HISTORY OF HYPERBARIC MEDICINE

Hyperbaric oxygen therapy (HBO) is a therapeutic modality that is based on obtaining high partial pressures of oxygen by breathing pure oxygen, inside a hyperbaric chamber, at a pressure higher than atmospheric.

It is therefore a pharmacological therapeutic, whose application margin is determined by the maximum pressure reached, the duration of inhalation and the frequency and total number of exposures.

The HBO has been known for more than 300 years, although it has only been properly used for 25. The documents and testimonies prior to 1961 have only historical or anecdotal value, but it is important to know them.

The first documented use of the hyperbaric chamber is prior to the discovery of oxygen, in 1662 the British clergyman Henshaw (physiologist and physician) intuits that the increase in air pressure could alleviate some acute injuries, while, according to him, low pressures could be useful in chronic pathologies. Henshaw built a chamber that was hyper and hypobaric. There was no scientific reason to apply this treatment yet. 

With current knowledge, we can deduce that Henshaw's chamber, which he called "Domicilium", did not modify the pressure much, but it was the first. 

In 1775 Joseph Priestley,  English scientist and theologian , was one of the first to isolate oxygen in gaseous form (although this fact has also been attributed, with some justification, to Carl Wilhelm Scheele and Antoine Lavoisier ) . In any case, he was one of the first to isolate it in gaseous form, and the first to recognize its fundamental role for living organisms. He called it "dephlogisticated air" (Scheele had called it igneous air, and Lavoisier, oxygen).

Henshaw's idea was later applied in different European countries to improve health with "Compressed Air Baths", as this therapy was called then. People were breathing air, not oxygen, but by increasing the pressure of the air, the partial pressure of oxygen rises. This increase turned out to be beneficial, but not yet understood by the clinicians applying the chamber sessions.

The explanation is this: 1 atmosphere corresponds to 760 mmHg, oxygen (21%) is at a pressure of 159 mmHg, which corresponds to these 21%.

When the pressure rises to 2 atmospheres, the partial pressure of oxygen rises to 318 mmHg (the same 21% remain, but already 1520 mmHg of total air pressure).

In 1834, the French doctor Junod built a hyperbaric chamber to treat lung conditions.

"Compressed air baths" spread throughout Europe, attracting patients from far away (including the United States).

Between 1837 and 1877 in several European cities (Berlin, Amsterdam, Brussels, London, Vienna and Milan) the so-called Pneumatic Centers were opened, among which the one founded by Bertini in Montpelier stood out.

In 1837 the French surgeon Charles Gabriel Pravaz built a hyperbaric chamber capable of treating 50 patients.

In 1879 the French surgeon Fontaine built an operating room on wheels, which could be pressurized. In this operating room, more than 20 surgical procedures were performed using nitrous oxide as an anesthetic.

Deep anesthesia was possible due to the proportional increase in the partial pressure of gases with pressurization; compressed air at 2 atmospheres produced the effect of breathing twice as much oxygen, which made anesthesia safer. According to Fontaine's observations, hernias were more easily reduced and patients returned to normal skin color coming out of anesthesia, no cyanosis was observed.

Fontaine's experience with hyperbaric surgery corresponds to the semi-scientific period of the use of compressed air for therapeutic purposes, since he wrote the first article on the use of compressed air as an adjunctive method in surgery.

The first chamber built in the Americas was in Oshawa, Canada in 1860. A year later, Corning built the first hyperbaric chamber in the United States in New York.

In 1921 Orville J. Cunningham, professor of anesthesia at the University of Kansas (Kansas City), uses high partial pressure of oxygen to treat hypoxic states, and observes that patients with heart problems and circulatory disorders, who felt bad living in the mountains, they improved at sea level, so he considers that increasing the pressure can be beneficial for these people.

During the influenza epidemic in 1918, this professor put a young doctor who was dying of suffocation in a hyperbaric chamber that he used for animal experiments, and saved his life by compressing him to 2 atmospheres, which was enough to overcome the hypoxic crisis.

Cunningham proved to himself that his concept was true and built a chamber 26.84 meters long and 3.05 meters in diameter and began to treat different diseases, most of them without any physiological basis at the time.

He treated Mr. Timkin, for kidney disease, in the hyperbaric chamber, curing him and this grateful man built a chamber with 5 floors and 19.5 m in diameter, being the largest chamber that had existed up to that moment. This steel ball hospital, located in Cleveland, Ohio, contained a smoking room on the top floor, dining rooms, and individual rooms.  This hospital was pressurized up to 3 ATA.

