UHMS Position Statement: Physician's Duties in Hyperbaric Medicine - 99183.

Introduction: The Undersea and Hyperbaric Medical Society (UHMS) is at the forefront of advancing medical knowledge and promoting patient safety in the field of hyperbaric medicine. In the dynamic landscape of healthcare, physicians' critical role in overseeing hyperbaric oxygen treatment (HBO2) cannot be overstated. This position statement aims to underscore the significance of physician involvement in delivering HBO2 and articulate UHMS's commitment to maintaining the highest standards of care and safety for patients undergoing hyperbaric treatments. Abstract: Hyperbaric oxygen treatment demands a meticulous approach to patient management. As the complexity of hyperbaric patients continues to evolve, the direct oversight of qualified physicians becomes paramount to ensuring optimal patient outcomes and safeguarding against potential risks. In this statement, we outline the key reasons physician involvement is essential in every facet of HBO2, addressing the technical intricacies of the treatment and the broader spectrum of patient care. Rationale: Physician oversight for hyperbaric oxygen treatment is rooted in the technical complexities of the treatment and the broader responsibilities associated with clinical patient care. The responsibilities outlined below delineate services intrinsic to the physician's duties for treating patients undergoing hyperbaric oxygen treatments.

Comparison of the efficacy of multiple antioxidant and hyperbaric oxygen treatments in the prevention of ischemia and necrosis of local random McFarlane skin flap.

OBJECTIVE: The aim of this study was to compare the efficacy of multiple antioxidant (Proxeed Plus (PP) with Carnitine, Selenium, Zinc, Coenzyme Q10, Vitamin C, Folic Acid, Vitamin B12) on local random skin flap healing with the hyperbaric oxygen (HBO) therapy. METHODS: Fourty rats were equally divided into five groups (Control, PP, HBO, HBO + PP, PP + HBO + PP). Local random McFarlane skin flap was applied to all rats. Following the applications, evaluations were made biochemical (TAS, TOS, OSI, IL-1ß, IL-6, TNF-α, TGF-ß, VEGF) and histopathological parameters. RESULTS: Necrosis percentage was found to be lower in the PP + HBO + PP group than all other groups whereas the necrosis percentages of PP and HBO groups were similar. Oxidative stress rates were significantly higher in the control group compared to the other groups whereas it was lower in the PP + HBO + PP group than all other groups. The inflammation parameters were the highest in the control group and the lowest in the PP + HBO + PP group. Growth factors were higher in the PP + HBO + PP group than all other groups. Epithelialization and wound healing were better in the HBO and PP groups than in the control group. The greatest healing, epithelialization and vascularization was seen in the PP + HBO + PP group. The histopathological findings in the PP + HBO + PP group were better in each inner region than in the other groups. CONCLUSION: Biochemical and histopathological parameters have shown that PP reduces ischemia and necrosis and increases oxygenation in flap healing by providing significant improvement thanks to the multiple molecular structures in its content.

Efficacy and safety evaluation of hyperbaric oxygen therapy for patients with ulcerative colitis: A protocol of systematic review and meta-analysis.

BACKGROUND: Ulcerative colitis (UC) belongs to chronic colitis whose etiology and pathogenesis still have remained unclear. Hyperbaric oxygen therapy (HBOT) has been demonstrated to be effective for UC therapy. Still, evidence of its efficacy and safety is inconclusive. The purpose of the protocol is to evaluate the efficacy and safety of HBOT in UC therapy. METHODS: This systematic review will retrieve studies that meet the requirements in Embase, MEDLINE, PubMed, Web of Science, Cochrane Library Central Register of Controlled Trials, the Chinese Biomedical Literature Database (CBM), China national knowledge infrastructure database (CNKI), Wei Pu database, Wan fang database, SinoMed, Google scholar, and Baidu Scholar from their inception to November 2020. Two authors are to be independent in their article selection, data collection, and research quality assessments. The primary outcome is the clinical effectiveness. And the secondary outcomes will include 4 criteria. RevMan 5.3 software will be utilized for analysis of the data. RESULTS: The results of this study are to be submitted via a peer-reviewed journal. CONCLUSIONS: The study is to assess the effectiveness and safety of HBOT for UC and provide valid and reliable evidence regarding HBOT for UC. INPLASY REGISTRATION NUMBER: INPLASY2020100118.

