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Subacute normobaric oxygen and hyperbaric oxygen therapy in drowning, reversal of brain volume loss: A case report

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A 2-year-old girl experienced cardiac arrest after cold water drowning. Magnetic resonance imaging (MRI) showed deep gray matter injury on day 4 and cerebral atrophy with gray and white matter loss on day 32. Patient had no speech, gait, or responsiveness to commands on day 48 at hospital discharge. She received normobaric 100% oxygen treatment (2 L/minute for 45 minutes by nasal cannula, twice/day) since day 56 and then hyperbaric oxygen treatment (HBOT) at 1.3 atmosphere absolute (131.7 kPa) air/45 minutes, 5 days/week for 40 sessions since day 79; visually apparent and/or physical examination-documented neurological improvement occurred upon initiating each therapy. After HBOT, the patient had normal speech and cognition, assisted gait, residual fine motor and temperament deficits. MRI at 5 months after injury and 27 days after HBOT showed near-normalization of ventricles and reversal of atrophy. Subacute normobaric oxygen and HBOT were able to restore drowning-induced cortical gray matter and white matter loss, as documented by sequential MRI, and simultaneous neurological function, as documented by video and physical examinations.
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IntroductIon
Pediatric drowning13 is treated with normobaric 100%
oxygen to maintain adequate systemic oxygenation.1 Serious
cases cause angiosomic-based4 deep gray matter and cortical5
injury with resultant atrophy/ventricular dilatation.5,6 To our
knowledge and investigation reversal of gray matter (cortical
volume loss) and white matter atrophy (ventricular dilatation)
are unreported with any therapy. We report subacute treatment
of a severe pediatric drowning case with repetitive short-
duration normobaric oxygen and then hyperbaric oxygen that
resulted in visually apparent and/or physical examination-
documented neurological improvement with each therapy and
near-complete reversal of cortical and white matter atrophy
on magnetic resonance imaging (MRI).
case rePort
A 2-year-old girl was resuscitated at Washington Regional
CASE REPORT
Medical Center, Fayetteville, AR, USA, from a Glasgow
Coma Scale (GCS) of 3, xed dilated pupils, and body tem-
perature of 85.1°F (28.9°C) after a 15-minute submersion in
41°F (5°C) water. After 100 minutes of cardio-pulmonary
resuscitation, the arterial pH was 6.53. Following hypo-
thermia, vasopressors, ventilator support (10 days), and
critical care at Arkansas Children’s Hospital, Little Rock,
AR, USA, the patient was discharged home 35 days post
drowning unresponsive to all stimuli, immobile with legs
drawn to chest, and with constant squirming and head
shaking. MRIs at 3 (Figure 1) and 31 (Figure 2) days post
drowning showed thalamic injury then generalized atrophy
with evolving gray and white matter injury.
Author Paul G. Harch was consulted and commenced
2 L/minute nasal cannula 100% oxygen for 45 minutes
twice/day bridging normobaric oxygen therapy at 55 days
post-drowning. Within hours the patient was more alert,
awake, and stopped squirming (see the movie at https://
Subacute normobaric oxygen and hyperbaric oxygen therapy in
drowning, reversal of brain volume loss: a case report
Paul G. Harch1, *, Edward F. Fogarty2
1 Department of Medicine, Section of Emergency Medicine, University Medical Center, Louisiana State University School of
Medicine, New Orleans, LA, USA
2 Department of Radiology, University of North Dakota School of Medicine, Bismarck, ND, USA
*Correspondence to: Paul G. Harch, M.D., paulharchmd@gmail.com or pharch@lsuhsc.edu.
orcid: 0000-0001-7329-0078 (Paul G. Harch)
A 2-year-old girl experienced cardiac arrest after cold water drowning. Magnetic resonance imaging (MRI) showed deep gray mat-
ter injury on day 4 and cerebral atrophy with gray and white matter loss on day 32. Patient had no speech, gait, or responsiveness to
commands on day 48 at hospital discharge. She received normobaric 100% oxygen treatment (2 L/minute for 45 minutes by nasal
cannula, twice/day) since day 56 and then hyperbaric oxygen treatment (HBOT) at 1.3 atmosphere absolute (131.7 kPa) air/45 minutes,
5 days/week for 40 sessions since day 79; visually apparent and/or physical examination-documented neurological improvement oc-
curred upon initiating each therapy. After HBOT, the patient had normal speech and cognition, assisted gait, residual ne motor and
temperament decits. MRI at 5 months after injury and 27 days after HBOT showed near-normalization of ventricles and reversal of
atrophy. Subacute normobaric oxygen and HBOT were able to restore drowning-induced cortical gray matter and white matter loss, as
documented by sequential MRI, and simultaneous neurological function, as documented by video and physical examinations.
