Introduction
Originally used to treat divers with decompression sickness, its application has grown, benefiting patients with various pathologies. In the following lines, the main advantages of HBO, the patients who can benefit, the contraindications, the myths and realities surrounding the therapy, the frequent fears of patients and the devices used, explaining their safety, will be discussed. There will be a special section on the indications of such treatment in patients undergoing cancer treatment.
Advantages of Hyperbaric Oxygenation Treatment
The use of hyperbaric oxygenation has multiple physiological benefits, including:
1. Increased tissue oxygenation: Under higher pressures, oxygen dissolves in the blood plasma, making it reach tissues with low blood flow or compromised by infection or ischemia.
2. Stimulation of wound healing: HBO promotes angiogenesis (formation of new blood vessels), which is especially useful in chronic wounds such as diabetic ulcers and even varicose ulcers.
3. Decreased inflammation: It has an anti-inflammatory effect by reducing the release of pro-inflammatory cytokines, improving conditions such as chronic osteomyelitis or severe infections.
4. Increased immune function: Improves the activity of white blood cells, promoting the body’s ability to fight bacterial infections, especially in necrotizing or resistant infections.
5. Detoxification: In cases of carbon monoxide poisoning, HBO accelerates the elimination of the toxic gas from the blood, reducing the risk of neurological damage.
Patients Who May Benefit
Hyperbaric oxygenation is used to treat a variety of clinical conditions, including:
1. Severe infections: Such as necrotizing fasciitis, where intense oxygenation is required to combat anaerobic bacteria.
2. Radiotherapy injuries: Patients who have suffered radiotherapy damage, such as bone or tissue necrosis, may benefit from the regeneration promoted by HBO.
3. Patients with conditions associated with chronic pain: Patients affected by osteoarthrosis, complications of osteoporosis, and some patients experiencing pain associated with antineoplastic treatments such as tumor ulcers or postoperative complications for cancer resection.
4. Diabetic ulcers: Patients with diabetes mellitus who develop non-healing ulcers may find in HBO a tool to avoid amputation.
5. Decompression sickness and air embolism: Divers and aviators with exposures to atmospheric pressure changes are classic candidates for therapy.
6. Carbon monoxide poisoning: In cases of smoke inhalation or CO poisoning, HBO is the treatment of choice to avoid serious complications.
Contraindications to Hyperbaric Oxygenation
Despite the many benefits, not all patients are ideal candidates for hyperbaric oxygenation. The main contraindications include:
1. Untreated pneumothorax: The increased pressure in the chamber may exacerbate a pre-existing collapsed lung.
2. Severe lung diseases: In patients with severe emphysema, HBO could cause barotrauma or damage the alveoli.
3. Upper respiratory tract infections: Colds or acute sinusitis can make the pressure inside the chamber painful or dangerous.
4. Patients with uncontrolled epilepsy: There is a small risk of seizures due to oxygen toxicity at high concentrations.
5. Severe claustrophobia: While many modern hyperbaric chambers are spacious, some patients may experience intense anxiety when in an enclosed environment.
Myths and Facts of Hyperbaric Oxygenation
Over time, several myths have arisen about hyperbaric oxygenation that need to be debunked:
– Myth 1: “Hyperbaric oxygenation cures all diseases”: While it has applications in a variety of conditions, it is not a miracle solution and is only approved for certain well-defined medical conditions.
– Myth 2: “HBO is addictive”: There is no scientific evidence to support this claim. The therapy is safe when administered in a controlled manner and under medical supervision.
– Myth 3: “Anyone can undergo hyperbaric oxygenation”: As discussed above, there are clear contraindications and it is not suitable for everyone.
Common Patient Fears
It is common for patients to experience certain fears prior to starting HBO therapy. Some of the most common fears include:
1. Claustrophobia: Many patients fear being in a closed chamber. However, modern chambers are much more spacious, and some centers offer multi-place chambers that allow several patients to be treated simultaneously in a larger environment.
Explosion risk: Although the therapy involves the use of oxygen at high pressure, modern devices are designed with multiple safety systems to prevent any risk.
