What is Hyperbaric Treatment of Diabetic Foot Ulcer?
Diabetic foot ulcers, or DFU in short, are a problem that affects about 15% of people who have diabetes. These open sores typically appear on the bottom part of the foot that supports your weight when you stand or walk. Out of those with a diabetic foot ulcer, 6% will need to be hospitalized because of infection or other issues related to the ulcer, and for 1% of these patients, amputation might be necessary. In fact, complications from diabetes are a top reason for amputations that aren’t related to injuries. This topic talks about hyperbaric oxygen therapy, which involves breathing in pure oxygen in a pressurized room or tube and has shown to be a successful treatment for this problem.
What Causes Hyperbaric Treatment of Diabetic Foot Ulcer?
Diabetic foot ulcers (DFUs) are a common complication in people with diabetes (DM). They can happen due to changes in the structure of the foot, foot numbness (peripheral neuropathy), and poor blood flow (atherosclerotic peripheral arterial disease). All of these conditions are more likely in people with diabetes.
A condition known as nonenzymatic glycation can make the foot’s ligaments stiff in individuals with diabetes. Additionally, diabetic neuropathy can lead to a loss of awareness of pain and sensation in the feet and lower limbs. This can make someone less aware of their body’s standing and moving (known as loss of proprioception), affect their balance, and lessen their ability to perceive pain.
Foot ulcers in people with diabetes usually start as small pressure spots or areas of irritation. They can also develop from a minor injury that a person may not even notice, especially if their feet and lower limbs have become insensate, meaning they’ve lost normal feeling.
Risk Factors and Frequency for Hyperbaric Treatment of Diabetic Foot Ulcer
Type II Diabetes is a growing health issue in the United States, especially because it’s increasing rapidly even among young people. This rise in diabetes cases leads to an increase in serious foot ulcers and infections associated with the disease. In fact, diabetes is the leading cause of non-accidental amputations in the country. A diabetic patient who has a lower limb amputated because of a foot infection has more than a 50% chance of losing the other limb within the next year. Furthermore, there’s a 70% mortality rate within five years for a diabetes patient who has had an amputation, and a 74% two-year mortality rate for a diabetic patient undergoing kidney replacement therapy.
There are various ways to grade diabetic foot ulcers, but the Classic Wagner Grading system is used most often. This system has 5 grades which depend on the severity of the ulcer and whether there’s an infection or gangrene present. A Grade 1 ulcer is more superficial, while a Grade 4 ulcer is deep, very serious, infected, and gangrenous. Most patients with diabetic foot ulcers that are treated at Wound Centers have Grade 2 to 4 ulcers.
- Wagner Grade 0: No open sores, but there may be healed sores
- Wagner Grade 1: A superficial ulcer that hasn’t penetrated deeper layers
- Wagner Grade 2: A deeper ulcer that has reached the tendon, bone, or joint
- Wagner Grade 3: Even deeper tissues are affected, with conditions like abscess, bone infection, or tendon inflammation
- Wagner Grade 4: Part of the foot has gangrene
- Wagner Grade 5: The entire foot, or enough of it, has gangrene to necessitate amputating the limb
Signs and Symptoms of Hyperbaric Treatment of Diabetic Foot Ulcer
If you have a diabetic foot ulcer (DFU), your doctor will want to know when you first noticed the wound and what treatments you’ve tried, if any. Some patients with nerve damage may not be aware they have a wound until it starts to drain or becomes discoloured and smells bad. This is known as “fetid foot”. Additionally, diabetes can affect your immune system, so you might not have a fever or elevated white blood cell count even when an infection is severe.
During your doctor’s visits, both of your feet will be examined. Special attention will be given to the areas between your toes to look for cracks, fissures, or signs of fungal infection. The doctor will likely ask about your blood sugar control as it should consistently be 150 mg/dL or less for DFUs to heal.
Your doctor will also perform a Semmes-Weinstein 10-gram monofilament test, which checks for a loss of protective sensation in your feet. They will also check the pulses in your foot. If these pulses can’t be felt, your doctor will use a Doppler device to check for blood flow and record the results. It’s recommended that all patients over 50 get a baseline arterial ultrasound to assess blood flow values. If there’s any issue with blood circulation in your limbs, you may be referred to a vascular surgeon.
