Hyperbaric oxygen therapy for late radiation tissue injury.

BACKGROUND: This is the third update of the original Cochrane Review published in July 2005 and updated previously in 2012 and 2016. Cancer is a significant global health issue. Radiotherapy is a treatment modality for many malignancies, and about 50% of people having radiotherapy will be long-term survivors. Some will experience late radiation tissue injury (LRTI), developing months or years following radiotherapy. Hyperbaric oxygen therapy (HBOT) has been suggested as a treatment for LRTI based on the ability to improve the blood supply to these tissues. It is postulated that HBOT may result in both healing of tissues and the prevention of complications following surgery and radiotherapy. OBJECTIVES: To evaluate the benefits and harms of hyperbaric oxygen therapy (HBOT) for treating or preventing late radiation tissue injury (LRTI) compared to regimens that excluded HBOT. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 24 January 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing the effect of HBOT versus no HBOT on LRTI prevention or healing. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. survival from time of randomisation to death from any cause; 2. complete or substantial resolution of clinical problem; 3. site-specific outcomes; and 4. ADVERSE EVENTS: Our secondary outcomes were 5. resolution of pain; 6. improvement in quality of life, function, or both; and 7. site-specific outcomes. We used GRADE to assess certainty of evidence. MAIN RESULTS: Eighteen studies contributed to this review (1071 participants) with publications ranging from 1985 to 2022. We added four new studies to this updated review and evidence for the treatment of radiation proctitis, radiation cystitis, and the prevention and treatment of osteoradionecrosis (ORN). HBOT may not prevent death at one year (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.47 to 1.83; I2 = 0%; 3 RCTs, 166 participants; low-certainty evidence). There is some evidence that HBOT may result in complete resolution or provide significant improvement of LRTI (RR 1.39, 95% CI 1.02 to 1.89; I2 = 64%; 5 RCTs, 468 participants; low-certainty evidence) and HBOT may result in a large reduction in wound dehiscence following head and neck soft tissue surgery (RR 0.24, 95% CI 0.06 to 0.94; I2 = 70%; 2 RCTs, 264 participants; low-certainty evidence). In addition, pain scores in ORN improve slightly after HBOT at 12 months (mean difference (MD) -10.72, 95% CI -18.97 to -2.47; I2 = 40%; 2 RCTs, 157 participants; moderate-certainty evidence). Regarding adverse events, HBOT results in a higher risk of a reduction in visual acuity (RR 4.03, 95% CI 1.65 to 9.84; 5 RCTs, 438 participants; high-certainty evidence). There was a risk of ear barotrauma in people receiving HBOT when no sham pressurisation was used for the control group (RR 9.08, 95% CI 2.21 to 37.26; I2 = 0%; 4 RCTs, 357 participants; high-certainty evidence), but no such increase when a sham pressurisation was employed (RR 1.07, 95% CI 0.52 to 2.21; I2 = 74%; 2 RCTs, 158 participants; high-certainty evidence). AUTHORS' CONCLUSIONS: These small studies suggest that for people with LRTI affecting tissues of the head, neck, bladder and rectum, HBOT may be associated with improved outcomes (low- to moderate-certainty evidence). HBOT may also result in a reduced risk of wound dehiscence and a modest reduction in pain following head and neck irradiation. However, HBOT is unlikely to influence the risk of death in the short term. HBOT also carries a risk of adverse events, including an increased risk of a reduction in visual acuity (usually temporary) and of ear barotrauma on compression. Hence, the application of HBOT to selected participants may be justified. The small number of studies and participants, and the methodological and reporting inadequacies of some of the primary studies included in this review demand a cautious interpretation. More information is required on the subset of disease severity and tissue type affected that is most likely to benefit from this therapy, the time for which we can expect any benefits to persist and the most appropriate oxygen dose. Further research is required to establish the optimum participant selection and timing of any therapy. An economic evaluation should also be undertaken.

Effect of self-acupressure on middle ear barotrauma associated with hyperbaric oxygen therapy: A nonrandomized clinical trial.

