Canada TWO Case Series - TOPICAL HYPERBARIC OXYGEN THERAPY: A CASE STUDY, Dutton, 2006

Lena Dutton, RN(EC), BScN, PHCNP, Linda Dalgleish, RN, BScN
Macassa Lodge, Hamilton, Ontario 

Abstract
Although the mechanism is not completely understood, topical hyperbaric oxygen (THBO) therapy has been used with some success in accelerating wound healing. PURPOSE: To observe the results of a therapeutic trial of THBO on a resident's difficult to heal wound in the long term care setting. METHOD: An 87 year old female resident underwent a trial of THBO to treat a large (19cm x 16cm) pyoderma gangrenosum leg ulcer, further complicated by arterial insufficiency (ABI 0.4) and diabetes. The trial consisted of daily 90 minute sessions with the limb enclosed in a vacuum sealed extremity chamber, and cycled pressurized oxygen delivered to the chamber unit. Diluted acetic acid soaks were used during treatment to offset pseudomonas growth. Local wound care consisted of moist wound healing and antimicrobial dressings. Digital photographs tracked weekly progress. RESULTS: The wound bed demonstrated light bleeding immediately following the first treatment (Day 0). Increased vascularity was noted on Day 3 and granulation tissue evident on Day 5. Successive weekly assessments revealed epithelial bridging and margin contraction (largest ulcer 17cm x 9.5cm on Day 21). At 28 weeks (Day 201) this wound size was reduced to 6.4cm x 2cm. CONCLUSION: The positive response to this therapeutic trial, given the challenges of both arterial insufficiency and a sub-optimal treatment of the pyoderma gangrenosum ulcer, suggests that THBO therapy is an effective therapy in accelerating healing in difficult wounds. Further investigations are warranted.

Introduction
Systemic hyperbaric oxygen is well established as an effective modality in wounds where perfusion is an issue (Ref. 1, 2), however the contraindications and limited access often makes it prohibitive to the long term care resident. In addition to the problems that oxygen toxicity in the co-morbid elderly may present (most notably, chronic obstructive pulmonary disease), the practical difficulties inherent in frequent transportation/transfer of the frail and immobile, and potential claustrophobic nature of the body chamber, makes this modality problematic. Although the mechanism of action is unclear, topical hyperbaric oxygen (THBO) therapy has also been found, in some cases, to accelerate wound healing (Ref. 3-5). The portability, few contraindications and relative ease of use makes this potential modality an attractive therapy, especially in the long-term care setting. The purpose of this case study was to observe the results of a therapeutic trial of THBO on a resident's difficult to heal wound in a long term care facility.

Methodology
A 87 year old female resident was chosen for this treatment, as a last option prior to amputation for an almost circumferential (19cm x 16cm) pyoderma gangrenosum ulcer on her R lower leg, complicated by severe arterial insufficiency (ABI= 0.4), diabetes, and a remote history of lupus (currently untreated). The THBO treatment consisted of daily to 3x wk 90 - 120 minute treatments with the limb enclosed in a vacuum sealed extremity chamber, and cycled pressurized oxygen delivered to the chamber unit. A written treatment protocol was followed, using ⁄ strength 1% acetic acid soaked gauze during the treatment to offset pseudomonas growth. Local wound care consisted of moist wound healing and antimicrobial (silver) dressings. Digital photographs were taken weekly to track progress.

Conclusion
Multiple challenges were encountered in treating this elderly woman's severe and complex ulcer. Arterial insufficiency, an inflammatory etiology (pyoderma gangrenosum), diabetes and other co-morbidities (CHF, lupus, anemia) all negatively impact on wound healing, and limit treatment options. Optimal treatment of the pyoderma gangrenosum (high dose steroids) was not achievable because of her co-morbidity. Given the size of the wound, the risk of sepsis was high, and the need for eventual amputation likely.

When an opportunity became available to trial an innovative treatment that might assist with wound closure to reduce the risk of infection, and preserve the limb, while allowing the resident to remain in her residence of choice, our attention was captured. Although we were skeptical that THBO would be effective, as the evidence was inconclusive, our options in this particular case were extremely limited. As we were in a position to control some of the wound healing factors, and monitor the progress daily, we presented this novel treatment to the resident who graciously consented.

The wound showed considerable healing with the THBO treatment - this prior to commencing the oral steroid on Day 49. When the THBO was discontinued for a week the wound deteriorated. Subsequent improvement when the treatment was resumed strongly suggests that the THBO had a positive role in healing. Although we cannot determine whether the THBO or the Tacrolimus treatment was the responsible agent for this improvement, it is interesting that the most distal (and presumably under-perfused) ulcer exhibited the most dramatic change, suggesting that the THBO played a significant role. Both agents may have provided a synergistic effect. The three bacteriologically determined infections, and delays in finding an appropriate agent, may have contributed to the prolonged healing time.

The response to this therapeutic trial, given the challenges of arterial insufficiency, suboptimal treatment of the pyoderma gangrenosum, and recurrent infections, suggests that the THBO modality was, in fact, beneficial.

As this was one individual case study, further and more rigorous investigations are recommended to determine if this therapy is indeed effective in facilitating healing in other challenging wounds in the long-term care setting.