nutrient is: a substance that provides nourishment essential for growth and the maintenance of life. Oxygen absolutely falls into that category! Like all nutrients in our body there are 3 ranges of dosage. The RDA or the minimum amount required before we express obvious disease or dysfunction of deficiency. The optimal range, or the amount required to make sure we are sufficient enough in that ingredient to ensure we have enough for all the complex interactions our body goes through in a given day. Lastly the megadose, Even when we are optimally sufficient there may be period in our life where a much higher dose is recommended or required for helping our body transition though a health challenge. Oxygen can be viewed through this lens. An oxygen deficiency is called hypoxia. Hypoxia can be systemic due to some cardiovascular or respiratory (heart, circulatory or lung) condition where we cannot efficiently absorb or deliver oxygen to our cells. Hypoxia can also be local. Meaning we absorb oxygen well, we can pump and circulate oxygen throughout our entire body but there is a problem delivering oxygen to a certain area, tissue type or organ. This is more common than many people realize. Perhaps a recent or even old injury where the microcirculation (capillary beds) were damaged, maybe an area of chronic inflammation, or a location of scar tissue and fibrosis not allowing normal circulation and therefore proper oxygenation of tissue. In some of these cases the tissue can be hypoxic because very little is getting through. The tissue is alive but functioning poorly. (common in TBI/Concussion as an example) Perhaps some oxygen is getting through enough to function under minimal daily routines but as soon as we increase demand (intense focus and concentration or increased physical demand) we cannot efficient increase oxygen supply and therefore our performance suffers. Like getting the RDA of oxygen but not really getting the optimal range. In other cases we can consistently supply the body with optimal ranges of oxygen and yet we still want to expose ourselves to mega doses periodically. Maybe this is to overcome an injury, or trauma. Maybe this is to help alleviate pain or chronic inflammation from a condition we have and sometimes this is to simply improve our performance capacity and quality of life. It turns out oxygen is a rate limiting step to many of our cells ability to make energy. As we step up our oxygen exposure, we are able to step up our mental and physical capacities for performing tasks. This may all sound great in theory. Increase your oxygen absorption = increase capacity to heal, detoxify, produce energy and perform however there is one major challenge. Based on our physiology and ability to carry oxygen, it is not an easy task to increase oxygen absorption. Generally speaking, without any cardiovascular or respiratory condition, we are all carrying almost all the oxygen we are capable of carrying. Our “optimal” dose of oxygen is 97-100% red blood cell oxygen saturation. Under normal conditions we rely on our red blood cells to carry oxygen to our tissues and cells and as we stand here right now they are almost already completely saturated with oxygen only able to carry 1-3% more at any time. So if we had a mask and a tank of oxygen we can increase our absorption by only a few percent and that is really not enough to make a difference in our health the way we would all want to.

Oxygenation:

There are many tools and techniques which can help us become more oxygen efficient. We can breathe on an oxygen tank for a while, this will help some. We can certainly learn how to breathe more effectively and deeply. We can use breathing techniques like Wim Hof and holotrophic breathing as examples and absolutely improve our tissue’s oxygenation on the cellular level. We can also use tools like EWOT which help to shift the supply and demand equation within our body helping to drive increased oxygen into our tissues. These are all great strategies however, by far, hyperbaric oxygen therapy (HBOT) is the most powerful way to deliver oxygen and change our physiology with regard to oxygenation of our tissues and cells. Pressure and Oxygen The reason we absorb any oxygen at all is due to pressure. Our atmosphere exerts a pressure on our body. We don’t feel it, but at sea level there is a constant 14.7 psi exerted on our bodies all the time. This pressure creates a gradient allowing oxygen to flow from high concentration (our atmosphere) to lower concentration (our lungs). At sea level we expect this pressure to be sufficient enough to oxygenate all of our tissues. At altitude, say 5000 ft above sea level, the pressure of our atmosphere is less and this allows less oxygen absorption than at sea level. Our body “feels” this difference and the result is an increase in red blood cell production. If we have more red blood cells, we can improve our efficiency of carrying oxygen required due to the decrease in pressure. I use the word “Feel” because as it turns out, we have oxygen sensors in our body that can not only detect changes in oxygen concentration but also changes oxygen pressure. There is 21% oxygen in our air no matter what the altitude we are at. The pressure of the atmosphere is what changes. At sea level, the pressure of air is 760mmHg and our oxygen pressure is 159 mmHg. At 8000 ft above sea level the pressure of air is 564 mmHg and the pressure of oxygen is 118 mmHg. That difference in pressure is  what makes the air “thinner” at altitude. It is the same but opposite phenomenon below sea level. As we descend below sea level the pressure increases and therefore the ability to absorb air and oxygen also increases. The deeper you go, the more pressure, the more we can absorb. In a hyperbaric environment, we can control the amount of pressure we exert on a person and the amount of time they are in this pressurized environment and therefore predictably control the amount of increased oxygen absorption they can take into their cells. Once absorbed this “extra” oxygen can be used for making ATP and energy, increasing the capacity for working tissues to perform or increase the capacity of healing and recovery.

Oxygen In Lungs

Oxygen in lungs and tissues are in equilibrium

Oxygen In Lungs

Increased pressure of oxygen in the lungs drive increased diffusion into tissues

Oxygen In Lungs

That Increased diffusion continues until equilibrium is reached again.

Nobel prize in medicine 2019

Three scientists were awarded the Nobel prize in medicine for their discovery of these oxygen sensors. They are called Hypoxic induction factors (HIF’s). These HIF’s are responsible for many of the changes our body goes through as oxygen percentages change as well as oxygen pressures change. It is well documented at this point that over 8100 different epigenetic factors are tied to and influenced by these changing pressures and changing oxygen levels. The moral of the story here is that if we really want to influence our body to improve healing, recovery, performance and quality of life we not only need to manipulate absolute oxygen levels, we need to also manipulate pressures as well, which is where hyperbaric oxygen really fits in. 10 well established benefits of Hyperbaric Oxygen

1. Increased oxygen perfusion- (Immediate increase in free floating oxygen available for tissue use)

2. Neovascularization- Angiogenesis (new blood vessel growth)

3. Increased white blood cell function (improved neutrophil and macrophage activity)

4. Nerve healing factors (increases in VegF, BDNF, HIF1)

5. Wound healing Increased capacity for healing (PDGF, VegF, collagen production circulatory
healing)

6. Stem cell release (up to 8-fold increase in mesenchymal and CNS stem cells)

7. Vasoconstriction (decrease edema and swelling from damaged tissues)

8. Mitochondrial healing (increase in size, shape and number of mitochondria)

9. Anti-inflammatory (reduction of inflammatory cytokines, increase in anti-inflammatory
cytokines)

10. Anti-microbial/microbiome balancing (reduction in anaerobic pathogens and increase in aerobic
probiotics)

O-P-M (Oxygen-Pressure-Minutes)

