Thermal Burns

Written By Elizabeth Gaffney

Hyperbaric Oxygen Therapy for Thermal Burns

Introduction

Hyperbaric Oxygen Therapy (HBOT) consists of breathing oxygen at a pressure higher than local atmospheric pressure for multiple sessions for the treatment or prevention of specific diseases. As per the European Code of Good Practice (Kot et al.), there is a general consensus that the term HBOT can only be applied when the partial pressure of oxygen in breathing mixture exceeds 1.5 absolute atmosphere (ATA) for a minimum period of 60 minutes (excluding compression and decompression).

HBOT is a valuable adjunctive treatment for thermal burns in which it can enhance oxygen delivery, reduce inflammation and support tissue repair. There is robust clinical evidence supporting HBOT for thermal burns and as part of a comprehensive treatment plan, HBOT can improve outcomes and quality of life for patients with thermal burns.

Mechanisms of Action of HBOT

HBOT enhances oxygen delivery to tissues damaged by thermal burns and promotes the healing process, as well as reducing oedema, decreasing fluid requirements and increasing angiogenesis and the immune response (Edwards & Cooper, 2023). During HBOT, patients are treated with pure oxygen inside a chamber in which the pressure is higher than atmospheric pressure (2 ATA) for 1.5 hours for multiple sessions.

1. Enhanced oxygenation: Thermal burns may be associated with damage to blood vessels and impaired blood flow. HBOT significantly increases the oxygen content in blood plasma, facilitating greater oxygen delivery to damaged and inflamed tissues (Cannellotto et al., 2024).

2. Reduction of oedema: Burn injuries typically lead to oedema that compromises blood flow. HBOT may reduce oedema (Nylander et al., 1985) by promoting vasoconstriction while enhancing oxygen delivery, which improves tissue perfusion and reduces the risk of compartment syndrome.

3. Promotion of angiogenesis: HBOT stimulates angiogenesis by inducing the release of VEGF and other pro-angiogenic factors (Cannellotto et al., 2024) and improves blood supply to the damaged tissues.

4. Anti-inflammatory effects: Inflammation is a critical component of burn injuries. HBOT exerts anti-inflammatory effects (Capó et al., 2023) by reducing the levels of pro-inflammatory cytokines, such as TNF-α and IL-1β, while promoting the release of anti-inflammatory cytokines.

5. Collagen synthesis: HBOT enhances collagen synthesis and supports fibroblast function (Bhutani & Verma, 2010), promoting the formation of new connective tissue and aiding wound closure.

6. Antimicrobial activity: HBOT enhances the bactericidal function of leukocytes (Memar et al., 2019), which is particularly beneficial in managing infected burns. The hyperoxic environment also inhibits the growth of anaerobic bacteria (Cannellotto et al., 2024).

Benefits of HBOT for Patients with Thermal Burns

HBOT is generally well tolerated and serious side effects are rare (Camporesi, 2014). Patients with thermal burns may experience numerous benefits from HBOT, leading to shortened hospital stays, improved outcomes and fewer complications.

1. Accelerated healing: HBOT promotes the healing process (Niezgoda et al., 1997) via improved oxygen delivery, reduced inflammation and enhanced angiogenesis (Bhutani & Vishwanath, 2012).

2. Reduced risk of infections: Infection is a common complication of burn wounds. HBOT enhances the antimicrobial activity of leukocytes, helping to prevent and manage infections (Memar et al., 2019), and inhibits the growth of anaerobic bacteria.

3. Pain relief: HBOT can help alleviate pain due to thermal burns (Chen et al., 2018) by reducing inflammation, promoting tissue repair and attenuating central sensitisation (Rasmussen et al., 2015).

4. Reduction of scarring: HBOT may also contribute to the reduction of hypertrophic scarring (Khan et al., 2023) by promoting collagen synthesis and reducing inflammation.

5. Improved functional outcomes: By accelerating healing and reducing the risk of complications, HBOT can improve functional outcomes for burn patients.

Clinical Evidence Supporting HBOT of Thermal Burns

Numerous studies and clinical reports support the use of HBOT as an adjunctive treatment to prevent dermal ischaemia, reduce oedema, modulate the zone of stasis and promote healing of thermal burn injuries (Weitgasser et al., 2019; Cianci et al., 2021). HBOT at 2 ATA or above is recognised by the US FDA for the treatment of thermal burns. The Undersea and Hyperbaric Medical Society (UHMS) has published guidelines for HBOT for thermal burns and supports the integration of HBOT into clinical practice for managing burns. HBOT may be particularly beneficial for patients with severe burns, particularly those at risk of necrosis or chronic non-healing wounds (Edwards & Cooper, 2023).

1. Systematic reviews: Meta-analyses and reviews have highlighted the potential of HBOT (typically 100% O2, 2 ATA, 90 mins, >10 sessions) as an adjunctive therapy for thermal burns (Alyafi et al., 2021; Villanueva et al., 2004). A Cochrane review (Villanueva et al., 2004) included a randomised trial (Hart et al., 1974) that demonstrated that HBOT (100% O2, 90 mins, 2–3 daily sessions until healed) improved healing and decreased fluid requirements in burns patients.

2. Randomised controlled trials: RCTs examining the efficacy of HBOT in thermal burns have shown promising results. Studies by Cianci et al. (1989) and Kumar et al. (Kumar & Tiwari, 2020) demonstrated that HBOT (100% O2, 2 ATA, 90 mins, 10 sessions) significantly accelerated healing in patients with burns.

3. Case reports and series: Numerous case studies and clinical reports highlight the successful use of HBOT in treating thermal burns (e.g. Chen et al., (2018); 100% O2, 1.6 ATA, 60 mins, 20 sessions) and report faster wound healing, reduced pain, lower infection rates and improved functional outcomes following HBOT (Chiang et al., 2017).

