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If you have diabetes or have received radiation treatment, please retain this booklet for future reference.
Breathe new life into old wounds
2
Please visit our website www.hyperbarichealth.com to download a copy of this booklet as a PDF. Alternatively, call 1300 HYPERBARIC (1300 497 372) and we’ll send a copy to you, a relative or a friend who may benefit from hyperbaric treatment.
The boDy hAs A very comPlex
sysTem oF heAling. Among
oTher Things, iT neeDs gooD
builDing blocks For rePAir
(e.g. gooD nuTriTion) AnD A
gooD TrAnsPorT sysTem To geT
The builDing blocks To The
siTe oF AcTion (boTh lArge
AnD smAll blooD vessels).
hyperbaric oxygen Therapy (hboT) delivers very
high concentrations of oxygen to the wound via the
bloodstream, allowing it to ‘kick start’ the healing
process. While doing this, it also develops new small
blood vessels in the tissues, healing the wound from
within and keeping further wounds at bay.
hboT has proven particularly effective in helping
people with diabetes who have long-term wounds,
as well as helping people who are experiencing late
effects of radiotherapy for cancer treatment.
This booklet describes how hboT is a proven
medical treatment and can help breathe new life
into old wounds.
•AllHyperbaricHealthFacilitiesareAchs Accredited and Department of health licenced Private hospitals
•HyperbaricHealthhascontractswithDvA and all major health funds
•Medicarepatientsarebulkbilled
•HyperbaricHealthwillassistinpatient transport and accommodation where available
3
Speeding up the healing process from the inside outHyperbaric (‘hyper’ meaning ‘over’, and ‘baric’ meaning
‘pressure’) literally translates to ‘over pressure’. HBOT
exposes the patient to higher than normal pressure while
the patient breathes 100% oxygen. This can only be
achieved in a pressurised vessel (hyperbaric chamber).
Breathing pure oxygen while in a pressurised environment
results in therapeutic effects for the patient. Hyperbaric
treatments for wounds occur at pressures between 2.0
and 2.4 times the pressure at sea level. In real terms, this
delivers up to 15 times the normal level of oxygen to the
body; this can only be achieved in a hyperbaric chamber,
and causes some important changes in the body.
HBOT has many benefits in wound healing, including
the following:
Overcomes areas of poor oxygenation
This is particularly true for parts of the body that have
poor small vessel circulation (such as in people with
diabetes). Oxygen at higher concentrations can supply
the most distant tissues (such as skin on the toes) with
the vital building blocks required to help repair damage.
In turn, this reduces the need for more radical treatment
such as surgery and potentially amputation.
Grows new small blood vessels in areas with poor small vessel circulation
This process is called angioneogenesis (literally ‘new blood
vessel growth’) as shown in Figure 1. This takes between 15
and 40 treatments to work and new small blood vessels can
be grown within tissues with degraded blood vessels.
This is a particular problem for people with diabetes
and people who have had radiotherapy for cancers.
The former may develop wounds that do not heal, leading
to amputations, while the latter can have problems such
as bleeding bowels, bladders or a breakdown of normal
tissues in the areas where they have received radiotherapy.
Increasedactivation
factors
Decreasedactivation
factors MFSCsMFSCs
MFSCmobilisationto circulation
Impaired MFSC
mobilisationto circulation
Bone marrow
Healthy wound
Migratingskin cells
Wound-inducedhypoxia
(low oxygen)Platelet
Blood vesselgrowth factorsBlood vessel
growth factors
Impaired healing enzyme activation
LimitedMFSC homingMFSCs
homingto wound site
CirculationBlood vesselcell migration
Precursors ofstructural cells
Macrophages(white blood cells)
Epithelial cells
Angioneogenesisand wound healing
Limited angioneogenesisand wound healing
Diabetic wound
Increasedactivation of
healing enzymes
Decreasedactivation of
healing enzymes
Improved by HBO therapy
Cell differentiation factors Limited cell differentiation factors
MFSCs = Multifunction stem cells
Macrophagefunction
Figure 1. Difference in healing with normal versus diabetic tissue.
