1. Hyperbaric Oxygen Therapy
Joel Silverstein
Scuba Training and Technology Inc.
Tech Diving Limited
Oxygen - What You Need To Know

2. Global View Definition of HBO HBO applications Treatment protocols
Fundamentals of HBO
Primary and secondary benefits of oxygen
Hyperoxia
Off phenomena
UPTD calculation
Therapy gases and equivalent air depth
Theory and pathophysiology of oxygen therapy
Case studies
Treatment tables and procedures for dive injuries
Treatment tables and procedures for non-diving injuries and maladies
Oxygen - What You Need To Know

3. What is HBO ?
Hyperbaric oxygen (HBO) therapy is the inhalation of 100% oxygen by a patient exposed to elevated ambient pressure in a chamber

4. Typical use of HBO Arterial gas embolism
Decompression sickness (except skin bends and “niggles”)
Clostridial myonnecrosis (gas gangrene)
Crush injuries
Problem wounds
Exceptional blood loss
Carbon monoxide poisoning
Necrotizing (dead or dying) soft tissue infections
Osteomyelitis (infection of bone)
Radiation tissue damage
Skin grafts and flaps (compromised)
Thermal burns
Diabetes

6. USN Multi-place Chamber

7. Treatment Protocols Examples:
Patient treatment varies greatly depending on the disease process for which HBO is being utilized.
Examples:
Selected non-healing wounds may be treated daily for 2 hours for up to treatments
Diving accident victims may receive only one hour treatment
Carbon monoxide poisoning is typically managed with a single treatment for 1-3 hours depending on patient condition

8. Fundamentals of HBO Therapy-1
Treating Decompression Illness
Raised
atmospheric
pressure
Raised
inspired
PO2
Adequate
time
Adequate fluid management
Appropriate drug therapy
Recompress
bubble
Washout of inert gas
Promote tissue oxygenation
Reduce edema
Allow enough time for other therapy to be effective
Reverse hemo-
concentration
Enhance micro-perfusion
Limit edema duration
Reduce edema
Reduce blood/tissue response to gas surface
Enhance micro-profusion
From: Rutkowski, Jan. 1991

9. Fundamentals of HBO Therapy-2
Pressure
Increase pressure – Boyle’s Law
Reduction in bubble size
Increase partial pressure - return gas to solution
Oxygen
Increases re-oxygenation of blocked tissues
Replaces problem inert gases (N2, HE) by forcing them into solution
Clinical treatment benefits
CO poisoning
Wound healing
Gas gangrene
Burns

10. Primary Benefits of HBOxygen
DCS and AGE are the result of the formation or introduction of bubbles (comprised mostly or entirely of nitrogen) in the body’s tissues and/or bloodstream.
Breathing 100% oxygen creates a pressure gradient in the body which reduces the amount of nitrogen in the bloodstream and in the tissues (oxygen window).
Lowering the nitrogen level in the lungs lowers the level in the blood, then the tissues, and finally the bubbles.
The greater the pressure gradient (higher concentration of inhaled oxygen) the faster nitrogen leaves the body.
Oxygen - What You Need To Know

11. Secondary Benefits of HBOxygen
Circulation in smaller blood vessels can be blocked by nitrogen bubbles. A high PO2 helps oxygenate the hypoxic areas.
Oxygen reduces edema (swelling) produced by the blockage of small blood vessels as is the case with DCS and AGE.
Reduction in swelling can restore function of affected nerve tissue.
Oxygen reduces blood sludging and platelet aggregation which occurs as bubbles form in the bloodstream.
Oxygen - What You Need To Know

12. Effects of Pressure Depth Pressure Volume Bubble % Diameter
(fsw) (atm abs) Length
100
79.3
69.3 63
58.5 55 48 /2 /3 /4 /5 /6
/10

13. Fundamentals of HBO Therapy
Therapy gases
Air: when no O2 is available
100% Oxygen: treatment gas of choice
60/40 Nitrox: used for higher PP O2 at depth
21% Heliox: Deeper therapy gas
95% nitrogen: for saturation treatments
Therapy gases are supplied via B.I.B.S.
there should be one setup per person inside chamber

14. Nitrox Therapy Gas
Nitrox can be used instead of air to increase PO2 at depths where 100% oxygen cannot be used due to the potential for oxygen toxicity
Nitrox mixtures containing either 40% or 50% oxygen (balance nitrogen) are routinely used during the USN Treatment Table 6A at 165 fsw pressure.
When using the US Navy Standard Air Decompression Tables with Nitrox mixtures, the decompression tables must be altered to account for the higher fraction of oxygen in the mixture

15. Hyperbaric O2 Therapy Time Fluid management Drug therapy
Critical factor
Must be computed based on pressure
Used incorrectly will have disastrous results - 02 toxicity
Basis of the treatment tables
Fluid management
Perfusion of tissues imperative
Tissues must be well hydrated
Drug therapy
Prescribed by physician
For thinning blood and reducing platelets
Oxygen - What You Need To Know

16. Pathophysiology Gas air embolism Decompression sickness
Increase pressure crushes bubbles - restores circulation
Oxygenates tissues
Decompression sickness
Increase pressure crushes bubbles
Increases the O2 gradient - forces inert gas into solution

