Diabetes

In 2015, it was estimated that roughly 30 million Americans have diabetes and another 84 million have prediabetes, which can lead to diabetes within 5 years1. Treatment of diabetes typically relies on lifestyle changes (exercise, diet, weight loss) and medications. However, in some cases diabetes can lead to the development of lower-extremity ulcers, which is where most of the HBOT research has focused2. As an adjunctive therapy, HBOT decreases wound size at a significantly faster rate than when patients do not receive HBOT3. Additionally, HBOT has been shown to decrease the risk of amputation, as well as increase the likelihood of intact skin once the ulcer has healed 4. HBOT also causes new microvasculature to develop at and around the site of the wound, which aids in the healing process 4.

HBOT Research Shows Improvement To:

  • Decreasing blood glucose levels
  • Decreasing size of wound
  • Increasing rate of wound healing
  • Decreasing risk of amputation
  • Neovascularization

Benefits of HBOT for Diabetes:

Increases Amount of Oxygen in the Blood

Stimulates development of new blood vessels from pre-existing vessels as well as the natural development of new blood vessels.

Accelerates Wound Healing

Increases production of nitric oxide in the bone marrow and microvasculature (smaller blood vessels). Stimulates stem cells from the bone marrow, accelerating wound healing. Dilation of smaller blood vessels enhances blood flow to areas of local tissue damage, hypoxia, and ischemia.

Maximizes Oxygen Transport

Allows for 100% saturation of hemoglobin molecules. Additional O2 molecules then dissolve directly into the plasma (the fluid component of blood) for transport.

Key Research on Hyperbaric Oxygen Treatment for Diabetes

Is HOT a Cool Treatment for Type 1 Diabetes?

The National Brain Injury Rescue and Rehabilitation Project was established as a preliminary study to test the safety and practicality of multi-center hyperbaric oxygen administration for the post-concussive symptoms of chronic mild traumatic brain injury as a precursor to a pivotal, independent, multi-center, controlled clinical trial. This report presents the results for 32 subjects who completed a preliminary trial of hyperbaric oxygen several years before the passage of the 21 st Century Cures Act. This study anticipated the Act and its reassessment of clinical research. Subjects received 40-82 one-hour treatments at 1.5 atmospheres absolute 100% oxygen. Outcome measures included repeated self-assessment measures and automated neurocognitive tests. The subjects demonstrated improvement in 21 of 25 neurocognitive test measures observed. The objective neurocognitive test components showed improvement in 13 of 17 measures. Earlier administration of hyperbaric oxygen post injury, younger age at the time of injury and hyperbaric oxygen administration, military status, and increased number of hyperbaric oxygen administrations were characteristics associated with improved outcomes. There were no adverse events. Hyperbaric oxygen was found to be safe, inexpensive and worthy of clinical application in the 21 st Century model of facile data collection provided by recent research regulatory shifts in medicine. The study was approved by the ethics review committee of the Western Institutional Review Board (WIRB; Protocol #20090761).

Influences of hyperbaric oxygen on blood pressure, heart rate and blood glucose levels in patients with diabetes mellitus and hypertension.

Abstract: We investigated the influences of hyperbaric oxygen (HBO(2)) on systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate…

The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial.

Abstract: ischaemic lower-extremity ulcers in the diabetic population are a source of major concern because of the associated high risk of…

Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers. Long-term follow-up.

The cause of diabetic foot ulcers is multifactorial, e.g., neuropathy and angiopathy, leading to functional disturbances in the macrocirculation and skin microcirculation. Adequate tissue oxygen tension is an essential factor in infection control and wound healing. Hyperbaric oxygen (HBO) therapy, daily sessions of oxygen breathing at 2.5-bar increased pressure in a hyperbaric chamber, has beneficial actions on wound healing including antimicrobial action, prevention of edema and stimulation of fibroblasts. The aim of the present study was to investigate the long-term effect of HBO in treatment of diabetic foot ulcers. Thirty-eight diabetic patients (30 males) with chronic foot ulcers were investigated in a prospective study. The mean age was 60+/-13 years and the mean diabetes duration 27+/-14 years. All patients were evaluated with measurements of transcutaneous oxygen tension (tcPO(2)), peripheral blood pressure, and HbA(1c). All patients had a basal tcPO(2) value lower than 40 mmHg, which increased to >/=100 mmHg, or at least three times the basic value, during inhalation of pure oxygen. Seventeen patients underwent 40-60 sessions of HBO therapy, while 21 patients were treated conventionally. The follow-up time was 3 years. 76% of the patients treated with HBO (Group A) had healed with intact skin at a follow-up time of 3 years. The corresponding value for patients treated conventionally (Group B) was 48%. Seven patients (33%) in Group B compared to two patients (12%) in Group A went to amputation. Peripheral blood pressure, HbA(1c), diabetes duration, and basal values of tcPO(2) were similar in both groups. Adjunctive HBO therapy can be valuable for treating selected cases of hypoxic diabetic foot ulcers. It seems to accelerate the rate of healing, reduce the need for amputation, and increase the number of wounds that are completely healed on long-term follow-up. Additional studies are needed to further define the role of HBO, as part of a multidisciplinary program, to preserve a functional extremity, and reduce the short- and long-term costs of amputation and disability.