- Examine both feet for wounds or signs of infection
- Check the areas between toes
- Assess blood sugar levels
- Perform a Semmes-Weinstein 10-gram monofilament test
- Check foot pulses
- Consider an arterial ultrasound (for patients over 50)
- Potential referral to a vascular surgeon (for blood circulation issues)
Your doctor will also look at your shoes and the way you walk. Many DFUs are caused by inappropriate footwear that puts pressure on the foot and causes friction. Lastly, the doctor will look at the wound. They will measure its length, width, and depth, and check if the wound tunnels deep into the tissue or hits bone. They’ll look at the surrounding tissues for signs of swelling, hardness, or dampness from wound drainage and note any odor, colour, and quality of wound drainage.
Testing for Hyperbaric Treatment of Diabetic Foot Ulcer
After checking and determining the stage of your diabetic foot ulcer (DFU), your doctor may need further information through some lab tests and x-rays.
A complete blood count (CBC) is a test that measures different components of your blood. Your doctor may also check your kidney function with a test named BUN (blood urea nitrogen) and creatinine. Other tests may include sedimentation rate, which assesses inflammation in your body, and C-reactive protein, another marker for inflammation often used to detect infections. Lastly, a glycosylated hemoglobin test checks your average blood sugar level over the past two to three months.
If there’s a possibility that the infection has reached your bone, the doctor might order an x-ray or an MRI scan, or a 3-phase bone scan – different kinds of imaging techniques that can show up any signs of bone involvement.
If your wound has a Wagner stage of 3 or more and fails to get better with standard wound care for over 30 days, you may be recommended to consult with a doctor specializing in hyperbaric medicine. Chronic, non-healing wounds and the skin around them lack oxygen. The only method to deliver more oxygen to these oxygen-starved tissues is through hyperbaric oxygen treatment.
This treatment increases the amount of oxygen reaching your wound, spurs development of new blood vessels in and around the wound, helps deliver certain antibiotics to your tissues, encourages the function of fibroblasts, cells that contribute to wound healing, and attracts growth factors, proteins that aid in wound repair.
Simply put, hyperbaric oxygen treatment is 100% oxygen provided under high pressure. For this treatment, you would be placed inside a specially designed chamber, and you would typically receive the treatment at pressures approximating the pressures at 33 feet to 42 feet underwater. Most frequently, these treatments would be given every day for about 60 to 90 minutes, and this would continue for 30 to 60 treatments or sessions.
To minimize the risk of oxygen toxicity for patients at risk, 5-minute air breaks are given every 30 minutes during the treatment. During these breaks, you would be breathing 21% oxygen through a mask or a handheld mouthpiece. This practice reduces the chances of seizures related to oxygen toxicity to approximately one in every 10,000 treatments.
Treatment Options for Hyperbaric Treatment of Diabetic Foot Ulcer
The key to treating diabetic foot ulcers (DFUs) is pressure removal, or ‘offloading’. Healing cannot occur unless the wound is relieved from continuous pressure. Various methods exist to achieve offloading, from specially made shoe inserts to boots that aim to decrease the pressure on the wound. Placing a total contact cast, which is a cast that is shaped specifically to the patient’s foot and leg, is viewed as the best method for offloading DFUs, especially when they are located on the heel which bears weight.
Clinical guidelines suggest the addition of hyperbaric oxygen treatment (HBOT), where a patient breathes pure oxygen in a pressurized room or tube, in dealing with DFUs. This treatment is particularly recommended for severe DFUs (classified as Wagner 3 or higher) after the infected foot has undergone surgical cleaning. Using HBOT shortly after this surgery can lower the risk of needing a major amputation and help skin grow back completely. Further recommendations suggest adding HBOT if standard treatments haven’t shown much improvement after 30 days for severe DFUs. They also recommend against using HBOT for less severe DFUs (Wagner 2 or lower).
Research has shown that patients who received HBOT for DFUs had faster healing rates and were less likely to have their ulcers return after a year, compared to those who did not receive HBOT.
What else can Hyperbaric Treatment of Diabetic Foot Ulcer be?
If you’re feeling unwell, it’s possible that the cause could be one of several conditions, such as:
- Anemia
- Arthritis
- Atherosclerosis (hardening of the arteries)
- Autonomic neuropathy (damage to the nerves that control your body’s automatic functions)
- Chronic venous insufficiency (impaired blood flow in the veins, usually in the legs)
- Diabetic foot infections
- Muscle pain
- Metabolic neuropathies (nerve disorders caused by metabolic problems)
- Myxedema (severe hypothyroidism)
- Radicular pain (pain that radiates along the nerve caused by inflammation or injury)
It’s always essential to visit a healthcare professional to get a proper diagnosis if you’re experiencing health concerns.