How many sessions do I need to do? Can I use a soft chamber or do I need a hard chamber? What is the best protocol for health optimization? I get questions like this all the time and there is unfortunately no single or simple answer to any of them. We have 3 variable we can manipulate, oxygen levels we are exposed to, pressure levels we are exposed to and minutes we are under pressure. We can use all three of these variables to create protocols. In some cases where higher pressure would have been great to have, we use higher oxygen levels and more sessions to make up for the loss in pressure. Time is our biggest input here. While there are certain conditions (gangrene, open wounds, osteomyelitis, radiation burns) that require absolute high pressure and high oxygen levels most of us are not using these chamber for those issues. Therefore we can use mild pressures and lower oxygen levels and use longer sessions and more frequent sessions to get the results we are all looking for, especially if we use a soft chamber in our home. Typically we offer people who buy home chambers a consultation to decide what their issues are, what their goals are and therefore what protocol they should use in order to get the most out of their equipment. It is important to us that people who choose this equipment learn how to use it properly, are safe and of course effective in implanting strategies that get them the results they need!

References:
Palzur E, Zaaroor M, Vlodavsky E, et al. Neuroprotective effect of hyperbaric oxygen therapy in brain injury is mediated by preservation of mitochondrial membrane properties. Brain Res., 1221 (2008), pp. 126-133

K.R. Dave, R. Prado, R. Busto, A.P. Raval, W.G. Bradley, D. Torbati, M.A. Pérez-pinzón, Hyperbaric oxygen therapy protects against mitochondrial dysfunction and delays onset of motor neuron disease in wobbler mice, Neuroscience, Volume 120, Issue 1, 2003, Pages 113-120

Gonzales-Portillo B, et al Hyperbaric oxygen therapy: A new look on treating stroke and traumatic brain injury. Brain Circ. 2019 Sep 30;5(3):101-105. doi: 10.4103/bc.bc_31_19

Vadas D, Kalichman L, Hadanny A, et al. Hyperbaric oxygen environment can enhance brain activity and multitasking performance. Front Integr Neurosci. 2017;11:25. Published 2017 Sep 27. doi:10.3389/fnint.2017.00025

Hadanny A, Maliar A, Fishlev G, et al. Reversibility of retinal ischemia due to central retinal artery occlusion by hyperbaric oxygen. Clin Ophthalmol. 2016;11:115–125. Published 2016 Dec 29. doi:10.2147/OPTH.S121307

Tal S, Hadanny A, Sasson E, et al. Hyperbaric oxygen therapy can induce angiogenesis and regeneration of nerve fibers in traumatic brain injury patients. Front Hum Neurosci. 2017;11:508. Published 2017 Oct 19. doi:10.3389/fnhum.2017.00508

Gil-Ortega M, Garidou L, Barreau C, et al. Native adipose stromal cells egress from adipose tissue in vivo: evidence during lymph node activation. Stem Cells. 2013;31:1309–1320

Milovanova TN, Bhopale VM, Sorokina EM, et al. Hyperbaric oxygen stimulates vasculogenic stem cell growth and differentiation in vivo. Journal of Applied Physiology. 2009;106:711–728

Tepper OM, Capla JM, Galiano RD, et al. Adult vasculogenesis occurs through in situ recruitment, proliferation, and tubulization of circulating bone marrow-derived cells. Blood. 2005;105:1068–1077.

Gallagher KA, Liu ZJ, Xiao M, et al. Diabetic impairments in NO-mediated endothelial progenitor cell mobilization and homing are reversed by hyperoxia and SDF-1 alpha. J Clin Invest. 2007;117:1249–1259

Gu GJ, Li YP, Peng ZY, et al. Mechanism of ischemic tolerance induced by hyperbaric oxygen preconditioning involves upregulation of hypoxia-inducible factor-1alpha and erythropoietin in rats. J Appl Physiol. 2008;104:1185–1191

Thom SR, Bhopale VM, Velazquez OC, et al. Stem cell mobilization by hyperbaric oxygen. Am J Physiol Heart Circ Physiol. 2006;290:H1378–H1386.

Xu, Y., Wang, Q., Qu, Z., Yang, J., Zhang, X., & Zhao, Y. (2019). Protective Effect of Hyperbaric Oxygen Therapy on Cognitive Function in Patients with Vascular Dementia. Cell Transplantation, 096368971985354. doi:10.1177/0963689719853540

Dinar S, Agir H, Sen C, et al. Effects of hyperbaric oxygen therapy on fibrovascular ingrowth in porous polyethylene blocks implanted under burn scar tissue: an experimental study. Burns. 2008;34:467–473

Schmidt TM, Kao JY. A little O2 may go a long way in structuring the GI microbiome. Gastroenterology. 2014;147(5):956–959. doi:10.1053/j.gastro.2014.09.025

Thompson CD, Uhelski ML, Wilson JR, et al. Hyperbaric oxygen treatment decreases pain in two nerve injury models. Neurosci. Res., 66 (3) (2010), pp. 279-283

Oyaizu T, Enomoto M, Yamamoto N, et al. Hyperbaric oxygen reduces inflammation, oxygenates injured muscle, and regenerates skeletal muscle via macrophage and satellite cell activation. Sci Rep. 2018;8(1):1288. Published 2018 Jan 22. doi:10.1038/s41598-018-19670-x

Oxygen

The Rate Limiting Compound?

Although our brain makes up less than 2% of our body’s mass it consumes 20-25% of our body’s oxygen intake. Unlike other organs, the brain has no storage capacity for energy, therefore it requires a constant and consistent blood flow for delivery of oxygen, glucose and fatty acids for metabolism.

20-25% is an incredibly high number for 1 organ and this means that our brain is massively energy dependent for proper function!

The next logical question would be, “Is that the correct percentage of oxygen our brain requires for optimal function, or is that just the maximum amount of oxygen the body has to spare and share with and feed the brain.”

In other words, if the brain had access to higher concentrations oxygen, could it function at a higher level? With greater nourishment to the brain, we could potentially heal faster from injury, perform at higher levels and generate greater capacity for neuroplasticity.

Research is now being conducted to try and answer this very question!

Background Information:

Under “normal” healthy circumstances, we are already about 97-99% saturated with oxygen. This means that we are already carrying almost all the oxygen we are capable of carrying.

