Were you in one of the photos,Julia? It is a pretty good article and very informative.
Ann - OH
Take a Dive with Hyperbaric Therapy
Marylisa Kinsley, RN, BSN
Masthead Date February 28, 2005
Hyperbaric oxygen therapy was introduced recently to Trinitas Hospital's Wound Healing Center. Pictured, a patient undergoes a hyperbaric "dive," supervised by Nada Raiser, director, and Peter Mlynarczyk, MD, medical director of the center.
Hyperbaric therapy is up and running -- with healing benefits for patients with specific diseases.
During a ``dive,'' an individual enters a chamber and uses 100% oxygen pumped into the chamber. The pressure is gradually increased to an equivalent of 1.5 to 3.0 times normal atmospheric pressure at sea level, or ``atmospheres absolute (ATA)'' and held at that level for anywhere from 60 to 90 minutes.
No, this ``dive'' is not describing someone about to enter the ocean. Rather, it's describing hyperbaric oxygen therapy or HBO. ``As a complementary therapeutic modality, HBO is very helpful,'' says Patricia Monterosa, RN, BSN, director of the Wound Center and Hyperbaric Services at Clara Maass Medical Center, Belleville, New Jersey. ``We see wounds that heal faster, especially in the case of recurrent wounds. We can institute treatment immediately and prevent many complications.''
At Trinitas Hospital, Elizabeth, New Jersey, the Wound Care Center staff uses hyperbaric therapy as well as conventional medical therapy in the treatment of wounds. They have been awarded a Disease-Specific Certification by the Joint Commission for Accrediting Healthcare Organizations (JCAHO). The director, Nada Raiser, RD, CDE, points out that not everyone can benefit from this type of treatment.
A physician screens patients before and after treatment. HBO is not the first method used on the wound. Medicare requires that in the case of patients with diabetic ulcers of the lower extremity, there be at least 30 days of documented unsuccessful medical treatment.
``We do transcutaneus oxygen tests on our patients before initiating hyperbaric treatment,'' she says. ``If we don't measure an increase in level of oxygen tissue perfusion while under pressure, we recommend a different type of therapy,'' says Raiser.
Most patients undergo an average of 30 dives at 2.0 to 2.5 atmospheres for wound care, each dive lasting about two hours. The treatment is helpful for patients with compromised skin grafts and flaps, diabetic ulcers, and osteoradionecrosis. ``We limit our practice to the diagnoses that are approved by the Centers for Medicare and Medicaid Services,'' says Raiser. ``Our primary healthcare providers are very particular about that.''
Julia Sudylo, RN, CHT, safety coordinator and treatment nurse at the New Jersey Hyperbaric Oxygen Therapy in Parsippany, N.J., talks with a patient during an HBO treatment.
New possibilities on the horizon
At New Jersey Hyperbaric Oxygen Therapy, a freestanding hyperbaric treatment center in Parsippany, New Jersey, treatment is used for a broad range of illnesses, many of them not yet approved by the Food and Drug Administration (FDA). Founded by Dr. Julia Bramwell, the facility has a pediatric focus and treats many children with cerebral palsy. This investigational use of HBO has shown equivocal results in formal studies, but there have been demonstrated improvements in vision and functional ability.1
``Parents report that there is a decrease in spasticity in these children,'' says Julia Sudylo, RN, CHT, safety coordinator and treatment nurse at the facility. ``That isn't the only type of patient we treat, however. We use it [HBO] as an adjunctive treatment with other modalities. Generally oxygen therapy assists the body to heal itself, while increasing alertness and decreasing fatigue.''
There is some evidence that HBO can be helpful for individuals who suffer from Lyme disease. The spirochete that causes Lyme disease cannot survive in air, but can survive in the oxygen level typically found in tissue. By using hyperbaric oxygen therapy, the partial pressure oxygen level can be safely increased to the level that is lethal to the microorganism. One study showed an 84% improvement in patients with Lyme disease.2
Sudylo has seen similar results in her patients. ``We have very good success with Lyme disease patients,'' she says. ``We dive them at 2.2 to 2.4 ATA for 60 minutes a day five days a week. The number of treatments depends on the patient, but it is usually around 40. Most of them get better after treatment, and have at least some relief of their symptoms.''
Using hyperbaric therapy to treat autism is controversial, but Sudylo has seen remarkable progress in these patients. Sally* was 6 years old and had never spoken. ``She was always hyperactive, and had a very flat affect within being hyperactive,'' says Sudylo. ``Her mother couldn't hug her -- she was too hyperactive. She was dived at 1.5 ATA for an hour a day for about 40 treatments, and she spoke her name two weeks ago. Her mother was thrilled.''
Connie Waltz, RN, BSN, CHRN, director of Nursing, Robert M. Lombard Hyperbaric Oxygenation Medical Center, Columbia, PA., sees patients with a wide variety of problems. The freestanding center has chambers for wound treatment and for complementary adjunctive treatment.
