Effect of hyperbaric oxygen therapy on peripheral vascular diseases

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Spasojević N. et al. MedPodml 2017, 68(4):27-31 doi:10.5937/mp68-13736
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EFFECT OF HYPERBARIC OXYGEN THERAPY ON
PERIPHERAL VASCULAR DISEASES
EFEKAT HIPERBARIČNE OKSIGENOTERAPIJE KOD
PERIFERNIH VASKULARNIH BOLESTI
Natalija Spasojević1, Predrag Brkić1
1 School of Medicine, University of Belgrade, Serbia
Correspondence: natalija_spa@hotmail.com
ABSTRACT
Key words:
Peripheral vascular disease,
Hyperbaric oxygen therapy,
Ulcer
Introduction: Peripheral vascular disease (PVD) is a common and concerning symp-
tom of several habits and illnesses and occurs most oen in the lower extremities. PVD
manifests itself by decreasing blood ow to tissues and therefore causing a lack of oxygen-
ation, which, if not treated, can ultimately progress to ulcer formation. It is suggested that
Hyperbaric oxygen therapy (HBOT) may lead to revascularization of the aected tissue.
Aim: is study was performed in order to determine whether HBOT can aid wound and
ulcer healing, caused by PVD.
Material and methods: 20 participants (14 male, 6 female and age ranging from 45 to
89) have taken part in this case study. All of them suered from PVD symptoms, such as
developed ulcers, open wounds and pain. At 2.2 atmospheres (ATM) with 100% oxygen,
the patients fullled 15 sessions, each lasting 60 minutes, where the decompression and
compression phases lasted 10 minutes each. Treatment took place in the HBO Medical
Center in Belgrade. Existing ulcers and their changes were classied. e subjective feel-
ing of pain has been evaluated routinely. e data were analyzed with the Student t-test
and ANOVA.
Results: e outcome presented itself with a clear commenced healing of ulcers, wound
and pain reduction. Additional improvements in elongation of intermittent claudication
distance and peripheral sensation could also be observed. Ten patients partook in 5 or 10
further sessions, before noteworthy progress could be observed.
Conclusion: According to this study, HBOT can facilitate the healing of existing ulcers
and wounds caused by PVD, if used as a preventative method. However, a larger amount
of participants, with control groups, should be used for a denitive conclusion.

Spasojević N. et al. Effect of hyperbaric oxygen therapy on peripheral vascular diseases. MedPodml 2017, 68(4):27-31
Medicinski podmladak / Medical Youth28
Ključne reči:
periferna vaskularna bolest,
hiperbarična oksigenoterapia,
ulcer
Introduction
It is a fact that the global number of people with
peripheral vascular diseases (PVD) is increasing, due to
the rise in the elderly population (1). Additional illnes-
ses and habits such as smoking, poor physical activity or
diabetes mellitus can also contribute to the development
of the disease. is and several other factors lead to the
formation of atherosclerosis, which is important in under-
standing the serious consequences of PVD.
A peripheral vascular disease is a slow and progre-
ssive circulation disorder caused by narrowing, blockage,
or spasms in a blood vessel. It can occur in any blood ve-
ssel outside the coronary system, most oen it is seen in
the ones leading to the lower extremities. is leads to di-
minished blood, and therefore oxygen and nutrient supply
of the surrounding tissue. Since the supply is decreased,
necrosis and formation of cutaneous wounds can occur.
Hyperbaric oxygenation (HBO) or hyperbaric
oxygen therapy (HBOT) is the therapeutic modality in
which a patient breathes 100% oxygen intermittently, whi-
le the pressure of the treatment chamber is increased to
more than one atmospheric pressure (2). Successful use
of hyperbaric oxygen has been noted for treatment for a
variety of conditions (3). It has been suggested by seve-
ral studies that hyperbaric oxygen therapy (HBOT) might
improve revascularization, and therefore wound healing.
However, two large scale studies contradict each other
in their ndings. While M. Löndahl MD and his colle-
agues (4) claim that HBOT treatment facilitates healing
of chronic foot ulcers in selected patients with diabetes,
L. Fedorko and his colleagues (5) follow the conclusion,
that HBOT does not reduce indications for amputation
in patients with diabetes with non-healing ulcers of lower
limbs.
Since the overall results are contradictory to one
another, this study has been conducted in order to contri-
bute, and hopefully shed some light on the possible outco-
me with HBOT and peripheral vascular disease.