The occurrence of delayed neuropsychologic sequelae in acute carbon monoxide poisoning patients after treatment with hyperbaric or normobaric oxygen therapy.

ABSTRACT: This study aimed at assessing which one of the 2 therapies is better for treating carbon monoxide (CO) poisoning from the perspective of reducing delayed neuropsychologic sequelae (DNS).We used Taiwan's National Health Insurance Research Database (NHIRD) to conduct a nationwide population-based cohort study to assess which therapy is better for CO poisoning patients. To accurately identify patients with DNS, the definition of DNS is included neurological sequelae, and cognitive and psychological sequele. The independent variable was therapy and the dependent variable was DNS occurred within 1 year after discharge from a medical institution. The control variables were age, gender, the severity of CO poisoning, and comorbidities present before CO poisoning admission.The risk of developing DNS in patients treated with Hyperbaric Oxygen (HBO) was 1.87-fold (P < .001) than normobaric oxygen (NBO) therapy. The severity of CO poisoning and comorbidities were also found to have significant influences on the risk of developing DNS.HBO may be a risk therapy for treating CO poisoning.

Environmental contamination in the isolation rooms of COVID-19 patients with severe pneumonia requiring mechanical ventilation or high-flow oxygen therapy.

BACKGROUND: Identifying the extent of environmental contamination of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is essential for infection control and prevention. The extent of environmental contamination has not been fully investigated in the context of severe coronavirus disease (COVID-19) patients. AIM: To investigate environmental SARS-CoV-2 contamination in the isolation rooms of severe COVID-19 patients requiring mechanical ventilation or high-flow oxygen therapy. METHODS: Environmental swab samples and air samples were collected from the isolation rooms of three COVID-19 patients with severe pneumonia. Patients 1 and 2 received mechanical ventilation with a closed suction system, while patient 3 received high-flow oxygen therapy and non-invasive ventilation. Real-time reverse transcription-polymerase chain reaction (rRT-PCR) was used to detect SARS-CoV-2; viral cultures were performed for samples not negative on rRT-PCR. FINDINGS: Of the 48 swab samples collected in the rooms of patients 1 and 2, only samples from the outside surfaces of the endotracheal tubes tested positive for SARS-CoV-2 by rRT-PCR. However, in patient 3's room, 13 of the 28 environmental samples (fomites, fixed structures, and ventilation exit on the ceiling) showed positive results. Air samples were negative for SARS-CoV-2. Viable viruses were identified on the surface of the endotracheal tube of patient 1 and seven sites in patient 3's room. CONCLUSION: Environmental contamination of SARS-CoV-2 may be a route of viral transmission. However, it might be minimized when patients receive mechanical ventilation with a closed suction system. These findings can provide evidence for guidelines for the safe use of personal protective equipment.

A Multistep Iter for Functional Reconstruction in Mangled Upper Limb: A Retrospective Analysis of Integrated Surgical and Medical Approach.

Background and objectives: Complex limb wounds with multiple tissue involvement are commonly due to high energy trauma. Tissue damage is a dynamic entity and the exact extent of the injury is rarely instantly perceptible. Hence, reconstruction frequently involves a multi-stage procedure concluding with tissue replacement. Materials and Methods: A retrospective study was conducted between 2006 and 2018 and included 179 patients with contaminated multi-tissue injuries treated with hyperbaric oxygen therapy, negative pressure therapy, physiotherapy and drug treatment associated with multiple surgical time in a multistep approach, focusing on pain levels and wound closure rates. Results: Despite the long-term response to traumatic events, a combined approach of delayed surgical reconstructive time in mangled upper limb yielded satisfactory functional outcomes. Conclusions: The complex upper limb wound with deep tissue exposure may be treated with a multi-stage procedure alternatively to immediate reconstruction. The integrated technique enables the preservation of existing healthy tissue and concurrent radical debridement, reducing the risk of infection, as well as avoiding the loss of free flaps and dehiscence due to incorrect wound estimation.