3. Ear pain: As on a flight, some patients may experience discomfort when the pressure changes, but this is usually relieved by simple techniques such as yawning or the Valsalva maneuver.
4. Seizures due to oxygen toxicity: Although oxygen at high concentrations can induce seizures, this risk is extremely low when the therapy is properly administered.
Hyperbaric oxygen therapy in conditions associated with chronic pain:
Indications and Contraindications in Patients on Active Cancer Treatment
The use of hyperbaric oxygenation (HBO) in cancer patients requires careful evaluation, as it may have both clear indications and contraindications depending on the oncologic treatment the patient is receiving. Specific indications and contraindications are explored below, particularly in patients undergoing treatment with chemotherapy and radiation therapy.
Indications for HBO in Cancer Patients
1. Late radiation therapy injury: Hyperbaric oxygenation is indicated in patients who have experienced adverse effects of radiation therapy, such as necrosis (necrosis refers in medicine to the destruction of tissues by loss of circulation) of bone or soft tissues (osteoradionecrosis or radionecrosis). These effects occur when irradiated tissues suffer from a prolonged decrease in blood flow, leading to a lack of blood flow with oxygen and nutrients to the tissues. HBO promotes the appearance of new blood vessels in body tissues, favoring the repair of these damaged tissues.
2. Post-surgical wound healing: Many cancer patients require surgery as part of their treatment. If there is poor healing, especially in patients who have received radiation therapy or in those with a compromised general condition, HBO can improve oxygenation of body tissues and stimulate wound healing after surgery.
3. Prevention of complications in radiotherapy: In some cases, HBO has been used preventively to reduce the likelihood of complications in patients undergoing radiotherapy, minimizing the associated tissue damage.
Contraindications to HBO in Patients Undergoing Chemotherapy
The combination of HBO and chemotherapy requires special consideration due to the potential interaction between hyperbaric oxygen and certain chemotherapeutic agents. Some chemotherapy drugs may increase the risk of toxicity when combined with HBO:
1. Bleomycin: This chemotherapeutic agent used in the treatment of several types of cancer (lymphomas, testicular cancer, among others) is known to cause pulmonary toxicity, especially when combined with oxygen at high concentrations. Exposure to HBO in patients receiving concomitant treatment with bleomycin may increase the risk of pulmonary fibrosis, making this treatment contraindicated.
2. Doxorubicin: Also known as “adriamycin,” this drug is used in several chemotherapy regimens. It can cause damage to heart cells, and exposure to high concentrations of oxygen during HBO can worsen this risk. In patients who are receiving or have received doxorubicin, HBO should be avoided or used with extreme caution.
3. Cisplatin: A potent chemotherapeutic used in the treatment of several solid cancers, cisplatin may have adverse effects on the kidneys and ear. There are no well-documented direct interactions between cisplatin and HBO, but possible toxic effects on the kidneys require rigorous monitoring of renal function in these patients.
Safety Issues in Patients Undergoing Radiation Therapy
Radiation therapy, especially in patients with head, neck, and pelvic cancers, can produce significant damage to surrounding normal tissues, which can result in late complications such as bone necrosis, tissue fibrosis, or skin lesions. HBO has been shown to be useful in repairing these lesions, but there are important safety issues to consider:
1. Control of tumor progression: There is a theoretical concern that the increased oxygenation provided by HBO may favor tumor cell proliferation, as some cancer cells may use oxygen more efficiently. However, conclusive evidence that HBO promotes tumor growth has not been demonstrated. Nevertheless, in patients with active disease, it should be evaluated on a case-by-case basis, and many physicians prefer to wait until oncologic therapy is complete or until the patient is in remission before initiating HBO.
2. Combined toxicity of radiation therapy and HBO: In cancer patients who have received high doses of radiation, the administration of HBO should be carefully managed so as not to exacerbate damage to irradiated tissues. HBO, when properly administered, can reduce radiotherapy-induced hypoxia, but should be avoided in patients with severe radiation-induced lung injury, as it may increase the risk of lung damage.
