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New scientific definitions: hyperbaric therapy and hyperbaric oxygen therapy
... The U.S. Food and Drug Administration (FDA) corrected the confusion and misunderstanding in this definition by re-categorizing HBOT as a prescription medical drug (oxygen) and device consisting of increased barometric pressure and hyperoxia (24). Scientifically, it has been defined as "a medical treatment that uses increased atmospheric pressure and increased oxygen as drugs by fully enclosing a person or animal in a pressure vessel and then adjusting the dose of the drugs to treat pathophysiologic processes of the diseases" (25,26). The exposure to increased atmospheric pressure and hyperoxia must be intermittent to achieve the therapeutic benefit, but the length and depth of exposure, use, frequency, and number of air breaks, frequency and total number of treatments, total oxygen and pressure dose, i.e., all variables of dosing, have not been well-defined. ...
... These sham exposure groups were based on the historical misdefinition of HBOT (22,23) that defined HBOT as the use of 100% oxygen at ≥1.4 ATA. The bioactive components of HBOT are increased barometric pressure and hyperoxia (25,26,42). A sham treatment must omit both of these to control for the independent effects of pressure and hyperoxia. ...
... Hyperbaric oxygen therapy is a dual-component drug therapy consisting of intermittent increased barometric pressure and hyperoxia (25,26) that has wide-ranging beneficial effects on acute and chronic wound pathophysiology (23,25,27,28) found in acute and chronic wound conditions (23,25,(27)(28)(29)(30) and inflammatory conditions (28)(29)(30)(31)(32)(33). HBOT has been demonstrated to have wideranging effects on inflammation and a dysregulated immune system (54-59) that may be due to its broad effects on expression and suppression of immune-active genes (60-62). ...
Background
Studies of hyperbaric oxygen therapy (HBOT) treatment of mild traumatic brain injury persistent postconcussion syndrome in military and civilian subjects have shown simultaneous improvement in posttraumatic stress disorder (PTSD) or PTSD symptoms, suggesting that HBOT may be an effective treatment for PTSD. This is a systematic review and dosage analysis of HBOT treatment of patients with PTSD symptoms.
Methods
PubMed, CINAHL, and the Cochrane Systematic Review Database were searched from September 18 to November 23, 2023, for all adult clinical studies published in English on HBOT and PTSD. Randomized trials and studies with symptomatic outcomes were selected for final analysis and analyzed according to the dose of oxygen and barometric pressure on symptom outcomes. Outcome assessment was for statistically significant change and Reliable Change or Clinically Significant Change according to the National Center for PTSD Guidelines. Methodologic quality and bias were determined with the PEDro Scale.
Results
Eight studies were included, all with < 75 subjects/study, total 393 subjects: seven randomized trials and one imaging case-controlled study. Six studies were on military subjects, one on civilian and military subjects, and one on civilians. Subjects were 3-450 months post trauma. Statistically significant symptomatic improvements, as well as Reliable Change or Clinically Significant changes, were achieved for patients treated with 40-60 HBOTS over a wide range of pressures from 1.3 to 2.0 ATA. There was a linear dose-response relationship for increased symptomatic improvement with increasing cumulative oxygen dose from 1002 to 11,400 atmosphere-minutes of oxygen. The greater symptomatic response was accompanied by a greater and severe reversible exacerbation of emotional symptoms at the highest oxygen doses in 30-39% of subjects. Other side effects were transient and minor. In three studies the symptomatic improvements were associated with functional and anatomic brain imaging changes. All 7 randomized trials were found to be of good-highest quality by PEDro scale scoring.
Discussion
In multiple randomized and randomized controlled clinical trials HBOT demonstrated statistically significant symptomatic improvements, Reliable Changes, or Clinically Significant Changes in patients with PTSD symptoms or PTSD over a wide range of pressure and oxygen doses. The highest doses were associated with a severe reversible exacerbation of emotional symptoms in 30-39% of subjects. Symptomatic improvements were supported by correlative functional and microstructural imaging changes in PTSD-affected brain regions. The imaging findings and hyperbaric oxygen therapy effects indicate that PTSD can no longer be considered strictly a psychiatric disease.
... For some, despite promising results, the level of evidence concerning their efficiency seemed to be insufficient (3). Among those therapies, hyperbaric treatment (HBT) is a medical treatment that involves breathing various concentration of oxygen in a pressurized chamber (5,6). It is used to treat various conditions, including decompression sickness, wounds that are difficult to heal, and carbon monoxide poisoning. ...