BACKGROUND: In hyperbaric oxygen therapy (HBOT), a patient is exposed to pure oxygen in a chamber. While HBOT is a long-standing and well-established treatment for a wide variety of medical conditions, one of the main complications is middle ear barotrauma (MEB), which can lead to complaints of ear discomfort, stuffiness or fullness in the ear, and difficulties in equalizing ear pressure. The aim of this study is to evaluate the efficacy of self-acupressure in preventing and reducing the degree of MEB associated with HBOT. METHODS: This is a prospective nonrandomized controlled study. A sample of 152 participants will be assigned to 2 groups in a 1:1 ratio. The participants in the control group will receive conventional Valsalva and Toynbee maneuvers, while those in the experimental group will be given additional self-acupressure therapy. The acupoints used will be TE17 (Yifeng), TE21 (Ermen), SI19 (Tinggong), and GB2 (Tinghui). The Modified Teed Classification, symptoms of MEB, and overall ear discomfort levels will be assessed. Data will be analyzed using the Chi-Squared test or t test. OBJECTIVES: This study aims to evaluate the efficacy of self-acupressure for preventing and reducing the degree of MEB associated with HBOT. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04311437. Registered on 17 March, 2020.

Pneumomediastinum and the use of hyperbaric oxygen treatment.

Pulmonary barotrauma may occur in diving and can result in a spectrum of injuries referred to as pulmonary over-inflation syndrome (POIS). Pneumomediastinum is a part of the POIS spectrum and only rarely results in respiratory symptoms. We present a case of a civilian diver who developed pneumomediastinum with respiratory symptoms which did not respond to normobaric 100% oxygen. After investigation for pneumothorax, he underwent hyperbaric oxygen treatment which resulted in significant alleviation of his symptoms. This is a novel case example of this treatment algorithm.

Effect of antiplatelet and/or anticoagulation medication on the risk of tympanic barotrauma in hyperbaric oxygen treatment patients, and development of a predictive model.

INTRODUCTION: Middle ear barotrauma (MEBt) is a common side effect of hyperbaric oxygen treatment (HBOT) and can result in pain, hearing loss, tinnitus and otorrhagia. The use of antiplatelet/anticoagulant drugs is thought to increase the risk and severity of MEBt during HBOT. METHODS: Single centre, retrospective observational cohort study of all patients treated with HBOT over a 4-year period (between 01 January 2015 to 31 December 2018) looking at the incidence of MEBt and the concurrent use of antiplatelet and/or anticoagulant drugs. MEBt was assessed by direct otoscopy of the tympanic membrane post-HBOT and scored using the modified Teed classification. Multivariate modelling assessed the relationship between antiplatelet and/or anticoagulation drug use, age, sex, and MEBt during HBOT. RESULTS: There was no evidence that antiplatelet and/or anticoagulation drugs increase the risk of tympanic barotrauma in HBOT patients. The prevalence of MEBt was higher in female patients than in males (χ2 P = 0.004), and increased with age (χ2 P = 0.048). No MEBt was recorded in patients undergoing recompression therapy for decompression sickness or cerebral arterial gas embolism. CONCLUSIONS: In this retrospective single-centre study, antiplatelet and/or anticoagulation drugs did not affect the risk of MEBt, but both age and sex did, with greater prevalence of MEBt among older patients and females compared with younger patients and males. A predictive model, requiring further validation, may be helpful in assessing the likelihood of MEBt in patients undergoing HBOT.

A comparison of two hyperbaric oxygen regimens: 2.0 ATA for 120 minutes to 2.4 ATA for 90 minutes in treating radiation-induced cystitis Are these regimens equivalent?