Key words: normobaric oxygen; hyperbaric oxygen; drowning; magnetic resonance imaging; brain volume; gray matter; white matter
doi: 10.4103/2045-9912.208521
How to cite this article: Harch PG, Fogarty EF. Subacute normobaric oxygen and hyperbaric oxygen therapy in drowning, reversal of
brain volume loss: a case report. Med Gas Res. 2017;7(2):144-149.
Abstract
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www.youtube.com/watch?v=Pdy9w_3x2Lw&feature=yo
utu.be. Entire movie is pre-, and post-drowning up to pre-
and post-normobaric oxygen therapy, shown at 7 minutes
40 seconds mark and then 9 minutes mark). Neurological
improvement rate increased over the ensuing 23 days with
laughing, increased movement of arms, hands, grasp with
the left hand, partial oral feeding, eye tracking, and short
sentence speech (pre-drowning speech level, but with di-
minished vocabulary). Physical (PT), occupational (OT),
and speech therapy (ST) were added on the 10th day for 2
weeks.
Seventy-eight days post-drowning, hyperbaric oxygen
treatment (HBOT) commenced with compressed air at 1.3
atmosphere absolute (1 ATA = 131.7 kPa) for 45 minutes
total treatment time, once daily. Within hours the patient
experienced decreased tone, increased gross motor ac-
tivity, vocabulary, and alertness. After 10 sessions of
HBOT, the patient’s mother reported that the patient
was “near normal, except for gross motor function;”
PT was then reinstituted. After 39 sessions of HBOT,
the patient exhibited: assisted gait, speech level greater
than pre-drowning, near normal motor function, normal
cognition, improvement on nearly all neurological exam
abnormalities, discontinuance of all medications (buspar,
propranolol, baclofen), and residual emotional, gait, and
temperament decits (Additional Video 1). Gait improve-
ment was documented immediately upon return home at
https://www.youtube.com/watch?v=m2SBmdY4RXg&f
eature=youtu.be. MRI at 27 days after 40-session HBOT
and 162 days post-drowning demonstrated mild residual
injury and near-complete reversal of cortical and white
matter atrophy (Figures 36), while further improved
gait was documented at: https://www.youtube.com/watc
h?v=UjtucZa7zmw&feature=youtu.be.
dIscussIon
Due to concern for oxygen toxicity,7,8 continuous nor-
mobaric oxygen in acute cerebral injury is only used for
normalization of systemic oxygenation.1 Short duration
normobaric oxygen has been applied to acute focal stroke9
and traumatic brain injury,10 yet is unexplored in subacute
hypoxic/ischemic encephalopathy (HIE). Short duration
hyperoxia at or slightly above the equivalent level of
normobaric oxygen in our case, in the form of hyperbaric
oxygen or air, has been achieved in chronic toxic brain
injury,11 traumatic brain injury,12,13 autism,14 and cerebral
palsy15,16 where it is used for deoxyribonucleic acid (DNA)
signal transduction17,18 in combination with increased baro-
metric pressure.19,20 Intermittent hyperoxia and increased
atmospheric pressure up- or down-regulate 8,101 genes in
human endothelial cells.21 Sequential application of normo-
baric oxygen and hyperbaric oxygen in our patient caused
visually apparent and/or physical examination-documented
neurological improvements consistent with gene signaling
effects of oxygen and then pressure20 as well as the clinical
effects demonstrated in chronic neurological disorders.11-16
Eight weeks post-drowning, our patient exhibited severe
predictable1,2 neurological decits and MRI ndings4-6,22 that
were reversed by short-duration normobaric oxygen and hy-
perbaric oxygen therapy. The decision to apply normobaric
100% oxygen was dictated by author PGH’s inability to obtain
HBOT in the patient’s location and PGH’s experience using
normobaric 100% oxygen in unpublished cases of chronic
multi-infarct dementia, traumatic brain injury and extremity
ulcers. Cortical cystic lesion and cortical atrophy regression
has been reported in a 2-year-old post-neonatal HIE, but
white matter loss was unchanged.23 Spontaneous regression
Figure 1: Magnetic resonance imaging at 3 days after injury of the
2-year-old girl who experienced cardiac arrest after cold water drowning.
