Ask a new question
You don't have permission, please login or register

Medical/Patient Care

Questions pertaining to medical or patient care

What are the recommendations/contraindications for concurrent HBO and Chemotherapy/Radiation?
Published: 20 January 2016

What are the recommendations/contraindications for concurrent HBO and Chemotherapy/Radiation?

This answer is from the recognized physician expert in the field of hyperbaric medicine dealing with oncological disease – John Feldmeier, DO.

“There is no easy answer to this question. We still struggle to answer the question of whether patients with a remote history can have HBO2.

Although I believe that in almost all cases this would be safe. There is very little published data with concurrent therapy. The issue of concurrent chemo/ HBO2 has next to no published information and really has become a fairly recent issue because patients are now living longer with active malignancy. There are more and more options for systemic treatment and quality of life issues are pertinent for patients even when they have active disease. The scenario where this becomes an issue is when a patient has had prior radiation, has a complication, needs HBO2 but is receiving chemo probably because recurrent or residual cancer has been found.

Chemo comes in many varieties with traditional cytotoxic drugs in at least 8 categories and now with more options including immune therapies and anti-angiogenic therapies. It is impossible to make a universal recommendation applicable to all chemotherapies.

Some of these drugs mediate their anti-tumor response through free radicals which cause chemical bond breaks in the DNA leading to reproductive death. Some are antibiotics: some are spindle cell blockers etc., etc. Those that mediate cytotoxicity through free radicals are likely to have their effect enhanced in the tumor and normal tissues.

This was the basis of using HBO2 as a sensitizer to radiation done from late 50's to early 70's. Since the therapeutic goal is to enhance QOL, this would not be perceived as an appropriate effect.

As I am sure, most of you know Eric Kindwall's book declares there to be a contraindication to Adriamycin and Cisplatin. This precaution is based on pretty weak evidence. On the other hand Dick Clarke has done a preliminary study with colleagues at U of Chicago using HBO2 along with Cisplatin and radiation without signs of increased toxicity.

I am especially concerned about Bleomycin and Avastin. Jake Freiberger, MD of Duke U. has reviewed their experience in treating patients with a PAST not concurrent history of Bleomycin exposure without a demonstrable ill effect. I would not give Bleo concurrently with HBO2. Avastin and some of the other so called biologics (Erbitux) target growth factors including VEGF to exert their effect. Since we enhance VEGF with HBO2 are we diminishing the anti-cancer effects of Avastin? Will HBO2 be effective if VEGF is being suppressed by the Avastin? We don't know.

My operational recommendation is: 1)to avoid chemo and HBO concurrently whenever possible.2) If you do give concurrently wait a few half-lives perhaps 4 or 5 to see serum levels significantly lowered before resuming HBO2 after each chemo administration. Half-lives for all the drugs are published. Avastin is 60 days!! 3) I would avoid Avastin and some of the other biologics as well as Bleomycin as concurrent therapies.“

I wanted to ask whether you had any knowledge of clinical circumstances or literature regarding having a patient with a 20+ year old mechanical aortic valve undergo HBO2. The valve has not been pressure tested by the manufacturer?
Published: 05 February 2016

I wanted to ask whether you had any knowledge of clinical circumstances or literature regarding having a patient with a 20+ year old mechanical aortic valve undergo HBO2. The valve has not been pressure tested by the manufacturer?

There are no pressure-sensitive components in a mechanical valve, since it contains no gas pockets. There are no issues with respect to hyperbaric oxygen therapy regarding a prosthetic valve.

We have a patient needing to start HBO2, but does peritoneal dialysis at night and states that there is about a liter of fluid left in his abdomen during the day. Would it be safe to treat the patient with that much fluid?
Published: 29 February 2016

We have a patient needing to start HBO2, but does peritoneal dialysis at night and states that there is about a liter of fluid left in his abdomen during the day. Would it be safe to treat the patient with that much fluid?

There is no risk of having 1 L of fluid in the peritoneal cavity.

One of the topics that has come up in our center is the concern surrounding treating active cancer (CA) patients. I would really appreciate your thoughts on this topic. From all the studies I've read, there still seems to be a fair amount of ambiguity in this area. Above all, I've yet to read a study where the results are conclusive; whether for or against the usage of HBO2 for the treatment of CA.
Published: 21 October 2016

One of the topics that has come up in our center is the concern surrounding treating active cancer (CA) patients. I would really appreciate your thoughts on this topic. From all the studies I've read, there still seems to be a fair amount of ambiguity in this area. Above all, I've yet to read a study where the results are conclusive; whether for or against the usage of HBO2 for the treatment of CA.