Introduction: Hyperbaric oxygen dosing variations exist in radiation cystitis treatment. The objectives of this study were to compare response and safety rates among patients with radiation cystitis treated with different protocols: 2.0 ATA (atmospheres absolute) for 120 minutes at the University of Pennsylvania; and 2.4 ATA for 90 minutes at Hennepin Healthcare. Materials and Methods: Retrospective chart review of radiation cystitis patients treated with hyperbaric oxygen at the University of Pennsylvania (January 2010-December 2018) and Hennepin Healthcare Minnesota (January 2014-December 2018). Primary outcome was response to treatment. Complications were limited to hyperbaric-related conditions. Regression analysis was performed with ordinal logistic regression and binary logistic regression. Result: 126 patients were included in the analysis (2.0 ATA: 66, 2.4 ATA: 60). Overall response rate was 75.4% (good) and was not significantly different between protocols (good response: 2.0 ATA 72.7% vs. 2.4 ATA 78.3% p=0.74). The 2.0 ATA group required additional treatments [2.0 ATA: 45.45 ± 14.5 vs. 2.4 ATA: 40.03 ± 9.7, p<0.05]. 6.1% (2.0 ATA) and 13.3% (2.4 ATA) required tympanostomy tube placement or needle myringotomy for otic barotrauma (p=0.22). Transfusion was associated with poorer outcomes (p<0.05). Conclusion: Both groups - 2.0 ATA and 2.4 ATA - had similar response and complication rates. Blood transfusion is a negative prognostic factor for treatment outcome.

A Free Diver with Hemoptysis and Chest Pain.

[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

[Diving accidents]. / Tauchunfälle.

Decompression injuries occur on account of the special hyperbaric effects during the emerge phase and require superior therapeutic knowledge. Vitally important is emergency treatment with high concentrated oxygen at an early stage. Sever decompression injuries require oxygenation in a hyperbaric treatment chamber.

Pneumomediastinum and pneumothorax during emergency tracheotomy under spontaneous ventilation: Macklin meets Müeller? / Neumomediastino y neumotórax en la traqueotomía urgente en ventilación espontánea. Cuando Macklin encontró a Müeller

Potentially serious complications associated to emergency tracheotomy continue being a matter of concern. We review the pathogenesis of gas leakage in this setting and discuss about the possible mechanisms involved in its cause. We present two cases of pneumomediastinum, subcutaneous emphysema and pneumothorax in the context of emergency tracheotomy under spontaneous ventilation, finally resolved by chest drainage. The combination of overly negative pleural pressures due to extreme inspiratory efforts in the context of an almost completely obstructed airway together with over-pressurized alveoli because of gaseous entrapment secondary to serious expiratory obstruction appears to be the most plausible primary cause of air leaks in our patients. Understanding the underlying mechanisms evolved in its production will help clinicians to suspect and diagnose this phenomenon (AU)

Las complicaciones graves asociadas a la traqueotomía urgente continúan siendo un desafío clínico. En este trabajo revisamos y discutimos la fisiopatología de la fuga aérea en el contexto de la traqueotomía urgente. Presentamos dos casos de neumomediastino, enfisema subcutáneo y neumotórax en el curso de sendas traqueotomías urgentes realizadas sobre pacientes en ventilación espontánea que se resolvieron tras inserción de drenaje pleural. Nuestra conclusión es que la combinación de presiones pleurales inspiratorias muy negativas por el esfuerzo inspiratorio contra una vía aérea obstruida junto con la presencia de alveolos hiper-presurizados por el atrapamiento gaseoso espiratorio constituyen la base etiopatogénica del proceso. La comprensión de los mecanismos que subyacen en la generación del neumotórax y neumomediastino en este contexto facilitará que los clínicos sospechen y diagnostiquen el cuadro (AU)

The O'Neill grading system for evaluation of the tympanic membrane: A practical approach for clinical hyperbaric patients.

Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are the two most common complications of clinical hyperbaric oxygen (HBO2) treatment. The current grading system, the Teed's Classification, was first described in 1944 with modifications to this system over the years, but none are specific for the evaluation and treatment of patients undergoing clinical HBO2 therapy. Currently, the standard of care is a baseline otoscopic examination performed prior to starting HBO2 therapy. Repeat otoscopy is required for patients having ETD, pain or other symptoms during the compression and/or decompression phase of the treatment. Results from these examinations are used to determine the proper course of treatment for the ETD or MEB. The Teed's classification was not intended to correlate with the consistency of diagnosis, the clinical approach to relieving symptoms or the treatment of the inflicted trauma. It is not a practical tool for the modern hyperbaric team. We describe a newer grading system, the O'Neill Grading System (OGS), which allows simple, practical and consistent classification of ETD and MEB by all members of the clinical hyperbaric medicine team. Based on the O'Neill Grade assigned, evidence supported suggestions for appropriate actions and medical interventions are offered.