In fact, we really need to be almost fully saturated with oxygen every minute of every day just to maintain “normal” healthy functions. Testing the question, can the brain increase performance if it had access to higher levels of oxygen?, has been generally overlooked since it is not easy to find ways of getting the body to absorb more than 100% oxygen saturation. One of the only ways to do this is through Hyperbaric Oxygen Therapy (HBOT). In a hyperbaric environment, we are able to absorb more oxygen because we can bypass the normal red blood cell carrying capacity all together. This lets us to absorb oxygen directly into the plasma of our blood and into our tissues, allowing us to access extraordinary amounts of “extra” oxygen. Depending on the amounts of pressure and oxygen being used along with manipulating the frequency and duration of treatments we are able to increase oxygen absorption well beyond the 100% carrying capacity of the red blood cells. It is possible to see anywhere from 15%-60% more absorption of oxygen in a hyperbaric environment.

By performing pre and post testing of multitasking and dual tasking activities, the research has proven beyond any shadow of a doubt that if our brains had access to higher levels of oxygen, they would be capable of higher and more complex processing of information and performance.

As a result of exposure to higher levels of oxygen following the HBOT treatments the subjects all demonstrated increases in their performance and capacity scores. This has obvious implications in improving performance as well as improving neuroplasticity healing and growth.

Dor Vadas1*, Leonid Kalichman2, Amir Hadanny3,4,5 and Shai Efrati3,4,6 (2017) Hyperbaric Oxygen Environment Can Enhance Brain Activity and Multitasking Performance Front. Integr. Neurosci., 27 September 2017 | https://doi.org/10.3389/fnint.2017.00025

Choi, M. H., Kim, J. H., Kim, H. J., Choi, J. S., Yi Jeong, H., and Chung, S. C. (2013). Correlation between cognitive ability measured by response time of 1 back task and changes of SpO 2  by supplying three different levels of oxygen in the elderly. Gerontology 13, 384–387. doi: 10.1111/j.1447-
0594.2012.00911.x

Boussi-Gross, R., Golan, H., Volkov, O., Bechor, Y., Hooflen, D., Schnaider Beeri, M., et al. (2015). Improvement of memory impairments in poststroke patients by hyperbaric oxygen therapy. Am. Psychol. Assoc. 29, 610–621. doi: 10.1037/neu0000149

Incorporating Hyperbaric Oxygen Therapy into a Functional Medicine Practice

by Drs. Jason and Melissa Sonners

Background:

Humans have very few absolute requirements for life; food, water, and oxygen. Well, especially in this group of people, we understand that we can go weeks (even months) without food, but we can only live a few days without water ultimately only a few minutes without oxygen. Proper oxygen levels is something our body literally needs every minute of everyday just to perform “normal” functions. If we look at oxygen through this lens, we begin to understand the role of oxygen not only as a gas, but as an essential nutrient. Like any other nutrient our body needs, there are times we may become deficient and this deficiency has consequences. Likewise, there may be times we want or need to get more the typical daily amount of oxygen required in order to help our body heal. The same way we might take “extra” vitamin C if we were getting a cold, there are time we would want “extra” oxygen to improve our ability to heal.

“Normal Oxygenation” 

Under normal circumstances, oxygen is transported throughout the body only by red blood cells. Assuming no cardiovascular or respiratory diseases, we are already carrying just about all the oxygen we are capable of carrying. Most of us are already between 96-99% saturated with oxygen. That said, learning how to maximize the remaining 1-4% of oxygen saturation can be very meaningful for optimizing function. Beyond that developing tools, techniques or other method of improving the rate and efficiency we oxygenate can have a powerful impact on our over health. Training at altitude (a legal strategy) and blood doping (not legal) are two techniques athletes have used to improve their oxygenation because they understand the massive benefits on performance, recovery and healing when we have access to increased oxygen!

Methods for Improving Oxygenation

Breathing techniques

We are designed to take in long, slow belly breaths using our diaphragm. If you ever watched a newborn breath, you’ll know what I’m talking about. Many of us however, live over-stressed lives. As a result, and without realizing it, many of us take very shallow chest breaths all day long.

This does 2 things:

1. Limits the amount of air and oxygen we are able to get into our lungs
2. Perpetuates the fight or flight bio-chemistry of the stress response.

Learning powerful breathing techniques (Fulford Breathing, Wim Hof Technique, even simple belly breathing techniques) will help to reduce the stress response so many of us deal everyday and equally important will maximize your lung capacity and oxygen absorption with each breath you take.

Pros: decreased stress response, improved relaxation, improved lung capacity, improved oxygenation

Cons: NONE

Exercise With Oxygen Therapy (EWOT)

The concept here is to improve oxygenation through increasing both oxygen demand and oxygen supply.

Demand

In this technique we are increasing demand through exercise. As we exercise our heart rate and breathing rate will both increase. The main reason for this change in rate is to increase the quantity of oxygen delivery to the working muscles supplying them with the fuel they need to keep moving.

Supply

As far as supply goes, we are using oxygen concentrators rather than ambient air as the oxygen source. Air is 21% oxygen which typically does supply us with enough oxygen for daily life but breathing through an oxygen concentrator we can breath 97% oxygen thereby increasing supply. The overall process here is that we create an increased oxygen demand through heavy exercise, usually through a bike, and then we massively increase the oxygen supply by breathing much higher levels of oxygen throughout the duration of that exercise session. This increases the saturation, the rate and amount of oxygen that our red blood cells can deliver to the working tissue helping to create an oxygen surplus.

Pros: Increased oxygen turn over, increased oxygen delivery, increased oxygen saturation.

Cons: Need to be able to exercise at a level meaningful to create the demand which depends on your health and ability or that of your patients. Also still relies on red blood cell carrying capacity Oxygen Deprivation Tents/Masks The theory here is similar to training at altitude. When we are exposed to low oxygen environments (like altitude) our body senses suboptimal oxygen levels and mild hypoxia. The response to that is an increase in red blood cell production. More red blood cells equal more oxygen carriers.

Pros: Increased red blood cell quantity which will increase the amount of oxygen able to be carried.

Cons: In order for this system to work the body needs to be in this low oxygen environment very consistently and for many hours each day. Also the amount of increased red blood cells is dependent on the amount of time spent in the oxygen deprived environment.

Hyperbaric Oxygen Therapy (HBOT)?

HBOT is a treatment which enhances the body’s natural healing process by inhalation of oxygen in a pressurized environment. Breathing in a pressurized environment allows our body to absorb more oxygen than any other tool on the market. Hyperbaric oxygen therapy (HBOT) is rapidly growing in popularity as a natural treatment used to help a large variety of conditions, usually as a part of a functional medicine care plan.

Pros: Very high increase in oxygen absorption, well beyond red blood cell carrying capacity. Passive therapy, almost anyone can receive this therapy

Cons: Sessions can be long, 30-90 minutes depending on patient needs.

How Does HBOT work?