Recent News on Hyberbaric Oxygen Treatment for Diabetes

Chronic Wounds and HBOT

Chronic Wounds and HBOT

KAMR/KCIT (Amarillo, TX) – NWTH Hyperbaric Certified Nurse, Shauna Webster, RN, sits down with Today in Amarillo’s Jason Britsch to talk about chronic wound care awareness. What wounds are considered chronic wounds? They are wounds that…

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Additional Research

The clinical use of hyperbaric oxygen in the treatment of Danish patients with diabetic foot ulcers.

Patients with diabetic foot ulcers (DFU) suffer from diabetes-related complications and comor-bidities. Hyperbaric oxygen therapy (HBOT) is a treatment modality with limited capacity used in the treatment of DFUs. It is important to ensure that HBOT is offered to patients who are suitable for this treatment regarding effect, compliance and life expectancy. The objective of the present study was to describe the population of patients with DFU who were referred to HBOT in Denmark in the 1999-2016 period. All patients with DFU who were treated at the HBOT chamber in Copenhagen during the study period were considered. Patients with an invalid social security number or an incorrect diagnosis were excluded. Data on comor-bidities, amputation and death were extracted from the Danish National patient Registry and the Danish Civil Registration System.

Malnutrition screening in outpatients receiving hyperbaric oxygen therapy: an opportunity for improvement?

Outpatients who receive hyperbaric oxygen treatment (HBOT) may represent a group at significant risk of malnutrition owing to the underlying conditions that are often treated with HBOT (e.g., non-healing diabetic wounds and radiation-induced skin injury). In this issue, See and colleagues provide new, preliminary evidence of the prevalence of malnutrition in a small group of HBOT outpatients treated in an Australian hospital, reporting that approximately one-third of patients receiving HBOT were at risk of malnutrition. To our knowledge, routine malnutrition screening is not available in HBOT centres providing outpatient treatment, which may be a key gap in the nutrition care of these patients. Malnutrition screening was developed to identify those at risk of malnutrition across the healthcare continuum.

Impact of Hyperbaric Oxygen on More Advanced Wagner Grades 3 and 4 Diabetic Foot Ulcers: Matching Therapy to Specific Wound Conditions.

The goal of this research was to identify a population of diabetic foot ulcer patients who demonstrate a significant response to hyperbaric oxygen therapy (HBOT) using a large sample size to provide guidance for clinicians when treating these complicated patients. The effect of HBOT on diabetic foot ulcers, Wagner grades 3 and 4, was evaluated using a retrospective observational real-world data set. The study reported on the overall healing rate, (74.2%) at the population level, for >2 million wounds. When a subgroup of patients of only foot ulcers with a Wagner grade 3 or 4 were considered, the healing rate was only 56.04%. The use of HBOT, without filtering for the number of treatments received, improved the healing rate to 60.01% overall.

Extracorporeal Shockwave Therapy for Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis.

Diabetes mellitus is one of the most common chronic diseases worldwide. Diabetic foot ulcers (DFUs) occur in over 10% of diabetic patients and are associated with high morbidity. Clinical trials have shown benefit from extracorporeal shockwave therapy (ESWT) in a DFU healing. This systematic review aims to assess the currently available evidence examining the efficacy of ESWT on healing of DFU. Electronic databases including PubMed, Ovid MEDLINE, Web of Science, Embase, CINAHL Plus, Cochrane Central Registry of Controlled Trials, and Clinical Trials Registry were searched up to November 2017 for terms related to ESWT in DFU. Articles were identified, and data were extracted by 2 independent reviewers onto Review Manager 5.3 software.

Might hyperbaric oxygen therapy (HBOT) reduce renal injury in diabetic people with diabetes mellitus? From preclinical models to human metabolomics.

Diabetic kidney disease (DKD) is the leading cause of end-stage renal failure in the western world. Current treatment of diabetic kidney disease relies on nutritional management and drug therapies to achieve metabolic control. Here, we discuss the potential application of hyperbaric oxygen therapy (HBOT) for the treatment of diabetic kidney disease (DKD), a treatment which requires patients to breathe in 100% oxygen at elevated ambient pressures. HBOT has traditionally been used to diabetic foot ulcers (DFU) refractory to conventional medical treatments. Successful clinic responses seen in the DFU provide the underlying therapeutic rationale for testing HBOT in the setting of DKD. Both the DFU and DKD have microvascular endothelial disease as a common underlying pathologic feature.

Hyperbaric Oxygen Therapy in Ischaemic Foot Ulcers in Type 2 Diabetes: A Clinical Trial.

