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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.

My understanding is that air breaks are uncommon anymore in the HBO2 community and I understand that there is a greater risk of O2 toxicity @ 2.4 ATA or greater. Is there any documented evidence for the need of air breaks during the hyperbaric treatments?
Published: 29 January 2016

My understanding is that air breaks are uncommon anymore in the HBO2 community and I understand that there is a greater risk of O2 toxicity @ 2.4 ATA or greater. Is there any documented evidence for the need of air breaks during the hyperbaric treatments?

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

The SC cannot recommend medical practice.  The hyperbaric treatment protocol is the responsibility of the medical director and the safety director.

Air breaks are used in the clinical setting for two primary reasons.  The first to reduce oxygen toxicity involving the central nervous system.  The second is to reduce oxygen toxicity to the pulmonary system. Due to the complexity of our patients and the underlying disease processes, the patient may present with conditions that could possibly lead to a lower threshold limit for oxygen toxicity (i.e. fever, low blood sugars, medications).    

A review conducted in 2003 by Hampson & Atik demonstrated an overall seizure rate of 1 in 3,388 treatments or 0.03% (Hampson & Atik, 2003). In 2011 Banham examined the incidence of oxygen toxicity seizures over 41,273 treatments for 3,737 patients and found the overall rate was 0.06% or 6/10,000 exposures with a higher incident rate in patients treated at increased pressures (0.56% at Navy Treatment Table 6 for dysbarism) (Banham, 2011). Another article reported zero per 10,000 at 2.0 ATA, 15 per 10,000 at 2.4/2.5 ATA and 51 per 10,000 at 2.8 ATA (Heyboer et al. 2014). Patients treated for CO poisoning or decompression illness have an incidence as high as 0.5-2%, presumably due to a combination of CNS injury and higher PO2 (2.8-3 ATA) used for treatment of those conditions (Hampson et. al. 1996; Banham, 2011). A 2016 retrospective chart review of 2334 patients treated at a hyperbaric center in Israel found a seizure incident rate of 0.3% (7 patients); however, they determined “only one patient (0.04%) had a true oxygen toxicity event” (Hadanny et al. 2016).

Major pulmonary oxygen toxicity has not been reported during routine clinical hyperbaric treatment, although there is a theoretical risk in patients who receive oxygen within a short interval after certain chemotherapeutic agents such as bleomycin and mitomycin C.

The rationale for air breaks is based upon a study in which volunteers breathed 100% O2 at 2 ATA for up to 19 hours (Hendricks PL, Hall DA, Hunter WL, Jr., Haley PJ. Extension of pulmonary O2 tolerance in man at 2 ATA by intermittent O2 exposure. J Appl Physiol. 1977;42(4):593-9). Use of 5-minute air breaks after every 20 minutes of 100% O2 delayed the onset of a measurable reduction in vital capacity (-5%) from 6 hours (without air breaks) to 17 hours. We are not aware of any specific studies that look at the influence of air breaks on CNS O2 toxicity.  Such a study would be difficult to perform since O2 toxicity is rare.

Air breaks are prescribed in some standard treatment procedures such as USN Treatment Tables for decompression illness. Routine use of air breaks for other hyperbaric treatment algorithms is at the discretion of the treating physician and is often implemented when treatment pressure exceeds 2 ATA. The time or length of the air break can vary from five (5) to ten (10) minutes (up to 15 minutes for treatment protocols used for decompression illness), typically after 100% O2 breathing periods of 20-30 minutes.

Banham ND. Oxygen toxicity seizures: 20 years' experience from a single hyperbaric unit. Diving Hyperb Med. 2011;41(4):202-10

Hadanny, A., Meir, O., Bechor, Y., Fishlev, G., Bergan, J., Efrati, Shai. (2016). The safety of hyperbaric oxygen treatment - retrospective analysis in 2,334 patients. Undersea and Hyperbaric Medicine, 43(2): 113-122

Hampson N, Atik D. Central nervous system oxygen toxicity during routine hyperbaric oxygen therapy. Undersea Hyperb Med. 2003;30(2):147-53

Heyboer M, 3rd, Jennings S, Grant WD, Ojevwe C, Byrne J, Wojcik SM. Seizure incidence by treatment pressure in patients undergoing hyperbaric oxygen therapy. Undersea Hyperb Med. 2014;41(5):379-85

DISCLAIMER
Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

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

Can you clarify? For dx of DFU 3 or higher, one of the qualifiers for HBO is that patient failed 30 days of wound care. If the patient''s wound was only a DFU 2 during those 30 days, does that count or does the wound need to be a DFU 3 during those 30 days?
Published: 04 December 2018

Can you clarify? For dx of DFU 3 or higher, one of the qualifiers for HBO is that patient failed 30 days of wound care. If the patient''s wound was only a DFU 2 during those 30 days, does that count or does the wound need to be a DFU 3 during those 30 days?