With HBOT, oxygen is dissolved into all of the body’s fluids, the plasma, the central nervous system fluids, the lymph, and the bone and can be carried to areas where circulation is diminished or blocked. Breathing oxygen under pressure (depending on the amount of pressure and duration of the treatment) we can absorb not the 1-3% as mentioned above but actually between 20-60% more oxygen. In this way, extra oxygen can reach all of the damaged tissues and the body can support its own healing process.

The increased oxygen greatly enhances the ability of white blood cells to kill bacteria, reduces swelling and inflammation, allows new blood vessels to grow more rapidly into the affected areas, improves oxygenation of poor blood flow areas like joints, ligaments and spinal discs, stimulates neuroplasticity, improves cognition, aids detoxification, increases mitochondrial efficiency and density making more ATP production possible, and so much more.  It is a simple, non-invasive and painless treatment with incredible results. It has long been known that proper healing of the body cannot take place without appropriate oxygen levels in the tissue.  Most illnesses and injuries occur, and often linger, at the cellular or tissue level due to the microcirculation damage associated with the damage.  Even in traditional medicine HBOT is used to help heal in really tough cases of anaerobic infections like Gangrene and osteomyelitis, non-healing wounds and radiation burns, diabetic neuropathy osteonecrosis. In all of these cases, circulatory damage, chronic inflammation and infection are preventing the body’s ability to heal because adequate oxygen cannot reach the damaged area.  Even in these very difficult to treat, often life-threatening cases hyperbaric oxygen therapy provides these patients with the extra oxygen they need to heal naturally and with minimal, often no side effects.

What are we using HBOT for in our offices?

For the same way HBOT helps with these acute, complex and difficult cases, it helps the exact same way with less intense but more chronic conditions. The mechanisms of inflammation, circulatory damage and often immune dysregulation exist in most of our chronic diseases as well. We have been successfully treating patients with hyperbaric oxygen therapy for more than a decade, focusing primarily on conditions such as:

Autism
Cerebral palsy
Chronic fatigue
Fibromyalgia
Crohn’s/Colitis
Dementia/Alzheimer’s
Lyme Disease
Multiple Sclerosis/ALS
Post-surgical care and healing
Post-stroke
TBI/concussion

And many more…

For More on HBOT…Check out this video!

Our company, HBOT USA, works to bring hyperbaric oxygen therapy to the widest possible audience. We are committed to education and implementation strategies for clinics wanting to utilize hyperbaric therapy as well as improving access for patients in need of this modality. We rent and sell chambers to patients for in-home use and to providers for use in their clinics. In addition, we offer programs to help providers build and run HBOT facilities. We’re happy to answer any questions about hyperbaric oxygen therapy in general as well as the specifics of how to run a successful HBOT practice.

Drs. Jason and Melissa Sonners are co-owners of HBOT USA.

Stroke Therapy

HBOT and Stroke Recovery

In order to understand how and why hyperbaric oxygen (oxygen under pressure) can help a patient recovering from a stroke it helps to first understand how hyperbaric oxygen therapy (HBOT) works. If you have not read the blog post titled “HBOT: How Does It Work?” please refer to that before you continue on.

The damage caused by stroke typically impacts several zones of the brain: The initial zone where the actual hemorrhage or ischemia occurred and then a zone surrounding that area that will typically become dormant or inactive. This secondary zone is affected primarily due to a loss of blood flow and therefore loss of oxygen to the tissue in question.

This dormant tissue results from a combination of blood vessel damage, decreased blood flow and surrounding inflammation depriving the brain of enough oxygen to complete its typical functions. Without the ability to nourish it with oxygen and remove cellular waste (carbon dioxide) this are of brain tissue needs to effectively shut down.

At the initial onset of a stroke, the goal is to improve blood flow, unblock any occlusions, stop any excess bleeding and return cerebral blood flow to as close to normal as quickly as possible to minimize the size of these zones and therefore the damage done by the stroke itself. Unfortunately for most stroke patients, once the initial crisis is under control, the only modality offered is physical rehabilitation (physical and/or occupational therapy) to try recovering as much function as possible but not much more is offered and little or nothing done to help the actual brain itself to heal.

This is where HBOT can step in. Oxygen under pressure has the ability to super saturate the damaged tissue with oxygen. The reason again for some of the damage and most of the dormant portion of brain tissue post stroke is loss of oxygen. If we can continue to help reduce the amount of swelling, and then provide very high levels of oxygen, enough to provide not only what is needed for normal function, but more importantly higher levels, enough to help promote healing, we can shrink the size of these damaged zones. How far can we shrink them? What symptoms are going to get better and in what order will they improve? We really do not know that answers to those questions. All we know is that if you can expose these patients to higher levels of oxygen, they can heal. As they heal, they will see an improvement in their symptoms and improvement in their overall ability to function and have an improved quality of life. Ease of movement, less spasm, improved cognition, improved vision, improved speaking ability, improved memory are all common improvements seen using Hyperbaric oxygen post stroke.

HBOT & Lyme Disease

HBOT and Lyme Disease

Lyme disease, which is borrelia burgdorferi bacteria transmitted to humans through a tick bite, can have massive and debilitating effects. Some of these include fatigue, joint pain, muscle pain, meningitis, migraines, among many others.

Unfortunately, the traditional treatments for Lyme are limited to basic antibiotic therapy. If caught quickly this is sometimes enough to recover, but often it is not enough. These infections are very strong and often prove resistant to many traditional therapies. Also, most often Lyme is not alone, since there are a multitude of coinfections that exist along with Lyme. A multi-therapeutic approach is needed to treat these infections. Addressing this condition from multiple angles is paramount to successfully healing.

One of the prongs on this multi-therapeutic approach should Hyperbaric Oxygen Therapy (HBOT). HBOT has the capacity to play a major role in healing from Lyme for a few reasons:

  • Lyme disease is in a classification of bacteria called anaerobes, meaning these bacteria thrive in very low oxygen environments.  HBOT, being a very high oxygen environment, has the ability to aid in the killing of the bacteria.

  • Lyme causes a great deal of inflammation throughout the body affecting joints, muscles and the nervous system. One of the primary uses of HBOT in general is to help manage inflammation. The more oxygen our body can absorb, the more inflammation we can process and move out of our body.

  • Oxygen is a major nutrient our body needs to heal from damage. As a result of the infection and associated inflammation, damage can be extensive. HBOT provides exceptionally high amounts of oxygen that the body can use to heal the brain, nerves, muscles and joints.

The use of HBOT as part of the multi-therapeutic approach for Lyme is growing rapidly.  Lyme experts are coming to see the obvious benefits of including HBOT as part of their patients’ recovery from this debilitating disease. For more info please read a case study below.