Note: (A) Axial diffusion weighted image at three days post drowning, showing
increased signal from acute ischemic injury to both thalami; (B) Coronal T2
weighted mid thalamic image 3 days post-drowning, showing subtle diffuse
thalamic signal changes, normal ventricles, and normal cortical sulcal cerebro-
spinal uid spaces.
Figure 2: Magnetic resonance imaging at 31 days after injury of
the 2-year-old girl who experienced cardiac arrest after cold water
drowning.
Note: (A) Axial uid attenuated inversion recovery (FLAIR) image at the level of
the basal ganglia at 31 days post-drowning, showing subtle persistent diffuse
signal irregularities in the gray and white matter (yellow arrows), diffuse gray
matter atrophy (enlarged sulcal spaces), and white matter atrophy (enlarged
lateral and third ventricles); (B) Coronal T2 image at the level of the thalami 31
days post-drowning, showing gray matter atrophy with increased cerebro-spinal
uid spaces at temporal and parietal lobes (green arrows) and cerebellar lobes
(red arrows), and white matter atrophy with thinned corpus callosum (yellow
arrow) and enlarged ventricles.
A AB B
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Figure 3: T2 coronal MRI images and axial uid attenuated inversion recovery (FLAIR) image of the 2-year-old girl who experienced cold water drowning.
Note: (A) T2 coronal images at the level of the thalami from left to right at 3, 31, and 162 days post-drowning, showing reversal of white matter and cortical
atrophy. Corpus callosum white matter and temporal lobe gray matter calculations embedded: 3.17, 2.00, 3.57 mm, and 8.10, 6.31, and 7.75 mm, at 3, 31, and
162 days respectively. (B) Axial FLAIR image at the level of the basal ganglia 162 days post-drowning, showing scattered residual signal change in the white
matter (yellow arrows) despite apparent global return to normal tissue volumes. MRI: Magnetic resonance imaging.
Figure 4: Three-dimensional DWI volumes obtained from the level of the pons to the centrum semi-ovale as viewed from a caudal-oblique projection
in the 2-year-old girl who experienced cold water drowning.
Note: Axial images at 3, 31, and 162 days (left to right) post-drowning with iso-contour three-dimensional brain volume calculations of 697, 611, and 696 cm3,
respectively. There is smaller volume and worsening of surface texture in the middle image and reversal of both in the third image. DWI: Diffusion weighted imaging.
Figure 5: Partial T2 coronal MRI images at the level of the thalami at 3, 31, and 162 days post-drowning of the 2-year-old girl who experienced cold
water drowning.
Note: (A) Partial T2 coronal image at the level of the thalami at 3 days post-drowning with right temporal lobe gray matter (2.70
3.87 mm) and corpus callosum
white matter (3.71
4.11 mm) thickness measurements. (B) Partial T2 coronal image at the level of the thalami 31 days post-drowning with right temporal lobe
gray matter (2.39
2.65 mm) and corpus callosum white matter (1.88
3.91 mm) thickness measurements. (C) Partial T2 coronal image at the level of the thalami
162 days post-drowning with right temporal lobe gray matter (2.56
4.01 mm) and corpus callosum white matter (3.67
4.37 mm) thickness measurements. MRI:
Magnetic resonance imaging.
A B
CB
A
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it is impossible to conclude from this single case if the
sequential application of normobaric oxygen then HBOT
would be more effective than HBOT alone.
conclusIon
Short duration normobaric oxygen and hyperbaric oxygen
therapy in the subacute phase of drowning recovery resulted
in video-documented near-complete resolution of severe
neurological decits and near-complete reversal of gray and
white matter atrophy on MRI. Hyperoxic and hyperbaric
gene signaling-induced growth of both gray and white mat-
ter is the most likely explanation.
Acknowledgments
We thank Chris and Kristal Carlson for allowing us to report
the treatment of their daughter, Henry Arnold, a Certicate of
Artistry Media Arts senior student at Lusher Charter School,
New Orleans, LA, USA for his expeditious and skilled editing
of the nal video used in this report, and Juliette Lucarini,
R.N., research nurse for the Family Physicians Center and
Harch Hyperbarics, Inc., New Orleans, LA, USA, for her
counseling/interface with the family during the normobaric
oxygen administration and facilitation of their eight week
sojourn to New Orleans. We would also like to acknowledge
the use of Osirix Open-source workstation software without
which the image analysis would not have been possible.
