Hyperbaric oxygen therapy: diagnostic usefulness and indications

PICHON RIVIERE, A.; AUGUSTOVSKI, F.; ALCARAZ, A.; BARDACH, A.; COLANTONIO, L.; FERRANTE, D.; GARCIA MARTI, S.; GLUJOVSKY, D.; LOPEZ, A.; REGUEIRO, A.

Documentos de Evaluación de Tecnologías Sanitarias

IECS

Año: 2006 p. 1 - 30

1668-2793

This report aims to assess the therapeutic usefulness of hyperbaric oxygen therapy and its applications in clinical practice.A search was performed on the main literature databases (MEDLINE, Cochrane, DARE, LILACS, NHS NICE, EMBASE, Centre for Reviews and Dissemination, York University), on general search engines, health technology assessment agencies and health sponsors, as well as in repositories of clinical practice guidelines and several institution coverage policies. In this report, priority was given to randomized clinical trials, meta-analyses and systematic reviews.There is a considerable number of studies and trials published on several hyperbaric oxygen (HBO) clinical applications. A group of medical technology assessment organizations have systematically reviewed the evidence available on the use of HBO for the indications tested. They include reports from the British National Institute of Clinical Excellence (NICE), the Alberta Heritage Foundation for Medical Research and 13 reviews from the Cochrane Collaboration, among others from several organizations. Generally, the different assessments agree. Also, there are multiple studies including randomized clinical trials on the different HBO applications. However, a considerable number of these studies present significant methodological flaws thus limiting their conclusions validity. Although there are reports documenting its benefits in multiple respiratory, cardiovascular, metabolic, neurological, infectious, and other clinical conditions, they do not have solid evidence to support most of them. This makes it difficult to accurately define HBO applications. However, it is possible to classify conditions according to their consensus level and for which HBO has been tested:Indications with wide level of consensus;Decompression sicknessLung overpressure syndromeAir or gas embolismGas gangrene / clostridal myonecrosisIndications with no consensus on recommendations from different organizations (Controversial Indications);Acute carbon monoxide poisoning: Reviewers concluded that the randomized trials available do not clearly state if administration of HBO to patients with carbon monoxide poisoning reduces the incidence of neurological adverse effects.Diabetic foot lesions: In patients with diabetes-related foot ulcers, HBO significantly reduced the risk of major amputation and could improve the possibilities of cure at 1 year. The group showing most benefits is that of patients with advanced diabetic foot lesions (those with gangrene). Because of the moderate number of patients and methodological deficiencies, this result must be cautiously interpreted and more trials of higher methodological quality should be performed to prove this result and define the subgroup of patients that could benefit the most.Necrotizing soft-tissue infections: the populations included in the different studies were not similar: An improvement in overall survival with HBO was reported, but only one study was statistically significant. This evidence is not enough to draw generalized conclusions on the effects of HBO in this group of patients.Prevention and treatment of bone necrosis due to radiation therapy: some studies showed benefits; however the treatment assessed in different trials is variable and differs in several aspects from the HBO regimens used for other indications, questioning the degree of possible generalization of results.Sudden deafness: Unequal results in the different assessments.Indications for which HBO would NOT be recommended (due to insufficient or adequate evidence of lack of benefit); Cyanide intoxication Thermal burns Wounds in non-diabetic patients and pressure sores Necrotizing spider bites Actinomycosis Osteomyelitis Multiple sclerosis Cerebral palsy Cardiovascular conditions such as myocardial infarction, acute coronary syndrome, cerebrovascular disease, peripheral artery disease. Soft tissue lesions including ankle sprains and crush injuries Bell paralysis Migraine and cluster headache Legg-Calve-Perthes disease (femoral head aseptic necrosis) Crohn's disease Osteoporosis Acquired cerebral lesion, cognitive alteration and senile dementia Glaucoma HIV infection Cancer Anemias Insulin dependent diabetes mellitus Facial neuritis Arthritis Spinal injury Non-junctional fracturesIn Argentina the HBO cost is $120 to $180 (Argentine pesos 2006) per session and a variable number is required depending on the condition to be treated (ranging from a few to 40). The Programa Medico Obligatorio (Mandatory Medical Plan) established by Argentina s Ministry of Public Health (a group of minimum mandatory services for the Social Security) stipulates mandatory coverage of HBO in the following clinical settings: Decompression sickness Gaseous gangrene Air or gas embolism