Case Study:

In April 2003, our patient was a 31-year-old healthy man who worked in the financial industry and lived in Taipei City, who began suffering from intermittent low- and high-grade fever. These symptoms were accompanied by fatigue and multiple bone pain, especially in the sternum, ribs, and lower back, which made it difficult for the patient to walk. Since that time, the patient had only received symptomatic medications such as painkillers. In January 2004, some erythema migrans lesions were found over the patient’s legs. In addition, he suffered from joint pain in both knees, the shoulders, and temporomandibular joints. Tracing back the patient’s history 2 years prior to clinical presentation, it was noted that he was a frequent hiker in the Yang-Ming Mountains in Taipei, Taiwan, where he often sat on the grass and had contact with wild cattle. He had previously visited infection and dermatology clinics, where his Borrelia serology IgG was positive, and Lyme disease was strongly suspected. Soon thereafter, 500 mg amoxicillin twice daily was prescribed for 1 month, which caused the patient’s symptoms to subside partially. However, in the next 3 years, he was bothered by symptoms including: (1) nervous system, comprised of irritability, mood swings, poor concentration, loss of short-term memory, sleep disturbance, facial tingling, blurred vision, and photophobia; (2) cardiovascular system, consisting of chest pains and palpitations; (3) musculoskeletal system, associated with migrating arthralgias; and (4) other problems, including headache and pelvic pain.

In 2007, the patient again visited another infection clinic, where he received antibiotic agents such as doxycycline, amoxicillin 250 mg + clavulanic acid 125 mg (Augmentin), parenteral penicillin, and oral cefuroxime over the following 4 years. Because the above symptoms had not improved significantly, in October 2011 the patient visited us for HBOT. Before HBOT, some residual symptoms such as elbow and joint pain, numbness of the extremities, perioribital twitch, sleep disorder, and affected thinking ability persisted. After we excluded other infectious and noninfectious etiologies that can mimic certain appearances of the typical multisystem illness seen in CLD, HBOT at 2.5 ATA with treatment duration of 1.5 hours for 30 sessions was given. In the first 10 sessions of HBOT, nervous-system-associated symptoms such as loss of thinking ability and sleep disorder disappeared. In the second 10 sessions of HBOT, additional nervous system symptoms such as numbness of the extremities and perioribital twitch also disappeared. In the third 10 sessions of HBOT, musculoskeletal system symptoms such as migrating arthralgia also vanished. Overall, completion of 30 sessions of HBOT caused noted longstanding Lyme-disease-related symptoms affecting most of the previously affected bodily areas to disappear.

How HBOT Works

HBOT: How Does It Work?

Everyone knows we need oxygen for our survival. It is a critical nutrient for our cells in order to function and produce energy.

So what is the difference between the air you and I we breathe, using medical grade green tank oxygen and using hyperbaric oxygen therapy (HBOT)?

The air we breathe is 21% oxygen. The rest is primarily Nitrogen. As we breathe air in, our body is able to take the oxygen (our body’s fuel source) from the air, dissolve it through our lungs and then carry it though our whole circulatory system (using red blood cells) to oxygenate every single cell we have (about 10 trillion). Once the oxygen has left the red blood cells, they picks up carbon dioxide (our cells waste product) and carries that back to our lungs for removal during an exhale. It’s a pretty amazing process actually!

If you have ever been in the hospital or perhaps at your annual physical, the doctor has put that little instrument on your finger that measures your pulse and oxygen saturation. If you are relatively healthy –  especially without lung or other breathing issues (COPD) – you would be about 98-100% saturated with oxygen. This means your red blood cells are currently maxed out and carrying as much oxygen as they possibly can. If there is some type of lung condition, that number will drop into the low 90s and possibly into the 80s. This would mean the lungs were not pulling enough oxygen out of the air in order to fill those red blood cells with oxygen. In those cases, medical grade green tank oxygen can be a miracle. Now instead of breathing 21% oxygen from the air, we can breathe 100% oxygen from a tank (or oxygen concentrator machine) and increase how much oxygen we can use to fill those red blood cells. In many cases, this is sufficient enough to help many COPD-type patients.

 

Becoming more than 100% Saturated

In certain cases, a patient may already be 100% saturated with oxygen (because there is NO pulmonary/lung disease), but one of the following conditions is present:

  • There is a blockage somewhere preventing the oxygen from getting where it needs it to go (TBI, neuropathy, stroke, trauma, excessive swelling). These patients cannot bring anymore oxygen in (they are 100% saturated, but, they cannot get oxygen to the area in need due to some other issue,trauma or condition.

OR

  • These patients really need a much higher amount of free floating oxygen (more than 100% saturation) in order to help heal from a certain condition (fibromyalgia, dementia, Lyme, CP, MS, ALS, etc ).  If the body had access to this “extra” oxygen, it would have more of what it needs to further promote healing and reduce inflammation and toxicity.

In these cases, HBOT is the necessary tool to administer the proper type and amount of oxygen. Simply put, HBOT does not rely on the red blood cell system carrying oxygen for the body. It will fill those cells, but even more, due to the pressure inside the chamber, it will dissolve “extra” oxygen into the plasma of the blood and directly into our tissues. In this case, we are able to effectively be 110-140% saturated, delivering 10-40% more oxygen to tissues that have literally been starving for more oxygen.

Most importantly it meets my standard of “safety to effectiveness” ratio. HBOT is one of the safest healthcare modalities that exists and yet is enormously effective in helping to heal from a large variety of conditions. Risk to benefit ratio is very clearly high benefit, low risk! It is a shame that HBOT is not on the front line of therapies for some of the above conditions.

 

What Is HBOT

Hyperbaric oxygen therapy (HBOT) is a medical treatment which enhances the body’s natural healing process by inhalation of 100% oxygen in a total body chamber, where atmospheric pressure is increased and controlled.  It is used for a wide variety of treatments usually as a part of an overall medical care plan.

Under normal circumstances, oxygen is transported throughout the body only by red blood cells. With HBOT, oxygen is dissolved into all of the body’s fluids, the plasma, the central nervous system fluids, the lymph, and the bone and can be carried to areas where circulation is diminished or blocked.  In this way, extra oxygen can reach all of the damaged tissues and the body can support its own healing process.  The increased oxygen greatly enhances the ability of white blood cells to kill bacteria, reduces swelling and allows new blood vessels to grow more rapidly into the affected areas.  It is a simple, non-invasive and painless treatment.

It has long been known that healing many areas of the body cannot take place without appropriate oxygen levels in the tissue.  Most illnesses and injuries occur, and often linger, at the cellular or tissue level.  In many cases, such as: circulatory problems; non-healing wounds; and strokes, adequate oxygen cannot reach the damaged area and the body’s natural healing ability is unable to function properly.  Hyperbaric oxygen therapy provides this extra oxygen naturally and with minimal side effects.