4
Fights infection
Infections are naturally attacked by the body’s white
blood cells that use chemicals to destroy bacteria and
are rapidly broken down to limit the damage to normal
tissues. Some of these chemicals are called ‘reactive
oxygen species’ and include chemicals such as hydrogen
peroxide (H2O2). For the white cells to work properly they
need oxygen to convert into these natural ‘antibiotics’ and
the additional oxygen delivered by HBOT optimises this
effect. High levels of oxygen can also deactivate some of
the toxins that are produced by bacteria, particularly in
gas gangrene, reducing the infection’s ability to spread.
In other words, ultra high levels of oxygen energise the
body’s natural immune system to better fight infection.
Delivers building blocks for wound healing
Wound healing is a complex process. It requires many
cellular components to come together at the correct time
in optimal amounts for a rapid, strong wound-healing
response. Several stages of the wound-healing process
require a good level of oxygen for cells to build the
structure around which the wound can heal. In some
conditions (such as diabetes or auto-immune diseases)
the reduced delivery of oxygen creates a weak healing
process ‘scaffold’ which leads to recurrence of the wound
or a wound that does not heal at all (see Figure 2).
Conversely, an increased delivery of oxygen provides a
strong healing ‘scaffold’ and fights infection, resulting in
complete and proper healing of the wound.
Figure 2. The wound healing process.
Enhances the delivery of stem cells
Stem cells are generic cells that can change into specific
cells that are needed in the body. The number of stem cells
decreases with age but they are often required; in particular,
for the process of wound healing. HBOT has been shown
to greatly enhance the development and release of stem
cells as well as their activation in wound healing.
HBOT is only one form of treatment that can help in the treatment of long-term wounds and tissue damage secondary to radiotherapy. However, if you have had a wound for longer than 3 months it is unlikely that it is going to heal by itself; you may like to consider HBOT as an option for treatment.
Skin surfaceRed blood cell
Epidermisanddermisof skin
Wound Platelet
Macrophage
Neutrophils (white blood
cells)
a Injury
Collagen Fibroblast
Fibrin
b Coagulation (clot forming)
d Late inflammation (48 h)
Macrophages(white blood cells)
e Proliferation (building tissue scaffolding – 72 h)
Oxygen dependent processes
c Early inflammation (24 h)
Neutrophils(white blood cells)
f Remodelling (scar formation and strengthening – weeks to months)
5
HBOT is a single treatment with many actions Several conditions are treated with HBOT but it is most
commonly used to treat long-term (chronic) wounds
and secondary tissue damage sustained from receiving
radiotherapy for cancer.
Long-term (chronic) woundsThese are wounds that have existed for longer than
3 months and are unlikely to heal by themselves. The
longer the wound exists, the less likely it is to heal with
repeated dressings. This leads to a repetitive, ongoing,
expensive and uncomfortable cycle of dressings and
interventions for complications (such as infections) that
can continue for years.
HBOT seeks to end that cycle through gentle healing.
Many long-term wounds often have an underlying low
oxygen concentration (called hypoxia) that prevents
them from healing. Hypoxia has been measured directly
in the laboratory and can be measured with a skin probe
called a trans-cutaneous oxygen measurement probe
(TCOM). The TCOM measures the amount of oxygen
being delivered to the skin (which is where the wound
occurs) by placing stick-on cups on the patient’s skin
(the procedure is non-invasive).
HBOT delivers oxygen to the wound, allowing it to ‘kick
start’ the healing process by promoting the development
of new small blood vessels. With this approach, the
wound can be healed and further wounds can be kept
at bay.
HBOT is by no means the only available treatment for
long-term wounds and assessment of the large blood
vessels by a vascular laboratory in conjunction with a
vascular surgeon is recommended. Proper dressings
and management of other medical issues (such as good
diabetes control, good nutrition and adequate vitamin
and mineral intake) all contribute to wound healing in
addition to HBOT.
Radiation tissue injuryWhen people have radiotherapy for cancer treatment,
damage invariably occurs to normal tissues around the
area being irradiated. This occurs because the field
being irradiated is slightly larger than the actual cancer
(to make sure all cancer cells are irradiated) and some
radiation must pass through normal tissues in order to
reach the tumour.