One of the topics that has come up in our center is the concern surrounding treating active cancer (CA) patients.  I would really appreciate your thoughts on this topic.  From all the studies I've read, there still seems to be a fair amount of ambiguity in this area.  Above all, I've yet to read a study where the results are conclusive; whether for or against the usage of HBO2 for the treatment of CA.  As a medical director, how do you approach these patients during the initial consultation with regards to the medical legal aspect?


I am attaching the paper I did a number of yrs ago which was fairly comprehensive at that time. Since then there have been a smattering of papers, mostly case reports or pre-clinical studies which are a mixed bag. I am still convinced that the evidence supporting a renewal or acceleration of cancer growth is not at all impressive. I advise those who ask me to include a statement like this in their consent..."While the vast majority of published papers show no evidence of cancer recurrence or enhanced growth, based on a few papers with very few patients some authors have expressed their concerns about cancer growth. You should take this information under consideration if you decide to have hyperbaric treatments." Many publications that question the issue of cancer growth and suggest that HBO does enhance growth are directly contradicted by papers of the same or similar design

See attached. It is not a straightforward issue. Some patients with cancer recur and some develop rapid growth (probably after collapse of their inherent immune response.) This happens whether or not they have HBO treatments.

pdfHyperbaric Oxygen: Does it promote growth or recurrence of malignancy?

I am looking for a Standard Guideline for the half-lives for Amiodarone, cisplatin, doxorubicin, sulfamylon and disulfiram and when we can treat a patient with HBO2 after they complete these medications?
Published: 01 February 2017

I am looking for a Standard Guideline for the half-lives for Amiodarone, cisplatin, doxorubicin, sulfamylon and disulfiram and when we can treat a patient with HBO2 after they complete these medications?

I am attaching a word document where I have downloaded from a Google search just using the drug serum half-life as search words, e.g. Amiodarone serum half-life. I have found all the drugs except Sulfamylon. Sulfamylon as far as I know is used as a topical drug and I don't think there are clear guidelines on serum absorption or serum half-life. I have highlighted info that I think is pertinent.

I think a good rule of thumb for cancer chemotherapy is to use an interval equal to the usual dosing interval for the drug. For example doxorubicin, Adriamycin, is typically given every 3 weeks indicating at that interval the body has recovered from the previous dose. However, a chemotherapy drug that really concerns me is Avastin (Bevacizimab). It has a serum half-life of about 50 days and has been associated with fatal ruptures of bowel suture lines after resection. The PDR recommends that at least 28 days should elapse between surgery and drug or drug followed by surgery.

Do you have any information regarding HBOT and concurrent use of chemotheapeutic agents 1) ixabepilone and 2) faslodex?
Published: 12 July 2017

Do you have any information regarding HBOT and concurrent use of chemotheapeutic agents 1) ixabepilone and 2) faslodex?

None of the drugs have a published experience discoverable on a pub med search.

Based on mechanisms of action I doubt any of the drugs wiuld have their toxicities enhanced by HBO2. However, as you know, the decision to treat a patient with HBO2 who is receiving these drugs is the managing physicians decision and our input is meant only to provide guidance based on the information that is discoverable.

Please see the attachment.

docxChemotx_and_HBO_3_drugs.docx

If a patient has infected orthopedic hardware, should it be removed first or can I treat with HBO first?
Published: 23 March 2015

If a patient has infected orthopedic hardware, should it be removed first or can I treat with HBO first?

There is no simple, single answer. A number of considerations are raised...       

First of all, the hardware (and bone cement) as an inanimate object, is not the endpoint infection concern since with its removal and its biofilm, the infection source is eliminated.  However, success or failure for eradicating the infection rests on how much the host tissues in which the  hardware was in contact is infected.  Even with the most meticulous debridements, residual contamination/infection of the surrounding host tissues is likely.    

If the infection is of a total joint arthroplasty, the hardware needs to be removed and replaced with an antibiotic laden bone cement spacer--or if the infection is of low virulence new hardware. After the joint cavity is "sterilized" new hardware is placed.  This is the standard of practice for orthopaedists at this time.  If the patient has significant comorbidities such as diabetes, peripheral artery disease, collagen vascular disease, end-stage renal disease  is on steroids or immunosuppressors, etc.,  I recommend the adjunctive use of HBO to help with sterilizing the remaining joint cleft.  The other consideration for HBO for the infected arthroplasty is that of threatened skin flaps--a not uncommon finding especially with re-do's in patients with comorbidities.