Cunningham considered that some anaerobic microorganisms were responsible for diseases such as hypertension, uremia, diabetes and cancer, and that compressed air therapy   helped destroy these microorganisms .

In 1930, the American Medical Association and the Cleveland College of Physicians, for not having any scientific justification as a basis for their treatments, forced him to close his hospital in 1930. Unfortunately, the "steel ball" was dismantled during World War II, in order to use the material.

SCIENTIFIC HYPERBARIC MEDICINE

The history of Scientific Hyperbaric Medicine begins with two names: Paul Bert (1833-1886) and John Scott Haldane (1860-1936).

In 1878, Paul Bert published the work La Pressure baroméetrique: recherches de physiologie expéerimentale, where he describes the results of subjecting the organism to variations in atmospheric pressure and oxygen pressure. It also refers to hypoxia and hyperoxia. 

Alphonse Gal, a doctor who lived in Greece, started diving to feel the reaction of the body in the underwater environment. Bert studied Gal's experiences and his reports on injured or dead divers.

In the experiments carried out by Paul Bert in 1878, he was able to verify that breathing high partial pressures of oxygen ends up causing convulsions. This poisoning or toxicity suffered by the Central Nervous System (CNS) is also called acute oxygen intoxication or the Paul Bert effect.

But his greatest discovery was the effect of saturation of tissues by nitrogen under pressure, and the production of bubbles during decompression. 

He explained that at a higher partial pressure of nitrogen, this gas dissolves in the tissues and then, with the subsequent reduction in pressure, the nitrogen "comes out" of the soluble state and forms the bubbles. 

Bert therefore concluded that caisson divers and workers should experience decompression slowly and at a rate that allows nitrogen not only to escape from the blood, but also to be removed from the vessels. tissues, pass into the blood, and then be eliminated from the blood.

These findings were used to manufacture diving suits with a pressure regulator. He later tried oxygen to "wash" and remove nitrogen. He built large hypopressure chambers and conducted tests with balloons.

He also proposed for divers to make decompression stops during ascent, in the middle of the distance, after a deep dive, which today is known as "a deep stop".

Bert was looking for treatment methods for decompression sickness once symptoms appeared. His experiments showed that symptoms can be relieved by returning the injured to the compressed space in the "caisson" or tunnel with subsequent slow decompression. This method was the beginning of recompression therapy which is the most effective method of treating decompression sickness today. It also showed that breathing pure oxygen was highly effective in relieving symptoms of decompression sickness. In one of the animal experiments he wrote: "The favorable action of oxygen is evident; after a few inhalations (of oxygen) the symptoms of distress disappear".

It is the reason why oxygen is so helpful in treating decompression sickness. Bert was the first to propose oxygen recompression therapy, although modern therapy was implemented years later.

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  DECOMPRESSION SICKNESS AND TREATMENT

Scottish physiologist John Scott Haldane is considered the father of modern decompression theory. Haldane was the first scientist to apply science to predict decompression outcomes, and his methods form the basis of most modern decompression theories. 

In 1906, together with John Gillies Priestley, he discovered that the respiratory reflex is "triggered" more by excess carbon dioxide in the blood than by lack of oxygen.

Haldane became an authority on the subject of respiratory diseases in industrial workers and in 1912 he was appointed Director of the Scientific Laboratory of Mines in Doncaster. Haldane founded the Journal of Hygiene and it was precisely in this magazine that the first set of decompression tables was published. During his professional life he wrote "The organism and the environment" (1917), "The breath" (1922), "The philosophy of the Biologist" (1936). Haldane died of pneumonia in 1936.

Haldane's most important works, however, are those devoted to diving. In 1905, he joined the Royal Navy's Deep Diving Committee to investigate diving disorders and Caisson's disease, which is what decompression sickness was called at the time.

Caisson workers employed in the construction of the bridges and tunnels often suffered from "bends" or joint pain. The symptoms were more severe when the workers worked at greater depths. Many suffered from total paralysis and death was frequent among them. The results of the studies suggested that the gases breathed under pressure diffused into the tissues of the body and when they left the tissues forming bubbles, decompression sickness appeared. The same symptoms were experienced by divers breathing air under high pressure. They were instructed to ascend slowly at depth and faster as they neared the surface. Thanks to Haldane's work, it is now known that this was a mistake and increased the risk of decompression sickness.