... This lower level of oxygen paired with the 1.5 ATA pressurization has been attempted to replicate the levels of oxygen perfusion that would normally be observed under ambient air. However, pressurization alone induce many physiological changes regardless of oxygenation, and it has been shown repeatedly that many powerful healing mechanisms can be activated even with a limited pressure increase (5,8,14,15). For this reason, it is inaccurate to consider any group receiving HBT as a control, regardless of their levels of oxygenation (8,(71)(72)(73). ...
The Gross Motor Function Measure is used in most studies measuring gross motor function in children with cerebral palsy. In many studies, including those evaluating the effect of hyperbaric treatment, the Gross Motor Function Measure variations were potentially misinterpreted because of the lack of control groups. The Gross Motor Function Measure Evolution Ratio (GMFMER) uses historical data from the Gross Motor Function Classification System curves and allows to re-analyze previous published studies which used the Gross Motor Function Measure by considering the natural expected evolution of the Gross Motor Function Measure. As the GMFMER is defined by the ratio between the recorded Gross Motor Function Measure score increase and the expected increase attributed to natural evolution during the duration of the study (natural evolution yields a GMFMER of 1), it becomes easy to assess and compare the efficacy of different treatments.
Objective
The objective of this study is to revisit studies done with different dosage of hyperbaric treatment and to compare the GMFMER measured in these studies with those assessing the effects of various recommended treatments in children with cerebral palsy.
Methods
PubMed Searches were conducted to included studies that used the Gross Motor Function Measure to evaluate the effect of physical therapy, selective dorsal rhizotomy, botulinum toxin injection, hippotherapy, stem cell, or hyperbaric treatment. The GMFMER were computed for each group of the included studies.
Results
Forty-four studies were included, counting 4 studies evaluating the effects of various dosage of hyperbaric treatment in children with cerebral palsy. Since some studies had several arms, the GMFMER has been computed for 69 groups. The average GMFMER for the groups receiving less than 2 h/week of physical therapy was 2.5 ± 1.8 whereas in context of very intensive physical therapy it increased to 10.3 ± 6.1. The GMFMER of stem cell, selective dorsal rhizotomy, hippotherapy, and botulinum toxin treatment was, 6.0 ± 5.9, 6.5 ± 2.0, 13.3 ± 0.6, and 5.0 ± 2.9, respectively. The GMFMER of the groups of children receiving hyperbaric treatment were 28.1 ± 13.0 for hyperbaric oxygen therapy and 29.8 ± 6.8 for hyperbaric air.
Conclusion
The analysis of the included studies with the GMFMER showed that hyperbaric treatment can result in progress of gross motor function more than other recognized treatments in children with cerebral palsy.
... Hyperbaric oxygen therapy is based on nearly 100% pure oxygen (at least 95% oxygen) and increased barometric pressure (47). When the patient inhales 100% oxygen, the extra pressure will increase the dissolved oxygen in plasma and increase the oxygen tissue transport independent of hemoglobin (48,49). ...
Hyperbaric oxygen therapy is a relatively safe treatment method that has been used for a long time in the clinic. It has been proven that it can enhance the sensitivity of radiotherapy and photodynamic therapy for cancer. However, there are few studies on hyperbaric oxygen and immunotherapy. In this article, we summarize that hyperbaric oxygen therapy regulates the tumor microenvironment through various pathways such as improving tumor hypoxia, targeting hypoxia-inducing factors, and generating reactive oxygen species. The change in the tumor microenvironment ultimately affects the curative effect of immunotherapy. Therefore, hyperbaric oxygen can influence immunotherapy by regulating the tumor microenvironment, providing a direction for the future development of immunotherapy.
... In 1857 Simpson published a paper using HBA to treat lung pathologies including tuberculosis (2). Interest in hyperbaric air as a medication surged following successful treatments of "Spanish flu" patients by Cunningham in 1918 (3)(4)(5). ...
Introduction
Hyperbaric air (HBA) was first used pharmaceutically in 1662 to treat lung disease. Extensive use in Europe and North America followed throughout the 19th century to treat pulmonary and neurological disorders. HBA reached its zenith in the early 20th century when cyanotic, moribund “Spanish flu pandemic” patients turned normal color and regained consciousness within minutes after HBA treatment. Since that time the 78% Nitrogen fraction in HBA has been completely displaced by 100% oxygen to create the modern pharmaceutical hyperbaric oxygen therapy (HBOT), a powerful treatment that is FDA approved for multiple indications. Current belief purports oxygen as the active element mobilizing stem progenitor cells (SPCs) in HBOT, but hyperbaric air, which increases tensions of both oxygen and nitrogen, has been untested until now. In this study we test HBA for SPC mobilization, cytokine and chemokine expression, and complete blood count.
