Practical Considerations With Using HBOT For Patients With Wounds

Continuing a discussion of the use of hyperbaric oxygen therapy (HBOT) for patients with wounds, the panelists offer insights on contraindications for HBOT as well as insurance issues. They also debate whether physicians over-utilize or underutilize HBOT.

Q:

Do you have any contraindications or warnings before starting HBOT?

A:

When considering HBOT, Enoch Huang, MD, MPH&TM, FACEP, FUHM, FACCWS, says a hyperbaric physician must screen all patients for potential risk factors and contraindications. As he notes, there are very few absolute contraindications to HBOT such as untreated pneumothorax. However, Dr. Huang says one must individually assess and address many relative contraindications such as a history of decompensated congestive heart failure or confinement anxiety.

While confinement anxiety or claustrophobia can be a problem, Kazu Suzuki, DPM, CWS, says this issue is rare and one can manage anxiety symptoms by giving patients sedatives before the procedure, which may be enough to resume the treatment. Ear problems (middle ear barotrauma) also reportedly occur in approximately 2 percent of the patients treated with HBOT and most HBOT centers work together with local ear-nose-throat doctors.¹

Dr. Suzuki says HBOT is safe for the vast majority of patients, even for some of the older patients he treats.

All the panelists note that chemotherapy agents can be contraindications. Caitlin Garwood, DPM, and John S. Steinberg, DPM, cite bleomycin and doxorubicin (Adriamycin, Pfizer) as absolute contraindications for HBOT. They note that when combined with HBOT, bleomycin can cause pulmonary toxicity and doxorubicin can cause heart problems.

Drs. Steinberg and Garwood advise caution in using HBOT in patients with conditions such as upper respiratory infections, chronic sinusitis, seizure disorders, emphysema, pulmonary lesions, sickle cell anemia, a history of thoracic or reconstructive ear surgery, and congenital spherocytosis.    

“Patients should be warned that treatment with HBOT requires a commitment of time and adherence to a comprehensive treatment plan in order to ensure success,” says Dr. Huang.

Q:

Do you believe HBOT is over- or underutilized in foot and ankle wounds?

A:

“I truly believe that HBOT is underutilized and it has a potential to save many limbs if it is started in a timely fashion for the proper diagnoses,” asserts Dr. Suzuki.

Even for patients who do not have diabetes, Dr. Suzuki says one can treat major reconstructive surgery foot and ankle post-op wounds with dehiscence with HBOT under a “failed skin flap” indication. For those patients who stick with the prescribed HBOT therapy (at least 20 sessions), Dr. Suzuki relates “great results and many limbs spared from major leg amputation.” He says HBOT helps treat the infection by potentiating some antibiotic agents or facilitates wound healing in otherwise hard-to-heal lower extremity wounds. Dr. Suzuki says the benefit from potential limb preservation and low-risk of HBOT often outweigh the medical cost of administering HBOT.

In contrast, Drs. Garwood and Steinberg do feel physicians overutilize HBOT. They note that although hyperbaric oxygen is a “great adjunct” and one should consider it for many limb salvage patients, appropriate screening is the key.

Dr. Steinberg says physicians and patients must understand that they cannot expect a wound to heal simply by referring them to HBOT as a “last resort” and there will be no success without appropriate offloading, adequate medical management, treatment of infection, local wound care, wound debridement or surgical treatment when necessary. Dr. Garwood emphasizes that it is imperative to remember that although HBOT, used appropriately with good patient selection, can be an excellent adjunct to the wound care regimen, it is not appropriate for all patients or all wounds.

Dr. Huang feels physicians both over-utilize and underutilize HBOT in the treatment of foot and ankle wounds, especially in the treatment of diabetic foot ulcers. Physicians overuse oxygen when using it to treat patients who will heal without it or in patients who will not heal with HBOT alone, according to Dr. Huang. He notes that removing devitalized tissue, controlling offloading and the treatment of infection are all mandatory before initiating HBOT as well as frequent reassessments for a clinical response to treatment. One should not simply treat a non-responding patient for the maximum number of treatments before proceeding with another treatment option, according to Dr. Huang.  

Dr. Huang says the Centers for Medicare and Medicaid Services (CMS) guidelines mandate waiting 30 days before using HBOT postoperatively to treat patients with Wagner 3 diabetic foot ulcers that require acute surgical interventions. He cites these guidelines as contributing to underutilization of HBOT. Dr. Huang explains that randomized controlled trials have shown that HBOT is most effective in preventing major amputations when treatment begins immediately after surgery but not when it begins after 30 days.^2-4 Patient selection, therefore, is of great importance in preventing over and underutilization of HBOT, according to Dr. Huang.

Q:

Do you ever experience insurance coverage issues with the use of HBOT for patients?

A:

Dr. Huang cites occasional trouble with insurance coverage issues for non-Medicare patients, saying his facility must go through a preauthorization process to get coverage. As he notes, that presents a problem if the patient needs HBOT urgently and cannot wait the time that insurance companies sometimes need to preapprove treatment. In those cases, he will treat the patient first and then reach out to the insurance company to expedite the authorization process.

Physicians should not encounter any insurance issues as long as they stay within the indications for HBOT as per the Undersea Hyperbaric Medical Society (UHMS), according to Dr. Suzuki. He believes documentation is the key and recommends thoroughly documenting the status of the wound. This entails taking measurements and digital pictures of the wound from multiple angles to prove that the wound is progressing due to local wound care with HBOT as an adjunctive therapy, notes Dr. Suzuki.

Q: 

How many HBOT sessions are “enough” in your opinion?

A:

Dr. Suzuki usually starts with 20 sessions of HBOT (30 sessions for osteomyelitis and radiation injury), and recommends extending treatment courses by scheduling 10 sessions at a time until the wound heals or until it is evident that the effect of HBOT has stalled. Dr. Suzuki has seen some international patients (from Europe and Japan) who received 100 to 200 HBOT sessions over several months to a year. However, he does believe there is a limitation to HBOT benefits and that there is a point of diminishing returns after 60 sessions of HBOT.

“The answer of how many HBOT sessions are ‘enough’ is a difficult one to answer as there is no ‘one-size-fits-all’ approach,” advises Dr. Huang. “This is an area that we as a specialty need to focus on because reimbursement is only going to become more restrictive, and we should try to apply as much decision making on when we should stop HBOT as to when we should start it.”

Dr. Garwood is the Diabetic Limb Salvage Fellow at MedStar Georgetown University Hospital.     

Dr. Huang is the President-Elect of the Undersea and Hyperbaric Medical Society, and the Medical Director of Wound Healing and Hyperbaric Medicine at Adventist Medical Center in Portland, Ore. He is an Affiliate Assistant Professor of Emergency Medicine at Oregon Health and Science University in Portland, Ore. He is also an Assistant Clinical Professor of Emergency Medicine at the Western University of Health Sciences in Pomona, Calif.

Dr. Steinberg is an Associate Professor at the Georgetown University School of Medicine. He is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. Dr. Suzuki can be reached via e-mail at Kazu.Suzuki@CSHS.org .

References
1. Camporesi EM. Side effects of hyperbaric oxygen therapy. Undersea Hyper Med. 2014; 41(3):253-7.
2. Faglia E, Favales F, Aldeghi A, et al. Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcer. A randomized study. Diabetes Care. 1996; 19(12):1338-43.
3. Faglia E, Favales F, Aldeghi A, et al. Change in major amputation rate in a center dedicated to diabetic foot care during the 1980s: prognostic determinants for major amputation. J Diabetes Complications. 1998; 12(2):96-102.
4. Londahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care. 2010; 33(5):998-1003.