Author contributions
PGH consulted on the patient during the patient’s hospital-
ization and after discharge from the hospital, evaluated the
patient, performed the hyperbaric treatment, videoed the
patient, drafted, and revised the manuscript. EFF reviewed,
analyzed, chose the representative slices, formatted, and
performed all of the calculations on the imaging, drafted,
and revised the manuscript.
Conflicts of interest
PGH is co-owner of Harch Hyperbarics, Inc., a corporation
that performs hyperbaric medicine consulting and expert
witness testimony/opinions. He is also on the board of di-
rectors of the International Hyperbaric Medical Association
(IHMA), a non-prot corporation. He derives no income
of both cortical and white matter atrophy is contrary to the
natural evolution of non-neonatal HIE.24 T2 signal changes
on days 4 and 32 indicated permanent brain tissue injury or
loss (increased uid spaces) and limited tissue salvage/future
neurological improvement. The diffuse regrowth of tissue
was validated by visual inspection and multiple calculations.
A minimum 12.3% volume loss (86 cm3, underestimated due
to inclusion of enlarged ventricles) was restored to the normal
volume of a 2436-month-old child.
Functional imaging has been used since 1990 in chronic
neurological disorders,25-43 to document HBOT-induced neu-
rological improvements. These improvements have evaded
anatomical imaging due to the paucity of subacute pediatric
cases, treatment of severe cases with large tissue loss, and the
inability to capture metabolic25,29,30 and microscopic chang-
es,31,35,42,44 including microscopic neurogenesis.42,45 The star-
tling macroscopic regrowth of tissue in this case is explicable
by early intervention prior to long-term tissue degeneration
(e.g., Wallerian degeneration, apoptosis) in a growing child.
The synergy of increased oxygen and increased oxygen with
pressure in the hormone-rich childhood cerebral milieu is con-
sistent with the synergy of growth hormones and hyperbaric
oxygen17,18 caused by normobaric and hyperbaric oxygen-
induced gene signaling trophic,21,46 anti-inammatory,21,46 and
anti-apoptotic effects21,46 on brain tissue.47 Trophism is the
basis of oxygen and hyperbaric oxygen based wound-healing
in animals and humans,48 including central nervous system
injuries48 and is underscored in this patient by the concomitant
rapid neurological improvements.
Substantial animal and human literature has demonstrated
benecial effects of hyperacute HBOT for resuscitation
and post-resuscitation recovery from global ischemia/an-
oxia.49 Late application to drowning patients32,36 and other
global ischemia patients28,49,50 produces more modest effects.
When hyperacute HBOT is precluded by availability or
other non-medical factors bridging short-duration repetitive
normobaric oxygen therapy may be an option until HBOT
is available. Such low-risk medical treatment may have a
profound effect on recovery of function in similar patients
who are neurologically devastated by drowning; however
Figure 6: T2 coronal MRI images of
the thalami in the 2-year-old girl who
experienced cold water drowning.
Note: T2 coronal images at the level of the
thalami of MRI 3 (A), 31 (B), and 162 days
(C) post-drowning with manually drawn
surface area calculations of 77.8, 59.9,
and 72.0 cm2, respectively. MRI: Magnetic
resonance imaging.
A B C
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Harch and Fogarty. / Med Gas Res www.medgasres.com
from the IHMA. EFF is president of the International
Hyperbaric Medical Foundation (IHMF), a non-prot
corporation that promotes education, research, and teach-
ing in hyperbaric medicine. He derives no income from
the IHMF.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient's parents have
given her consent for her images and other clinical infor-
mation to be reported in the journal. The patient’s parents
understand that their names will be published.
Open access statement
This is an open access article distributed under the terms
of the Creative Commons Attribution-NonCommercial-
ShareAlike 3.0 License, which allows others to remix,
tweak, and build upon the work non-commercially, as long
as the author is credited and the new creations are licensed
under the identical terms.
Contributor agreement
A statement of “Publishing Agreement” has been signed
by an authorized author on behalf of all authors prior to
publication.
Plagiarism check
This paper has been checked twice with duplication-
checking software iThenticate.
Peer review
A double-blind and stringent peer review process has been
performed to ensure the integrity, quality and signicance
of this paper.
Open peer reviewers
Reviewer 1, Lei Huang, Loma Linda University, USA;
Reviewer 2, Wen-wu Liu, Second Military Medical Uni-
versity, China.
