1. Cerebral Arterial Gas Embolism
A major life-threatening event, with significant morbidity and mortality, CAGE can occur following reductions in ambient pressure (in divers and aviators), traumatically, in penetrating chest injuries, and, most commonly, in the clinical setting
secondary to invasive diagnostic or therapeutic procedures.
Cost Impact:
HBOT is the primary choice of treatment for CAGE. HBOT decreases the high mortality and prevents or medicates neurologic sequelae. HBOT is a cost effective treatment considering the potential costs of rehabilitation from a neurologic event.
2. Carbon Monoxide Poisoning
Carbon monoxide is one of the most common causes of poisoning in Canada. In its subtle forms, the diagnosis is easily missed. A new application for the phenomenon of clinical relapse following non-H.B.O. treatment and its potential long-term sequelae has increased the importance of early referral for hyperbaric evaluation.
Cost Impact:
The modest cost of HBO therapy for CO poisoning represents a potentially large dollar savings when compared to the cost of treatment for delayed neurologic sequelae.
3. Clostridial Myonecrosis
Anaerobic infections are among the most challenging infectious diseases. Optimum management of Clostridial Perfringens infections is well established. The combination of antibiotic therapy, surgical debridement, and hyperbaric oxygen will reduce mortality and limit tissue loss.
Cost Impact:
The addition of HBOT to the treatment regime reduces morbidity and improves the level of amputation in affected limbs, thus justifying the cost.
4. Crush Injury: Other Acute Ischemias
Hyperbaric oxygen has been observed to arrest the progression of a skeletal muscle compartment syndrome. Its use is based upon a number of mechanisms and serves to limit tissue necrosis. While not proposed as a replacement for surgical decompression in severe cases, hyperbaric oxygen has been used effectively in intermediate settings and in other acute ischemias to preserve marginally perfused tissue.
Cost Impact:
The cost of decompression of compartment syndrome by HBO therapy is about one fourth that of surgical intervention. The cost of HBO therapy is small relative to that of treating the
complications of acute traumatic ischemias.
5. Problem (non-healing) Wounds
Problem wounds are defined as wounds that fail to show improvement in four weeks or complete healing in eight weeks despite standard medical and surgical intervention. These may include diabetic foot ulcers, vascular insufficient wounds, and non-healing traumatic wounds. All of these wounds have the underlying problems of tissue hypoxia. Therefore, HBO is an adjunctive therapy in treatment of hypoxic wounds by producing effects of fibroblast proliferation, neo-vascularization and leukocyte oxidative killing. Recent literature has shown reduction in major amputation for patients with diabetic foot ulcers. HBO for problem wounds should be undertaken with the clear understanding that it must be part of a vigorous and coordinated multidisciplinary team approach to wound care.
Cost Impact:
The treatment and follow-up costs for HBO and wound care for healing are significantly lower than those who undergo major amputation and rehabilitation.
6. Necrotizing Soft Tissue Infections
Hyperbaric oxygen is used as an adjunct to surgical debridement and antibiotic therapy. Limited clinical trials have indicated reduced mortality, and a reduction in the need for repeated debridements when hyperbaric oxygen is added to surgical and medical management.
Cost Impact:
These infections are associated with high mortality and morbidity. The addition of HBOT, in many cases, has reduced the number of surgical interventions and shortened hospital stay.
7. Refractory Osteomyelitis
Osteomyelitis is essentially a surgical disease. Appropriate antibiotics and debridement are effective in the majority of cases.
Where bone infections persist, adjunctive hyperbaric oxygen has been demonstrated to help the healing process in
a high percentage of otherwise refractory cases, through a number of direct and indirect mechanisms.
Cost Impact:
When used according to guidelines and as an adjunct to
adequate surgical care and antibiotic therapy, HBOT is clinically efficacious and cost effective. In one review, cost effectiveness was five-fold in favor of using adjunctive HBOT for chronic refractory osteomyelitis.
8. Osteoradionecrosis
Laboratory investigations and recently reported controlled trials have demonstrated the clinical and cost-effective advantages of hyperbaric oxygen therapy in effectively managing this particularly difficult problem.
Cost Impact:
Osteoradionecrosis, at best, is an extremely painful and debilitating condition. It can be potentially fatal if a major vessel becomes involved. The introduction of HBOT to the treatment plan can have a significant impact on a potentially long and expensive treatment course.
9. Radiation Tissue Injury
Based upon laboratory and clinical studies of osteoradionecrosis, the use of hyperbaric oxygen has been extended to late radiation change in soft tissue, where similar pathophysiology, therapeutic and cost saving responses are reported.
Cost Impact:
The incorporation of HBOT to the treatment plan can have a significant impact on surgical intervention, standard drug therapy and a potentially long and expensive treatment course.
10. Therapeutically Irradiated Patients requiring Osseointegrated
HBO is central to the management of patients undergoing implantation in irradiated bone. Dental extractions in these patients often leads to non-healing wounds.
Cost Impact:
It has been found that in irradiated patients, the osseointegrated implant failure rate was 54%, whereas in the irradiated and HBOT managed group the failure rate was reduced to 8%.
11. Compromised Skin Grafts and Flaps
While not indicated in non-compromised settings, postoperative hyperbaric oxygen has been particularly helpful in host compromised patients where graft of flap viability is in question, and in preparing the poorly responding wound for coverage.
Cost Impact:
A failed flap or graft may conservatively cost up to $30,000 in additional care. HBOT can reduce this extra cost by contributing to the salvage of transplanted tissue.
12. Decompression Sickness
The occupational disease of divers, aviators and tunnel workers is no longer limited in presentation to coastal regions and military institutions. With more recreational divers flying to and from various dive sites, the potential for this illness must be considered, regardless of geographical location.
Cost Impact:
Untreated, DCS can result in permanent nerve, spinal cord, or brain damage. HBOT is cost effective considering the limited number of persons who acquire DCS, balanced against the expensive support of those not treated.
13. Acute Exceptional Blood Loss Anemia
Hyperbaric oxygen is used to extend the physiologic limits of the cardiovascular system in those patients who cannot or will not accept blood transfusions during acute and severe episodes of blood loss anemia.
Cost Impact:
In this difficult clinical challenge, a course of HBOT would
represent additional cost, but could be lifesaving.
14. Reperfusion Injuries: Frostbite
The pathophysiology for frostbite is similar to that of other reperfusion injuries such as crush injury, compartment syndrome, and acute traumatic ischemia. Tissue destruction results from the primary injury where tissue damage is unrepairable, or by secondary injury during reperfusion. Most tissue loss is from the body’s inability to handle the primary injury thus resulting in secondary injury. As the tissue receives the first available oxygen it is converted to toxic radicals which are overwhelmed causing a vasoconstriction, thrombosis and ischemic swelling of soft tissues such as muscles. Delivery of oxygen and nutrients to the tissues is disrupted due to the stasis of the microcirculation.
During rewarming, oxygen demands are greatest therefore the primary and most important role is hyperoxygenation to maintain tissue viability. The key to a successful outcome with Hyperbaric oxygen therapy is when it is applied during the ischemic phase within hours of injury.
Cost Impact:
Hyperbaric Oxygen Therapy when applied during the ischemic phase will decrease edema and congestion limiting tissue damage. HBOT hastens demarcation for nonviable tissue and prevents the extension of infection from necrotic tissue to the adjacent severely injured tissue. The cost effectiveness is in promoting wound healing and decreasing the number of surgical amputations.
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