Several treatment modalities and protocols for ischaemic foot ulcers are available. However, little consensus exists on optimal treatment. The aim of this study was to compare Standard Wound Care (SWC) alone SWC with adjunct hyperbaric oxygen therapy (HBOT) in the treatment of ischaemic Diabetic Foot Ulcers (DFUs). Twenty-six patients with Type 2 Diabetes Mellitus (T2DM) presenting with a newly diagnosed ischaemic foot ulcer were included. These were divided into group A (SWC with adjunct HBOT) and group B (SWC only). Participants were followed every week for 4 weeks and their ulcers were measured for their surface area and depth to assess any change in wound size. Both treatment arms succeeded in reducing ulcer area and depth (p<0.001).

New trends in the orthopaedic management of diabetic foot.

Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.

Early Effects of Hyperbaric Oxygen on Inducible Nitric Oxide Synthase Activity/Expression in Lymphocytes of Type 1 Diabetes Patients: A Prospective Pilot Study.

This study aimed at examining the early effects of hyperbaric oxygen therapy (HBOT) on inducible nitric oxide synthase (iNOS) activity/expression in lymphocytes of type 1 diabetes mellitus (T1DM) patients. A group of 19 patients (mean age: 63 ± 2.1) with T1DM and with the peripheral arterial disease were included in this study. Patients were exposed to 10 sessions of HBOT in the duration of 1 h to 100% oxygen inhalation at 2.4 ATA. Blood samples were collected for the plasma C-reactive protein (CRP), plasma free fatty acid (FFA), serum nitrite/nitrate, and serum arginase activity measurements. Expression of iNOS and phosphorylation of p65 subunit of nuclear factor-B (NFB-p65), extracellular-regulated kinases 1/2 (ERK1/2), and protein kinase B (Akt) were examined in lymphocyte lysates by Western blot.

A Pilot Study of Short-Duration Hyperbaric Oxygen Therapy to Improve HbA1c, Leukocyte, and Serum Creatinine in Patients with Diabetic Foot Ulcer Wagner 3-4.

To evaluate the short-duration hyperbaric oxygen therapy (HBOT) can improve HbA1c levels, leukocyte count, and serum creatinine levels in patients with diabetic foot ulcer (DFU) Wagner 3-4. Blood samples from all DFU patients at Sanglah General Hospital, Denpasar, were taken for HbA1c, leukocyte, and serum creatinine test before debridement procedure, and the patients were then grouped into either standard therapy or standard therapy with HBOT for 10 sessions (combination therapy). At the end of therapy, all blood tests were resumed. Each group consisted of 15 patients. Results of laboratory analysis before and after treatment were significant regarding decrease of HbA1c levels in standard therapy (10.98 ± 2.37 % to 9.70 ± 2.46 %; p = 0.006), HbA1c levels in combination therapy (9.42 ± 1.96 % to 7.07 ± 1.16 %; p < 0.001), and leukocyte count in combination therapy (13.97 ± 6.24 x 10 cells/L to 8.84 ± 2.88 x 10 cells/L; p = 0.009).

Ulcerated Necrobiosis Lipoidica.

A 23-year-old Caucasian female, with type I diabetes mellitus, presented with a 7-month history of two painful yellowish-red plaques with ulcerated centre in the left leg. A diagnosis of ulcerated necrobiosis lipoidica (NL) was made and she was started on pentoxifylline 400 mg tid and tacrolimus ointment 0.1%. After four months of treatment with no improvement, the patient was proposed for hyperbaric oxygen therapy (HBOT). Overall, she received a total of 30 sessions of HBOT, after which the wounds healed completely. There have been no recurrences in the 14 months following resolution.

References
  1. “CDC Press Releases.” CDC, January 1, 2016. https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html.
  2. “Diagnosis and Classification of Diabetes Mellitus.” Diabetes Care 33, no. Suppl 1 (January 2010): S62–69. https://doi.org/10.2337/dc10-S062.
  3. Abidia, A., G. Laden, G. Kuhan, B. F. Johnson, A. R. Wilkinson, P. M. Renwick, E. A. Masson, and P. T. McCollum. “The Role of Hyperbaric Oxygen Therapy in Ischaemic Diabetic Lower Extremity Ulcers: A Double-Blind Randomised-Controlled Trial.” European Journal of Vascular and Endovascular Surgery 25, no. 6 (June 1, 2003): 513–18. https://doi.org/10.1053/ejvs.2002.1911.
  4. Kalani Majid, Gun Jörneskog, Nazanin Naderi, Folke Lind, and Kerstin Brismar. “Hyperbaric Oxygen (HBO) Therapy in Treatment of Diabetic Foot Ulcers: Long-Term Follow-Up.” Journal of Diabetes and Its Complications 16, no. 2 (March 1, 2002): 153–58. https://doi.org/10.1016/S1056-8727(01)00182-9.

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