Hyperbaric oxygen therapy improves the quality of life of the patient in many areas when standard medicine is not working.  Many conditions such as stroke, cerebral palsy, head injuries, and chronic fatigue have responded favorably to HBOT.

The Benefits Of HBOT

We know that oxygen is essential to normal cellular physiology. Cancer cells have an altered metabolism and no longer depend upon oxygen. In fact, high oxygenated environments are toxic to cancer cells and both slows their growth and triggers cell death mechanisms within them. Is there a way to increase oxygen in the body to support healthy cell function while being a detriment to cancer cell function?

Our bodies rely on the constant supply of oxygen intake to survive. Our atmosphere is approximately 21% oxygen. This element is required by every cell in the human body to produce cellular energy via the mitochondria. High flow oxygen therapy can deliver 100% oxygen in a pressurized atmosphere and results in extraordinary healing benefits.

When oxygen is administered at high pressure rates, up to 20 times more oxygen can be absorbed by the bloodstream. This oxygen is transported to damaged organs and tissue which speeds up both healing and recovery time. Hyperbaric oxygen therapy delivers pure oxygen up to 3 times the normal atmospheric pressure. Sessions typically ranges from 30 to 90 minutes.

What is Hyperbaric Oxygen Therapy?

Hyperbaric oxygen therapy (HBOT) refers to breathing in conditions of 100% pure oxygen under high pressure. This process encourages oxygen to be quickly absorbed and dissolved into the bloodstream at an expedited rate. Infection can slow healing because the blood supply to the affected site is damaged. HBOT increases the oxygen supply to these damaged tissues.

This form of hyperbaric therapy which utilizes 100% of oxygen requires a prescription under FDA guidelines due to its classification as a drug. Mild hyperbaric therapy or mHBOT has also shown significant health benefits and administers 95% oxygen in a small range of 1.3 to 1.4 atmospheric pressure. Requiring no doctor’s prescription, providing incredible health benefits and a process that has minimal to zero risks, mHBOT is a much more affordable treatment option.

Systems range in cost from as low as $5 to $25,000. You can also get treatments at around $50 to $100 a session. HBOT that provide more than 1.5 times the atmospheric pressure and administers 100% oxygen are about $200 per treatment session.

Benefits of Hyperbaric Oxygen Therapy

HBOT can benefit any patient who is healing from a condition triggered by inflammation in the body. The healing process can be improved using HBOT to deliver a higher rate of oxygen to damaged tissue. In fact, oxygen controls more than 8,000 genes and is one of the most natural forms of antibiotics. Twenty sessions of therapy improves the function of stem cells by eightfold.

HBOT has also been shown to help with the following:

  • Stimulates new blood vessel growth and increase blood flow
  • Elevates the body’s natural immune defenses to fight infection and bacteria
  • Reduces swelling that may occur around damaged areas
  • Speeds up healing by increasing tissue oxygen levels to areas in the body where they are reduced due to injury or illness

HBOT cancer treatment

What is a hyperbaric chamber? It is a device that a person enters in order to have oxygen under pressure given to them.

There is definite research showing the benefits of hyperbaric for a variety of complaints from decubitus ulcers (bedsores) and diabetic non-healing wounds to cancer treatment [1, 2] For cancer treatment, oxygen makes cancer cells weaker and less resistant to treatment. [3, 4]

Dominic D’Agostino of the University of South Florida has done research for the Department of Defense for work with Navy SEALS. His work shows that a ketogenic diet and hyperbaric oxygen therapy prolong survival in mice with systemic metastatic cancer. [5] In fact, this work shows a ketogenic diet with hyperbaric oxygen stops the tumor growth progression.

But a good hard shell hyperbaric chamber will cost around $75,000. (That’s the price of a very nice new BMW!) Taking time out of the day to drive to a clinic and paying for the use of a hard shell? Who has that much time? So what are the alternatives?

Manfred von Ardenne, a student of Otto Warburg, investigated the delivery of oxygen to the patient in what he called the “Oxygen Multistep Therapy” or O2MT which evolved into at home therapy called “Exercise With Oxygen Therapy” or EWOT. Dr. Ardenne found that this therapy stimulated the immune system, impacts microcirculation, increases oxygen status and improves the overall energetic status. [6]

This work is so impressive that Warburg wrote a letter to von Ardenne stating: “In these last few years you have certainly reached the peak of cancer research; I certainly know of no single book in the whole of cancer research in which anyone else has tackled the therapy problem with the same energy and breadth. My instinct tells me that, in the long run, your victory is certain.” [6]

 

Studies

. 1998 Oct 24; 317(7166): 1140–1143.
PMCID: PMC1114115
PMID: 9784458
ABC of oxygen

Hyperbaric oxygen therapy

Over the past 40 years hyperbaric oxygen therapy has been recommended and used in a wide variety of medical conditions, often without adequate scientific validation of efficacy or safety. Consequently a high degree of medical scepticism has developed regarding its use. The Undersea and Hyperbaric Medical Society approves use of hyperbaric oxygen for a few conditions for which there is thought to be reasonable scientific evidence or well validated clinical experience. In these conditions early referral is essential.

Therapeutic uses of hyperbaric oxygen

Strong scientific evidence

Main treatment

  • Decompression sickness
  • Arterial gas embolism
  • Severe carbon monoxide poisoning and smoke inhalation

Adjunctive treatment

  • Prevention and treatment of osteoradionecrosis
  • Improved skin graft and flap healing
  • Clostridial myonecrosis

Suggestive scientific evidence

Adjunctive treatment

  • Refractory osteomyelitis
  • Radiation induced injury
  • Acute traumatic ischaemic injury
  • Prolonged failure of wound healing
  • Exceptional anaemia from blood loss

Hyperbaric oxygen has been shown ineffective in diseases such as multiple sclerosis and dementia, but it continues to be used despite the risks of the treatment. For conditions where its use remains unproved—for example, rheumatoid arthritis, cirrhosis, and gastroduodenal ulcer—hyperbaric oxygen should be used only in the context of well controlled clinical trials.

Biochemical and physiological effects

At sea level the plasma oxygen concentration is 3 ml/l. Tissues at rest require about 60 ml of oxygen per litre of blood flow (assuming normal perfusion) to maintain normal cellular metabolism, although requirements vary between tissues. At a pressure of 3 atmospheres (304 kPa) dissolved oxygen approaches 60 ml/l of plasma, which is almost sufficient to supply the resting total oxygen requirement of many tissues without a contribution from oxygen bound to haemoglobin. This has advantages in situations such as carbon monoxide poisoning or in severe anaemia where difficult crossmatching or religious belief prevents blood transfusion.

