In 2009, a photo of Michael Jackson was circulated, showing him sleeping in a hyperbaric oxygen chamber. Hyperbaric oxygen therapy (HBOT) involves breathing pure oxygen in a pressurized room or tube; it’s a well-established treatment for decompression sickness, or “the bends,” a very painful and possibly fatal condition that can occur when a deep sea diver comes up too fast. It has also been used in burn units and for serious infections and wounds that won’t heal. That is why it is increasingly used as a viable treatment for persistent wounds in diabetes patients.
Why would this therapy be applicable to diabetes patients? One of the major issues in diabetes is poor blood circulation, which is especially problematic when patients sustain open wounds in the lower extremities. The limited circulation means that sufficient oxygen doesn’t reach the wounds to aid in healing. That makes people with diabetes vulnerable to infections developing in open wounds; these infections can progress to gangrene and the need for amputation.
The intense oxygen therapy, which results in a person’s lungs gathering up three times the normal volume of oxygen, leads to formation of new blood vessels and better oxygen perfusion at the wound site, and nudges the formation of new healthy skin around the affected area.
What the research showed
Hyperbaric oxygen therapy’s movement into wound care, and specifically diabetes wound care, occurred in 2002, thanks to a huge lobbying effort. In 2002, a study published in Journal of Diabetes and Complications suggested that daily sessions of hyperbaric oxygen as adjunctive therapy, could be of value in treating “select cases” of hypoxic diabetes-related foot ulcers.
The findings suggested that hyperbaric oxygen therapy accelerated healing, reduced the need for amputation, and increased the overall number of wounds that completely healed based on long term follow up.
Side effects of HBOT can include ear and sinus pressure issues, paralysis of limbs and air embolisms. The FDA warns that this treatment has not been confirmed as an effective therapy for diabetes wound care.
The few large trials that suggest the therapy’s efficacy were done outside the U.S. Despite the feeling by experts that HBOT might help to some degree, there is clearly an opportunity for abuse, overuse, and overly hopeful expectations from patients themselves. On average, 20 to 30 sessions are used for diabetes wound healing. Patients with serious foot ulcers should recognize that the therapy may not avert amputations.
The Medicare factor
According to the International Hyperbaric Medical Association “hundreds of millions of Medicare dollars (an estimated $348 million) are being saved yearly by preventing 11 percent of the 158,000 amputations yearly, by the use of Hyperbaric Oxygen therapy (HBOT).”
Kaiser Health News recently featured the treatment being implemented in diabetes care at The Villages Regional Hospital in Central Florida. This retirement community was supplying nearly half the patients being seen at the hospital, specifically for diabetes wound care. The hospital decided to add hyperbaric oxygen therapy in 2013. One huge enticement – Medicare reimburses quite well for the therapy.
Medicare typically pays $450 for a two-hour session in the hyperbaric chamber. The reimbursement rate was instituted in 2002 and resulted in a huge escalation of these units nationwide. In fact, about 1300 hospitals now have hyperbaric oxygen therapy, a tripling since 2002. This, despite the fact that solid evidence of wound healing improvement has not been formally validated by research.
Medicare also covers use of this therapy for 16 conditions, including a dozen in which skin fails to heal. Still, according to a Washington Post article, Medicare is looking into overuse of the therapy. The cost to install a unit with two chambers is about $500,000. Patients lie in the chamber for two hours, breathing the pure oxygen under a doctor or respiratory therapist’s supervision.
In 2015, Medicare imposed stricter regulations regarding the use of HBOT for diabetes wound care, and in some states (Illinois, Michigan, New Jersey) prior authorization is required before administering the therapy. In other states, strict documentation is required for Medicare reimbursement.
Keep in mind
It’s important to proactively prevent any foot wounds from progressing to the point of needing amputation of a foot or limb. According to the American Podiatric Medical Association patients with diabetes should have regular foot checks so that even the smallest abrasion can be detected and treated. To keep an ulcer from getting infected:
- Keep blood glucose levels under tight control
- Keep the ulcer clean and bandaged
- Cleanse the wound daily and use sterile wound dressings
- Avoid walking barefoot
Diabetes care of a foot ulcer should include preventing infection, taking pressure off the area (off-loading), removing dead skin (debridement), which should be done by a healthcare professional, applying appropriate local medications, taking oral antibiotics when appropriate, and managing glucose and any other health issues.
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