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Breathe new life into old wounds
1 If you have diabetes or have received radiation treatment, please retain this booklet for future reference.
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.
• All Hyperbaric Health Facilities are ACHS Accredited and Department of Health Licenced Private Hospitals • Hyperbaric Health has contracts with DVA and all major health funds • Medicare patients are bulk billed • Hyperbaric Health will assist in patient transport and accommodation where available
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Speeding up the healing process from the inside out Hyperbaric (‘hyper’ meaning ‘over’, and ‘baric’ meaning
HBOT has many benefits in wound healing, including
‘pressure’) literally translates to ‘over pressure’. HBOT
the following:
exposes the patient to higher than normal pressure while
Overcomes areas of poor oxygenation
the patient breathes 100% oxygen. This can only be achieved in a pressurised vessel (hyperbaric chamber).
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 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.
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.
Figure 1. Difference in healing with normal versus diabetic tissue.
Healthy wound
Diabetic wound MFSCs = Multifunction stem cells
Migrating skin cells
Platelet Cell differentiation factors
Circulation MFSC mobilisation to circulation
Blood vessel growth factors
Blood vessel growth factors
Epithelial cells
Macrophages (white blood cells) Precursors of MFSCs structural cells homing to wound site
Wound-induced hypoxia (low oxygen)
Limited cell differentiation factors
Macrophage function
Limited angioneogenesis and wound healing
Angioneogenesis and wound healing
Limited MFSC homing
Impaired healing enzyme activation Improved by HBO therapy
Blood vessel cell migration
Bone marrow MFSCs
Increased activation factors
Increased activation of healing enzymes
Decreased activation of healing enzymes
Decreased activation factors
MFSCs
Impaired MFSC mobilisation to circulation
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Fights infection
Figure 2. The wound healing process.
Infections are naturally attacked by the body’s white
Red blood cell Skin surface Wound Platelet
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
Macrophage
Neutrophils (white blood cells)
Fibrin
Epidermis and dermis of skin b Coagulation (clot forming)
a Injury
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
Macrophages (white blood cells)
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.
d Late inflammation (48 h)
Collagen
Neutrophils (white blood cells) c Early inflammation (24 h)
Fibroblast
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
e Proliferation (building tissue scaffolding – 72 h)
f Remodelling (scar formation and strengthening – weeks to months)
Oxygen dependent processes
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).
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,
Conversely, an increased delivery of oxygen provides a
for the process of wound healing. HBOT has been shown
strong healing ‘scaffold’ and fights infection, resulting in
to greatly enhance the development and release of stem
complete and proper healing of the wound.
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.
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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) wounds These 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.
The longer the wound exists, the less likely it is to heal with repeated dressings
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 injury When 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
Many long-term wounds often have an underlying low
(increase in size) and inflammation (the redness) in the
oxygen concentration (called hypoxia) that prevents
early stages, but is much more effective in the treatment
them from healing. Hypoxia has been measured directly
of late-onset radiation effects. This is particularly evident
in the laboratory and can be measured with a skin probe
in people who develop dental cavities (holes in their
called a trans-cutaneous oxygen measurement probe
teeth) secondary to radiation therapy of the head and
(TCOM). The TCOM measures the amount of oxygen
neck, who require removal of the teeth. For people with
being delivered to the skin (which is where the wound
cancers of the head and neck, removal of radiation-
occurs) by placing stick-on cups on the patient’s skin
damaged teeth can lead to exposure of the mandible
(the procedure is non-invasive).
(jaw-bone) and breakdown of both the soft tissues of
HBOT delivers oxygen to the wound, allowing it to ‘kick
the gums and the bone itself. This can require extensive
start’ the healing process by promoting the development
reconstructive surgery that, because it is in an irradiated
of new small blood vessels. With this approach, the
field with poor blood flow, can lead to further wound
wound can be healed and further wounds can be kept
breakdown and further surgery.
at bay.
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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
The 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.
radiotherapy and depend on the type and total amount
In several medical conditions, some (or all) of these items
of radiotherapy that each person receives.
are missing or compromised. The problem with this is
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.
rep
eal i n g w o und
de e ate
rep
x pens i v e w o u n d d r e
e ated
re p
e a te
vis i t s t o t h e d o
ssin
ct o r
d a d mi s s i o n s t o h o s p
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can end up in a dysfunctional downward spiral. Without intervention, this downward spiral continues until the patient follows one of two pathways: person with a diabetic foot ulcer)
Figure 3. The downward spiral of chronic wounds.
non h
that the wound ‘stalls’ in its healing process and patients
• a poor outcome (such as amputation in the case of a
It’s all about ending the cycle.
