Hyperbaric Chambers

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Hyperbaric medicine, also known as hyperbaric oxygen therapy (HBOT), is the medical use of oxygen at a level higher than atmospheric pressure. The equipment required consists of a pressure chamber, which may be of rigid or flexible construction, and a means of delivering 100% oxygen. Operation is performed to a predetermined schedule by trained personnel who monitor the patient and may adjust the schedule as required. HBOT found early use in the treatment of decompression sickness. But it has also shown great effectiveness in treating conditions such as gas gangrene and carbon monoxide poisoning. More recent research has examined the possibility that it may also have value for other conditions such as cerebral palsy and multiple sclerosis, but no significant evidence has been found.

Several therapeutic principles are made use of in HBOT:[1]
The increased overall pressure is of therapeutic value when HBOT is used in the treatment of decompression sickness and air embolism;[2]
For many other conditions, the therapeutic principle of HBOT lies in its ability to drastically increase partial pressure of oxygen in the tissues of the body. The oxygen partial pressures achievable using HBOT are much higher than those achievable while breathing pure oxygen at normobaric conditions (i.e. at normal atmospheric pressure);
A related effect is the increased oxygen transport capacity of the blood. Under normal atmospheric pressure, oxygen transport is limited by the oxygen binding capacity of hemoglobin in red blood cells and very little oxygen is transported by blood plasma. Because the hemoglobin of the red blood cells is almost saturated with oxygen under atmospheric pressure, this route of transport cannot be exploited any further. Oxygen transport by plasma, however is significantly increased using HBOT as the stimulus.
Recent evidence notes that exposure to hyperbaric oxygen (HBOT) mobilizes stem/progenitor cells from the bone marrow by a nitric oxide (·NO) -dependent mechanism.[3] This mechanism may account for the patient cases that suggest recovery of damaged organs and tissues with HBOT.
[edit]Indications

In the United States the Undersea and Hyperbaric Medical Society, known as UHMS, lists approvals for reimbursement for certain diagnoses in hospitals and clinics. The following indications are approved (for reimbursement) uses of hyperbaric oxygen therapy as defined by the UHMS Hyperbaric Oxygen Therapy Committee:[1][4] However, these are reimbursement decisions based on cost of medical treatments vs HBOT at the average U.S. hospital charge of $1,800.00 per 90 minute HBOT treatment. China and Russia treat more than 80 maladies, conditions and trauma with HBOT, since costs are insignificant in those countries.[5]
Air or gas embolism;[6]
Carbon monoxide poisoning;[7][8]
Carbon monoxide poisoning complicated by cyanide poisoning;[9][10][11]
Clostridal myositis and myonecrosis (gas gangrene);[12][13][14]
Crush injury, compartment syndrome, and other acute traumatic ischemias;[15][16]
Decompression sickness;[17][18][19]
Enhancement of healing in selected problem wounds;[20][21][22]
Diabetically derived illness, such as diabetic foot,[23][24] diabetic retinopathy,[25][26] diabetic nephropathy;[27]
Exceptional blood loss (anemia);[28][29]
Intracranial abscess;[30][31]
Necrotizing soft tissue infections (necrotizing fasciitis);[32][33]
Osteomyelitis (refractory);[34][35][36]
Delayed radiation injury (soft tissue and bony necrosis);[37][38][39]
Skin grafts and flaps (compromised);[40][41]
Thermal burns.[42][43]
HBOT is recognized by Medicare in the United States as a reimbursable treatment for 14 UHMS "approved" conditions. A 1-hour HBOT session may cost between $108 and $250 in private clinics, and over $1,000 in hospitals. U.S. physicians (either M.D. or D.O.) may lawfully prescribe HBOT for "off-label" conditions such as Lyme Disease,[44] stroke,[45][46][47] and migraines.[48][49][50] Such patients are treated in outpatient clinics. In the United Kingdom most chambers are financed by the National Health Service, although some, such as those run by Multiple Sclerosis Therapy Centres, are non-profit.
Other reported applications include:
Autism. A small 2009 double-blind study of autistic children found that 40 hourly treatments of 24% oxygen at 1.3 atm provided significant improvement in the children's behavior immediately after treatment sessions.[51] The study's effect has not been independently confirmed. Research conducted by the Center for Autism and Related Disorders (CARD) found that hyperbaric oxygen therapy does not have a significant effect on symptoms of autism.[52]
Cerebral Palsy;[53]
Epidural abscesses;[54]
Certain kind of hearing loss;[55]
multiple sclerosis[56]
Radiation-induced hemorrhagic cystitis;[57]
Inflammatory bowel disease.[58][59]
Psoriasis.[60]
The toxicology of the treatment has recently been reviewed by Ustundag et al.[61] and its risk management is discussed by Christian R. Mortensen, in light of the fact that most hyperbaric facilities are managed by departments of anaesthesiology and some of their patients are critically ill.[62]
[edit]Hyperbaric chambers



