The Top Ten Tips For Optimizing Oxygen Therapy in Your Practice
Editorial Summary Oxygen therapy is a well evidenced modality of care in clinical wound practice. It can provide many benefits, such as a reduction in hospitalizations and amputations for diabetic foot ulceration patients. This article provides a practical top ten tips for the methods of optimization of oxygen therapy in your practice; taking into account factors for delivery of this modality such as activity, wound impacting factors; comfort, economic impact; geographic factors, capable participation level; compliance/ adherence, number of wounds and severity, and active infections, all of which will be discussed in this article to improve patient care delivery.
Introduction
This article is the second of two I have written on oxygen therapy for Wound Masterclass; the first, ‘Optimizing Oxygen Therapy in Your Clinical Wound Practice’, published in the inaugural May – June issue, provided a concise background and overview to this modality. This second article is intended to complement the first with a practical ‘Top Ten Tips’ of use to the clinican, in introducing this modality to their practice and how to approach the various factors involved.
1. Activity Level How active is my patient?
If they need to be active because they are still working and supporting a family you may want to consider a portable continuous diffusion device. Are they retired and have a more sedentary lifestyle, where at home delivery devices that are not as mobile may be used? Is the mobility from some delivery systems beneficial for the patient, or will the ambulation and freedom from a more portable device enable your patient to partake in more activities than you recommend? The boot systems and chambers are great for providing guaranteed non ambulatory stationary time when activity restriction is desired. The pressurized system requires the patient to sit near the condenser unit, ensuring that during device use they cannot do much, thus allowing protected offloading time. If they do need to be mobile, the continuous delivery systems offer that freedom. If you want to limit mobility, the boot/ sleeve systems require close association to the base unit and do not allow free movement while on therapy.
2. Wound Impacting Factors
Some of the delivery systems differ in the ability to move edema during use, adding the benefit of fluid control. The cyclic pressurized TOT delivery system (not the continuous flow TOT systems) has the added benefit of sequential non-contact compression of the limb, which helps to reduce peripheral edema in addition to the oxygen, and promotes arterial blood flow. Wound bed dryness is another consideration. Topical oxygen requires delivery to the wound surface and requires a moist wound environment; HBOT delivers the oxygen systemically and does not have this requirement. Dry wound beds will have an issue with the diffusion of oxygen, and thick gel wound care products will inhibit diffusion of the oxygen molecules. Pressurized cyclical TOT has the added benefit of adding humidification for oxygen diffusion. Keep in mind, moist wound environments have better outcomes compared to dry wound therapy.
3. Comfort
For some, group settings have a positive impact on patients, while it makes others withdraw from social interactions because of the wounds. HBOT requires frequent interactions in a facility and may utilize multi-place units or single full body chambers, which have the additional claustrophobic issue. If the patient is not comfortable, they will not use the therapy and thus the treatment is ineffective. It has been well documented that oxygen therapy reduces wound pain; this benefit is achieved from both HBOT and TOT. Physical discomfort may come from devices that require seals (TOT boots/ sleeves) to achieve pressure, or from prolonged stationary positions (HBOT and high/ low pressurized TOT systems) for 60120 minutes at a time. The TOT systems have less noticeable negative side effects during use compared to HBOT, which can cause temporary myopia, glycemic control issues, middle ear barotrauma, pulmonary oxygen toxicity, and CNS oxygen toxicity.
4. Economic Impact to the Patient
Can your patient afford to drive or take transportation daily to your office or treatment facility, if HBOT is the recommendation? Does their insurance plan cover the therapy or is it an out-of-pocket expense? Can they maintain their job occupation under the therapy, or do they need to take time away in order to utilize the therapy?
5. Geographic Location
Where is the patient located? What if your patient is in a rural area and can only make infrequent appointments? Don’t forget about the homebound patients who cannot leave, and telehealth patients who prefer to stay virtual. HBOT requires daily transportation to a specific location. TOT devices can be used at home and do not require transportation, and can also be used in skilled facilities and inpatient settings.
6. Capable Participation Level
How involved is your patient in their care? Are they capable of performing their own dressing changes and therapy or do they rely on others to help, and are they capable of helping with the therapy prescribed? Patients that cannot perform their own care but have no problem getting transportation may do better with HBOT. Pressurized TOT systems are daily applications; patients or caregivers that can participate in donning and doffing of boot/chamber delivery systems daily will find benefit from this therapy. Continuous TOT device systems may stay in place in the dressing for 1 – 2 weeks and do not need to be changed as often, but do require batteries that need to be charged/ changed often, which can also be problematic. Cognition deficiencies pose wound care problems in general with dressing changes, without the added daily application or battery changes.