Haldane showed that the body can tolerate a small excess of gas with no apparent ill effects. He wrote that the formation of bubbles obviously depends on the presence of a state of supersaturation of the liquids of the organism with nitrogen, he supposed that the body represents a group of tissues that absorb and eliminate gases at different rates. He proposed mathematical models to describe these phenomena and defined the limits of supersaturation that tissues can tolerate. 3194-bb3b-136bad5cf58d_

Haldane introduced the concept of the half-time of saturation and desaturation of nitrogen. The half time is the time during which a certain tissue can be half saturated with an inert gas.

Haldane showed that decompression is more dangerous near the surface, he developed practical decompression tables that included slower ascent rates as divers got closer to the surface. 

The conclusions of his studies were accepted throughout the world and became the basis of the operations of divers in Great Britain and in other countries. In 1912 the US Navy accepted these tables as the basis of diving operations and used them until 1956.

In 1933, Damant and Philips, of the British Navy, began to use oxygen breathing in a hyperbaric chamber to reduce decompression times after diving.

  HYPERBARIA AND SURGERY

In the 50s of the last century, heart surgeons, including Dr. Christian Barnard, began to use hyperbaric oxygen in interventions for congenital or acquired valve disease and coronary disease, since they needed to increase the partial pressure of oxygen in the blood. .

The modern scientific use of the hyperbaric chamber begins with the work of Dr. Ite Boerema, Professor of Surgery at the University of Amsterdam, who proposed using hyperbaric oxygen to increase the tolerance of cardiac arrest by patients. Dr. Churchill Davidson, in England, was the first to apply hyperbaric oxygen therapy in 1955 to enhance the effect of irradiation in cancer patients.

Dr. Boerema can be considered the forerunner of hyperbaric surgery.

The first investigations were carried out on animals using the Den Helder hyperbaric tank. The researchers found that pigs inhaling oxygen at a pressure of 3 atmospheres could survive for periods of 15 minutes, with only 0.4% hemoglobin, as their bodies became saturated with oxygen dissolved in plasma, and when they returned to atmospheric pressure and the extracted blood was returned to them, the animals continued to live. About this experiment Boerema published an article with the title "Life without blood". The impact of this experiment was transcendent.

It was shown that the oxygen content of blood plasma increases twenty times if it is inhaled at a pressure of 3 atmospheres.

In 1959, a gigantic steel chamber was built at the Wilhelmina Gasthuis hospital in Amsterdam that housed an operating room measuring 3.5 x 5.5, a small cabinet for instruments and an anteroom where doctors and nurses underwent surgery. compression or decompression. Hyperpressure of 3 atmospheres was achieved in 12 minutes.

In the year 1960, the first surgical experiences were carried out under hyperbaria, they were performed on children affected by congenital heart disease. In those days, coronary patients who had suffered a heart attack were placed in the hyperbaric chamber. If the time lapse from the beginning of the attack did not exceed 2 hours, this technique allowed to overcome the crisis.

   HYPERBARIA IN MEDICINE

The application of HBOT was successfully used in the treatment of gas gangrene, since the increase in the partial pressure of oxygen in the blood destroyed anaerobic organisms. On October 25, 1960, the first patient with gas gangrene was treated in a hyperbaric chamber at this hospital in Amsterdam.

Boerema also used HBO to revitalize skin flaps in polytraumatized patients, complicated fractures, and frostbite cases.

The development of HBOT in the former USSR was very important thanks to the heart surgeon Dr. Nikolai Amosov and Dr. Boris Petrovsky, also a heart surgeon and Minister of Public Health in the USSR.

In 1974 a barocenter was created in Moscow, with 6 multiplace chambers within the Scientific Institute of Clinical and Experimental Surgery, in this center between 1974 and 1990 more than 1000 cardiac and vascular surgeries were performed 

Baro-operating theatres, multi-seater and single-seater hyperbaric chambers appeared throughout the territory of the Soviet Union. In the 1980s there were more than 700 HBO centers across the country. The treatment was applied in many diseases, among others, in helping women with heart disease to give birth.

Russia today has more than 500 HBO centers, and since 1996 the Journal of Hyperbaric Medicine and Physiology has been published.

HYPERBARY AT PRESENT

Currently, hyperbaric medicine has become a specialty throughout the world with a large bibliography on its application in various pathologies, and is highly developed in Norway, France, England, Italy, Spain, Greece, Portugal, Finland, Germany and Austria. .

In 1963, Boerema creates the International Congress of Hyperbaric Medicine that meets every 3 years. In Barcelona, the meeting took place in September 2005,

This is the oldest organization that exists of hyperbaric medicine

In 1973, the European Underwater and Baromedical Society (EUBS) was founded at the Karolinska Institute in Stockholm (European  Underwater and Baromedical  Society), which has since held annual congresses .

