TOPICAL HYPERBARIC OXYGEN THERAPY FOR CHRONIC WOUNDS

GWR Medical, L.L.P. manufacturers, distributes and sells medical devices for Topical Hyperbaric Oxygen Therapy for difficult to heal recalcitrant wounds. The patented therapy and devices reduce the time for these types of wounds to heal and dramatically reduces the costs involved with wound management and wound healing. GWR Medical, L.L.P. markets these products in conjunction with wound dressings and wound management products utilizing the GWR Medical marketing network.
For more information, e-mail our office at thbo@erols.com or fax us at (610) 558-1280.

DEFINITIONS

Hyperbaric Oxygen:
Oxygen applied at pressure greater than one atmosphere. Pressure is typically expressed as atmospheres, millimeters of mercury (mm Hg) or as pounds per square inch (psi). One atmosphere is ambient pressure at sea level, which is equivalent to 760 mm Hg., or 14.7 psi.
Systemic Hyperbaric Oxygen (HBO):
Hyperbaric oxygen administered in full body chambers. The patient breathes 100% oxygen intermittently while the pressure of the treatment chamber is increased to 2 -3 atmospheres, equivalent to 1500 - 2500 mm Hg or 30 - 45 psi.
Topical Hyperbaric Oxygen (THBO):
Oxygen applied directly to the base of an open wound at pressure slightly above atmospheric e.g. 1.03 atmospheres (22 mm Hg or 0.4 psi.).
Disposable, Topical Hyperbaric Oxygen devices:
Disposable THBO devices are designed to be used one time and discarded. (Earlier multiple use extremity chamber devices were heavy, awkward to handle and difficult to clean and disinfect, increasing the risk of cross contamination between patients, and making home care use impractical.)

PURPOSE OF TOPICAL HYPERBARIC OXYGEN THERAPY
Oxygen is required for all new cell growth. Tissue at the base of chronic or non healing wounds tends to be ischemic. Application of topical hyperbaric oxygen induces the growth of new blood vessels at the wound base. The new blood vessels allow an increased flow of oxygenated blood to the wound which begins the healing process.

As healing progresses, new granulation tissue that is exposed to hyperbaric oxygen is better vascularized. This in turn leads to higher tensile strength collagen being formed during wound healing, which reduces scarring and the risk of recidivism.

Another important benefit of hyperbaric oxygen is that it is bactericidal for anaerobic bacteria e.g. Staphylococcus aureus and E.coli.

The difference between systemic HBO and topical hyperbaric oxygen (THBO) in therapeutic approach is that systemic HBO increases blood oxygen levels. However, blood oxygen levels are normally adequate for wound healing. The problem is that oxygen delivery to the wound site can be limited by poor wound tissue vascularization.

Topical hyperbaric oxygen on the other hand delivers oxygen directly to the wound. Transcutaneous oxygen levels are increased, despite the lack of well vascularized wound tissue. In addition, because this therapy is topical and relatively low pressure, there is no systemic absorption of oxygen, and therefore no risk of pulmonary or central nervous system toxicity that can result from breathing high pressure (30 - 45 psi) oxygen in full body chambers.

HOME CARE WITH DISPOSABLE, TOPICAL HYPERBARIC OXYGEN
Unlike systemic HBO, which requires specialized facilities, THBO therapy can be easily administered in patients' homes. The features that facilitate home care use include:

  • Disposable THBO products are light weight. A single box containing four units (a one week supply) weighs 5 lb.
  • They can use any source of medical grade oxygen, including light weight cylinders used by ambulatory respiratory patients. A pressure relief valve prevents over-inflation.
  • One-way filling valves allow them to be disconnected from the oxygen source during treatment, allowing the patient to move about.
  • They incorporate hydrocolloid adhesive backings, similar to ostomy products, that hold them in place over the wound.
  • "CAUTION: OXYGEN IN USE" and "NO SMOKING" signs are included with each package.

TREATMENT PROTOCOL - TOPICAL HYPERBARIC OXYGEN, DISPOSABLE
Week 1.

  • One (1) 90 minute treatment per day for four (4) consecutive days, followed by
  • Three (3) days with no THBO therapy. This period of relative hypoxia is an important step in the healing process.
  • Continue using preferred conventional modalities between THBO sessions.

Week 2 and beyond, until wound is healed

  • same as week one

Case Study #2- Referred on 2-11-93

Patient: 81 year old male

Wound type:

Full thickness (stage IV) sacral pressure ulcer acquired at his home with sacral spinous processes and sacral ligament exposure.

Complicating Factors:Patient has PMH of CAD and severe cardiac myopathy with only 20% ejection fraction noted in studies.

Previous Treatment:Patient had surgical debridement of necrotic tissue with post-operative hospitalization. Admitted for inpatient stay in sub-acute wound care center.

Problem List:

  1. Patient exhibits large stage IV pressure ulcer over sacral region measuring 14cm X 3.2cm depth. Under- mining in multiple directions.
  2. Patient is extremely debilitated. Unable to stand, roll or scoot in bed.
  3. Patient exhibits dehydration and is slightly malnourish- ed.

Approach:

  1. Topical hyperbaric oxygen sacral pouch X 2 hours 5X/week. Given the patient's poor cardiac function, oxygen delivery to the wound site is severely limited. Topical oxygen will promote macrophage function to secrete the growth factors needed to progress along the wound healing cycle.
  2. Patient will undergo a progressive physical therapy cardiac rehab program to restore physical function. Hydration monitored.
  3. Dietitian to consult and begin high calorie intake diet. Vitamin therapy initiated as well as high protein snacks and supplements.
  4. Pressure relief achieved with pressure relief specialty bed.
  5. Patient was matched with roommate of similar age and recreational activities provided that both patients would enjoy.

Wound Progression

Patient received topical oxygen 5X/week X 8 weeks during which time wound measures decreased from 14cm X 9cm X 3.2cm depth on 2-11-93 to 6.1cm X 2.2cm X1cm depth on 4-8-93. This represented 89% decrease in wound area and a 69% in wound depth in only 8 weeks. During this period topical oxygen was the only PT wound modality being used.

At this time, treatment was changed to high voltage pulsed current electrical stimulation (100 Volts, 100 PPS, (+) Polarity) X 1 hour and ultrasound (0.5W/cm2 550% DUTY, 3Mhz) X 8 minutes daily 5X/week. The patient's wound further decreased to 4cm X 1.6cm X 0.5cm depth at time of discharge from the wound healing center on 5-7-93, 85 days after admission.

Outcome Analysis

This patient was discharged from the facility 85 days after admission, with the patient's wife able to perform dressing changes when needed. The patient had undergone cardiac rehab and was ambulating with a rolling walker functional distances up to 500 feet. The wound had decreased in area by 95% and in depth by 84% at time of discharge. The patient did not require home care and returned for outpatient physical therapy for wound care for 60 visits before the wound healed in October 1993.

Comments by Treating Therapist:

This patient was the first patient for whom I used topical hyperbaric oxygen. It is my belief that the patient could not have healed without oxygen intervention, given the the poor perfusion of the wound area with the patient's reduced cardiac function. Besides the amazing decrease in wound size during treatment, the wound never acquired an infection during the patient's stay, thus, averting the possibility of sepsis so common with wounds as large as this one. Although oxygen played a pivotal role in this patient's healing, it was part of a larger focus of attention upon establishing an optimal wound healing environment. This was accomplished by eliminating any factor which might have slowed wound healing and by adding every factor which we, as clinicians in each discipline, felt would accelerate the healing process.

James Phillips, MS PT

Return to Main Page, Wound Care Institute Newsletter, Fall 1996