4. Foot burns in diabetic patients: HBOT at 2 ATA before and after surgery (total 14–20 sessions) may improve graft take and complication rates in diabetic patients with foot burns (Jones et al., 2014; Jones et al., 2015).

5. Enhanced graft survival: Clinical studies indicate that HBOT (e.g. 100% O2, 90 mins, 2–3 daily sessions until healed) significantly improves the survival and integration of skin grafts in burn patients (Perrins, 1967; Hart et al., 1974), reducing the need for repeat grafting procedures.

Conclusion

HBOT can be an effective adjunctive treatment for thermal burns by enhancing oxygen delivery, reducing oedema, exerting anti-inflammatory effects, promoting angiogenesis and improving leukocyte function. Clinical evidence, including RCTs, case reports and systematic reviews, support the use of HBOT for thermal burns. HBOT may accelerate healing, reduce infection rates, alleviate pain, improve functional outcomes and reduce scarring in thermal burn patients.

References

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  • Cannellotto, M., Yasells García, A., & Landa, M. S. (2024). Hyperoxia: Effective mechanism of hyperbaric treatment at mild-pressure. International Journal of Molecular Sciences, 25(2), 777.

  • Capó, X., Monserrat-Mesquida, M., Quetglas-Llabrés, M., Batle, J. M., Tur, J. A., Pons, A., … & Tejada, S. (2023). Hyperbaric oxygen therapy reduces oxidative stress and inflammation, and increases growth factors favouring the healing process of diabetic wounds. International Journal of Molecular Sciences, 24(8), 7040.

  • Chiang, I. H., Chen, S. G., Huang, K. L., Chou, Y. C., Dai, N. T., & Peng, C. K. (2017). Adjunctive hyperbaric oxygen therapy in severe burns: experience in Taiwan Formosa Water Park dust explosion disaster. Burns, 43(4), 852-857.

  • Chen, K. L., Wu, C. J., Tseng, W. S., Lee, H. C., Tsai, T. P., & Huang, W. S. (2018). Improvement of satisfaction in burn patients receiving adjuvant hyperbaric oxygen therapy. Formosan Journal of Surgery, 51(5), 184-191.

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  • Cianci, P., Sato, R. M., & Faulkner, J. (2021). Hyperbaric oxygen for thermal burns. Undersea & Hyperbaric Medicine, 48(4).

  • Edwards, M., Cooper, J.S. (2023). Hyperbaric Treatment of Thermal Burns. In: StatPearls. StatPearls Publishing, Treasure Island (FL).

  • Hart, G. B., O’reilly, R. R., Broussard, N. D., Cave, R. H., Goodman, D. B., & Yanda, R. L. (1974). Treatment of burns with hyperbaric oxygen. Surgery, Gynecology & Obstetrics, 139(5), 693-696.

  • Jones, L. M., Coffey, R., Khandelwal, S., Atway, S., Gordillo, G., Murphy, C., … & Dungan, K. (2014). A clinician’s guide to the treatment of foot burns occurring in diabetic patients. Burns, 40(8), 1696-1701.

  • Jones, L. M., Rubadue, C., Brown, N. V., Khandelwal, S., & Coffey, R. A. (2015). Evaluation of TCOM/HBOT practice guideline for the treatment of foot burns occurring in diabetic patients. Burns, 41(3), 536-541.

  • Khan, N., Halaseh, F. F., Pillai, K., Zaki, D. P., Sayadi, L. R., & Widgerow, A. D. (2023). Hyperbaric and topical oxygen therapies in thermal burn wound healing: a review. Journal of Wound Care, 32(Sup2), S20-S30.

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  • Kumar, N., & Tiwari, V. K. (2020). Evaluation of efficacy of hyperbaric oxygen therapy as an adjunctive therapy in the management of thermal burns. Indian Journal of Burns, 28(1), 44-50.

  • Memar, M. Y., Yekani, M., Alizadeh, N., & Baghi, H. B. (2019). Hyperbaric oxygen therapy: Antimicrobial mechanisms and clinical application for infections. Biomedicine & Pharmacotherapy, 109, 440-447.

  • Niezgoda, J. A., Cianci, P., Folden, B. W., Ortega, R. L., Slade, B. J., & Storrow, A. B. (1997). The effect of hyperbaric oxygen therapy on a burn wound model in human volunteers. Plastic & Reconstructive Surgery, 99(6), 1620-1625.

  • Nylander, G., Lewis, D., Nordström, H., & Larsson, J. (1985). Reduction of postischemic edema with hyperbaric oxygen. Plastic & Reconstructive Surgery, 76(4), 596-601.

  • Perrins, D. J. D. (1967). Influence of hyperbaric oxygen on the survival of split skin grafts. The Lancet, 289(7495), 868-871.

  • Rasmussen, V. M., Borgen, A. E., Jansen, E. C., Rotbøll Nielsen, P. H., & Werner, M. U. (2015). Hyperbaric oxygen therapy attenuates central sensitization induced by a thermal injury in humans. Acta Anaesthesiologica Scandinavica, 59(6), 749-762.

  • Villanueva, E., Bennett, M. H., Wasiak, J., & Lehm, J. P. (2004). Hyperbaric oxygen therapy for thermal burns. Cochrane Database of Systematic Reviews, (2).

  • Weitgasser, L., Ihra, G., Schäfer, B., Markstaller, K., & Radtke, C. (2021). Update on hyperbaric oxygen therapy in burn treatment. Wiener Klinische Wochenschrift, 133, 137-143.

 

Elizabeth Gaffney https://www.sourceprojects.co
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