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Giving the body building blocks to repair itself
OR
• develop an overwhelming problem (such as an infection), requiring time in hospital.
gs
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
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
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
• 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
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.
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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.
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Multiplace chambers
Monoplace chambers
Multiplace chambers are large metal chambers that can
Monoplace chambers are single-person chambers that
treat a number of people simultaneously (hence ‘multi’
are generally smaller than multiplace chambers. They
place). Patients enter the chamber via a door that creates
are usually made of acrylic (a very strong clear plastic)
a pressure seal and they sit or lie down (depending on
and are pressurised with pure oxygen (i.e. patients
the condition and type of chamber). A trained hyperbaric
generally don’t have to wear a mask or hood). Patients lie
nurse is always present within the chamber during the
on a trolley and slide into the chamber. Patients can see
treatment. While they are being treated, patients can
around themselves quite clearly (a bit like a tunnel in a
read a book and breathe normally. It’s just like going for a
large aquarium where you can look at the fish swimming
ride in a plane. In these chambers pressure is delivered
around you) and normally there are video screens so
with air but the patients inside breathe 100% oxygen
patients can watch their favourite movie or television show
either though a fitted mask or a ‘hood’.
while undergoing treatment.
This effect is the same as breathing normally if the
Advantages of the monoplace chambers are a slightly
chamber was pressurised with 100% oxygen. To increase
faster treatment time and treatment can be based around
safety the chamber is filled with air and 100% oxygen is
the patient’s schedule as there is no need to wait for other
only delivered to the hood or mask. The treatment lasts
patients to start treatment.
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).
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.
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Medicare recognised treatments HBOT 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 (low oxygen) and chronic (long term) wounds • gas gangrene and necrotising infections • decompression illness (the bends) • arterial gas embolism (AGE). Other conditions have recognised HBOT as a valid treatment but currently Medicare will only fund the conditions above.
Recognised indications for Hyperbaric Oxygen Therapy This 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* Infective conditions Acute ischaemic conditions
prophylaxis and management of bony and soft tissue radionecrosis including radiation proctitis, radiation cystitis, maxillofacial bony and soft tissue necrosis necrotising infections*, refractory osteomyelitis, malignant otitis externa compromised 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
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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.
Referral form
For 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:
Decompression illness (DCI)
Compromised flaps/grafts Crush injury/compartment syndrome Reperfusion injury Avascular necrosis Sudden sensorineural hearing loss Please phone the nearest facility
Toxic gas poisoning
Please phone the nearest facility
Ocular ischaemic pathology
Retinal artery/vein occlusion Please discuss with facility prior to referral
Acute ischaemic conditions
Adjuvant to radiotherapy Miscellaneous
Thermal burns Frostbite Background 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:
Melbourne Located at St. John of God Hospital Gibb Street, Berwick VIC 3806
[email protected] Ph: (03) 9707 1420 Fax: (03) 9707 1860 Located at Brunswick Private Hospital 82 Moreland Avenue, Brunswick VIC 3056
[email protected] Ph: (03) 9383 6505 Fax: (03) 8587 2489
Perth Opening in 2011 Located at St. John of God Hospital Subiaco WA 6008
[email protected] New Zealand Quay Park Medical Centre 68 Beach Road, Auckland 1010
[email protected] Ph: (09) 919 2340 Fax: (09) 919 2341
Sydney Suite 3, Ground Floor, 46–50 Kent Road, Mascot NSW 2020
[email protected] Ph: (02) 9578 0000 Fax: (02) 9578 0050
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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 number 1300 HYPERBARIC (1300 497 372) or call the Hyperbaric Health Wound Centre closest to you: Berwick St. John of God Hospital Gibb Street, Berwick VIC 3806
[email protected] Ph: (03) 9707 1420
Brunswick Brunswick Private Hospital 82 Moreland Avenue, Brunswick VIC 3056
[email protected] Ph: (03) 9383 6505 Perth Opening in 2011 St. John of God Hospital Subiaco WA 6008
[email protected]
© Hyperbaric Health 2010. Sydney Suite 3, Ground Floor 46–50 Kent Road, Mascot NSW 2020
[email protected] Ph: (02) 9578 0000
New Zealand Quay Park Medical Centre 68 Beach Road, Auckland 1010
[email protected] Ph: (09) 919 2340