3. Prophylactic use: In some cases, HBO can be used preventively in patients who are about to receive radiotherapy, particularly in those with risk factors for late complications such as diabetes or poor wound healing. The goal is to better prepare the tissues to resist radiation damage and reduce the risk of long-term complications.
Hyperbaric Oxygenation in Patients with Osteoarthrosis
Osteoarthrosis is a degenerative joint disease characterized by progressive degeneration of articular cartilage, thickening of subchondral bone and the development of osteophytes. In this disease, blood flow to joint tissues may be compromised, affecting the ability of these tissues to repair and regenerate. Although not one of the most common indications for hyperbaric oxygenation (HBO), this therapy may have benefits for certain patients with osteoarthrosis.
1. Reduction of inflammation: One of the main effects of HBO is its ability to reduce systemic and local inflammation by decreasing the release of proinflammatory cytokines. In patients with osteoarthrosis, this can translate into a reduction of joint pain and inflammation in the affected joints.
2. Improved blood flow and oxygenation: Osteoarthrosis is often associated with decreased blood supply to the joints, making it difficult to repair damaged cartilage. HBO increases tissue oxygenation, promoting cartilage regeneration and improving the overall condition of affected joints.
3. Relief of chronic pain: In many patients with advanced osteoarthrosis, pain is one of the main complaints. The anti-inflammatory effect of HBO, combined with its ability to enhance tissue regeneration, may help reduce chronic pain in some patients, improving their quality of life.
Hyperbaric Oxygenation in Osteoporosis Patients
Osteoporosis is a systemic skeletal disease characterized by decreased bone density and deterioration of bone microarchitecture, which increases fragility and the risk of fractures. Although HBO is not a standard therapy for osteoporosis, it may have beneficial effects in certain disease-related scenarios.
1. Promotion of fracture healing: One of the potential uses of HBO in osteoporosis is its ability to enhance bone fracture healing. Since patients with osteoporosis are more prone to fractures, and healing in them is often slower, the improved oxygenation provided by HBO may speed up the repair process of injured bone tissues.
2. Increased bone formation: Some studies suggest that HBO may stimulate the activity of osteoblasts, the cells responsible for bone formation. Although the results are preliminary, the possibility that HBO may contribute to bone regeneration makes it an interesting tool for treating osteoporosis-related fractures.
3. Prevention of bone necrosis: Osteoporosis increases the risk of avascular bone necrosis (death of bone tissues due to insufficient blood vessels carrying oxygen- and nutrient-rich blood), especially in areas with compromised blood supply, such as the femoral head. HBO enhances the appearance of new blood vessels, which may prevent or minimize the effects of bone necrosis in patients with advanced osteoporosis.
Management of Ischemia Injuries and Ulcer Management with Hyperbaric Oxygenation
Management of Ischemia Injuries
Ischemia occurs when blood flow to a specific area of the body is severely reduced or blocked, limiting the delivery of oxygen and essential nutrients to tissues. This lack of oxygen can lead to the death of part of the tissues and the formation of severe lesions, which, if not adequately treated, can result in permanent damage or loss of function of the affected organ or limb.
Hyperbaric oxygenation (HBO) has proven to be an effective treatment in the management of various ischemic conditions by improving oxygenation of the affected tissues:
1. Increased tissue oxygenation: During HBO, dissolved oxygen in the plasma increases significantly, allowing it to reach even ischemic tissues with poor blood flow. This is essential to prevent cell death and allow recovery of tissues at risk.
2. Promotion of angiogenesis: HBO stimulates the formation of new blood vessels (angiogenesis), which improves blood supply to ischemic areas. This is particularly beneficial in chronic conditions such as peripheral arterial disease, where blood supply is compromised.
3. Improved cellular function: By increasing the level of available oxygen, HBO also promotes the activity of fibroblasts and endothelial cells, essential for tissue regeneration. These effects are crucial to repair the damage caused by ischemia.
4. Edema reduction: HBO helps to reduce the swelling and edema that often accompanies ischemic injury. By reducing inflammation, it improves circulation and promotes tissue healing.
