Intern Tutorial Program [Presentation title]

Ian GawthropeSCGH Registrar Teaching 2017Hyperbaric medicine

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Fremantle Hyperbaric Unit

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Fiona Stanley Hyperbaric Unit

Multiplace chambers

Monoplace chambers

Critical care patients

Registrars!

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History of Hyperbaric Medicine1928 Cunningham built a 64 foot diameter steel hyperbaric ball with five floors at Cleveland Ohio USAPatients lived inside chamber at 2ATA

Scrapped for metal during World War II

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Hyperbaric Medicine Unit

1372 rooms on 5 floors, 3880 m3, max 2 bar, medical areas, theatre, grand piano, smoking room.

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Mild Hyperbaric

http://www.naturalhealthperth.com/hyperbaric-therapy.html

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Burns received when his hair caught fire from fireworks during the making of a Pepsi commercial in 1984. Treated with HBO and eventually bought his own chamber.Michael Jackson and HBO

Mechanisms of actionPharmacological effectIn vitroAnimal modelsClinical findingsBubble size reductionBoyles law (ca. 1662)(Waite et al. 1967)Gas washout(Haldane 1922)(Peterson and Stewart 1970)(Jay et al. 1995) (Myers et al. 19484)(Vorosmarti et al. 1978)Upregulation of growth factors and GF receptors(Feng et al. 1998)(Sheikh et al. 2000)(Bonomo et al. 1998)Inhibition of neutrophil adhesion(Thom 2004)(Thom 2004)(Boykin and Baylis 2007)Inhibition of infection(Kaye 1967) (Hohn et al. 1976)(Mader et al. 1980) (Kaye 1967)(Hohn et al. 1976)(Wilkinson and Doolette 2004) (Roje et al. 2008)Modulation of inflammation(Thom 2004)(Thom 2004) (Buras at al. 2006)(Zhang et al. 2008)(Yogaratnam et al. 2000)Alex et al. 2005)Reduction of ischaemia-reperfusion injury(Takahashi et al. 1992)(Strauss et al. 1983) (Zamboni et al. 1993)(Buras et al. 2000)(Mazariegos et al. 1999)(Dekleva et al. 2004)Neovascularisation(Sander et al. 2009) (Hopf et al. 2005) (Marx et al. 1990)(Marx 2008)Osteogenesis(Sawai et al. 1996) (Johnsson et al. 1999) (Sever et al. 2010)(Marx 2008)Angiogenesis(Sander et al. 2009) (Hopf et al. 2005) (Hunt and Pai 1972)(Marx 2008) (Hammarlund and Sunberg 1994)Stem cell growth and release(Milovanova et al. 2009)(Thom et al. 2011)

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HBO - MECHANISMS OF ACTION

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Recognised Indications for Hyperbaric OxygenDysbaric (Bubble) InjuryDecompression IllnessAcute Ischaemic ConditionsCompromised Flaps and GraftsCrush InjuryCompartment SyndromeReperfusion InjuryInfective ConditionsNecrotising FasciitisMalignant Otitis ExternaRefractory OsteomyelitisRefractory Mycoses

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Recognised Indications for Hyperbaric OxygenDelayed Radiation InjuryOsteoradionecrosisSoft Tissue RadionecrosisProblem WoundsDiabetic UlcersVenous UlcersDecubitus UlcersFrostbiteToxic Gas PoisoningCarbon Monoxide

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Absolute contraindicationsUntreated pneumothoraxAcute severe bronchospasmConcomitant treatment with DoxorubicinCardiac toxicity 87% mortality in rats when chemotherapeutic agent combined with HBOPrevious treatment with BleomycinReports of elevation in FiO2 intraoperatively causing interstitial pneumonitis even if Bleomycin therapy had ceased years before.Probably overstated risk. Safe administration of hyperbaric oxygen after bleomycin: a case series of 15 patients. Undersea Hyperb Med. 2012 Sep-Oct;39(5):873-9. Torp KD1, Carraway MS, Ott MC, Stolp BW, Moon RE, Piantadosi CA, Freiberger JJ.

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Relative contraindicationsConcomitant treatment with Cis-PlatinumHBO increases cytotoxic effect of drug in tissues and impedes wound healing.Concomitant treatment with Disulfiram (Antabuse)Blocks the production of superoxide dismutase which may increase the risk of oxygen toxicitySeizure disordersLowered seizure threshold may increase risk of oxygen toxicity seizuresCOPD with CO2 retentionLoss of hypoxic driveUpper respiratory tract infections and sinusitisRisk of barotraumaClaustrophobia and anxiety/mental illnessConsider use of benzodiazepinesHeart failureRisk of pulmonary oedema due to reduction in cardiac outputBullous lung diseasePregnancy

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ComplicationsBarotrauma (2-4% of treatments)Middle ear, sinus squeezeOxygen toxicity seizuresPulmonary oxygen toxicityRare with routine daily exposuresTemporary worsening of short-sightednessWorsening of known cataractsFire