17. Pathophysiology-2 CO poisoning Necrotising disease Burns
Hyper oxygenates blood
Breaks the CO - hemoglobin attraction
Necrotising disease
Stops spread of gangrene
Gangrene will not function in an O2 environment
Burns
Adjunct to skin grafting
Oxygenates tissues

18. Graphic Photos Next

19. Crush injury

22. Facial Burn Example
Day 1 Christmas Eve

23. Day 2

24. Day 3

25. Day 45

26. 1 Year Later

27. Dive Treatment Tables Types Structure
U.S. Navy (Tables 5, 6, 6A, and 7 use oxygen)
U.S. Air Force
Royal Navy
COMEX
Private companies
Structure
Time
Pressure, (depth)
Specific illness
Gas air embolism
Type I DCS
Type II DCS
Saturation
Treatment gas
Air
Oxygen
Nitrox

28. USN Treatment Table 5

29. USN Treatment Table 6

30. USN Treatment Table 6A

31. USN Treatment Table 7

32. Flying after treatment time
Patient
Hours
Type I with complete resolution 24
Type II with complete resolution 48
Tables 4 and 7 with complete resolution 72
Residual symptoms after treatment (with DMO approval)
Tender
TT5, TT6, TT6A, TT1A, TT2A, TT3 12
TT4 and TT7

33. within 60 minutes of chamber for 24 hrs
Time at or near chamber
Patient with complete relief
Hours
TT5
2 at chamber
Type II DCS or TT6 for Type I DCS
6 at chamber
Patient with residual symptoms
Transfer to medical facility when in patient’s best interest
Ambulatory patient
can be sent home if with someone familiar with case and could return them to the chamber
Tenders
After treatment 1
TT4 and TT7
within 60 minutes of chamber for 24 hrs

34. Return to diving Patient Hours TT5 48 TT6 for Type I DCS 1 week
Patchy parasthesia
2 weeks
Other Type II DCS or AGE
4 weeks
TT4 or TT7
3 months
Tender
TT5, TT6, TT6A, TT1A, TT2A, TT3 12
TT4 and TT7

35. Wound-Healing Treatment

36. Carbon Monoxide Treatment
Additional O2 periods at 33 fsw as indicated
TBT from surface till leaving 33 fsw
Observer on O2 last breathing period and ascent
Table time 2:29 to 4:29 depending on patient
66’ O2
Air
PT Off O2
IO On O2
Depth
33’ 15 5 10
0 ‘ 3 23 5 23 5 25 5 25 5 25 5 25 5 25 5 25 10
Time (Mins)

37. HBO Review
HBO is used for the treatment of both medical and diving-related maladies
HBO therapy involves pressure, oxygen, time, fluid management, and drug therapy
Patients must be observed closely for signs and symptoms of CNS oxygen toxicity
Pulmonary oxygen toxicity can be a problem in lengthy treatments with aggressive oxygen breathing

38. HBO review
Nitrox may be used to increase PO2 to the patient or to reduce decompression for the tender
Treatment tables vary according to the malady
The most widely used treatment table in the world for DCS and AGE is the US Navy Table 6
Follow-up recompression treatments may be required
Follow guidelines for flying after treatment and remaining at or near chamber after treatment
“Fresh” cases respond to recompression therapy better than “old” cases, therefore don’t wait to report signs & symptoms

39. Training Programs DAN Diving and Hyperbaric Medicine Course
6 day program for medical professionals
NOAA Physician’s Course
6 day program for physicians
Hyperbarics International Inc.
Advanced Diving/Hyperbaric Medical Team Training Program with Chamber Operations
Life Support Technologies Inc.
Introduction to Hyperbaric Medicine
Undersea & Hyperbaric Medical Society
on-line seminars

40. Publications Hyperbaric Medicine Practice, 3rd Edition
Eric Kindwall, MD (the bible)
Physiology and Medicine of Hyperbaric Oxygen Therapy E-Book
Tom S. Neuman MD & Stephen R. Thom, MD, PhD.
NOAA Diving Manual 4th Edition
Best Publishing
US Navy Diving Manual Rev
Oxygen Hackers Guide
Airspeed Press
NAUI Nitrox: Guide to Diving with Oxygen Enriched Air
Hamilton & Silverstein

43. O & G Slides

44. Hyperoxia- in chamber (too much O2 convulsions)
Treatment for convulsions while breathing 100% oxygen via BIBS mask:
Immediately remove BIBS mask
Wait until all symptoms subside
Wait an additional 15 minutes
Don BIBS mask and try to resume oxygen breathing (normally a one-time occurrence)
If able to tolerate oxygen, resume time at point of interruption (ignore time spent on air)
If unable to tolerate oxygen, discontinue and shift to an “air” treatment table (consult DMO for guidance)

45. Off Phenomena-1
Refers to the sudden onset of convulsions or other symptoms immediately following the removal of the oxygen mask from an oxygen-breathing patient
Believed to be caused by the following:
Oxygen is an intense cerebral vasoconstrictor
The return to breathing air after removal of the oxygen mask causes an abrupt drop in arterial PO2 before the cerebral circulation responds by vasodilation
A brief period of cerebral hypoxia is superimposed on other toxic effects resulting from vasoconstriction which initiates the convulsion

46. Off Phenomena-2
Prevention: Persons breathing oxygen by BIBS mask or hood, under pressure, should not be standing or walking when taking off the breathing delivery system, but should be sitting or laying down during the removal and for a short period thereafter.