1 / 65

Hyperbaric Medicine Past, Present, and Future

Hyperbaric Medicine Past, Present, and Future. Anthony Lagina III, MD FACEP Assistant Professor of Emergency Medicine Hyperbaric Medicine and Wound Care Clinic Wayne State University/Detroit Receiving Hospital. Outline. Introduction History and development Physiology and theory

gita
Télécharger la présentation

Hyperbaric Medicine Past, Present, and Future

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Hyperbaric MedicinePast, Present, and Future Anthony Lagina III, MD FACEP Assistant Professor of Emergency Medicine Hyperbaric Medicine and Wound Care Clinic Wayne State University/Detroit Receiving Hospital

  2. Outline • Introduction • History and development • Physiology and theory • Current indications for treatment • Future indications for treatment

  3. Definition • Hyperbaric Oxygen Therapy is the administration of oxygen at pressure greater than sea level. • Patient is placed in a chamber and pressurized • 100% oxygen • Room air with oxygen via a hood

  4. History • First theories developed 300 years ago • Henshaw in 1662 • Built the domicilium - metal chamber with a pair of large organ bellows • "In times of good health this domicilium is proposed as a good expedient to help digestion, to promote insensible respiration, to facilitate breathing and expectoration and consequently, of excellent use for prevention of most affections of the lungs."(Henshaw, 1664) • “It seemed like a good idea”

  5. History • France 1880s • Fashionable among the wealthy to increasethe circulation to the internal organs • Fontaine 1877 - First mobile hyperbaric chamber

  6. Early Chambers

  7. The Steel Ball

  8. History • Caisson Disease • First described in France during bridge building in 1840s • Symptoms = dizziness, coughing and joint pain with some deaths

  9. History • The Bends • Vernacular for Caisson disease • Coined during Hudson Tunnel Project in Brooklynn • Named after ladies posture

  10. Hyperbaric Chambers Today

  11. Portable Monoplace

  12. Multiplace Chambers

  13. Chamber Capability -Maximum depth: 6 Atmospheres (165 FSW) -Maximum depth for administering 100% O2: 3 Atmospheres (66 FSW) • Ventilator support and cardiac monitoring for the critically ill patient

  14. Not Hyperbaric Therapy!!!

  15. Theory • Components of dry Atmospheric Air • Nitrogen 78.084 • Oxygen 20.946 • Carbon Dioxide 0.033 • Argon 0.0934 • Other Gases Neon, Helium, Krypton, Xenon, Hydrogen, Methane, Nitrous Oxide

  16. The Ideal gas Law • PV=nRT • Pressure and volume are inversely proportional • Pressure and moles of gas are directly related • Percentages of gases don’t change, the amount (moles) does

  17. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Hyperoxygenation of tissues • Mechanical Bubble Crunching • Neoangiogenesis • Bacteriocidal / Bacteriostatic Effects • Potent Vasoconstriction

  18. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Hyperoxygenation of Tissues • Plasma diffuses through tissue  supplying oxygen downstream from an occlusion • Helps ischemic tissues meet metabolic needs during the wound healing process • Increased breakdown of old bone • Forms new capillaries in wound areas

  19. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Hyperoxygenation is a temporary measure maintaining tissue viability until corrective measures are implemented or new blood supply is established

  20. Physiological Effects Main Concept: Once the hemoglobin is saturated,  in FiO2 can only affect the fraction of oxygen dissolved in the plasma.

  21. Relationship Between Respiratory Gas and Blood PO2 Atmospheric Breathing FiO2 Theoretical Measured Measured Pressure (ATA) Gas (mmHg) Alveolar & Arterial Venous Arterial PO2 PO2 (mmHg) PO2 (mmHg) (mmHg) ===================================================================== 1.0 Air 160 110 89 +/- 3.2* 41 +/- .9* ------------------------------------------------------------------------------------------------------ 1.0 100% O2 760 673 507 +/- 13.9 57 +/- 3.5 ------------------------------------------------------------------------------------------------------ 3.0 100% O2 2280 2193 1721 +/- 33.5 424 +/- 77.8 --------------------------------------------------------------------------------------------------------- * +/- one standard error Mean blood levels measured in 10 normal subjects (modified from Saltzman, Smith et al, 1965)

  22. Oxygen solubility • Hemoglobin oxygen content • sea level or at depth = 19.8 ml O2/ dl blood • Plasma oxygen content • 0.0031 ml O2/ dl blood with air at sea level • 2.1 ml O2/ dl blood 100% O2 at sea level • 6.8 ml O2/ dl blood 100% O2 at 3 ATA • Body use • Human at rest = 6 ml O2/ dl blood • ****Theoretically no Hb required for oxygenation of tissues at 3 ATA****

  23. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Mechanical Bubble Crunching – Boyle’s Law: • Oldest application of hyperbaric medicine • HBO primary treatment in “bubble diseases” • Arterial gas embolus • Decompression syndrome

  24. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Mechanical Bubble Crunching – Boyle’s Law: • Increases the “wash out” of gases other than oxygen • Nitrogen • Carbon Monoxide • Room air t1/2= 320 minutes • 3 ATA t1/2= 23 minutes

  25. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Neoangiogenesis (Neovascularization): • Decreased oxygen tissue tensions stimulate new vessel growth • At the same time, underlying supporting collagen needs oxygen to form • Collagen deposition and the tensile strength of wounds improve

  26. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Bacteriocidal and Bacteriostatic Effects: •  leukocyte production of toxic radicals (enhanced phagocytosis) • Synergistic effect with aminoglycosides • Post antibiotic effect is prolonged with tobramycin against Pseudomonas aeruginosa