Periorbital emphysema after dive barotrauma without radiological evidence of paranasal sinus injury.

BACKGROUND: Scuba diving has increased in popularity since its invention in 1943, with over 21 million PADI registered members worldwide. Injuries to the paranasal sinuses caused by barotrauma are the second most common after injury to the middle ear. CASE REPORT: In this paper we present a case of unilateral periorbital surgical emphysema in a 23-yr-old male commercial scuba diver with minimal symptoms following an uneventful 13-ft (4-m) dive. The only symptoms experienced were pain and pressure over the right maxillary sinus and retrorbitally. Imaging with computed tomography showed no fracture of his paranasal sinuses. DISCUSSION: The authors recommend that a high index of suspicion for paranasal sinus barotrauma should be maintained in all patients reporting minor symptoms after diving (even to shallow depths) to facilitate rapid clinical diagnosis and prompt medical management.

A prospective analysis of independent patient risk factors for middle ear barotrauma in a multiplace hyperbaric chamber.

INTRODUCTION: Middle ear barotrauma (MEBT) is the most common complication of hyperbaric oxygen therapy (HBOT). We wished to determine whether independent risk factors could predict which patients will require tympanostomy tubes in order to continue HBOT. METHODS: Data regarding demographics, medical history and physical examination were collected prospectively over one year. Multivariate logistic regression was used to analyse the data. RESULTS: One hundred and six patients were included. The cumulative risk of MEBT over the first five treatments was 35.8% and that for needing tympanostomy tubes was 10.3%, while that for needing tubes at any time was 13.2%. Risk factors for MEBT on bivariate analysis were older age, history of ENT radiation and anticoagulant use. Risk factors for requiring tympanostomy tubes included a history of cardiovascular disease and patients being treated for an infective condition. The adjusted multivariate logistic model identified history of difficulty equalising as the only characteristic significantly associated with MEBT during the first five treatments, adjusted odds ratio (AOR) (95%CI): 11.0 (1.1 - 111.7). Being female, AOR (95%CI): 24.7 (1.8 - 339.7), and having a history of cardiovascular disease, AOR (95%CI): 20.7 (2.0 - 215.3), were significantly associated with the need for tympanostomy tubes during the first five HBOT, but there was no significant association between any other characteristics and the need for tubes at any point. CONCLUSION: Despite some significant risk factors for MEBT being identified, we were unable to predict accurately enough which patients needed tympanostomy tubes during their HBOT to recommend these being placed prophylactically in selected patients.

Inner ear decompression sickness in scuba divers: a review of 115 cases.

Inner ear decompression sickness (IEDCS) in scuba divers is increasingly observed, but epidemiological data are limited to small case series and the pathogenesis remains elusive. We report our experience over a 13-year period. We also thought to demonstrate that the development of this injury is mainly attributed to a mechanism of vascular origin. Diving information, clinical data, presence of circulatory right-to-left shunt (RLS), and laboratory investigations of 115 recreational divers were retrospectively analyzed. A follow-up study at 3 months was possible with the last 50 consecutive cases. IEDCS (99 males, 44 ± 11 years) represented 24 % of all the patients treated. The median delay of onset of symptoms after surfacing was 20 min. Violation of decompression procedure was recorded in 3 % while repetitive dives were observed in 33 %. The median time to hyperbaric treatment was 180 min. Pure vestibular disorders were observed in 76.5 %, cochlear deficit in 6 % and combination of symptoms in 17.5 %. Additional skin and neurological disorders were reported in 15 % of cases. In 77 %, a large RLS was detected with a preponderant right-sided lateralization of IEDCS (80 %, P < 0.001). Incomplete recovery was found in 68 % of the followed patients. Time to recompression did not seem to influence the clinical outcome. IEDCS is a common presentation of decompression sickness following an uneventful scuba dive, but the therapeutic response remains poor. The high prevalence of RLS combined with a right-sided predominance of inner ear dysfunction suggests a preferential mechanism of paradoxical arterial gas emboli through a vascular anatomical selectivity.