This has two effects:
• There can be acute (early) radiation damage such as
swelling and ‘sunburn’ effects, for example on skin
• There can be late-onset radiation damage. This occurs
12–18 months after radiotherapy and is due to damage
of the small blood vessels.
HBOT can help in both cases with reduction of swelling
(increase in size) and inflammation (the redness) in the
early stages, but is much more effective in the treatment
of late-onset radiation effects. This is particularly evident
in people who develop dental cavities (holes in their
teeth) secondary to radiation therapy of the head and
neck, who require removal of the teeth. For people with
cancers of the head and neck, removal of radiation-
damaged teeth can lead to exposure of the mandible
(jaw-bone) and breakdown of both the soft tissues of
the gums and the bone itself. This can require extensive
reconstructive surgery that, because it is in an irradiated
field with poor blood flow, can lead to further wound
breakdown and further surgery.
THe LOngeR THe WOund exISTS, THe LeSS LIkeLy IT IS TO HeaL WITH RePeaTed dReSSIngS
6
HBOT is also helpful for people who have undergone
radiotherapy to the pelvis for prostate or gynaecological
cancers and developed injuries to other pelvic organs
(such as the bladder and bowel). In the pelvis, the lining
of the bladder and lower bowel can become damaged
by radiotherapy, leading to bladder and bowel frequency
(frequent visits to the toilet), bleeding (with multiple
transfusions) and considerable pain and discomfort.
These effects do not occur in all people who have
radiotherapy and depend on the type and total amount
of radiotherapy that each person receives.
HBOT can end the potentially destructive downward
spiral of damage to irradiated tissues, surgical operations
in the irradiated field, followed by non-healing of the
surgical wound.
It’s all about ending the cycle.
Figure 3. The downward spiral of chronic wounds.
giving the body building blocks to repair itselfThe body has a very complex system of healing.
you need good building blocks for repair, (e.g. good
nutrition), a good transport system (both large and small
blood vessels), a good ability to fight infection and a good
cellular system to put it all together.
In several medical conditions, some (or all) of these items
are missing or compromised. The problem with this is
that the wound ‘stalls’ in its healing process and patients
can end up in a dysfunctional downward spiral. Without
intervention, this downward spiral continues until the
patient follows one of two pathways:
• a poor outcome (such as amputation in the case of a
person with a diabetic foot ulcer)
OR
• develop an overwhelming problem (such as an
infection), requiring time in hospital.
repeated admissions to hospital
repeated visits to the doctor
repeated expensive wound dressings
non healing wound
HBOT IS an eFFeCTIve, MInIMaLLy InvaSIve Way OF endIng THe WOund CyCLe and MakIng a deFInITe MOve TOWaRd a nORMaL HeaLIng PROCeSS
Ask your doctor whether your wound is suitable for HBOT
7
Some facts about wounds• The number of people with long-term wounds
(more than 3 months’ duration) in Australia is
estimated to be approximately 200,000 people1
• The rate of lower limb wounds in diabetics is
estimated at 1.9% at any one time2
• The overall lifetime chance of a person with
diabetes developing a leg wound is up to 25%3
• between 76 and 85% of amputations in people
with diabetes begin as an ulcer4,5
• The chance of requiring further amputation
(either on the same leg or the other leg) after
an amputation is between 30 and 50%6
• Diabetes mellitus is the most common cause of
non-traumatic amputations in Australia2
Some facts about post-radiotherapy damage• Damage can start between 12 and 18 months
after radiotherapy
• infection, surgery or trauma can accelerate
the breakdown of bone and soft tissue in an
irradiated area
• re-operating in an irradiated area can precipitate
further damage and a cycle of operations
and re-operations
references
1. elephant in The room: Wound Awareness campaign 2010. Australian Wound management Association. www.elephantintheroom.com.au. viewed 17 october 2010.
2. Australian institute of health and Welfare. Diabetes: Australian facts 2008. canberra: Australian government, Australian institute of health and Welfare, 2008.
3. singh n, Armstrong Dg, lipsky bA. Preventing foot ulcers in patients with diabetes. JAmA 2005; 293 (2): 217–28.