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An example of mild portable hyperbaric chamber. This 40-inch-diameter (1,000 mm) chamber is one of the larger chambers available for home.
There are several sizes of portable chambers, which are used for home treatment. These are usually referred to as "mild personal hyperbaric chambers", which is a reference to the lower pressure (compared to hard chambers) of soft-sided chambers. Food and Drug Administration (FDA) approved chambers for use with room air are available in the USA and may go up to 4.4 pounds per square inch (psi) above atmospheric pressure,[citation needed] which equals 1.3 atmospheres absolute (ATA), equivalent to a depth of 10 feet of sea water. In the US, these "mild personal hyperbaric chambers" are categorized by the FDA as CLASS II medical devices and requires a prescription in order to purchase one or take treatments.[66] Personal hyperbaric chambers are only FDA approved to reach 1.3 ATA.[citation needed] While hyperbaric chamber distributors and manufacturers cannot supply a chamber in the US with any form of elevated oxygen delivery system, a physician can write a prescription to combine the two modalities, as long as there is a prescription for both hyperbarics and oxygen.[citation needed] The most common option (but not approved by FDA) some patients choose is to acquire an oxygen concentrator which typically delivers 85–96% oxygen as the breathing gas. Due to the high circulation of air through the chamber, the total concentration of oxygen in the chamber never exceeds 25% as this can increase the risk of fire.[citation needed] Oxygen is never fed directly into soft chambers but is rather introduced via a line and mask directly to the patient. FDA approved oxygen concentrators for human consumption in confined areas used for HBOT are regularly monitored for purity (+/- 1%) and flow (10 to 15 liters per minute outflow pressure). An audible alarm will sound if the purity ever drops below 80%. Personal hyperbaric chambers use 120 volt or 220 volt outlets. Ranging in size from 21 inches up to 40 inches in diameter these chambers measure between 84 in (7 ft) to 120 in (10 ft) in length.[citation needed] The soft chambers are approved by the FDA for the treatment of altitude sickness, but are commonly used for other "off-label" purposes.[citation needed]
[edit]Possible complications and concerns
There are risks associated with HBOT, similar to some diving disorders. Pressure changes can cause a "squeeze" or barotrauma in the tissues surrounding trapped air inside the body, such as the lungs,[67] behind the eardrum,[68][69] inside paranasal sinuses,[68] or trapped underneath dental fillings.[70] Breathing high-pressure oxygen may cause oxygen toxicity.[71] Temporarily blurred vision can be caused by swelling of the lens, which usually resolves in two to four weeks.[72][73]
There are reports that cataract may progress following HBOT.[74] Also a rare side effect has been blindness secondary to optic neuritis (inflammation of the optic nerve).[citation needed]
[edit]Effects of Pressure
Patients inside the chamber may notice discomfort inside their ears as a pressure difference develops between their middle ear and the chamber atmosphere.[75] This can be relieved by the Valsalva maneuver or by "jaw wiggling". As the pressure increases further, mist may form in the air inside the chamber and the air may become warm. Increased pressure may also cause ear drums to rupture, resulting in severe pain.
To reduce the pressure, a valve is opened to allow air out of the chamber. As the pressure falls, the patient’s ears may "squeak" as the pressure inside the ear equalizes with the chamber. The temperature in the chamber will fall. The speed of pressurization and de-pressurization can be adjusted to each patient's needs.
[edit]Contraindications
The only absolute contraindication to hyperbaric oxygen therapy is untreated tension pneumothorax.[67] Also, the treatment may raise the issue of Occupational health and safety (OHS), which has been encountered by the therapist.[76][clarification needed]
Patients should not undergo HBO therapy if they are taking or have recently taken the following drugs:
Doxorubicin (Adriamycin) – A chemotherapeutic drug.
Cisplatin – Also a chemotherapeutic drug.
Disulfiram (Antabuse) – Used in the treatment of alcoholism.
Mafenide acetate (Sulfamylon) – Suppresses bacterial infections in burn wounds
The following are relative contraindications -- meaning that special consideration must be made by specialist physicians before HBO treatments begin:
Cardiac disease
Upper respiratory infections – These conditions can make it difficult for the patient to equalise their ears or sinuses, which can result in what is termed ear or sinus squeeze.
High fevers – In most cases the fever should be lowered before HBO treatment begins.
Emphysema with CO2 retention – This condition can lead to pneumothorax during HBO treatment.
History of thoracic (chest) surgery – This is rarely a problem and usually not considered a contraindication. However, there is concern that air may be trapped in lesions that were created by surgical scarring. These conditions need to be evaluated prior to considering HBO therapy.
Malignant disease: Cancers thrive in blood rich environments but may be suppressed by high oxygen levels. HBO treatment of individuals who have cancer presents a problem, since HBO both increases blood flow via angiogenesis and also raises oxygen levels. Taking an anti-angiogenic supplement may provide a solution.[77][78] A study by Feldemier, et al. and recent NIH funded study on Stem Cells by Thom, et al., indicate that HBO is actually beneficial in producing stem/progenitor cells and the malignant process is not accelerated.[79]
Middle ear barotrauma is always a consideration in treating both children and adults in a hyperbaric environment because of the necessity to equalise pressure in the ears.
Pregnancy is a relative contraindication to both SCUBA diving and hyperbaric oxygen treatments. In cases where a pregnant woman has carbon monoxide poisoning there is evidence that lower pressure (2.0 ATA) HBOT treatments are not harmful to the fetus, and that the risk involved is outweighed by the greater risk of the untreated effects of CO on the fetus (neurologic abnormalities or death.)[80][81]
[edit]Neuro-rehabilitation