[Decompression illness: minor symptoms, major consequences]. / Decompressieziekte: geringe klachten, ernstige gevolgen.

Nowadays, diving is being performed ever more frequently; it is thus important to take diving injuries into consideration in patients presenting with even minor complaints after diving. Every dive is risky and could result in decompression illness, barotrauma and/or death. We report on two cases of decompression illness: a 30-year old man, an occupational diver, and a 46-year old man, an experienced diver, who were both clinically suspected of having decompression illness and were treated with hyperbaric oxygen in a recompression chamber. Both were eventually symptom-free after several treatments. Decompression illness is caused by a reduction in ambient pressure, which results in intra- or extravascular bubbles. Symptoms vary and are dependent on the site affected: from minor pain to neurological symptoms and death. If patients are suspected of having diving injuries, we recommend contacting a centre specialised in diving and hyperbaric medicine. Recompression in a hyperbaric chamber is the definitive treatment for decompression illness and should be performed as soon as possible.

Diagnosis and management of environmental thoracic emergencies.

Physiologic sequelae from increasing ambient pressure in underwater activities, decreasing ambient pressure while at altitude, or the consequences of drowning present a unique set of challenges to emergency physicians. In addition, several environmental toxins cause significant respiratory morbidity, whether they be pulmonary irritants, simple asphyxiants, or systemic toxins. It is important for emergency physicians to understand the pathophysiology of these illnesses as well as to apply this knowledge to the clinical arena either in the prehospital setting or in the emergency department. Current treatment paradigms and controversies within these regimens are discussed.

[Case report: fatal diving-accident. Or: accident while diving?]. / Tödlicher Tauchunfall. Oder: Unfall während des Tauchens mit Todesfolge?

This example of a fatal diving accident shows how challenging such cases can be in pre-hospital and clinical care. There is no common mechanism in diving fatalities and more than one group of disorders coming along with decompression sickness. Diving medicine is not an element of medical education, which results in insecurity and hampers adequate therapy of diving incidents. This is aggravated by an insufficient availability of hyperbaric chambers in Germany.

Middle ear barotrauma after hyperbaric oxygen therapy - the role of insuflation maneuvers.

OBJECTIVE: To analyze the association of insuflation maneuvers status before hyperbaric oxygen therapy with middle ear barotrauma. MATERIALS AND METHODS: Fouty-one patients (82 ears) admitted to the Department of Hyperbaric Medicine from May 2011 to July 2012. Assessments occurred: before and after the first session, after sessions with symptoms. During the evaluations were performed: otoscopy with Valsalva and Toynbee maneuvers, video otoscopy and specific questionnaire. Middle ear barotrauma was graduated by the modified Edmond's scale. Tubal insuflation was classified in Good, Median and Bad according to combined results of Valsalva and Toynbee maneuvers. INCLUSION CRITERIA: patients evaluated by an otolaryngologist before and after the first session, with no history of ear disease, who agreed to participate in the research (convenience sample). RESULTS: Of the 82 ears included in the study, 32 (39%) had barotrauma after the first session. The rate of middle ear barotrauma according to tubal insuflation was: 17.9% (Good insuflation) 44.4% (Median insuflation) and 55.6% (Bad insuflation) (P = 0.013). CONCLUSION: Positive Valsalva and Toynbee maneuvers before the first session, alone or associated were protective factors for middle ear barotrauma by ear after the first session.

ENT morbidity at high altitude.