Cellular and biochemical benefits of hyperbaric oxygen

  • Promotes angiogenesis and wound healing
  • Kills certain anaerobes
  • Prevents growth of species such as Pseudomonas
  • Prevents production of clostridial alpha toxin
  • Restores neutrophil mediated bacterial killing in previously hypoxic tissues
  • Reduces leucocyte adhesion in reperfusion injury, preventing release of proteases and free radicals which cause vasoconstriction and cellular damage

Oxygen at 300 kPa increases oxygen tension in arterial blood to nearly 270 kPa and in tissue to about 53 kPa. This improves the cellular oxygen supply by raising the tissue-cellular diffusion gradient. The hyperoxia has potential benefits including improved angiogenesis. The formation of collagen matrix is essential for angiogenesis and is inhibited by hypoxia. In irradiated tissue hyperbaric oxygen is more effective than normobaric oxygen at raising tissue partial pressure of oxygen and promoting angiogenesis and wound healing. The healing process may also be helped in non-irradiated tissues with compromised perfusion, but this requires further validation.

Advice on the nearest suitable UK unit and help to coordinate the management can be obtained from the Institute of Naval Medicine, Gosport (24 hour emergency number 0831 151523, daytime inquiries 01705 768026)

The value of hyperbaric oxygen therapy in decompression illness and arterial gas embolism depends on the physical properties of gases. The volume of a gas in an enclosed space is inversely proportional to the pressure exerted on it (Boyle’s law). At 300 kPa bubble volume is reduced by about two thirds. Any intravascular bubbles causing obstruction move to smaller vessels, which reduces extravascular tissue damage. Dissolution of the gas bubble is enhanced by replacing the inert gas in the bubble with oxygen, which is then rapidly metabolised by the tissues.

Availability and administration

Multiplace chambers are available in a few NHS hospitals (Aberdeen, Craigavon, Newcastle upon Tyne), Royal Navy centres, private units, police diving units, professional diver training schools, and sites associated with the North Sea oil industry. The United States has over 250 facilities.

Comparison of monoplace and multiplace hyperbaric oxygen chambers

Monoplace

  • Claustrophobic environment;limited access to patient
  • Whole chamber containshyperbaric oxygen,increasing fire risk
  • Lower cost
  • Portable

Multiplace

  • More room; assistant canenter to deal with acuteproblems such aspneumothorax
  • Hyperbaric oxygen via tightfitting mask—chamber gascan be air (reduced fire risk)
  • Risk of cross infection whenused for ulcers etc

Often early treatment is essential for maximum benefit. This poses appreciable practical problems as severely ill patients may have to be transported long distances and may require intensive medical support, including mechanical ventilation, between treatment sessions. It is important to discuss the potential benefits and risks for each patient with the regional hyperbaric oxygen facilities.

Multioccupancy chambers are required for critically ill patients who require an attendant within the chamber and are usually used for acute problems. Monoplace chambers can be used to treat patients with chronic medical conditions. Hyperbaric oxygen is inhaled through masks, tight fitting hoods, or endotracheal tubes.

Inside the chambers pressure is usually increased to about 250-280 kPa, equivalent to a depth of 15-18 m of water. The duration of treatment varies from 45 to 300 min and patients may receive up to 40 sessions. Appropriate monitoring is essential during treatment, and facilities for resuscitation and immediate mechanical ventilation should be available.

Dangers of hyperbaric oxygen

The potential risks and risk-benefit ratio of hyperbaric oxygen have often been underemphasised in therapeutic trials. The side effects are often mild and reversible but can be severe and life threatening. In general, if pressures do not exceed 300 kPa and the length of treatment is less than 120 minutes, hyperbaric oxygen therapy is safe. Overall, severe central nervous system symptoms occur in 1-2% of treated patients, symptomatic reversible barotrauma in 15-20%, pulmonary symptoms in 15-20%, and reversible optic symptoms in up to 20% of patients.

Reversible myopia, due to oxygen toxicity on the lens, is the commonest side effect and can last for weeks or months. Epileptic fits are rare and usually cause no permanent damage. A suggested carcinogenic effect of hyperbaric oxygen has not been substantiated in extensive studies.

Risks of hyperbaric oxygen

Fire hazard

Most common fatal complication

General features

  • Claustrophobia
  • Reversible myopia
  • Fatigue
  • Headache
  • Vomiting

Barotrauma

  • Ear damage
  • Sinus damage
  • Ruptured middle ear
  • Lung damage

Oxygen toxicity

  • Brain
    •  Convulsions
    •  Psychological
    • •  Lung
    •  Pulmonary oedema,haemorrhage
    •  Pulmonary toxicity
    •  Respiratory failure (may beirreversible when due topulmonary fibrosis)

Decompression illness

  • Decompression sickness
  • Pneumothorax
  • Gas emboli

Pneumothoraces must be adequately drained before treatment with hyperbaric oxygen. Pulmonary oxygen toxicity with chest tightness, cough, and reversible falls in pulmonary function may occur with repeated treatment, particularly in patients exposed to high oxygen levels before treatment. Oxygen toxicity can be prevented in most tissues by using air in the chamber for 5 minutes every 30 minutes. This allows antioxidants to deal with free oxygen radicals formed during the hyperoxic period.

Therapeutic uses

Decompression sickness and arterial gas embolism

When divers surface too rapidly the partial pressure of nitrogen dissolved in the tissues may exceed the ambient atmospheric pressure sufficiently to form gas bubbles in the blood and the tissues. Although less common, rapid ascent to over 5500 m can result in high altitude decompression sickness.

Decompression sickness may produce mild problems such as rash or joint pain or be more serious with paralysis, confusion, convulsions, and ultimately death secondary to blockage of vital blood vessels. Hyperbaric oxygen is the main treatment, and its efficacy has been validated by extensive clinical experience and scientific studies. Recompression rapidly alleviates the symptoms, and tables are available to determine safe periods for subsequent decompression. Treatment should be started as soon as possible and given in sessions of 2-5 hours until the symptoms have resolved.

Air may also enter the circulation during placement of arterial and venous catheters, cardiothoracic surgery, haemodialysis, or mechanical ventilation. Although no formal trials support the use of hyperbaric oxygen in air embolism, the well established physical properties of gases and extensive clinical experience justify its use as the primary treatment. Treatment should begin immediately at pressures of 250-300 kPa for 2-5 hours. Benefit is reported when hyperbaric oxygen therapy begins several hours after the onset of air embolism but further trials are required to establish the delay after which hyperbaric oxygen is no longer of value.