Methods
Ten 34–35-year-old healthy volunteers were exposed to 1.27ATA (4 psig/965 mmHg) room air for 90 min, M-F, for 10 exposures over 2-weeks. Venous blood samples were taken: (1) prior to the first exposure (served as the control for each subject), (2) directly after the first exposure (to measure the acute effect), (3) immediately prior to the ninth exposure (to measure the chronic effect), and (4) 3 days after the completion of tenth/final exposure (to assess durability). SPCs were gated by blinded scientists using Flow Cytometry.
Results
SPCs (CD45dim/CD34⁺/CD133⁻) were mobilized by nearly two-fold following 9 exposures (p = 0.02) increasing to three-fold 72-h post completion of the final (10th) exposure (p = 0.008) confirming durability.
Discussion
This research demonstrates that SPCs are mobilized, and cytokines are modulated by hyperbaric air. HBA likely is a therapeutic treatment. Previously published research using HBA placebos should be re-evaluated to reflect a dose treatment finding rather than finding a placebo effect. Our findings of SPC mobilization by HBA support further investigation into hyperbaric air as a pharmaceutical/therapy.
Introduction
Oxygen toxicity has been defined as acute central nervous system (CNS), acute pulmonary, and chronic pulmonary oxygen toxicity. This study identifies acute and chronic CNS oxygen toxicity under 2.0 atmospheres absolute (ATA) pressure of oxygen. Methods: The authors’ medical records from September 29, 1989 to January 20, 2023 and correspondence to the authors (9/1994 to 1/20.2023) from patients with signs and/or symptoms historically identified as acute CNS oxygen toxicity and those with neurological deterioration receiving hyperbaric oxygen for neurological conditions were reviewed. Acute cases were those occurring with ≤5 HBOTs and chronic cases >5 HBOTs. Chronic cases were separated into those at 1.5 ATA, > 1.5 ATA, or < 1.5 ATA oxygen. Cumulative dose of oxygen in atmosphere-hours (AHs) was calculated at symptom onset.
Results
Seven acute cases, average 4.0 ± 2.7 AHs, and 52 chronic cases were identified: 31 at 1.5 ATA (average 116 ± 106 AHs), 12 at >1.5 ATA (103 ± 74 AHs), and 9 at <1.5 ATA (114 ± 116 AHs). Second episodes occurred at 81 ± 55, 67 ± 49, and 22 ± 17 AHs, and three or more episodes at 25 ± 18, 83 ± 7.5, and 5.4 ± 6.0 AHs, respectively. Most cases were reversible. There was no difference between adults and children ( p = 0.72). Acute intervention in cases (<3 months) was more sensitive than delayed intervention (21.1 ± 8.8 vs. 123 ± 102 AHs, p = 0.035). Outside sources reported one acute and two chronic exposure deaths and one patient institutionalized due to chronic oxygen toxicity. A withdrawal syndrome was also identified.
Conclusion
Hyperbaric oxygen therapy-generated acute and chronic cases of CNS oxygen toxicity in chronic neurological conditions were identified at <2.0 ATA. Chronic CNS oxygen toxicity is idiosyncratic, unpredictable, and occurred at an average threshold of 103–116 AHs with wide variability. There was no difference between adults and children, but subacute cases were more sensitive than chronic intervention cases. When identified early it was reversible and an important aid in proper dosing of HBOT. If ignored permanent morbidity and mortality resulted with continued HBOT.
Background
Mild traumatic brain injury results in over 15% of patients progressing to Persistent Postconcussion Syndrome, a condition with significant consequences and limited treatment options. Hyperbaric oxygen therapy has been applied to Persistent Postconcussion Syndrome with conflicting results based on its historical understanding/definition as a disease-specific therapy. This is a systematic review of the evidence for hyperbaric oxygen therapy (HBOT) in Persistent Postconcussion Syndrome using a dose-analysis that is based on the scientific definition of hyperbaric oxygen therapy as a dual-component drug composed of increased barometric pressure and hyperoxia.