Ulcer Management (non-healing extremity wounds)
Chronic ulcers, such as diabetic, venous or pressure ulcers, represent a major medical challenge due to the difficulty in achieving complete healing. Ulcers usually form in areas with compromised blood flow, which creates a hypoxic environment that impedes the healing process. HBO has proven to be an effective option in the treatment of these complex lesions.
1. Diabetic ulcers: Diabetic foot ulcers are one of the main indications for HBO. Patients with diabetes often have poor circulation in the lower extremities, which impedes proper healing of ulcers. HBO improves tissue oxygenation and reduces the risk of infection, which facilitates healing. Several studies have shown that HBO significantly reduces amputation rates in patients with severe diabetic ulcers.
2. Venous ulcers: These ulcers are common in patients with chronic venous insufficiency. HBO helps to improve oxygenation in the ulcer bed, which allows regeneration of damaged tissues and reduces the risk of infection.
3. Pressure ulcers (bedsores): In immobilized patients, pressure ulcers are a common problem. HBO improves tissue oxygenation, which promotes healing and reduces the risk of infections that could aggravate the condition.
4. Accelerated healing: HBO stimulates fibroblast and collagen activity, which accelerates the formation of new tissue in chronic wounds. In addition, increased oxygenation reduces bacterial activity, creating an environment more conducive to healing.
5. Infection prevention: Chronic ulcers are prone to bacterial infections that can delay healing or even lead to sepsis. HBO improves white blood cell function, strengthening the patient’s immune defenses and reducing the risk of infections.
Devices Used in Hyperbaric Oxygenation and their Safety
There are several types of hyperbaric chambers, and all have undergone rigorous safety testing:
1. Single-Person Chambers: These chambers are suitable for the treatment of a single patient, allowing for a more private experience. They are pressurized with pure oxygen and the risks are carefully controlled.
2. Multiplace chambers: They allow several patients to be treated at the same time. Instead of being pressurized with pure oxygen, they use compressed air, while patients inhale oxygen through special masks or helmets.
3. Portable Systems: Although less common, portable devices exist for lighter treatments, but they are limited in terms of the maximum pressure they can reach and are therefore not suitable for all pathologies.
All hyperbaric chambers have continuous monitoring systems and automatic controls to maintain oxygen and pressure levels in safe ranges.
Conclusion
Hyperbaric oxygenation is a valuable tool in the medical arsenal, especially in the treatment of conditions difficult to manage by other conventional means. Although it has many advantages, its use should be restricted to clear indications and under the supervision of a trained specialist. Although myths and fears may discourage some patients, the reality is that it is a safe and effective treatment when administered correctly.
In cancer patients, hyperbaric oxygenation can be a beneficial tool, particularly for the management of radiation therapy complications and wound healing. However, it is critical to be aware of potentially dangerous interactions with certain chemotherapeutics, such as bleomycin and doxorubicin, which contraindicate the use of HBO due to their risks of pulmonary or cardiac toxicity. In patients with active or recent radiotherapy, HBO should be considered with caution, taking into account the type of treatment received, the location of the tumor and the patient’s general condition.
Although hyperbaric oxygenation is not a standard treatment for osteoarthrosis or osteoporosis, it can be a valuable adjunctive tool in certain cases. In osteoarthrosis, the ability of HBO to reduce inflammation and improve tissue oxygenation may help control pain and improve joint function. In osteoporosis, HBO can accelerate fracture healing and improve bone health, particularly in patients at increased risk of complications such as avascular necrosis. However, its use in these conditions should be evaluated on a case-by-case basis, and always under the supervision of a specialist.
Hyperbaric oxygenation plays a crucial role in the management of ischemic lesions and chronic ulcers. By improving tissue oxygenation, reducing inflammation and promoting the formation of new blood vessels, HBO accelerates ulcer healing, minimizes complications due to lack of blood flow and reduces the need for amputations. For patients with these conditions, HBO offers a therapeutic option that can significantly improve quality of life and long-term outcomes.
By: Frantz Colimon MD FIPP
Anesthesiologist,
Specialist in Interventional Analgesia
General Director: Centro de Especialistas en el Alivio del Dolor (CEAD)