Research Design and Methods
is study is a case series study that was conducted
on 20 patients that were admitted to the HBO Medical
Center in Belgrade, due to a previous diagnosis of perip-
heral vascular disease.
e participants in the study were informed about
research protocol and written approval for participation
in the study was obtained from each patient. Our research
was approved by the Ethical Committee of the Center for
Hyperbaric Medicine (EC 9/20016).
e patients from both groups were exposed to
100% oxygen in the multi-measuring hyperbaric cham-
ber (Model: Haux Starmed, Haux Life Support GmbH,
Karlsbad-Ittersbach, Germany)
e rst part of the treatment was the compression
phase, which lasted for 10 minutes and was followed by
a period with an atmospheres absolute of 2.2 (ATA) for
60 minutes. e last part, the decompression phase lasted
for another 10 minutes. Every session was performed once
per day. ere were 15 treatment sessions in total, which
were held during work days, without the weekends.
During the study, all of the patients continued with
their regular therapy, noted glycaemia was followed and
cutaneous wounds were regularly checked, measured and
SAŽETAK
Uvod: Periferna vaskularna bolest (PVB) je čest i zabrinjavajući simptom određenih na-
vika i bolesti, te se najčešće pojavljuje u donjim ekstremitetima. Manifestuje se kroz sma-
njenu vaskularizaciju tkiva i stoga izaziva smanjenu oksigenaciju. Nelečena, može da do-
vede do formiranja ulcera. Smatra se da tererapija hiperbaričnom oksigenacijom (HBOT)
može da dovede do revaskularizacije i obnove oboljelog tkiva.
Cilj: Ovo istraživanje je sprovedeno kako bi se utvrdila efektivnost HBOT u oporavku
rana i tkiva oboljelih od periferne vaskularne bolesti.
Materijal i metode: U ovoj studiji slučaja učestvovalo je 20 pacijenata (14 muškaraca, 6
žena, starosti 45-89 godina). Svi su imali simptome PVB, kao što su razvoj ulcera, otvo-
rene rane i bol. Tokom 15 seansi, pacijenti su izloženi pritisku od 2,2 atmosfere (ATM),
primjenom 100% kiseonika. Svaka seansa je trajala 60 minuta, od čega su faze kompresije i
dekompresije trajale po 10 minuta. Tretmani su sprovedeni u Centru za hiperbaričnu me-
dicinu u Beogradu. Klasikovani su postojeći ulceri i njihove promjene. Subjektivni osje-
ćaj bola je redovno praćen. Podaci su analizirani uz pomoć Studentovog t-testa i ANOVA
testa.
Rezultati: Ishod istraživanja su početak zarastanja ulcera, umanjenje perifernih senzor-
nih tegoba, kao i smanjenje bola. Registrovano je i produženje klaudikacione distance.
Deset pacijenata je učestvovalo u dodatnih 5 ili 10 sesija prije nego što se moglo ustanoviti
značajno poboljšanje.
Zaključak: Prema ovom istraživanju, HBOT može da doprinese zarastanju postojećih ul-
cera i rana izazvanih perifernom vaskularnom bolesti, ako se koristi kao preventivna me-
toda. Veći broj učesnika sa kontrolisanim grupama doprinio bi denitivnom zaključku.

Medicinski podmladak / Medical Youth
Spasojević N. et al. Effect of hyperbaric oxygen therapy on peripheral vascular diseases. MedPodml 2017, 68(4):27-31
29
bandages were changed. e wounds and ulcers on the
lower extremities were classied by the widely accepted
and universally used grading system, Wagner – Meggitt’s
classication (6).
Some patients were suering from muscle cramps
and discomfort in their lower extremities while walking.
ese symptoms are also called intermittent claudication
and it is due to the poor vascularization of tissues in PVD.
It was suggested that revascularization of wounds can im-
prove symptoms (7). Since about a third to a half of pa-
tients with PVD have this symptom (8), the changes were
regularly followed. A common nominator of all patients
was lower limb pain. e importance of this lies in that
continuous, unrelieved pain can not only aect the physi-
cal but also psychological state of the patient (9). In or-
der to measure such an unpleasant sensory and emotional
experience associated with tissue damage (10), the “Verbal
Scale of Pain” was used. e scale was constructed with
four options, each of which stood for a short description
of momentary pain feeling such as “without pain, slight
feeling of pain, moderate feeling of pain and strong pain”
(11). Patients were daily inquired about their subjective
pain feeling and they responded by choosing one of the
options mentioned above.
Statistical analysis
For the evaluation of non numerical parameters,
descriptive statistics were used. All numerical parameters
were depicted as the middle value with the corresponding
standard deviation. In order to test the signicant die-
rence for independent and related causes, analysis of va-
riance (ANOVA) and the Student’s t-test were used. All
the results obtained during the study were processed with
the statistical computer program SPSS 12.0 for Windows.