Methods
In this review, PubMed, CINAHL, and the Cochrane Systematic Review Database were searched from August 8–22, 2021 for all adult clinical studies published in English on hyperbaric oxygen therapy in mild traumatic brain injury Persistent Postconcussion Syndrome (symptoms present at least 3 months). Randomized trials and studies with symptomatic and/or cognitive outcomes were selected for final analysis. Randomized trials included those with no-treatment control groups or control groups defined by either the historical or scientific definition. Studies were analyzed according to the dose of oxygen and barometric pressure and classified as Levels 1–5 based on significant immediate post-treatment symptoms or cognitive outcomes compared to control groups. Levels of evidence classifications were made according to the Centre for Evidence-Based Medicine and a practice recommendation according to the American Society of Plastic Surgeons. Methodologic quality and bias were assessed according to the PEDro Scale.
Results
Eleven studies were included: six randomized trials, one case-controlled study, one case series, and three case reports. Whether analyzed by oxygen, pressure, or composite oxygen and pressure dose of hyperbaric therapy statistically significant symptomatic and cognitive improvements or cognitive improvements alone were achieved for patients treated with 40 HBOTS at 1.5 atmospheres absolute (ATA) (four randomized trials). Symptoms were also improved with 30 treatments at 1.3 ATA air (one study), positive and negative results were obtained at 1.2 ATA air (one positive and one negative study), and negative results in one study at 2.4 ATA oxygen. All studies involved <75 subjects/study. Minimal bias was present in four randomized trials and greater bias in 2.
Conclusion
In multiple randomized and randomized controlled studies HBOT at 1.5 ATA oxygen demonstrated statistically significant symptomatic and cognitive or cognitive improvements alone in patients with mild traumatic brain injury Persistent Postconcussion Syndrome. Positive and negative results occurred at lower and higher doses of oxygen and pressure. Increased pressure within a narrow range appears to be the more important effect than increased oxygen which is effective over a broad range. Improvements were greater when patients had comorbid Post Traumatic Stress Disorder. Despite small sample sizes, the 1.5 ATA HBOT studies meet the Centre for Evidence-Based Medicine Level 1 criteria and an American Society of Plastic Surgeons Class A Recommendation for HBOT treatment of mild traumatic brain injury persistent postconcussion syndrome.
This comprehensive volume captures the latest scientific evidence, technological advances, treatments and impact of biotechnology in hyperbaric oxygen therapy. Divided into three distinct sections, the book begins with basic aspects that include history, equipment, safety and diagnostic approaches; this is followed by clinical applications for hyperbaric oxygen therapy in various modalities; the last section provides an overview of hyperbaric medicine as a specialty with best practices from around the world. Integration of multidisciplinary approaches to complex disorders are also covered.
Updated and significantly expanded from previous editions, Textbook of Hyperbaric Medicine, 6th Edition will continue to be the definitive guide to this burgeoning field for students, trainees, physicians and specialists.
This chapter deals with the role of research in hyperbaric medicine. It is discussed under the topics of animal experiments and clinical trials. Application of biotechnology to research in combination with HBO is described. Biomarkers can be used to monitor the effects of HBO. Controlled clinical trials are important as most of the evidence for efficacy or lack of it is obtained in clinical treatment of thousands of patients. Clinical trials are difficult to design, conduct, and finance as there are no profitable products for marketing as in the case of pharmaceutical companies developing new drugs.
This paper reviews experiments in which cells, subjected to hydrostatic pressures of 20 kPa or less, (micro-pressures), demonstrate a perturbation in growth and or metabolism. Similarly, the behavioural responses of aquatic animals (lacking an obvious compressible gas phase) to comparable pressures are reviewed. It may be shown that in both cases the effect of such very low hydrostatic pressures cannot be mediated through the thermodynamic mechanisms which are invoked for the effects of high hydrostatic pressure. The general conclusion is that cells probably respond to micro-pressures through a mechanical process. Differential compression of cellular structures is likely to cause shear and strain, leading to changes in enzyme and/or ion channel activity. If this conclusion is true then it raises a novel question about the involvement of 'micro-mechanical' effects in cells subjected to high hydrostatic pressure. The responses of aquatic animals to micro-pressures may be accounted for, using the model case of the crab, by the mechanical, bulk, compression of hair cells in the statocysts, the organ of balance. If this is true, it raises the interesting question of why the putative cellular mechanisms of micro-pressure transduction appear to have been superseded by the statocyst.
Hyperbaric oxygen therapy indications
- R E Moon
Moon RE. Hyperbaric oxygen therapy indications. 14 th ed. North Palm
Beach, FL: Best Publishing Company. 2019.
The uncertain miracle: hyperbaric oxygenation
- V H Trimble
Trimble VH. The uncertain miracle: hyperbaric oxygenation. Garden
City, NY: Doubleday & Company, Inc. 1974.