Hyperbaric oxygen therapy and mortality from carbon monoxide poisoning: A nationwide observational study.

BACKGROUND: The effects of hyperbaric oxygen therapy (HBOT) on mortality or morbidity in patients with carbon monoxide (CO) poisoning remain unknown. We examined the effects of HBOT on CO poisoning and further strived to delineate its inherent effects on specific subgroups of patients using a nationwide inpatient database. METHODS: We identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2016. Propensity score-matching was performed to compare patients who received HBOT within 1 day of admission (HBOT group) with those who did not receive HBOT (control group). The primary outcome was in-hospital mortality. The secondary outcomes were a depressed mental status and reduced activities of daily living (ADL) at discharge. We also performed subgroup analyses divided according to severity of CO poisoning. RESULTS: Eligible patients were categorized into the HBOT group (n = 2034) or the control group (n = 4701). One-to-one propensity score-matching created 2034 pairs. In-hospital mortality was not significantly different between the HBOT and control groups (0.8% vs. 1.2%, risk difference: -0.4%, 95% confidence interval: -1.0 to 0.2). Patients in the HBOT group had significantly lower proportions of a depressed mental status and reduced ADL at discharge than did those in the control group. Similar associations were shown in the non-severe poisoning subgroup. CONCLUSIONS: Although HBOT was not significantly associated with reduced mortality, it was significantly associated with a favorable consciousness level and ADL in patients with CO poisoning. HBOT may be beneficial even for patients with non-severe CO poisoning.

Effect of hyperbaric oxygen therapy and corticosteroid therapy in military personnel with acute acoustic trauma.

INTRODUCTION: Acute acoustic trauma (AAT) is a sensorineural hearing impairment due to exposure to an intense impulse noise which causes cochlear hypoxia. Hyperbaric oxygen therapy (HBO) could provide an adequate oxygen supply. The aim was to investigate the effectiveness of early treatment with combined HBO and corticosteroid therapy in patients with AAT compared with corticosteroid monotherapy. METHODS: A retrospective study was performed on military personnel diagnosed with AAT between November 2012 and December 2017. Inclusion criteria for HBO therapy were hearing loss of 30 dB or greater on at least one, 25 dB or more on at least two, or 20 dB or more on three or more frequencies as compared with the contralateral ear. RESULTS: Absolute hearing improvements showed significant differences (independent t-test) between patients receiving HBO and the control group at 500 Hz (p=0.014), 3000 Hz (p=0.023), 4000 Hz (p=0.001) and 6000 Hz (p=0.01) and at the mean of all frequencies (p=0.002). Relative hearing improvements were significantly different (independent t-test) at 4000 Hz (p=0.046) and 6000 Hz (p=0.013) and at all frequencies combined (p=0.005). Furthermore, the percentage of patients with recovery to the functional level required by the Dutch Armed Forces (clinical outcome score) was higher in the HBO group. CONCLUSIONS: Early-stage combination therapy for patients with AAT was associated with better audiometric results at higher frequencies and better clinical outcome score.

Low-pressure fabric hyperbaric chambers.

Hyperbaric oxygen therapy is defined as an intervention in which an individual breathes near 100% oxygen while wholly enclosed inside a hyperbaric chamber at a pressure ≥1.4 atmosphere absolute (ATA). The Southern African Underwater and Hyperbaric Medical Association (SAUHMA)-approved indications commence at pressures ≥2 ATA. Low-pressure hyperbaric chambers, at pressures ≤1.4 ATA, are approved for acute mountain sickness only. Mild hyperbaric exposures with air deliver no more oxygen to the body than breathing oxygen by mask at sea level pressure. Exposure to treatment pressures <2.0 ATA while breathing air does not meet the SAUHMA definition of therapeutic hyperbaric oxygen therapy and does not achieve the minimum pressure and oxygen levels required for any SAUHMA-approved indication. All SAUHMA-approved indications require that the patient breathe near 100% oxygen while enclosed in a chamber pressurised to a minimum of 2 ATA. SAUHMA does not recommend the use of mild hyperbaric therapy for any medical purpose other than acute mountain sickness.