Additional file
Additional Video 1: Author PGH video exams at hyper-
baric clinic pre- and post-hyperbaric oxygen therapy--Eden
Carlson.
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Supplementary resource (1)

... The use of hyperbaric oxygen (HBO 2 ) therapy in HIE constitutes a type 3 recommendation, since it is considered a possible measure but not supported by sufficiently strong evidence [3,4]. Nevertheless, there are clinical reports that HBO 2 therapy could enhance recovery in children with HIE due to non-fatal drowning, with clinical and imaging benefits [5,6]. Normobaric oxygen (NBO 2 ) therapy, applied repetitively and for a short period of time, can be used when HBO 2 therapy is not immediately available [5]. ...
... Nevertheless, there are clinical reports that HBO 2 therapy could enhance recovery in children with HIE due to non-fatal drowning, with clinical and imaging benefits [5,6]. Normobaric oxygen (NBO 2 ) therapy, applied repetitively and for a short period of time, can be used when HBO 2 therapy is not immediately available [5]. ...
... HBO 2 therapy has a role in improving the transport of oxygen to the tissues, increasing the expression of antioxidation enzymes and modulating the expression of growth factors and cytokines [3], with subsequent anti-inflammatory and antiapoptotic actions and promotion of neurogenesis and angiogenesis [9,10]. Harch and Fogarty [5,6] published three case reports where HBO 2 therapy was used in pediatric non-fatal drowning. Clinical benefit in spasticity, cephalic control, deglutition, non-verbal communication, awareness and attention were reported. ...
Article
Paroxysmal autonomic instability syndrome with dystonia (PAISD) is a possible complication that worsens the prognosis of hypoxic-ischemic encephalopathy related to non-fatal drowning. There are case reports of hyperbaric oxygen (HBO2) therapy enhancing recovery in such cases. We report a case of a 5-year-old boy admitted to the Pediatric Intensive Care Unit after a non-fatal drowning. He was transferred under mechanical ventilation and sedation, with hemodynamic instability and hypothermia. On admission he had a Glasgow Coma Score of 6. On the fifth day of admission he presented episodes of dystonia with decerebration posture, diaphoresis, tachycardia and hypertension, sometimes with identified triggers, suggesting PAISD. The episodes were difficult to control; multiple drugs were needed. Electroencephalography showed diffuse slow wave activity, and cranioencephalic magnetic resonance imaging showed hypoxia-related lesions, suggesting hypoxic-ischemic encephalopathy. Early after admission the patient started physiotherapy combined with normobaric oxygen therapy. Subsequently he started HBO2 therapy at 2 atmospheres, with a total of 66 sessions. Dystonia progressively subsided, with gradual discontinuation of therapy. He also showed improvement in spasticity, non-verbal communication and cephalic control. This case highlights the diagnostic and therapeutic challenges of PAISD and the potential benefit of HBO2 therapy, even in the subacute phase, in recovery of hypoxic-ischemic encephalopathy.
... The result that patients who received oxygen therapy presented reduced GMV in frontal regions can be supported by the observations that individuals who were lack of oxygen supply to J o u r n a l P r e -p r o o f the brain demonstrated regional GMV reduction (Zhang, Wang et al. 2013, Harch andFogarty 2017). Patients with chronic obstructive pulmonary disease that can cause reduced oxygen supply to the brain have shown GMV reduction in widespread regions, including the frontal cortex, the cingulate cortex, and other subcortical regions (Zhang, Wang et al. 2013). ...
... year-old girl who suffered from water drowning demonstrated GMV atrophy in temporal, parietal, and cerebellar lobes, and the GMV atrophy was dramatically improved after receiving oxygen therapy (Harch and Fogarty 2017). ...
