Hyperbaric Oxygen Therapy in the Pediatric Patient: The Experience of the Israel Naval Medical Institute Dan Waisman, MD*i; Avi Shupak, MD‡i; Giora Weisz, MD§i; and Yehuda Melamed, MDi¶ ABSTRACT. The pediatric patient is to be found in here are numerous reports in the pediatric, hyperbaric facilities throughout the world, receiving hy- hyperbaric, and general medical literature of perbaric oxygen (HBO) therapy for both life-threatening children treated with hyperbaric oxygen and chronic diseases. T (HBO) therapy. However, there are very few reports Objective. To review the experience accumulated at that include a broader review of specific approaches the Israel Naval Medical Institute in the treatment of to the pediatric patient in the hyperbaric chamber.1–4 pediatric patients. Design. A retrospective analysis and review of all All branches of pediatric medicine—the general records of patients younger than age 18 years. pediatrician, the pediatric intensive care unit (ICU), Results. Between 1980 and 1997, 139 pediatric patients the neonatal ICU, and the pediatric surgeon and age 2 months to 18 years (mean, 7.7 years) received HBO orthopedic surgeon—may be involved in treating a treatment at the Israel Naval Medical Institute. Of the chil- child with one of the conditions that can benefit from dren, 111 (79%) suffered from acute carbon monoxide (CO) HBO therapy. poisoning; 13 (9.2%) were treated after crush injury, trau- In the present article, we emphasize the impor- matic ischemia, or compartment syndrome; 4 (2.8%) had tance of consultation and collaboration between the clostridial myonecrosis; 1 (0.7%) had necrotizing fasciitis; 5 pediatrician and the staff at the hyperbaric chamber. (3.6%) had refractory osteomyelitis; 2 (1.4%) had suffered This starts in the emergency room, pediatric ICU, or massive air embolism; 2 (1.4%) had purpura fulminans; and 1 (0.7%) suffered from decompression sickness. Outcome, neonatal ICU, where the pediatrician should be ca- judged by neurologic sequelae, mortality, and extent of soft pable of recognizing those indications for which tissue loss and limb amputation, was favorable in 129 pa- HBO may be of benefit. It continues during the HBO tients (93%). Two patients (1.4%) died, 1 as a result of CO sessions, with proper management of the pediatric poisoning and the other, gas gangrene; 2 of the patients in patient, especially critically ill children, to meet their the CO group (1.4%) remained with neurologic sequelae, particular requirements. and 6 patients in the acute traumatic ischemia group (4.3%) The results of our experience at the Israel Naval underwent limb amputation. Medical Institute (INMI) will be presented for each of Conclusions. We had a favorable experience with 129 the major clinical indications for hyperbaric treat- of a total 139 pediatric patients treated at our facility for the ment. Indications relevant to pediatric patients, indications listed. A basic knowledge of HBO therapy is based on current clinical practice and reviews, are needed to refer the pediatric patient for treatment when 2–6 indicated. The needs of the pediatric patient, especially the listed in Table 1. critically ill, require specific skills and equipment inside the hyperbaric chamber. Close collaboration between the HBO—PRINCIPLES AND MECHANISMS OF pediatrician and the hyperbaric medicine physician is es- ACTION sential to ensure adequate care for infants and children. HBO therapy uses intermittent breathing of 100% Pediatrics 1998;102(5). URL: http://www.pediatrics.org/cgi/ oxygen at pressures .1 atmosphere absolute (ATA). content/full/102/5/e53; hyperbaric oxygenation, pediatrics, Animal studies, clinical trials, and a growing body of carbon monoxide poisoning, crush injury, gas gangrene, ne- clinical experience have shown HBO to be effective crotizing fasciitis, refractory osteomyelitis, purpura fulmi- in a number of indications.5,6 nans, decompression sickness, arterial gas embolism. The therapeutic effect of HBO is attributable to the mechanical effect of increased environmental pres- ABBREVIATIONS. HBO, hyperbaric oxygen; ICU intensive care sure on gas-containing spaces in the body and the unit; INMI, Israel Naval Medical Institute; ATA, atmospheres physiologic changes induced by hyperoxia. The in- absolute; AGE, arterial gas embolism; DCS, decompression sick- ness; CNS, central nervous system; CO, carbon monoxide; GG, gas spiration of high levels of oxygen has a negligible gangrene. impact on the total hemoglobin oxygen content. However, HBO increases the amount of oxygen dis- solved in plasma, from 0.32 to 6 mL O2/100 mL of blood when breathing 100% O at 3 ATA. This con- From the Departments of *Neonatology, ‡Otolaryngology, and §Cardiology, 2 Carmel Medical Center and Faculty of Medicine, Technion-Israel Institute of siderable increase in the amount of oxygen made Technology, Haifa, Israel; iIsrael Naval Medical Institute, Haifa, Israel; and available to the tissues is of great importance when ¶Hyperbaric Medical Center–Elisha-Rambam Hospitals, Haifa, Israel. tissue oxygenation is impaired. Received for