Hyperbaric Oxygen Therapy

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Jennifer Spector, DPM:
Welcome back to Podiatry Today podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today. This episode is our newest Wound Care Q&A featuring Dr. Kazu Suzuki. Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, and he's a member of the attending staff at Cedar-Sinai Medical Center in California. Welcome, Dr. Suzuki. And today we're going to be talking a little bit about wound care and hyperbaric oxygen therapy. So when it comes to hyperbaric oxygen therapy, could you give us a little bit of historic context from your experience such as when you began using it and what your journey with it has been like?

Kazu Suzuki, DPM, CWS:
So hyperbaric oxygen therapy is adjunct therapy. I would say it's certainly not the mainstream or mainstay of the therapy that we use. I've been using it throughout my career. It is a known internationally recognized medical therapy that aids wound healing and infection control.

Jennifer Spector, DPM:
So approximately how many years have you been incorporating it into your practice?

Kazu Suzuki, DPM, CWS:
So really throughout my career, I focus my career on wound care and limb preservation on my career. So basically it really goes in hand in hand with severe diabetic infections, severe diabetic wounds, and limb preservation.

Jennifer Spector, DPM:
So can you share with the audience what the current indications are for hyperbaric oxygen therapy?

Kazu Suzuki, DPM, CWS:
Yes. So I do want to direct people to UHMS, that's Undersea Hyperbaric Medical Society. So that's the medical organization that kind of oversees an authority of this medical therapy. So you can get more information there. There are two absolute indications for hyperbaric oxygen. One is carbon monoxide poisoning and the other one is bends, which is a diving accident. Another name for is decompression sickness, DCS. Now we don't really treat those things ourselves, but those are two absolute indication for hyperbaric oxygen. Now, having said all of that, most hyperbaric oxygen therapy done in this country anyway are wound care indications such as severe diabetic infections, severe diabetic wounds where there are four foot gangrene defined as Wagner grade three or worse sometime with the burns, as well as failed skin grafts, failed skin flaps. And lastly, maybe very importantly, radiation injury. Radiation therapy can create soft tissue necrosis and bone necrosis and the hyperbaric oxygen is truly the only medical therapy that reverses and mitigates those radiation injury.

Jennifer Spector, DPM:
Obviously insurance is different all throughout the country and all throughout each region, but are those indications fairly standard in your experience as far as what covered diagnoses apply to hyperbaric oxygen therapy?

Kazu Suzuki, DPM, CWS:
Yes, so what I just told you, all the indications that I told you is more or less standard, I should say. The standards vary not from the region to region, but more to do with the insurance coverage. So let's say Blue Cross Blue Shield may have different policy as opposed to Medicare or other companies. In my experience, Medicare may be the most lenient and probably have the broadest coverage. While the private insurers may have their own, what we call technical reviews, they kind of have the right to make up their own rules such that they may be a lot more restrictive compared to Medicare policy.

Jennifer Spector, DPM:
So when it comes to the literature evidence for hyperbaric oxygen therapy, can you share some of the pearls and pitfalls when looking at that?

Kazu Suzuki, DPM, CWS:
Yes, the medical evidence is not very robust. The main problem being there's no research money in it given the fact that this is decal therapy, their manufacturer that makes the chambers, but they're not really equipped or it's probably appropriate enough for them to fund the therapy research. So the research is, to be honest, lackluster, it's really quite weak. Having said that, all the collective evidence that we have, all the experience that we have over several decades is that hyperbaric oxygen therapy is absolutely helpful in fighting off infection and increasing granulation tissue formation, and in the all together combined helpful in limb preservation, in limb threatening disease.

Jennifer Spector, DPM:
Definitely staying in those indications and applying the right therapy to the right cases is paramount. In your experience, are there any particular pearls or tasks that you really want doctors to keep in mind when they're considering hyperbaric oxygen as part of their treatment regimen?

Kazu Suzuki, DPM, CWS:
Yeah, so I don't recommend them routinely. The main problem of hyperbaric oxygen therapy is the logistics. The patients are required to go to the clinic, hyperbaric clinic once a day every day, Monday through Friday for 20 sessions. So essentially it takes a month of therapy every day. That's the ideal duration, ideal way to do this. So oftentimes there's a logistic issue that you have to, let's say you have a full-time day job. How are you going to do that if you don't have a car? How are you going to do that? Let's say if you're retired financially comfortable, you have a car, you could drive a car, then it may work for you, but logistically very intensive with therapy. But on the other hand, in my experience, if you can stick with it, it works exceedingly well and I've seen amazing results and the outcomes because if they could stick with it, it is amazingly effective therapy with caveat that it's not for everybody. It's really, I try to reserve it for really essentially limb preservation cases, whether we are wondering if I should take this leg off or not, that's when we use it.

Jennifer Spector, DPM:
Is there anything else you'd like to add about hyperbaric oxygen?

Kazu Suzuki, DPM, CWS:
Yes, I want to stress that it is adjunctive therapy. It is not for every wounds. Again, keep in mind of the logistic issues, it's very difficult for the patients to be compliant with the therapy. And having said that, if it's indicated, it is a powerful therapy that's been proven to be safe, and we've been using this therapy for the last, I don't know, five decades. So safety is there, efficacy is there, logistic is difficult. So I do encourage the audience to educate themselves, and especially if you're in diabetic limb preservation arena, I do encourage the audience to educate themselves and have it on the back of your pocket as your part of your armamentarium.

Jennifer Spector, DPM:
Thank you so much Dr. Suzuki for sharing your experience with us today, and I hope the readers will evaluate where hyperbaric oxygen might have a place in their wound care practices. We hope everyone will join us again for future episodes of Podiatry Today Podcast and Wound Care Q&A, which you can find@podiatrytoday.com and on your favorite podcast platforms.