Problem Wounds

Some wounds do not heal in response to standard treatment, or in the time expected.

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Info for Patients

Wounds can be caused by many different problems, with diabetes being one of the common causes of wounds that are not healing. The term ‘chronic wound’ may be used – in medical terms this means a wound has been a persistent, long-term wound.

Problem wounds have not progressed through the different stages of wound healing. Often these wounds are low in oxygen. This means the body’s ability to heal or fight infection are affected. White blood cells, which fight infection, need oxygen to be able to kill bacteria. Some of the processes which re-build tissue, need oxygen to be able to progress.

During HBO, the area surrounding a chronic wound has high levels of oxygen, whilst the wound itself is low in oxygen.  This difference in oxygen levels encourages growth of small blood vessels into the wound. This in turn increases oxygen levels which helps the body’s own functions to fight infection and to re-build damaged tissue.

These processes all take time. A person having HBO to help heal a problem wound will usually have 20-40 HBO sessions, once per day, five days per week. Not much difference will be obvious for the first two weeks of treatment. Good wound care, proper foot wear and other factors such as good control of diabetes are also important in helping a wound heal.

Info for Professionals

Chronic wounds

We routinely treat selected patients here with problematic poor healing wounds. These patients are referred to us by their treating hospital consultant.

Oxygen plays a key role in many of the steps throughout wound healing:

  1. During the initial inflammatory phase of wound healing, oxygen is essential for platelet aggregation.
  2. During the proliferative phase, high levels of oxygen are required for angiogenesis to occur.
  3. Finally, during the remodelling phase, it is essential for collagen formation and to aid the strengthening of the extracellular matrix.

Wounds that do not heal with standard medical and surgical therapy are often underperfused with resultant poor oxygen tensions within the tissue. They may also be chronically infected. This infection may be the cause of hypo-perfusion (by interrupting wound healing) or may perpetuate the chronic wound hypoxia.

Hyperbaric Oxygen Therapy (HBOT) increases the diffusion gradient of oxygen in subcutaneous tissue by about 10-20 fold to allow hyperoxygenation of ischaemic tissue. Numerous animal and clinical studies have shown that this results in:

  • Reduced inflammatory cytokines
  • Stimulation of growth factors
  • Enhancement of antibacterial activity, including production of oxygen free radicals
  • Reduction in non-specific activation of inflammatory cells
  • Promotion of transmigration of stem cells to infected wound tissue
  • Alteration of leukocyte-endothelial adhesion
  • Promotion of collagen formation

However, it is important for us to assess each wound prior to HBOT as some chronic wounds will not respond to hyperbaric oxygen. Each wound is assessed with TCOM (Transcutaneous Oxygen Monitoring); probes detect the baseline oxygen tension in the skin, which is used as a marker of perfusion. A rise in oxygen tension should be seen as the patient is exposed to increased oxygen levels.

 

Diabetic Foot Ulcers

We routinely treat diabetic foot ulcers in patients who have failed to respond to treatment with standard multidisciplinary foot clinic input, in particular to try and avoid surgical intervention if at all possible.

HBOT should be used in conjunction with gold standard wound care and in these circumstances evidence suggests that HBO will improve healing. There is also evidence with some studies where long term follow up occurred that a continued benefit was seen.

Further information regarding the Referral and Funding process can be found here.

Treatment entails up to 40 sessions of HBO over a 8 week period subject to response to treatment.

 

References

Abidia A, Laden G, Kuhan G, Johnson BF, Wilkinson AR, Renwick PM, Masson EA, McCollum PT. The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial. Eur J Vasc Endovasc Surg. 2003 Jun;25(6):513-8. doi: 10.1053/ejvs.2002.1911. PMID: 12787692.

Doctor N, Pandya S, Supe A. Hyperbaric oxygen therapy in diabetic foot. J Postgrad Med. 1992 Jul-Sep;38(3):112-4, 111. PMID: 1303408.

Faglia E, Favales F, Aldeghi A, Calia P, Quarantiello A, Oriani G, Michael M, Campagnoli P, Morabito A. Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcer. A randomized study. Diabetes Care. 1996 Dec;19(12):1338-43. doi: 10.2337/diacare.19.12.1338. PMID: 8941460.

Kalani M, Jörneskog G, Naderi N, Lind F, Brismar K. Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers. Long-term follow-up. J Diabetes Complications. 2002 Mar-Apr;16(2):153-8. doi: 10.1016/s1056-8727(01)00182-9. PMID: 12039398.

Mathieu D, Marroni A, Kot J. Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving Hyperb Med. 2017 Mar;47(1):24-32. doi: 10.28920/dhm47.1.24-32. Erratum in: Diving Hyperb Med. 2017 Jun;47(2):131-132. doi: 10.28920/dhm47.2.131-132. PMID: 28357821; PMCID: PMC6147240.

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