CMS clearly states must be Wagner Grade III or higher. See links below for the NCD and also for the UHMS CPG for Diabetic Foot Ulcer.

The question concerns a 49-year-old otherwise healthy woman who presented in 2017 with complaints of progressive noise magnification and severe headaches.
Published: 05 December 2018

The question concerns a 49-year-old otherwise healthy woman who presented in 2017 with complaints of progressive noise magnification and severe headaches.

There are several anecdotal reports of HBO2 for brain necrosis. In some radiosurgery series, the incidence of brain necrosis is as high as 25%.As with all CNS injuries early intervention is likely to have a higher rate of success. Determinants of outcome obviously include neurologic symptom response, but some series report decreases in steroid requirements and improvement on brain imaging mostly MRI. In my reading of the literature Avastin does not give consistent response.

I would recommend at least 40 treatments at 2.4 ATA. Many patients appear to require a good number of treatments for sustainable response, perhaps well over 60.To my knowledge no one has reported a higher likelihood of seizures during HBO with this group. If seizure activity is part of the picture adequate coverage with anti-convulsants is obviously needed.

See the below abstract and some pdf of slides from one of my presentations.

John Feldmeier

 

61 year old patient with bilateral optic neuropathy secondary to radiation. Has recently been started on prednisone 80mg daily, vitamin E 1000U daily, and pentoxifylline 400mg TID by neuro-ophthalmology. I know the steroids can increase oxygen toxicity, but that the Vitamin E also decreases this risk. Not sure if they offset each other. No seizure history, no pulmonary history, no history of tobacco use. Plan would be 90 minutes at 2.0 ATA with one 5 minute air break? Should number of air breaks be
Published: 25 March 2019

61 year old patient with bilateral optic neuropathy secondary to radiation. Has recently been started on prednisone 80mg daily, vitamin E 1000U daily, and pentoxifylline 400mg TID by neuro-ophthalmology. I know the steroids can increase oxygen toxicity, but that the Vitamin E also decreases this risk. Not sure if they offset each other. No seizure history, no pulmonary history, no history of tobacco use. Plan would be 90 minutes at 2.0 ATA with one 5 minute air break? Should number of air breaks be

Other history: Previously healthy male diagnosed with grade 4 glioblastoma 10/2017 s/p resection and chemoradiation (completed 1/2018).  Loss of visual acuity bilaterally x 4 weeks, with nearly complete loss of vision on the right.  MRI consistent with radiation optic neuropathy.  Patient hoping to preserve what vision he has left.  Understands data is limited.  Also noteworthy, patient has a known atrial septum defect with bidirectional shunting.

 

A: Treatment for this disorder is recommended. I am always in favor of 2.4 ATA for treatment of radiation injuries especially of the CNS. Many if not most of these patients  are on steroids. In the fairly large series from Laurie Gesell while at U of Cincinnati, these folks were not prone to O2 related seizure though certainly this can happen. The known septal defect is not an issue because we are not talking about an air dive. Treatment with Vitamin E might offer some slight protection. If I were to treat this patient, I would treat 3 30 min periods with 5 minute airbreaks at 2.4 ATA and only depart from this if there was a seizure. Informed consent of course is important. This profile chosen because of the severity of the condition and the track record in treating radiation injuries at 2.4 ATA-also the animal study by Marx et al. The profile you suggest is certainly safe but may not be as effective.

John Feldmeier, DO

Anybody have any experience treating pneumocephaly (complication of epidural injection) with HBOT?
Published: 18 March 2019

Anybody have any experience treating pneumocephaly (complication of epidural injection) with HBOT?

Unless there is a clinical problem besides the presence of air (while will resolve on its own), I see no reason to treat. If there is a desire to accelerate resolution, 100% O2 administration at 1 ATA will do that.

Is there any salutary effects for the use of HBO in aggressive glioblastoma ?
Published: 17 April 2019

Is there any salutary effects for the use of HBO in aggressive glioblastoma ?

As yet, there are no approved or reimbursed indications for HBO2 and the treatment of GBM or the complications of its treatment except for the treatment of radiation necrosis. Please see the attached. It comes from a draft of the about to be published update of the Indications BOOK (HBO2 Committee Report). As such it is unpublished data,.and as such its reproduction is prohibited.

John Feldmeier