  27. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Potent Vasoconstriction: • Hyperoxia constricts normal blood arterioles and venules • Ischemic blood vessels do not constrict thus allowing tissue oxygen increases • Despite  blood flow, tissue oxygen  due to high PaO2

  28. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Potent Vasoconstriction – continued: • Reduces edema and  oxygenation at the same time • Vasoconstriction  peripheral vascular resistance (PVR) and mean arterial pressure (MAP) afterload

  29. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Rationale for Hyperbaric Oxygen in Problem Wounds: • Enhances fibroblast replication •  collagen synthesis •  neovascularization •  leukocyte bacteriocidal activity •  O2 tension  greater capillary oxygen diffusion distances

  30. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Definitive treatment for: • Arterial Gas Embolism (AGE) • Decompression Sickness (DCS) • Carbon Monoxide (CO) Poisoning

  31. Additional Clinical Indications Gas Gangrene Crush Injury Problem Wounds Intracranial Abscess Idiopathic Sudden Sensorineural  Hearing Loss-2011 Exceptional Blood Loss Anemia Necrotizing Infections Osteomyelitis (Refractory) Late Effects of Radiation Skin Grafts Thermal Burns Central Retinal Artery occlusion Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen

  32. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Air or Gas Embolism: • Occurs when gas bubbles enter directly into the arteries or veins • Pulmonary Barotrauma (overinflation) • breath-holding on ascent • Mechanical ventilation • Blast injury, penetrating chest trauma, chest tube placement and bronchoscopy • Things residents do!!!

  33. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Arterial Gas Embolism: • Cause – Central Line Placement.

  34. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Cerebral Air Gas Embolism (CAGE) – from lung biopsy procedure

  35. Hyperbaric Treatment Protocol Arterial Gas Embolism CAUSE Diving Related Iatrogenic Dive History ACLS Measures Chest X-ray IV Fluids History- Central Line Placement Chest X-ray IV Fluids ACLS Measures U.S.N. Treatment Table 6 Symptoms Resolved ? Yes No Consider extensions at 2.8 ATA Or 1.9 ATA as needed. Finish out on Table 6 Compress to 6 ATA Patient on 50/50 Nitrox Yes Symptoms Resolved? No Complete Table 6a to Table 6

  36. CO Poisoning • Most common fatal poison in USA/France • 40,000 seek medical attention • 500+ die of unintentional exposure • Inhalation or methylene chloride exposure

  37. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Carbon Monoxide (CO) Poisoning: • Carbon Monoxide (CO) exposure leads to hypoxic stress mediated by an elevated carboxyhemoglobin (COHb) level • Two (2) organ systems most susceptible to injury from CO • Cardiovascular • Central nervous systems

  38. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Carbon Monoxide (CO) Poisoning – continued: • Hyperbaric oxygen • causes COHb dissociation at levels greater than at sea level •  pathophysiological events associated with central nervous system (CNS) injuries mediated by CO

  39. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Carbon Monoxide (CO) Poisoning – continued: • Hyperbaric Oxygen: • Improvement in mitochondrial oxidative processes • Inhibition of lipid peroxidation • Impairment of leukocyte adhesion to injured microvasculature

  40. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Decompression Sickness (DCS): • Decompression sickness (the bends) • The generation of bubbles of inert gas in the tissues and / or blood in volumes sufficient to interfere with organ function. • Rapid decompression during ascent from diving, flying or in a hyperbaric chamber

  41. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Decompression Sickness: • Clinical Manifestations: • Type I, Pain Only • Joint Pain • Cutaneous Eruptions (Skin Bends). • Type II • Neurological Dysfunction • Both Central and Peripheral Nervous Systems • Cardiorespiratory Symptoms • Pulmonary Edema (Chokes)

  42. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Decompression Sickness: • Clinical Diagnosis: • History of Dive, Altitude or Hyperbaric Exposure. • Manifestations most commonly include: paresthesias, hypersthesia, joint pain, skin rash and malaise. • More serious signs and symptoms include: • Motor Weakness, ataxia, dyspnea, urethral and anal sphincter dysfunction, shock, and death

  43. Hyperbaric Treatment Protocol Decompression Sickness History of dive (s) > 30 FSW Yes Institute U.S. Navy Treatment Table 6 Signs and Symptoms Onset of musculoskeletal pain. Cutaneous manifestations. Central or peripheral neurological deficits. Cardiopulmonary symptoms. Complete history of dive (s). Neurological examination. Physical examination. STAT Chest x-ray. ECG. Labs. IV Fluids. Yes No Yes Symptoms Resolved ? Monitor Vital signs 100 % oxygen by mask No Follow-up Neurology Consult. Residual symptoms- Retreat @ 2.4 ATA Or U.S. Navy Table 6 After 4-8 hour interval. Consult DAN / NEDU Consider extensions at 2.8 ATA and / or 1.9 ATA

  44. Navy Treatment Table 7

  45. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Crush Injuries and Compartment Syndromes: • Crush injuries are directly associated with trauma • Skeletal muscle compartment syndromes arise from ischemia, venous outflow obstruction, exertion, external compression as well as trauma

  46. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen

  47. Clinical Uses and Therapeutic Effects of Hyperbaric Oxygen • Crush Injuries and Compartment Syndromes: • Management of the most severe cases always involves surgery • Studies show statistically significant reductions in loss of muscle function, metabolites associated with muscle injury, edema and muscle necrosis with HBO

More Related