7. Compliance/ Adherence
No matter which therapy you think would be best, it all comes down to your patient’s willingness to participate. If you know your patient misses recommended appointments but oxygen therapy is indicated, then a system which requires the least amount of patient involvement would likely work better. Continuous diffusion systems do not need to be changed/ used daily and do not require daily transportation to another location. Home health agencies can preform the dressing changes and they are user friendly, for the more independent individual.
8. Number of Wounds and Severity
Let’s face it, some patients unfortunately have more than one wound or wounds that are very large. Continuous TOT devices are designed for single wounds or smaller wounds grouped together. They rely on tubing under occlusive dressing to deliver the oxygen. Larger wounds and patients with multiple wounds need a larger surface area of coverage, which would best be found from the pressurized devices and HBOT.
9. Active Infection
All oxygen delivery systems can be used in conjunction with treated infections but are not a substitute for antibiotic therapy. HBOT has the added benefit of being synergistic with some antibiotics due to its systemic delivery where the TOT do not, and HBOT also has a specific indication for osteomyelitis. HBOT has the strongest evidence of support with severe infections to include necrotizing and clostridial. Cyclic pressurized TOT systems, along with HBOT, have been shown to increase local wound partial oxygen tension. Increasing the wound oxygen tension has a direct effect on leukyocyte activity in clearing the infection. Activated neutrophils produce NADPH oxidase to generate reactive oxygen species, which also consumes the available oxygen. Between the cellular activity needed to fight an infection, the now increased metabolic demand of oxygen to heal damage tissue, and bacterial or fungi consumption thereof, the wound tends to be depleted of available oxygen creating a hypoxic like environment. Chronic wounds with suspected biofilms will have a chronic increase of neutrophils, thereby high oxygen consumption that continues to impede wound healing.
10. Dressing Compatibility
HBOT can be used with any dressing choice. Topical delivery systems cannot be used in conjunction with gels, as they hinder the oxygen from getting into the wound bed (they can be wiped out before device use for the noncontinuous delivery devices). Continuous non pressurized devices require occlusive dressings to keep the oxygen locally and if not kept in check can lead to maceration of the periwound. Pressurized systems can go through breathable dressings like unna boots, compression systems, and even TCC.
Cyclical Pressurized TOTNon-cyclical pressurized TOTContinuous non-pressurized TOT HBOT ACTIVITY LEVEL DESIRED 60-90 minutes daily stationary time 60-90 minutes daily stationary time Allows 24 hour mobilityUp tp 2 hours daily stationary time PROMOTES OFFLOADING OF WOUND AREA DURING USE Highly likelyHighly likelyNoneLikely EDEMA CONTROL YesLittleNoneLittle HUMIDIFICATION YesNoYesNo NEEDS INTACT VASCULATURE FOR DELIVERY NoNoNoYes LOCATION COMFORT Home basedHome basedHome basedFacility based only PHYSICAL COMFORT Limited-Stationary near deviceLimited-stationary near device Allows flexibility in positioning Limited-facility arranged setting WOUND COMFORT Evidence of pain reductionEvidence of pain reductionEvidence of pain reductionEvidence of pain reduction DEVICE DELIVERY DISCOMFORT Some maySome mayLess likelyMore likely ADDITIONAL COSTS Some insurance coverageSome insurance coverageSome insurance coverageMost insurance coverage. Requires daily transportation to a facility LOCATION OF THERAPY Medical settings Home useMedical settings Home useNo restriction on locationOnly at a HBOT facility PATIENT PARTICIPATION Self care Care giver Self care Care giver Self care Care giver H/H agency Rely on facility Rely on transportation DEVICE USE REQUIRES Ability to preform donning and doffing Breathable dressing Ability to preform donning and doffing Breathable dressing Daily charging of batteries Disposable unit for application Occlusive dressing A health care professional COMPLIANCE Patient dependant unless in a facility Patient dependant unless in a facility Patient dependantPatient dependant Transportation dependant VARIABLE WOUND SIZES YesYes No, limited to smaller wounds Yes WOUND DEPTH AllAllAllDeeper wounds ACTIVE INFECTION Yes with infection treatmentYes with infection treatmentYes with infection treatmentYes with infection treatment DRESSING SELECTION Flexible (remove or use with breathable dressing) Flexible (remove or use with breathable dressing) OcclusiveFlexible OINTMENTS/ GEL USE Must be wiped off prior to useMust be wiped off prior to use NoYes