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COVID-19, the infectious disease caused by the most recently discovered severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has become a global pandemic. It dramatically affects people's health and daily life. Neurological complications are increasingly documented for patients with COVID-19. However, the effect of COVID-19 on the brain is less studied, and existing quantitative neuroimaging analyses of COVID-19 were mainly based on the univariate voxel-based morphometry analysis (VBM) that requires corrections for a large number of tests for statistical significance, multivariate approaches that can reduce the number of tests to be corrected have not been applied to study COVID-19 effect on the brain yet. In this study, we leveraged source-based morphometry (SBM) analysis, a multivariate extension of VBM, to identify changes derived from computed tomography scans in covarying gray matter volume patterns underlying COVID-19 in 120 neurological patients (including 58 cases with COVID-19 and 62 patients without COVID-19 matched for age, gender and diseases). SBM identified that lower gray matter volume (GMV) in superior/medial/middle frontal gyri was significantly associated with a higher level of disability (modified Rankin Scale) at both discharge and six months follow-up phases even when controlling for cerebrovascular diseases. GMV in superior/medial/middle frontal gyri was also significantly reduced in patients receiving oxygen therapy compared to patients not receiving oxygen therapy. Patients with fever presented significant GMV reduction in inferior/middle temporal gyri and fusiform gyrus compared to patients without fever. Patients with agitation showed GMV reduction in superior/medial/middle frontal gyri compared to patients without agitation. Patients with COVID-19 showed no significant GMV differences from patients without COVID-19 in any brain region. Results suggest that COVID-19 may affect the frontal-temporal network in a secondary manner through fever or lack of oxygen.
... Yet, for students pursuing undergraduate health science degrees, where biochemistry courses are at the core of the curriculum, or even for high school students taking chemistry and biology subjects in anticipation of university admission, there is a heightened need to appreciate the role that oxygen plays in sustaining life processes [1][2][3]. Recent reports of brain volume loss reversals in drowning victims treated with normobaric and hyperbaric oxygen serve to underline this need for awareness [4]. ...
Article
Full-text available
The appreciation and understanding of gas generation through processes is vital in biochemical education. In this work, an augmented reality tool is reported to depict the redox reaction between hydrogen peroxide and sodium hypochlorite solutions, two ubiquitous oxidizing agents, to create oxygen, a combustible gas. As it operates out of smartphones or tablets, students are able to conduct the exercise collaboratively, respond in a manner similar to an actual physical experiment, and able to depict the oxygen volume changes in relation to the volume of hydrogen peroxide of different concentrations used. The tool offers to help students acquire bench skills by limiting handing risks and to mitigate possible student anxiety on handling chemical materials and implements in the laboratory. The feedback received from Year 11 and 12 high school student participants in an outreach exercise indicate the overall effectiveness of this tool. © 2018 by The International Union of Biochemistry and Molecular Biology, 2018.
Chapter
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Hyperbaric oxygen (HBO) therapy has been used in a number of conditions characterized by global ischemia (as opposed to focal ischemia of stroke), and anoxia, and leading to impairment of consciousness. Conditions such as coma due to brain injury and anoxia associated with drowning and hanging are discussed under the following headings: (1) pathophysiology, (2) rational basis of HBO therapy, (3) review of animal experimental studies, and (4) review of human clinical studies. Finally case studies are given.
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Drowning is a leading cause of neurological morbidity and mortality in young children. Anoxic brain injury (ABI) can result from nonfatal drowning and typically entails substantial neurological impairment. The neuropathology of drowning-induced pediatric ABI is not well established. Specifically, quantitative characterization of the spatial extent and tissue distribution of anoxic damage in pediatric nonfatal drowning has not previously been reported but could clarify the underlying pathophysiological processes and inform clinical management. To this end, we used voxel-based morphometric (VBM) analyses to quantify the extent and spatial distribution of consistent, between-subject alterations in grey and white matter volume. Whole-brain, high-resolution T1-weighted MRI datasets were acquired in 11 children with chronic ABI and 11 age- and gender-matched neurotypical controls (4–12 years). Group-wise VBM analyses demonstrated predominantly central subcortical pathology in the ABI group in both grey matter (bilateral basal ganglia nuclei) and white matter (bilateral external and posterior internal capsules) (P < 0.001); minimal damage was found outside of these deep subcortical regions. These highly spatially convergent grey and white matter findings reflect the vascular distribution of perforating lenticulostriate arteries, an end-arterial watershed zone, and suggest that vascular distribution may be a more important determinant of tissue loss than oxygen metabolic rate in pediatric ABI. Further, these results inform future directions for diagnostic and therapeutic modalities.