BACKGROUND: People suffer unique health problems in high altitude areas, due to such factors as elevation, aircraft ascent and descent, extreme cold, hypoxia, hypobaria, and low relative humidity. This study was conducted to evaluate ENT morbidity at high altitude. METHODS: Serving soldiers introduced to a high altitude environment who presented with various ENT symptoms were examined to identify ENT disease. In addition, patients undergoing hyperbaric chamber therapy, tracheostomy and treatment of cold injuries were also examined for ENT problems. RESULTS: The following were detected: 13 cases of otic barotrauma, 11 cases of sinus barotrauma, three cases of vertigo, six cases of pinna frostbite, three cases of barotrauma caused by hyperbaric chamber therapy, an unusually high incidence of epistaxis, and innumerable patients with high altitude pharyngitis. CONCLUSION: Diseases of the ear, nose and throat contribute significantly to high altitude morbidity. In a military context, health education of troops is necessary to avoid such problems.

Middle ear barotrauma with hyperbaric oxygen therapy: incidence and the predictive value of the nine-step inflation/deflation test and otoscopy.

We conducted a prospective study to determine the incidence of middle ear barotrauma in patients who were undergoing hyperbaric oxygen therapy (HBOT). We also investigated the value of the nine-step inflation/deflation test and otoscopic findings before and immediately after the initial HBOT session in predicting barotrauma in an attempt to establish some criteria for prophylaxis. The study was conducted on 36 ears of 18 adults who had no history of eustachian tube dysfunction. Patients were being treated with HBOT for sudden hearing loss, wound-healing complications, or complications of diabetes. After 7 days of HBOT, barotrauma was seen in 12 of the 18 patients (66.7%) and in 18 of the 36 ears (50.0%). The nine-step inflation/deflation tests, which were performed before and immediately after the initial HBOT session, were not predictive of barotrauma (p = 0.095 before and p = 0.099 after). However, otoscopic findings obtained immediately after the first session of HBOT were predictive of barotrauma, with a sensitivity and specificity of 83 and 100%, respectively. We conclude that patients with even minor positive pathologic findings on otoscopy immediately following HBOT are at increased risk of middle ear barotrauma if HBOT is to be continued without prophylaxis.

Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up.

INTRODUCTION: Diving accidents affecting the inner ear are much more common than was once thought. Among the 319 patients treated in our clinic between January 2002 and November 2005, 46 cases involved 44 divers with symptoms of acute inner ear disorders. The objective of the present article is to investigate the symptoms of the acute disorders and assess any residual damage. STUDY DESIGN: Retrospective case analysis. MATERIALS AND METHODS: The medical records were used to study the cases of 18 divers treated for inner ear decompression illness on 20 occasions and 26 divers who had inner ear barotrauma. The symptoms of the disorder at the beginning of treatment, latency period before the first therapeutic measures, kind of initial therapy, symptoms after the accident, and hearing and balance functions at the last examination in our clinic were assessed. Divers with inner ear decompression illness were examined via means of transcranial or carotid Doppler ultrasonography for the presence of a vascular right-to-left (R/L) shunt. RESULTS: Of 18 divers with inner ear decompression illness, 17 reported vertigo as the main symptom. In one diver, the inner ear decompression illness was manifested bilaterally. The divers with inner ear decompression illness had been treated with hyperbaric oxygen therapy in 14 of 20 cases; the average latency period before the start of therapy was 40 hours (median, 10 h). In 15 (83%) of 18 patients, a large R/L shunt was detected, and in 14 (78%) of 18 patients, residual cochleovestibular damage was detected. Only 9 of 26 patients with inner ear barotrauma mentioned feeling dizzy, and in no patient was vertigo the main symptom. Twenty-one patients complained of tinnitus, whereas 20 complained of hearing loss. The hearing loss ranged from an unobtrusive difference of 10 dB between the ears up to complete deafness. Three patients were subjected to tympanoscopy because of suspected rupture of the round window membrane. Of patients with inner ear barotrauma, 78% had residual cochleovestibular damage. CONCLUSION: We describe for the first time a patient with bilateral manifestation of inner ear decompression illness. Inner ear decompression illness is frequently associated with a R/L shunt; therefore, after a diving accident, the patient's fitness to dive should be assessed via a specialist in diving medicine. Both decompression illness and barotrauma of the inner ear result in residual cochleovestibular damage in more than three of four patients.