Identification and control of a multiplace hyperbaric chamber.

This work presents the automation of a multiplace hyperbaric chamber. It includes the system modeling, identification, controller calculation and system validation. With the proposed approach a good pressure profile tracking and repeatability are achieved. Moreover, the proposed automation includes the implementation of powerful treatment tools such as Pause and Alleviation procedures. The control system implemented is based on a special zero-pole cancellation regulator. Experimental results are provided to illustrate the behavior of the automated chamber. It is important to remark that the chamber automated in this work is being successfully used in a real hospital since 2015 treating more than 40 patients per day, five days a week.

Hyperbaric Oxygen Therapy as an Adjunct for Treating an Individual with Poorly Healing Bilateral Mandibular Fractures Suspect of Developing Towards Osteomyelitis: A Case Report and Clinical Experience.

PURPOSE: To present a case that benefited from utilizing hyperbaric oxygen therapy in conjunction with antibiotics for a non-healing mandibular fracture that was highly suspicious of osteomyelitis. Also, to discuss research set forth by Undersea and Hyperbaric Medical Society that supports the use hyperbaric oxygen in such cases. CASE: A 25-year-old male status post fist to face resulting in bilateral mandibular fracture. He underwent two surgeries in an attempt to plate the fracture with the assistance of a bone graft. After failure of the bone graft and significant soft tissue wound breakdown, the surgeon was concerned for osteomyelitis and began therapy with intravenous antibiotics and hyperbaric oxygen therapy. CONCLUSION: The patient completed 30 hyperbaric oxygen treatments and 30 d of intravenous antibiotics. Clinically, the patient responded well and showed healed intraoral wounds and an objective decrease in erythrocyte sedimentation rate over the course of treatment. Unfortunately, on serial imaging the patient showed to have fibrous non-bony union of left fracture site. Even though the patient will need a final definitive plate for his fracture, it will be performed from an extraoral approach with no evidence of underlying infection.

The Hyperbaric Oxygen Therapy Registry: Driving quality and demonstrating compliance.

OBJECTIVE: To provide an update on the status of provider participation in the US Wound Registry (USWR) and its specialty registry the Hyperbaric Oxygen Therapy Registry (HBOTR), which provide much-needed national benchmarking and quality measurement services for hyperbaric medicine. METHODS: Providers can meet many requirements of the Merit-Based Incentive Payment System (MIPS) and simultaneously participate in the HBOTR by transmitting Continuity of Care Documents (CCDs) directly from their certified electronic health record (EHR) or by reporting hyperbaric quality measures, the specifications for which are available free of charge for download from the registry website as electronic clinical quality measures for installation into any certified EHR. Computerized systems parse the structured data transmitted to the USWR. Patients undergoing hyperbaric oxygen (HBO2) therapy are allocated to the HBOTR and stored in that specialty registry database. The data can be queried for benchmarking, quality reporting, public policy, or specialized data projects. RESULTS: Since January 2012, 917,758 clinic visits have captured the data of 199,158 patients in the USWR, 3,697 of whom underwent HBO2 therapy. Among 27,404 patients with 62,843 diabetic foot ulcers (DFUs) captured, 9,908 DFUs (15.7%) were treated with HBO2 therapy. Between January 2016 and September 2018, the benchmark rate for the 1,000 DFUs treated with HBO2 was 7.3%, with an average of 28 treatments per patient. There are 2,100 providers who report data to the USWR by transmitting CCDs from their EHR and 688 who submit quality measure data, 300 (43.6%) of whom transmit HBO2 quality data.