4. ulbrecht Js, cavanagh Pr, caputo gm. Foot problems in diabetes: an overview. clin infect Dis 2004; 39 (suppl. 2): s73–82.
5. boulton AJ, vileikyte l, ragnarson-Tennvall g et al. The global burden of diabetic foot disease. lancet 2005; 366 (9498): 1719–24.
6. ollendorf DA, kotsanos Jg, Wishner WJ et al. Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Diabetes care 1998; 21(8): 1240–5.
8
Treating people from age 1 to 100+Breathing oxygen is indistinguishable from breathing air. as the pressure gently changes patients will need to
clear their ears just as you may do occasionally on a plane.
HBOT is a very safe treatment. We regularly treat people aged in their 90s. Children can also be safely treated in a
hyperbaric chamber.
There are two main types of chambers:
• multiplace chambers
• monoplace chambers.
9
Multiplace chambersMultiplace chambers are large metal chambers that can
treat a number of people simultaneously (hence ‘multi’
place). Patients enter the chamber via a door that creates
a pressure seal and they sit or lie down (depending on
the condition and type of chamber). a trained hyperbaric
nurse is always present within the chamber during the
treatment. While they are being treated, patients can
read a book and breathe normally. It’s just like going for a
ride in a plane. In these chambers pressure is delivered
with air but the patients inside breathe 100% oxygen
either though a fitted mask or a ‘hood’.
This effect is the same as breathing normally if the
chamber was pressurised with 100% oxygen. To increase
safety the chamber is filled with air and 100% oxygen is
only delivered to the hood or mask. The treatment lasts
approximately 2 hours (the actual treatment time at
pressure is 90 minutes but an additional 30 minutes is
allowed for getting the chamber to pressure).
Monoplace chambersMonoplace chambers are single-person chambers that
are generally smaller than multiplace chambers. They
are usually made of acrylic (a very strong clear plastic)
and are pressurised with pure oxygen (i.e. patients
generally don’t have to wear a mask or hood). Patients lie
on a trolley and slide into the chamber. Patients can see
around themselves quite clearly (a bit like a tunnel in a
large aquarium where you can look at the fish swimming
around you) and normally there are video screens so
patients can watch their favourite movie or television show
while undergoing treatment.
advantages of the monoplace chambers are a slightly
faster treatment time and treatment can be based around
the patient’s schedule as there is no need to wait for other
patients to start treatment.
Both chamber types give the same treatment and the type
of chamber patients will have depends on the facilities at the
Hyperbaric Health Wound Centre that is closest to them.
10
Medicare recognised treatmentsHBOT is recognised as an effective treatment by Medicare and, for common conditions, Medicare and health
funds will pay for the treatment as a legitimate effective treatment. Hyperbaric Health facilities charge a very
small facility fee (for lunch or afternoon tea after the treatment) but the assessment, management by specialist
doctors and treatment itself do not cost the patient any money.
Hyperbaric Health bulk bills and has ‘no-gap’
arrangements with most of the major private health funds
and the department of veterans affairs.
The conditions that are paid for by Medicare include:
• treatment for soft tissue and bone radionecrosis
(damage due to radiotherapy – both as a preventative
measure and as treatment)
• hypoxic(lowoxygen)andchronic(longterm)wounds
• gasgangreneandnecrotisinginfections
• decompressionillness(thebends)
• arterialgasembolism(AGE).
Other conditions have recognised HBOT as a valid treatment
but currently Medicare will only fund the conditions above.
Recognised indications for Hyperbaric Oxygen TherapyThis list is based on the best evidence currently available and is by no means exhaustive. it is based on
the Australian and new Zealand hyperbaric medicine group (AnZhmg) list of indications for treatment.