In all the tests, the dened statistical signicance value was
p < 0.05 and p < 0.01
Results
A total of 20 eligible patients, 14 of which were
men and 6 women, participated in the study. e sex dis-
tribution depends on the incidence of disease in the popu-
lation. All patients who were treated in our center during
a six month period (October 1, 2016 to February 1, 2017)
were included.
A number of 4 (20%) patients completed 25 sessi-
ons, 6 (30%) completed 20 sessions and 10 (50%) comple-
ted 15 sessions (Tab le 1 ). ere were no withdrawals or
early treatment cancellations.
Table 1. Number of HBOT treatments
Female sex 20.83
Male sex 17.5
ere were 14 (100%) men and 4 (66.7%) women
with diabetes mellitus type 2 and 2 (33.3%) women with
diabetes type 1. Both diseases have been present in all pa-
tients for > 30 years (Tab l e 2 ). Ulcer appearance was iden-
tied in 13 (93%) men and 6 (100%) women. e majority
of both groups was aected by multiple ulcers (Tab l e 3).
Claudication was present in 2 (14.3%) men and 2 (33%)
women. e intensity of the verbal scale of pain in the
lower extremities belonged mostly to numbers 3 and 4. A
number of 9 (64.3%) men and 2 (33.3%) women experien-
ced peripheral edema (Tabl e 4) and 12 (85%) men and 3
(50%) women had reduced sensibility of the aected limbs
(Tabl e 5). All results in summary are listed in Tab le 6 .
Table 2. Baseline patient characteristic
Table 3. Peripheral complications
Table 4. Mobility
Male sex Female sex
n (20) 14 6
Age (years) 65 (45-81) 69 (49-89)
BMI (kg/m2) 26 (22-32) 23 (18.8-26)
Type I diabetes 0 (0%) 2 (33.3%)
Type II diabetes 14 (100%) 4 (66.7%)
Glycaemia (mol/L) 11.4 (6-19.6) 8.8 (5.5-15.9)
Diabetes duration (years) 30 > 35 >
Smoking habits
Current (%) 14.3% 33.3%
Previous (%) 78.6% 0%
Hypertension 10 4
Previous peripheral artery
revascularization 7 1
Previous amputation 6 2
Male sex Female sex
Ulcer (%) 93% 100%
Multiple (%) 54% 67%
Single (%) 46% 33%
No. of days/months
with ulcer
4.9 months (3-6)
*no data, n=6
4.4 months (3-5)
*no data, n=1
Wagner grade
0 6
1 0 0
2 1 3
3 3 1
4 4 1
5 0 0
Male sex Female sex
Walking without support (%) 9 5
Walking with support (%) 5 1
Wheelchair 1 0
Claudication presence (%) 14.3% 33%
Presence of pain in lower extremities (Verbal scale of pain)
1 0 0
2 1 1
3 8 3
4 5 2
Presence of edema 9 (64.3%) 2 (33.3%)

Spasojević N. et al. Effect of hyperbaric oxygen therapy on peripheral vascular diseases. MedPodml 2017, 68(4):27-31
Medicinski podmladak / Medical Youth30
Table 5. Peripheral sensibility
Table 6. Outcome
Discussion
e claudication distance was elongated in 13
(93%) men and 3 (50%) women. e proportion of wo-
men receiving HBOT was signicantly lower comparing
to the male group, which is in accordance with other stu-
dies (12,13).
e verbal scale of pain intensity went down to
being most prominent on numbers 1 and 2. Edema was
reduced in 9 out of 9 (100%) men and 2 out of 2 (100%)
women. In 10 out of 12 (83%) men and 2 out of 3 (66%)
women an improvement in peripheral sensibility was ob-
served. e reduction of cramps and numbness was seen
in 3 out of 3 (100%) men and in 1 out of 2 (50%) men and
no women since none of them were aected by these two
symptoms. An additional reduction of tingling occurred
in 10 out of 11 (90%) men and 2 out of 3 (66%) women.
Distinct positive trophic changes were seen, such
as a loss in depth of deep and supercial layers of wounds,
which ultimately started to close up (Figure 1). A clear
improvement in coloration, increase in temperature and
vascularization of the lower limbs was noted in more than
half of the male and female patients that weren’t categori-
zed in Wagner grade 0.