``In cases of stroke and traumatic brain injury, we see the best results when the treatment is instituted as soon as the patient becomes stable,'' Waltz says. ``There is often an increase in attentiveness in these patients. There is sometimes an improvement in patients with cerebral palsy who are cortically visually impaired, and that makes a huge difference in their quality of life.''
How it helps
Today, hyperbaric oxygen therapy (HBO) is an important tool in a variety of treatments. There are 14 identified diagnoses currently approved as clinical applications of HBO, either as a primary or adjunctive therapy --
Carbon monoxide poisoning
Cerebral arterial gas embolus
Decompression sickness (``the bends'')
Clostridial gas gangrene
Radiation tissue damage
Acute ischemia and/or crush injuries
Acute exceptional blood loss
Acute thermal burns
Compromised skin grafts or flaps
Selected problem wounds
Within this list, one of the most common uses is in the treatment of ``problem wounds,'' those that are persistent and non-healing. In this field, HBO is considered a complementary
therapy and is used in conjunction with well-established medical treatment protocols.
The FDA list of approved uses for HBO is used by most insurances (including Medicare) as a criteria for coverage. The treatment is very costly when paid out of pocket -- anywhere from $150 to $250 per treatment session. Most patients receive anywhere between 30 and 60 treatments. Many facilities will work with individual families to help manage the cost. ``If you have a child with CP and he or she gets good results from this treatment, the cost may be worth it,'' says Sudylo.
The bottom line
Hyperbaric medicine is generally very safe, when patients are appropriately screened and monitored. Usually toxicity is only associated with prolonged treatments at a deep pressure. Occasionally oxygen-induced seizures occur and are treated with decompression and subsequent observation. Middle ear injury is more common, but can sometimes be avoided if the individual performs the Frenzel maneuver, which involves pinching the nostrils and closing the glottis while increasing the pressure in the oral pharynx.3
The bottom line is a question mark when it comes to the efficacy of HBO in new situations. Most studies that have been published are based on small samples, and most conclude that further research is required to make definitive statements. HBO is becoming more frequently considered as an adjunctive therapy for everyone from Terrel Owens, a professional football player who wanted to heal a fractured ankle in time for the Superbowl, to the parents who just hope to see their child walk across the room.
*Name has been changed.
How it works
HBO is founded on the general properties of gases under pressure and the way in which the body responds. Usually oxygen is carried in the body bound to hemoglobin, a major component of red blood cells. Under normal conditions at sea level, the arterial saturation is 97% and the venous saturation is 70%. There is additional oxygen dissolved in the plasma.
Under increased pressure -- up to three atmospheres -- the saturation of dissolved oxygen increases and the excess can be supplied to the tissues. This increased oxygen saturation results in an increase in fibro-blasts as well as an increase in vascular tissue formation.3
There are two types of chambers-- monoplace chambers (those that accommodate one individual) and multiplace, with space for up to ten patients. Patients are able to communicate with the staff via speaker, and the monoplace chambers are made of acrylic, so the patient can usually watch television and see the staff throughout the dive.
A historical perspective
A British clergyman named Henshaw in 1662 built the first hyperbaric treatment chamber. Although it was used to treat a variety of ailments, it probably did not deliver enough compression to be truly effective.
In the late nineteenth century, patients who were operated on in a mobile pressurized operating suite operated by a French surgeon were reported to experience better outcomes because they had better oxygenation and less nausea and vomiting. In the early twentieth century, it was noted that victims of some cardiovascular diseases seemed to improve when transported from high altitudes to sea level.
During the Spanish Flu epidemic of 1918, Dr. Orville Cunningham treated a sick physician in a compression chamber -- with complete recovery. Although there was no concrete evidence of causality, the use of the compression chamber was credited with the cure. During the next ten years, hyperbaric treatment was used for hypertension, syphilis, diabetes and cancer, until the lack of scientific evidence of efficacy finally threw the modality into general disfavor.
In the 1950s, however, interest in the modality resurfaced as an effective treatment for decompression sickness, some forms of anemia, and some anaerobic infections. By the 1960s, modern hyperbaric medicine was on its way.3
Marylisa Kinsley, RN, BSN, is a frequent contributor to Nursing Spectrum.
1. Packard M. Cornell University Study on Hyperbaric Oxygen Therapy for Cerebral Palsied Children. Presented at the University of Graz, November 18, 2000. Available at: http://hbotoday.com/treatment/clinical/researchstudies/ cornellstudy.shtml. Accessed on January 23, 2005.
2. Fife W. Effects of Hyperbaric Oxygen Therapy On Lyme Disease, January 1998. Available at: http://hbotoday.com/ treatment/clinical/researchstudies/effectsonlyme.shtml. Accessed on January 20, 2005.
3. Neumeister M. Hyperbaric Oxygen Therapy. November 11, 2004,. Website: eMedicine -- Hyperbaric Oxygen Therapy. Available at: www.emedicne.com/plastic/topic526.html. Accessed on January 18, 2005.