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Objective: The current study aimed to better understand trends and risk factors associated with non-fatal drowning of infants and children in the USA using two large, national databases. Methods: A secondary data analysis was conducted using the National Inpatient Sample and the Nationwide Emergency Department Sample databases. The analytic sample (n=19 403) included children <21 years of age who had a diagnosis code for near-drowning/non-fatal drowning. Descriptive, χ(2) and analysis of variance techniques were applied, and incidence rates were calculated per 100 000 population. Results: Non-fatal drowning incidence has remained relatively stable from 2006 to 2011. In general, the highest rates of non-fatal drowning occurred in swimming pools and in children from racial/ethnic minorities. However, when compared with non-Hispanic Caucasian children, children from racial/ethnic minorities were more likely to drown in natural waterways than in swimming pools. Despite the overall lower rate of non-fatal drowning among non-Hispanic Caucasian children, the highest rate of all non-fatal drowning was for non-Hispanic Caucasian children aged 0-4 years in swimming pools. Children who were admitted to inpatient facilities were younger, male and came from families with lower incomes. Conclusions: Data from two large US national databases show lack of progress in preventing and reducing non-fatal drowning admissions from 2006 to 2011. Discrepancies are seen in the location of drowning events and demographic characteristics. New policies and interventions are needed, and tailoring approaches by age and race/ethnicity may improve their effectiveness.
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ACCORDING TO THE WORLD HEALTH ORGANIZATION (WHO), 0.7% OF ALL deaths worldwide - or more than 500,000 deaths each year(1) - are due to unintentional drowning.(2) Since some cases of fatal drowning are not classified as such according to the codes of the International Classification of Disease, this number underestimates the real figures, even for high-income countries,(3) and does not include drownings that occur as a result of floods, tsunamis, and boating accidents. Drowning is a leading cause of death worldwide among boys 5 to 14 years of age.(2) In the United States, drowning is the second leading cause of injury-related death among children 1 to 4 years of age, with a death rate of 3 per 100,000,(4) and in some countries, such as Thailand, the death rate among 2-year-old children is 107 per 100,000.(5) In many countries in Africa and in Central America, the incidence of drowning is 10 to 20 times as high as the incidence in the United States. Key risk factors for drowning are male sex,(4) age of less than 14 years,(6) alcohol use,(7) low income,(1) poor education,(5) rural residency,(5) aquatic exposure,(6,7) risky behavior,(6,7) and lack of supervision.(6) For people with epilepsy, the risk of drowning is 15 to 19 times as high as the risk for those who do not have epilepsy.(8) Exposure-adjusted, person-time estimates for drowning are 200 times as high as such estimates for deaths from traffic accidents.(9) Coastal drownings are estimated to cost more than $273 million per year in the United States(10) and more than $228 million per year (in U. S. dollars) in Brazil.(11) For every person who dies from drowning, another four persons receive care in the emergency department for nonfatal drowning.(12)
Article
Full-text available
Objective: The present study aimed to assess the effect of intensive rehabilitation combined with hyperbaric oxygen (HBO2) therapy on gross motor function in children with cerebral palsy (CP). Methods: We carried out an open, observational, platform-independent study in 150 children with cerebral palsy with follow-up over eight months to compare the effects of standard intensive rehabilitation only (control group n = 20) to standard intensive rehabilitation combined with one of three different hyperbaric treatments. The three hyperbaric treatments used were: air (FiO2 = 21%) pressurized to 1.3 atmospheres absolute/atm abs (n = 40); 100% oxygen pressurized at 1.5 atm abs (n = 32); and 100% oxygen, pressurized at 1.75 atm abs (n = 58). Each subject assigned to a hyperbaric arm was treated one hour per day, six days per week during seven weeks (40 sessions). Gross motor function measure (GMFM) was evaluated before the treatments and at two, four, six and eight months after beginning the treatments. Results: All four groups showed improvements over the course of the treatments in the follow-up evaluations (p < 0.001). However, GMFM improvement in the three hyperbaric groups was significantly superior to the GMFM improvement in the control group (p < 0.001). There was no significant difference between the three hyperbaric groups. Conclusion: The eight-month-long benefits we have observed with combined treatments vs. rehabilitation can only have been due to a beneficial effect of hyperbaric treatment.
Chapter
Cerebral palsy is a chronic neurological disorder that can be due to several causes of brain damage in utero, in the perinatal period, or postnatally. Hyperbaric oxygen has been shown to be useful in treating children with cerebral palsy. This topic is discussed under the following headings.