Cardiovascular Abnormalities in Carbon Monoxide Poisoning.

Acute carbon monoxide (CO) poisoning is the most common cause of poisoning and poisoning-related death in the United States. It manifests as broad spectrum of symptoms ranging from mild headache, nausea, and fatigue to dizziness, syncope, coma, seizures resulting in cardiovascular collapse, respiratory failure, and death. Cardiovascular complications of CO poisoning has been well reported and include myocardial stunning, left ventricular dysfunction, pulmonary edema, and arrhythmias. Acute myocardial ischemia has also been reported from increased thrombogenicity due to CO poisoning. Myocardial toxicity from CO exposure is associated with increased short-term and long-term mortality. Carboxyhemoglobin (COHb) levels do not correlate well with the clinical severity of CO poisoning. Supplemental oxygen remains the cornerstone of therapy for CO poisoning. Hyperbaric oxygen therapy increases CO elimination and has been used with wide variability in patients with evidence of neurological and myocardial injury from CO poisoning, but its benefit in limiting or reversing cardiac injury is unknown. We present a comprehensive review of literature on cardiovascular manifestations of CO poisoning and propose a diagnostic algorithm for managing patients with CO poisoning.

Risk of continuous bladder irrigation in the monoplace hyperbaric chamber: a cautionary tale.

We previously published our method of performing continuous bladder irrigation (CBI) in a monoplace hyperbaric chamber [1]. This method entailed the use of an IV pump to infuse saline into the monoplace chamber. The specter of causing iatrogenic rupture of the bladder was raised following such a case, reported herein, of a woman with hemorrhagic radiation cystitis leading to cystectomy. Due to the danger of bladder rupture while providing CBI with a pump, we retract ourpreviously reported method and encourage the use of either a gravity-fed system or delay in hyperbaric oxygen therapy treatment until CBI is no longer necessary.

Adjunctive Hyperbaric Oxygen Therapy for Healing of Chronic Diabetic Foot Ulcers: A Randomized Controlled Trial.

PURPOSE: The purpose of this study was to compare the effect of standard wound care with adjunctive hyperbaric oxygen therapy (HBOT) to standard wound care alone on wound healing, markers of inflammation, glycemic control, amputation rate, survival rate of tissue, and health-related quality of life in patients with diabetic foot ulcers (DFUs). DESIGN: Prospective, randomized, open-label, controlled study. SUBJECTS AND SETTING: The sample comprised 38 patients with nonhealing DFUs who were deemed poor candidates for vascular surgery. Subjects were randomly allocated to an experimental group (standard care plus HBOT, n = 20) or a control group (standard care alone, n = 18). The study setting was a medical center in Kaohsiung City, Taiwan. METHODS: Hyperbaric oxygen therapy was administered in a hyperbaric chamber under 2.5 absolute atmospheric pressure for 120 minutes; subjects were treated 5 days a week for 4 consecutive weeks. Both groups received standard wound care including debridement of necrotic tissue, topical therapy for Wagner grade 2 DFUs, dietary control and pharmacotherapy to maintain optimal blood glucose levels. Wound physiological indices were measured and blood tests (eg, markers of inflammation) were undertaken. Health-related quality of life was measured using the Medical Outcomes Study 36-Item Short Form. RESULTS: Complete DFU closure was achieved in 5 patients (25%) in the HBOT group (n = 20) versus 1 participant (5.5%) in the routine care group (n = 18) (P = .001). The amputation rate was 5% for the HBOT group and 11% for the routine care group (χ = 15.204, P = .010). The HBOT group showed statistically significant improvements in inflammation index, blood flow, and health-related quality of life from pretreatment to 2 weeks after the last therapy ended (P < .05). Hemoglobin A1c was significantly lower in the HBOT group following treatment (P < .05) but not in the routine care group. CONCLUSIONS: Adjunctive HBOT improved wound healing in persons with DFU. Therapy also reduced the risk of amputation of the affected limb. We assert that at least 20 HBOT sessions are required to be effective.