Carbon monoxide poisoning

Carbon monoxide poisoning is an important cause of death from poisoning, particularly in the United States. Carbon monoxide binds to haemoglobin with an affinity 240 times that of oxygen. This reduces the oxygen carrying capacity of the blood. Unoccupied haemoglobin binding sites have an increased affinity for oxygen, further reducing the availability of oxygen to the tissues. In addition, carbon monoxide binds to the large pool of myoglobin increasing tissue hypoxia. Hyperbaric oxygen provides an alternative source of tissue oxygenation through oxygen dissolved in the plasma. It also facilitates dissociation of carbon monoxide from the haemoglobin and myoglobin; the carboxyhaemoglobin half life is 240-320 min breathing air, 80-100 min breathing 100% oxygen, and about 20 min with hyperbaric oxygen. In addition, hyperbaric oxygen dissociates carbon monoxide from cytochrome c oxidase, improving electron transport and cellular energy state.

Symptoms of carbon monoxide poisoning

  • Loss of consciousness
  • Neurological abnormalities
  • Myocardial ischaemia
  • Pulmonary oedema
  • Metabolic acidosis
  • Headache
  • Nausea
  • Delayed neuropsychological features (often permanent)

Controlled studies comparing hyperbaric oxygen and normobaric 100% oxygen in the acute and delayed effects of carbon monoxide poisoning have produced conflicting results, although some benefit was seen in patients who experienced loss of consciousness or neurological abnormality.

The clinical severity of carbon monoxide poisoning does not correlate well with carboxyhaemoglobin concentrations

If carbon monoxide poisoning results in unconsciousness, convulsions, neurological impairment (including abnormal gait or mental state test results) or severe metabolic acidosis the case should be discussed with the nearest regional centre. A single session of hyperbaric oxygen therapy will usually reverse the acute, potentially life threatening effects of carbon monoxide poisoning, but additional treatments may be needed to reduce the delayed neuropsychological sequelae. Patients with less severe poisoning should be treated with 100% oxygen.

Necrotising infections and osteomyelitis

The primary treatment of myonecrosis and gas gangrene of soft tissues resulting from clostridial infection and alpha toxin production is surgical debridement and antibiotics. However, experimental evidence and clinical experience suggest that adjunctive treatment with hyperbaric oxygen improves systemic illness and decreases tissue loss by demarcating the border between devitalised and healthy tissue. This reduces the extent of surgical amputation or debridement. Controlled trials of hyperbaric oxygen and normobaric 100% oxygen are not available. In necrotising fasciitis (rapidly progressive skin infection without muscle disease) retrospective studies suggest that hyperbaric oxygen is beneficial in combination with surgical debridement but prospective controlled trials are lacking.

Hyperbaric oxygen is also claimed to be helpful in refractory osteomyelitis. Animal experiments show improved healing of osteomyelitis compared with no treatment, but the effect is no better than that with antibiotics alone and the two treatments have no synergistic effect. Uncontrolled trials of surgery and antibiotics combined with hyperbaric oxygen in refractory osteomyelitis have reported success rates of as high as 85%, but controlled trials are needed.

Post radiation damage

Soft tissue radionecrosis and osteonecrosis after surgery on irradiated mandibles are reduced by hyperbaric oxygen. In a controlled study comparing osteoradionecrosis at six months postoperatively, the incidence was 5% in patients receiving 30 preoperative hyperbaric oxygen treatments compared with 30% in patients who received only preoperative antibiotics. A similar improvement in wound healing after surgery has been shown in patients with irradiated tissue who receive preoperative hyperbaric oxygen therapy. Normobaric 100% oxygen does not seem to confer the same benefits. The higher partial pressures achieved with hyperbaric oxygen may stimulate new vessel growth and healing in damaged irradiated tissue which has lost the capacity for restorative cellular proliferation.

To prevent mandibular osteonecrosis after surgery on irradiated facial and neck tissue 30 preoperative 90 minute sessions and 10 postoperative sessions are recommended

Skin grafts, flaps, and wound healing

In poorly vascularised tissue hyperbaric oxygen improves both graft and flap survival compared with routine postoperative surgical care alone. The effect of normobaric 100% oxygen was not examined in these studies. In the United States problem wounds are the commonest indication for a trial of adjunctive hyperbaric oxygen therapy and include diabetic and other small vessel ischaemic foot ulcers. Several studies have shown improved healing and a lower incidence of amputation with 4-30 sessions.

Hyperbaric oxygen should be considered for problem wounds if the facility is readily available

Other indications

Hyperbaric oxygen has been used successfully to treat haemorrhagic shock in patients who refuse blood on religious grounds or for whom suitable blood was not available. Similarly, there is evidence for benefit in acute traumatic ischaemic injuries including compartmental syndromes and crush injuries.

Conditions which do not benefit

Hyperbaric oxygen has been tried in numerous conditions and is often reported to be beneficial. However, in many of these situations the scientific evidence is flimsy and use should be restricted to randomised controlled trials. Hyperbaric oxygen has been clearly shown not to be beneficial in several diseases including multiple sclerosis and senility.

Summary

  • Lack of randomised controlled trials makes it difficult to assess the efficacy of hyperbaric oxygen in many diseases
  • Side effects are usually mild but can be life threatening
  • Clear evidence of benefit has been found in decompression sickness and a few other conditions
  • Much work remains to be done to establish the timing, indications, and therapeutic regimens required to obtain the best clinical and cost effective results
  • The cellular, biochemical, and physiological mechanisms by which hyperbaric oxygen achieves beneficial results are not fully established

The suggestion that hyperbaric oxygen may be beneficial in multiple sclerosis arose from animal work suggesting that it improved experimental allergic encephalomyelitis and several uncontrolled studies suggesting disease remission in humans with multiple sclerosis. In 1983, a small controlled trial reported significant benefit, and large numbers of patients with multiple sclerosis were treated with hyperbaric oxygen. Since this initial trial at least 14 trials, of which eight are high quality randomised controlled studies, have been published. In the eight high quality studies the patients had chronic stable or chronic progressive multiple sclerosis, had at least 20 sessions of therapy for 90 minutes over four weeks, and were adequately assessed with evoked potentials and for functional and disability state. Only one study showed a benefit from hyperbaric oxygen.

No convincing evidence exists for using hyperbaric oxygen in thermal burns. In the only randomised controlled trial of hyperbaric oxygen and usual burn care the length of hospital stay, need for autografting, and mortality were virtually identical with both treatments.

Footnotes

P Wilmshurst is consultant cardiologist at Royal Shrewsbury Hospital, Shrewsbury.

The ABC of Oxygen is edited by Richard M Leach, consultant physician, department of intensive care, and P John Rees, consultant physician, department of respiratory medicine, Guy’s and St Thomas’s Hospitals Trust, London.

The pictures of the hyperbaric chamber and necrotic heel of diabetic patient were downloaded from the internet with permission from Proteus Hyperbaric Systems. The picture of gas gangrene was downloaded with permission from St Joseph Medical Center, Fort Wayne, Indiana, USA


Articles from The BMJ are provided here courtesy of BMJ Publishing Group

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