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BarotraumaMost common side effect of HBOTIncidence of middle ear barotrauma ~ 2%Pseudoephedrine has been demonstrated to be effective in preventing barotitis mediaBrown M et al. Pseudoephedrine for the prevention of barotitis media: a controlled clinical trial in underwater divers. Ann Emerg Med. 1992;21:849-852Sinus squeeze second most complicationDecongestant/steroid nasal spraysSerous otitis media can developEvidence to suggest HBO might cause a reversible derangement in middle ear chemoreceptor reflex arcs that regulate middle ear aerationTypanometry may be helpful to predict Eustachian tube dysfunctionTympanostomy tubes may be required

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Oxygen toxicity seizuresIncidence 1 in 1650 patient treatmentsBanham. Oxygen toxicity seizures: 20 years' experience from a single hyperbaric unit. DHM 2011;41:202-10Seizures are generalized tonic-clonic resolving without residual effects when oxygen removedMechanism poorly understoodAir breaks are thought to reduce the risk

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Progressive myopiaLenticular in originDue to changes in the refractive index of the lensEvanger K et al. Myopic shift during Hyperbaric Oxygenation attributed to lens index changes. Optom Vis Sci. 2015; 92(11): 1076-84.Usually fully reversible within 4-8 weeksIsolated case reports of worsening of known cataractsDevelopment of new cataracts very rare and usually only in patients receiving >150 treatments

Palmquist et al. Nuclear cataract and myopia during hyperbaric oxygen therapy. Br J Opthal. 1984;68:113-117.

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Fire risk!

Fiona Stanley Hyperbaric UnitPatient Treatment Statistics: 1 July 2015 - 30 June 2016 - 163 patients

Fiona Stanley Hyperbaric UnitDCI treated fiscal yearly since Nov 1989 at FH and FSH HMUs

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http://en.wikipedia.org/wiki/Radiation_therapyDelayed Radiation Injury

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The Role of HBO in Delayed Radiation InjuryLag phase

Angiogenic phase

Plateau phase

HBO and Delayed Radiation Injury

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Soft tissue radionecrosisWound spontaneously broke down 20 years after radiotherapyWound healed after 30 HBO and wound care

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HBO in Wound Healing

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Treatment tables

Decompression Illness

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DefinitionDecompression illness arises in compressed gas divers, aviators, and astronauts when bubbles form in blood and / or in tissues, during or after a decrease in environmental pressure

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The Gas LawsBoyles law: The volume of a gas is inversely proportional to the pressure provided the temperature and mass are constant

Henrys law: The amount of any given gas that will dissolve in a liquid at a given temperature is a function of the partial pressure of that gas in contact with the liquid.

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History of DCIFirst noted in Caisson workers around 1845 - Caissons Disease

Term Bends adopted during construction of Brooklyn Bridge in reference to Grecian Bend of women

In 1889 25% of workers on Hudson river tunnel died of DCI. A recompression chamber reduced this to 1.7%

Mechanisms of bubble formation

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Two mechanisms of bubble formationBUBBLE FORMATIONDissolved gasPulmonary barotrauma

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Pulmonary barotrauma Divers ascend head firstCAGE is primary concern

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Arterial bubbles and the brainMuth CM, Shank ES. New Eng J Med 2000;347:476-82

WBCs

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Presentation of CAGERapid onset of neurological symptomsoften immediately at surfaceunconsciousness in 50%hemiparesis, monoparesis, sensory changes, visual change, dysphasia, disorientation, dissociation

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Natural history of CAGE5 - 10% die early30% static60% spontaneous recoveryclinical correlate of bubble redistribution50% of those recovering suffer progressive relapseclinical correlate of inflammatory events

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Two mechanisms of bubble formationBUBBLE FORMATIONDissolved gasPulmonary barotrauma

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Symptoms of DCISymptom% of patientsSymptom% of patientsPain67Dyspnoea13Fatigue54Itch10Tingling46Visual disturbance8Headache46Rash7Numbness35Loss of consciousness5Weakness26Cough3Cognitive difficulty25Urinary dysfunction1Dizziness20Other13Ataxia17

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Two mechanisms of bubble formation with a twist!BUBBLE FORMATIONDissolved gasPulmonary barotraumaVenous bloodArterial blood Tissues

Patent foramen ovale + other shunts

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Treatment tables for DCI

Treatment tables for DCI

Case History 127 year old maleRecreational diverSpear fishing on surface supply hookah15 metres depth for 15 minsRapid ascent whilst reloading spear gunLoss of buoyancyTwo further attempts with rapid ascents!

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Case History 1Third uncontrolled ascent on surface confused, with blurred vision and felt unable to move limbsRescued to the boatKept supineTransferred to Busselton ED

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Case History 1In ED no neurological symptoms and felt wellComplained of chest pain CT Thorax was normalCreatinine 120 Self discharged

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Case History 1Returned 9 hours laterDiffuse abdominal painLactate 10.8Treated with IV fluids and oxygen after consulting Hyperbaric teamLactate normalisedCreatinine 987

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Case History 1Transferred to Fremantle HospitalDiagnosed with ATNHigh fractional urinary excretion of 5.5%Elevated LDH 468 (125-250)MAG3 scan in keeping with ATN

No myglobinuria, CK 893 Rhabdomyolysis induced ATN unlikely

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Case History 1Creatinine peaked at 1210

Case History 1Treated with daily Hyperbaric oxygen for seven daysCreatinine normalised

Returned to divingFull recovery

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Questions?