Article
Importance Improvement has been anecdotally observed in patients with persistent postconcussion symptoms (PCS) after mild traumatic brain injury following treatment with hyperbaric oxygen (HBO). The effectiveness of HBO as an adjunctive treatment for PCS is unknown to date.Objectives To compare the safety of and to estimate the efficacy for symptomatic outcomes from standard PCS care alone, care supplemented with HBO, or a sham procedure.Design, Setting, and Participants Multicenter, double-blind, sham-controlled clinical trial of 72 military service members with ongoing symptoms at least 4 months after mild traumatic brain injury enrolled at military hospitals in Colorado, North Carolina, California, and Georgia between April 26, 2011, and August 24, 2012. Assessments occurred before randomization, at the midpoint, and within 1 month after completing the interventions.Interventions Routine PCS care was provided in specialized clinics. In addition, participants were randomized 1:1:1 to 40 HBO sessions administered at 1.5 atmospheres absolute (ATA), 40 sham sessions consisting of room air at 1.2 ATA, or no supplemental chamber procedures.Main Outcomes and Measures The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) served as the primary outcome measure. A change score of at least 2 points on the RPQ-3 subscale (range, 0-12) was defined as clinically significant. Change scores from baseline were calculated for the RPQ-3 and for the total RPQ. Secondary measures included additional patient-reported outcomes and automated neuropsychometric testing.Results On average, participants had sustained 3 lifetime mild traumatic brain injuries; the most recent occurred 23 months before enrollment. No differences were observed between groups for improvement of at least 2 points on the RPQ-3 subscale (25% in the no intervention group, 52% in the HBO group, and 33% in the sham group; P = .24). Compared with the no intervention group (mean change score, 0.5; 95% CI, −4.8 to 5.8; P = .91), both groups undergoing supplemental chamber procedures showed improvement in symptoms on the RPQ (mean change score, 5.4; 95% CI, −0.5 to 11.3; P = .008 in the HBO group and 7.0; 95% CI, 1.0-12.9; P = .02 in the sham group). No difference between the HBO group and the sham group was observed (P = .70). Chamber sessions were well tolerated.Conclusions and Relevance Among service members with persistent PCS, HBO showed no benefits over sham compressions. Both intervention groups demonstrated improved outcomes compared with PCS care alone. This finding suggests that the observed improvements were not oxygen mediated but may reflect nonspecific improvements related to placebo effects.Trial Registration clinicaltrials.gov Identifier: NCT01306968
Article
In this single-center, double-blind, randomized, sham-controlled, prospective trial at the U.S. Air Force School of Aerospace Medicine, the effects of 2.4 atmospheres absolute (ATA) hyperbaric oxygen (HBO 2) on post-concussion symptoms in 50 military service members with at least one combat-related, mild traumatic brain injury were examined. Each subject received 30 sessions of either a sham compression (room air at 1.3 ATA) or HBO 2 treatments at 2.4 ATA over an 8-week period. Individual and total symptoms scores on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT Ò) and composite scores on Post-traumatic Disorder Check List-Military Version (PCL-M) were measured just prior to intervention and 6 weeks after completion of intervention. Difference testing of post-intervention means between the sham-control and HBO 2 group revealed no significant differences on the PCL-M composite score (t = -0.205, p = 0.84) or on the ImPACT total score (t = -0.943, p = 0.35), demonstrating no significant effect for HBO 2 at 2.4 ATA. PCL-M composite scores and ImPACT total scores for sham-control and HBO 2 groups revealed significant improvement over the course of the study for both the sham-control group (t = 3.76, p = 0.001) and the HBO 2 group (t = 3.90, p = 0.001), demonstrating no significant HBO 2 effect. Paired t-test results revealed 10 ImPACT scale scores in the sham-control group improved from pre-to post-testing, whereas two scale scores significantly improved in the HBO 2 group. One PCL-M measure improved from pre-to post-testing in both groups. This study showed that HBO 2 at 2.4 ATA pressure had no effect on post-concussive symptoms after mild TBI.
Article
Drowning and submersion injuries are highly prevalent, yet preventable, causes of childhood mortality and morbidity. Although much of the resuscitation of the drowning pediatric victim is basic to all respiratory and cardiac arrest situations, there are some caveats for treatment of this type of injury. Risk factors for drowning victims include epilepsy, underlying cardiac dysrhythmias, hyperventilation, hypoglycemia, hypothermia, and alcohol and illicit drug use. Prehospital care should focus on restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult. Diagnostic testing for symptomatic patients may include blood glucose level, arterial blood gas level, complete blood count, electrolytes levels, chest radiography, and cardiorespiratory monitoring with pulse oximetry and a rhythm strip. In this review, passive external, active external, and active internal rewarming techniques for treatment of hypothermic patients are discussed. A systematic approach to treatment and disposition or admission of pediatric drowning victims is also included, with extensive clinical pathways for quick reference.