A previous randomized, double blinded study by
Löndahl et al. (4) suggests similar conclusions. In this
study, therapy duration over 10 weeks with a total of 94
patients was exercised (4). ‘An HBOT session included a
period of compression in air for 5 min, followed by a tre-
atment period at 2.5 atmospheres absolute (ATA) for 85
min, and then a decompression period of 5 min’ (4). e
participants used gas masks in which either gas or air was
administered. erefore a control group could be followed
at the same time. A majority of the patients completed the
full 40 sessions (4). Löhndal et al. formed an index ulcer,
that belonged to Wagner’s grade 3 and 4 (4). e healing
process could be observed aer two months. ‘Complete
healing of the index ulcer was achieved in 37 patients at
1-year of follow-up in 25/48 (52%) in the HBOT group
and 12/42 (29%) in the placebo group (P = 0.03)’ (4). e
study by Löndahl et al. diered in having more partici-
pants, longer duration and a higher number of treatment
sessions. e results obtained, such as the signicant chan-
ge in ulcer reduction in patients, align with the direction
of the study discussed in this paper.
Another double blinded, placebo-controlled study
by Fedorko et al. ‘aimed to assess the ecacy of HBOT
in reducing the need for major amputation and impro-
ving wound healing in patients with diabetes and chronic
DFUs’ (5). Over a period of 6 weeks, a total of 103 patients
underwent treatment and a majority of both groups com-
pleted all of the sessions. e 30 HBOT sessions lasted 5
days per week and consisted of ‘breathing oxygen for 90
min at 244 kPa of pressure, with 5-min intervals of breat-
hing air for every 30 min of oxygen’ (5). e control group
sessions breathed air of about 125 kPa of pressure (5). e
outcomes stated that there was a ‘lack of signicant pro-
gress in wound healing over the follow-up period, which
indicated ongoing risk of severe systemic infection rela-
ted to the wound. Persistent deep infections involving the
bone and tendons and the inability to bear weight on the
aected limb’ (5) were also part of the results.
A non signicant dierence was found for HBOT,
with 11 (22.5%) HBOT group participants and 13 (24.1%)
sham group participants meeting the criteria for major
amputation (odds ratio [OR] 0.91 [95% Cl 0.37, 2.28], P =
0.846) at the end of the 12-week study period. e hypot-
hesized benet of HBOT was a reduction in indication for
amputation of 28%, and the results indicated a dierence
of < 3 percentage points (5).
Male sex Female sex
Reduced sensibility (%) 85.7% 50%
Cramps (%) 29% 0%
Numb (%) 7% 0%
Tingling (%) 86% 50%
Male sex Female sex
Elongation of
Claudication distance (%)
93% 50%
Presence of pain in lower extremities (Verbal scale of pain)
0 (no pain) 1 1
1 9 4
2 4 1
3 0 0
4 0 0
Reduction of edema (%) 9 out of 9 (100%) 2 out of 2 (100%)
Improvements in
sensibility (%)
85.7% 76.8%
Reduction of Cramps (%) 3 out of 3 (100%) 1 out of 2 (50%)
Reduction of Numbness
(%)
83.9% 86%
Reduced Tingling (%) 10 out 11 (90%) 2 out of 6 (30%)
! !
Figure 1. Foot wound before and aer HBOT treatment

Medicinski podmladak / Medical Youth
Spasojević N. et al. Effect of hyperbaric oxygen therapy on peripheral vascular diseases. MedPodml 2017, 68(4):27-31
31
Even though there was a larger group of partici-
pants and an additional control group in the study desi-
gned by Fedorkos et al., as opposed to the one in this artic-
le, the results are contrary to it and the above mentioned
one by Löhndal et. al. Although the number of HBOT se-
ssions was slightly higher than in the study of this paper,
wound complications rather than improvement through
healing was noted.
Conclusion
e results of our study are in agreement with the
ones published in the earlier mentioned one by Löndahl
et al. (5), in which they stated that HBOT helps the hea-
ling process of ulcers of diabetic patients. In contrast to the
above mentioned study, our research was limited in the
way that we didn’t have a control group.
An additional constraint in reaching other conclu-
sions was that our group of participants wasn’t large eno-
ugh, in order to determine other factors and dierences
that might play a role in HBOT. For instance, a clear distin-
ction of whether the treatment worked better in women or
in men isn’t possible because there wasn’t an equal amount
of either involved. However, HBOT was seen to have evi-
dent curative eect on already present PVD symptoms but
a greater benet was found if used as a preventative tre-
atment. We observed that Hyperbaric Oxygen erapy is a
useful preventative measure for growth and development
of ulcers, as it supports the revascularization and healing
process of PVD wounds. A vast majority of patients regai-
ned health benets, as a cause of this therapy. In addition,
this treatment increases the patient’s life quality by decrea-
sing the amount of possible surgical interventions, such as
amputations and medical costs.
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