publication Jan 28, 1998; accepted Jun 23, 1998. According to Boyle’s law, which states that the Reprint requests to (D.W.) Department of Neonatology, Carmel Medical Center, 7 Michal St, 34 362 Haifa, Israel. product of pressure and volume is constant, any PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad- increase in environmental pressure will affect gas emy of Pediatrics. bubble size. Thus, elevation of the ambient pressure http://www.pediatrics.org/cgi/content/full/102/5/Downloaded from www.aappublications.org/newse53 PEDIATRICS by guest on October Vol. 102 3, 2021 No. 5 November 1998 1of9 TABLE 1. Accepted Indications for HBO Therapy for Infants Pulmonary barotrauma is uncommon, but to prevent and Children2–6 its occurrence during decompression, it is essential Smoke inhalation, CO intoxication that pulmonary cysts, emphysema, and asthma be AGE ruled out. These are not absolute contraindications to Compartment syndrome; acute traumatic peripheral ischemia HBO treatment, but special care must be taken when GG; complex anaerobic infections Compromised skin flaps and grafts treating a patient in whom any of these diseases are Chronic or refractory osteomyelitis present, especially during decompression. To pre- Osteoradionecrosis; radiation-induced soft tissue injury vent middle ear and pulmonary barotrauma, the pa- Purpura fulminans tient must undergo otoscopic examination and chest Chronic, nonhealing wounds DCS radiography before treatment is initiated. The toxic effects of oxygen that may appear during HBO therapy are central nervous system (CNS) and pulmonary oxygen toxicity. CNS oxygen toxicity will by a factor of 6 (6 ATA 5 a depth of 50 m 5 165 feet) develop within a short time on exposure to high will reduce bubble volume by the same magnitude. oxygen partial pressures. However, in the hyperbaric Henry’s law states that the amount of gas that will chamber, CNS toxicity usually will not develop at dissolve in a liquid at a constant temperature is oxygen partial pressures ,2.8 ATA. Factors favoring directly proportional to the partial pressure of that toxicity are prolonged exposure in the hyperbaric gas. These physical effects are of great importance in chamber to partial pressures of oxygen .2.0 ATA, the treatment of arterial gas embolism (AGE) and exercise, cold, immersion, an increase in end tidal 12 decompression sickness (DCS), in which inert gas CO2, fever, steroid treatment, and carbon monoxide (nitrogen) bubbles are present in tissues and blood (CO) intoxication.13,14 CNS toxicity is characterized vessels. During compression and oxygen breathing, by irritability, decreased visual fields (tunnel vision), bubble size is reduced, oxygen replaces the inert gas, nausea, tinnitus, dizziness, muscle twitching, and and surrounding tissues are able to metabolize the generalized convulsions. The sequence of symptoms oxygen.7 is highly variable, and the appearance of generalized Oxygen has a direct antimicrobial effect, particu- convulsions may not necessarily be preceded by any larly on anaerobes. A tissue Po2 of at least 30 mm Hg of the other signs. CNS oxygen toxicity is completely of oxygen is considered necessary for normal phago- reversible once the oxygen supply is disconnected. cytosis and oxidative burst to occur. In damaged The reported incidence of CNS toxicity during HBO tissues, the oxygen partial pressure is often lower exposure is 1:10 000 for therapeutic sessions con- than this. Increasing the partial pressure of oxygen in ducted at oxygen partial pressures between 2 and 3 hypoxic tissue can lead to the restoration of white ATA.14 blood cell function and the return of adequate anti- Pulmonary oxygen toxicity may appear during microbial action.8,9 prolonged exposure to a partial pressure as low as Because of the vasoconstrictive effect of oxygen, 0.5 ATA (50% Fio2). The higher the partial pressure HBO is believed to reduce tissue edema.10 HBO is in of oxygen, the shorter will be the time to the appear- wide use for the treatment of problem wounds. ance of toxicity. The signs of pulmonary toxicity are When a hypoxic environment is created, wound- coughing and irritation of the upper airways and a healing is compromised by local infection and a de- progressive decrease in vital capacity. Continued ex- crease in fibroblast proliferation, collagen synthesis, posure eventually will result in the adult respiratory and capillary angiogenesis. The adjunctive use of distress syndrome. Whereas susceptibility to CNS HBO has been shown to restore a favorable cellular oxygen toxicity is highly variable and unexpected, milieu, in which the wound-healing process and host pulmonary oxygen toxicity is related directly to the antibacterial mechanism are enhanced.11 dose of oxygen delivered, and thus mostly can be avoided.12 Pulmonary oxygen toxicity is completely SIDE EFFECTS OF HBO reversible, unless permanent structural damage to The side effects of HBO are related to pressure/ the alveolo-capillary unit has already developed as a volume changes and to oxygen toxicity. The most result of adult respiratory distress syndrome.