A Case Study in Hyperbaric Oxygen Therapy for Wound Healing

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by Lydia A Meyers RN, MSN, CWCN

Hyperbaric Oxygen Therapy (HBOT) is a type of therapy that is oxygen done under greater than atmospheric pressure. Treatments are done according to approval by Medicare/Medicaid rules and regulations. At this time HBOT has been approved for the following:

  1. Acute carbon monoxide intoxication
  2. Decompression illness
  3. Gas embolisms
  4. Gas gangrene-clostridial myositis and myonecrosis
  5. Crush injuries and suturing of severed limbs, acute traumatic peripheral ischemia (ATI), and acute peripheral arterial insufficiency associate with arterial embolism and thrombosis
  6. Necrotizing fasciitis
  7. Preparing and preservation of compromised skin grafts
  8. Chronic refractory osteomyelitis
  9. Osteoradionecrosis
  10. Cyanide poisoning
  11. Actinomycosis
  12. Treatment of diabetic wounds of the lower extremities

These diagnoses are per the Local Coverage Determinations (LCD) of the Centers for Medicare & Medicaid Services (CMS) and what insurances use when approving or disapproving treatment coverage.

HBOT is an advanced therapy that is often overlooked and misunderstood. HBOT has been around since 1662 and has been used in the treatment of a variety of illnesses and diseases throughout its history. Research into HBOT was stopped with the Depression and World War I and II. The use of HBOT did not restart until the 1960s and then was mostly used for Decompression Sickness.

The use of HBOT was helped by the research done by the Undersea and Hyperbaric Medical Society (UHMS) which was founded in 1967. Today HBOT is located in many wound care centers and hospitals throughout the country. Much research continues even today into uses for more than just wounds. The changes in the muscle damage from loss of oxygen have been proven to improve with the use of HBOT. Recent research includes study of HBOT in heart attacks, strokes and neurological diseases.

Hyperbaric Oxygen Therapy: Using the Wagner System

A young man enters the clinic related to having a diabetic ulcer that is not healing. Two years prior, the patient had a below the knee amputation. The patient had several disabilities including: diabetes, mentally challenged, pacemaker/defibulator and dialysis. The wound was located on the lateral side of the foot and into the foot to include exposed bones. This is an indication of a Wagner III and supports the use of HBOT.

The Wagner system is used for diabetic foot ulcers in wound clinics, since this is a way to determine not just the depth of the wound but also helps with monitoring and treatment of the ulcer to assure proper treatment is being done. The system includes the following:

  • Grade 1- Superficial and would be full- or partial-thickness wound
  • Grade 2- Involves the ligaments, tendons, the joint capsule or deep band of fibrous connective tissue that separate or bind together muscles
  • Grade 3- These are deep and include abscesses, osteomyelitis, or joint infection
  • Grade 4- Includes gangrene (decay of body tissues) in the anterior part of foot or heel region
  • Grade 5- Involves extensive gangrene

The higher the grade the faster the patient needs to be placed in HBOT.

After documentation to qualify for HBOT was received, the patient needed to be cleared medically for approval. The one part that needed to be approved was the ability of the patient to dive (that is what the treatments are called since generally the patient is going 2.0 ATA [atmospheres absolute] in 100% oxygen). The pacemaker/defibulator needed to be checked for approval and any problems that could be associated with diving. Once calling the company it showed that the patient could only dive to 1.8 ATA. All other qualifications had been met within chamber T-Com to show the wound would have the improvement in arterial flow with each treatment.

Center for Medicare & Medicaid Services Documentation Requirements for Hyperbaric Oxygen Therapy

CMS requires appropriate documentation to support the medical necessity of HBOT. These include:

  1. Past treatments and how this treatment is more effective
  2. Documentation of all medical personnel involved in treatment of the wound
  3. Goals of the therapy and how the treatment should be evaluated for effectiveness
  4. All lab tests, x-rays, CT scans, wound care notes and evaluations that support the diagnosis and safe use of HBOT for the wound and the patient

Once all information was received and antibiotic therapy started during dialysis, the patient started treatment. Each week the wound was checked for healing and changes in wound bed were noted on each visit. The labs drawn for antibiotic therapy and changes were made as needed. The patient did have a reaction to antibiotic therapy and needed to be admitted to hospital for a short period of time, which interfered with only two weeks of the therapy. Once returned to the wound clinic, the treatment was restarted and another test completed to show any changes from when treatments began. The noted changes were an increase in oxygenation to the wound and lower foot by double from previous testing.

Transcutaneous oxygen measurement (TCOM) is often performed to show arterial flow of extremities. This is accomplished by placing electrodes on the area around the wound and on the foot to indicate the amount of oxygenation the foot is getting. TCOM can be used to measure oxygenation before, during and after HBOT. The readings then will indicate any changes and improvement in the limb prior to treatment and after treatment. This is useful for those patients with arterial insufficiency that will not benefit or are not able to have vascular surgery.

This is only one diagnosis for which HBOT is appropriate and truly a benefit for the patient and medical dollars. The patient went on to heal, remained at home and could continue with their current life. He was able to move himself around his home and could transfer with the use of the one good leg. The patient did not have to be admitted to a Skilled Nursing Facility and could remain with his family.

About the Author
Lydia Meyers RN, MSN, CWCN has been a certified wound care nurse for over 15 years with experience working in home healthcare, extended care facilities, hospice care, acute care, LTAC, and wound clinics. Her nursing philosophy to "heal wounds as quickly as possible" is the guiding force behind her educational pursuits, both as a teacher and a student.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

WoundSource ENEWS


Thank you for this informative article and case study.

Thank you. Nice combination of basic information with the Wagner scale and reimbursement criteria but adding a human face to the care for your patient.

I am surprised at the choice of highlighting the Wagner System, rather than the UT System, which adds the dimension of grading the ulcers for ischemia or presence of infection and is a better predictor of wound healing than is the classic Wagner system (Oyibo, 2001). Unlike the Wagner system, the UT system has been validated in diabetic populations (Karthikesalingam, 2010). A 2010 Consensus Panel recommends staging DFUs using the UT system, rather than the Wagner system (Synder, 2010). The International Working Group of the Diabetic Foot also advises against the use of the Wagner System (Game, 2012).

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