Diabetic wounds* ulcers, post-surgical wounds, gangrene
Problem wounds* chronic ischaemic wounds, post surgical problem wounds, venous ulcers
Late radiotherapy tissue injury*prophylaxis and management of bony and soft tissue radionecrosis including radiation
proctitis, radiation cystitis, maxillofacial bony and soft tissue necrosis
Infective conditions necrotising infections*, refractory osteomyelitis, malignant otitis externa
Acute ischaemic conditionscompromised flaps and grafts, crush injury, compartment syndrome, reperfusion
injury, idiopathic sudden sensorineural hearing loss, avascular necrosis
Decompression illness (DCI)* decompression sickness, cerebral arterial gas embolism including iatrogenic injury
Toxic gas poisoning carbon monoxide poisoning
Ocular ischaemic pathology cystoid macular oedema, retinal artery or vein occlusion
Adjuvant to radiotherapy adjunct to radiotherapy for solid tumours
Miscellaneous thermal burns, frostbite
The anZHMg, a sub-committee of the South Pacific underwater Medicine Society (SPuMS), review evidence and recommend conditions for
which HBOT may be employed biennially. Hyperbaric Health, as policy, uses the anZHMg Indications.
*Indications funded by Medicare
11
MelbourneLocated at St. John of god Hospitalgibb Street, Berwick vIC [email protected] Ph: (03) 9707 1420 Fax: (03) 9707 1860
Located at Brunswick Private Hospital 82 Moreland avenue, Brunswick vIC [email protected] Ph: (03) 9383 6505 Fax: (03) 8587 2489
Sydney Suite 3, ground Floor, 46–50 kent Road, Mascot nSW 2020 [email protected] Ph: (02) 9578 0000 Fax: (02) 9578 0050
Perth Opening in 2011Located at St. John of god HospitalSubiaco Wa 6008 [email protected]
New ZealandQuay Park Medical Centre 68 Beach Road, Auckland 1010 [email protected]: (09) 919 2340 Fax: (09) 919 2341
Referral formFor urgent referrals please contact your nearest facility listed below.
Patient name:
address:
date of birth: (dd-mm-yy) daytime telephone:
Private referral Medicare referral
Please tick indication for hyperbaric oxygen therapy (HBOT)
Problem wounds diabetic non diabetic
Late radiation tissue injury Soft tissue Prophylaxis
Bone established disease
Infective conditions Suspected organism:
acute ischaemic conditions
Compromised flaps/grafts Crush injury/compartment syndrome Reperfusion injury avascular necrosis Sudden sensorineural hearing loss
decompression illness (dCI) Please phone the nearest facility
Toxic gas poisoning Please phone the nearest facility
Ocular ischaemic pathology Retinal artery/vein occlusion
adjuvant to radiotherapy Please discuss with facility prior to referral
Miscellaneous Thermal burns FrostbiteBackground medical history – Please include as much information as possible and attach extra sheets and test results to this referral sheet
Referring doctor:
address:
Telephone: Medicare provider number:
HBOT is a non-invasive medical treatment involving breathing 100% oxygen while inside a pressurised hyperbaric
chamber. HBOT increases oxygen delivery to tissues higher than is otherwise possible.
To find out if you would benefit from HBOT please complete this form in consultation with your doctor and contact
your nearest Hyperbaric Health Wound Centre.
If you have more than one specialist please photocopy this referral and take it to all your doctors.
Do you or someone you care for have a wound or injury that is:
having trouble healing or due to diabetes complications or due to radiation treatment or causing ongoing pain?
hyperbaric oxygen Therapy may help.
speak to your doctor, call 1300 HYPERBARIC (1300 497 372) or visit www.hyperbarichealth.com for more information or to download a copy of this booklet as a PDF.
Call us on our national free call number1300 HYPERBARIC (1300 497 372) or call the Hyperbaric Health Wound Centre closest to you:
BerwickSt. John of god Hospitalgibb Street, Berwick vIC [email protected] Ph: (03) 9707 1420
BrunswickBrunswick Private Hospital82 Moreland avenue, Brunswick vIC [email protected] Ph: (03) 9383 6505
SydneySuite 3, ground Floor46–50 kent Road, Mascot nSW [email protected] Ph: (02) 9578 0000
PerthOpening in 2011St. John of god HospitalSubiaco Wa 6008 [email protected]
New ZealandQuay Park Medical Centre 68 Beach Road, auckland 1010 [email protected]: (09) 919 2340
© Hyperbaric Health 2010.