If the patient has hardware to stabilize a long bone fracture, infected, non viable sequestra need to be removed and the fracture allowed to heal with the hardware in place.  HBO is a useful adjunct--and I have witnessed granulation tissue growing over the bone and  eventual epithelialization of the wound.  Once the fracture is healed, the hardware can be removed, but often the infection is arrested once the fracture is healed.

If the long bone fracture is healed, the infected hardware needs to be removed, the bone under the hardware debrided and the screw holes curetted. If the patient has significant, comorbidities, as mentioned above, I recommend HBO as an adjunct to arresting the infection.

Finally, if hardware was used for a foot deformity, especially in the diabetic and/or patient with peripheral artery disease, the hardware needs to be removed, the site debrided and external fixation placed until wound healing and a soft tissue mantel has been established (typically 6 to 8 weeks).

hello, apologize if you have already received this same question from me (2nd submission). Have you heard of any reports of increased incidence and increased risk of CNS oxygen toxicity seizure immediately (or shortly following) the scheduled air break? A colleague heard (from a very learned/experienced HBO MD) that patients were actually most at risk for O2 Toxicity seizure right after the air break? due to return to increased pulmonary artery dilation/cerebral vasoconstriction post air break? trying to
Published: 14 April 2017

hello, apologize if you have already received this same question from me (2nd submission). Have you heard of any reports of increased incidence and increased risk of CNS oxygen toxicity seizure immediately (or shortly following) the scheduled air break? A colleague heard (from a very learned/experienced HBO MD) that patients were actually most at risk for O2 Toxicity seizure right after the air break? due to return to increased pulmonary artery dilation/cerebral vasoconstriction post air break? trying to

Question answered by UHMS HBO2 Committee member Michael Bennett, MD:

As far as I am aware, there are no data to support this phenomenon. The 'off-oxygen' effect is completely anecdotal I think. and I am not at all sure if oxygen breaks confers any benefit or harm in this respect. 

We have a candidate for HBOT who has cochlear implants. Is this contraindicated?
Published: 13 January 2018

We have a candidate for HBOT who has cochlear implants. Is this contraindicated?

Dr. Richard Moon has provided an opinion.

“My own practice is to avoid diving in patients with cochlear implants. However there are some otolaryngologists who have approved this, apparently without problems though I don’t have any details. My suggestion is to discuss this with a specialist.” RM

The latest research we can find on www.pubmed.gov

Otol Neurotol. 2002 Jul;23(4):463-7; discussion 467.

Effects of hyperbaric exposure on the integrity of the internal components of commercially available cochlear implant systems.

Backous DD1, Dunford RG, Segel P, Muhlocker MC, Carter P, Hampson NB.

Author information

Abstract

HYPOTHESIS:

This study investigated whether pressure changes common to scuba diving and to hyperbaric oxygen therapy would not cause crush damage or leakage from critical seals in commercially available cochlear implants.

BACKGROUND:

The implanted packages of cochlear implants are susceptible to electrical failure caused by leakage from critical seals and to crush injury when exposed to changing barometric pressures encountered in recreational diving and in hyperbaric oxygen therapy.

METHODS:

Six Clarion 1.2, eight MED-EL Combi-40+, six Nucleus CI22M, and six Nucleus CI24M cochlear implants underwent three exposures at 165 feet of seawater (FSW) (6 ata abs), 99 FSW (4 ata abs), and 60 FSW (2.8 ata abs), simulating rates in accordance with U.S. Navy dive tables for nondecompression dives. Dives to 45 FSW (2.4 ata abs) simulated wound therapy. Before each dive began, after each dive, and after completion of the dive protocol, each device underwent telemetry and electrical integrity checks. All implants were returned to their respective factories for final electrical and quality control testing.

RESULTS:

All 26 devices completed the dive protocol. One Nucleus CI24M implant had a fault recorded at electrode lead 18 on predive and final product testing, which was absent during interval dive measurements. All 26 devices passed final electrical and quality control testing. In addition, the six Clarion units passed repeat helium leak testing.

CONCLUSION:

The implanted components of the Clarion 1.2, MED-EL Combi-40+, and Nucleus CI22M and CI24M were safely subjected to repeated pressure changes up to 6 atm abs, equivalent to 165 feet of seawater, without electrical failure from leakage at critical seals or crush damage.