To all that has been said, the European Committee for Hyperbaric Medicine (European Committee for  Hyperbaric  Medicine, ECHM) is also added.

In the United States, there are currently almost 600 chambers, hyperbaric doctors are gathered in the American Undersea and Hyperbaric Medical Society (UHMS), which has more than 2000 members worldwide, and there is also another body that is the College American College of Hyperbaric Medicine.

Since April 2003, the American medical mutual Medicare & Medicaid, covers hyperbaric treatment for patients with diabetic foot lesions of Wagner classification 3 or higher, refractory to standard therapy for 1 month

In Japan there is also a great development of hyperbaric medicine, whose recommendations include neurological indications.  Hyperbaric medicine is also highly developed in China, Korea, Australia, India and Turkey.

In Latin America, the great development of the HBOT began in Cuba, promoted by Professor Manuel Castellanos in 1967. Later, in 1983, the Cuban government decided to create a coordination group for the development of the HBOT in Cuba and sent its members to be trained in the former USSR and other Eastern European countries. Currently, Cuba has almost 50 hyperbaric chambers. Mexico also has 124 hyperbaric medicine centers.

Argentina began with HBO in 1960 at the Pirovano Hospital in Buenos Aires, at the Mar del Plata Naval Base, in 1986 the Argentine Society of Hyperbaric Medicine and Underwater Activities was founded, and they work  _cc781905 -5cde-3194-bb3b-136bad5cf58d_currently 15 centers throughout the country under the rules issued by this society. De estos 15 centros, 5 de ellos están en Hospitales Navales y 10 son centros     privados.

  HYPERBARIA IN CATALONIA

In Spain, in parallel, the Center for Underwater Recovery and Research ( CRIS ) was created in 1954 in Barcelona, which is one of the oldest in the world. 

From 1954 to 1966, decompression accidents were treated in a single-seat hyperbaric chamber, popularly known as the "recompression cartridge." In 1963, the first civilian multiplace hyperbaric chamber in our country was placed in premises donated by the Barcelona Red Cross assembly.

A new stage was beginning that would allow a more comfortable, more effective, and above all, safer treatment of diving accidents. The Drs. Merino and Guijarro on behalf of the Red Cross, and Dr. Ricardo Bargués on behalf of the CRIS were in charge of medical care. 

Until 1978, 32 diving accidents were treated in the new multiplace chamber, and the cartridge was progressively out of service, until it became a curious museum piece.

In 1979, the number of diving accidents increased considerably and some of them were very serious, posing important care and personal availability problems.

The following years were of great activity and this new department, since then under the direction of Dr. Jordi Desola, became a true medical service integrated into the Catalan health care network. Gradually, the therapeutic indications of the hyperbaric chamber were extended to other diseases not related to diving, but also liable to be treated with hyperbaric oxygen therapy. 

The Servei Català de Salut soon accredited CRIS-UTH as an Out-of-Hospital Medical Service and granted it the status of Concerted Entity. Later, and in accordance with the requirements of the General Sports Law, CRIS-UTH was recognized as a first-class Sports Medicine service. The progressive volume of work made it necessary to professionalize the staff of the chamber, not only with its own doctors, but also with chamber technicians, nurses, health assistants, and administrative personnel with permanent work dedication. 

Currently, the Hyperbaric Chamber is located in the new Moisés Broggi Hospital en  San Joan Despi (Barcelona).

Publications on hyperbaric and diving medicine are under review by different European and American Committees.

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At this time, in Spain, in terms of medicinal application of HBOT, in addition to the Barcelona chamber, we have different chambers spread throughout the Spanish territory, among them stand out.

Until 1994, a total of 10,000 man-hour exposures to HBO had been carried out in the multiplace chamber installed in the Hospital de Caridad de Cartagena, without there being a single case of intolerance or adverse effect that could be interpreted as being due to oxygen. The results obtained allow us to appreciate the extraordinary efficacy of the system in the treatment of a series of clinical conditions that until now have been considered to have a poor prognosis using conventional therapies.

At the Marqués de Valdecilla University Hospital, in Santander, the HBOT unit was created in 1982. Ten years later, in 1993, 600 patients were treated in an old 4-bed chamber. At this time, a modern hyperbaric center with a capacity for 14 patients is being created. During the first 5 years, HBO has been used almost exclusively for urgent indications, understood as: decompression sickness, air embolism, poisoning by CO, traumatic ischemia, necrotizing soft tissue infections and sudden deafness.

In the last 5 years, indications in a chronic situation have been included: alterations due to tissue irradiation, refractory chronic osteomyelitis, torpid wounds and peripheral arteriopathies. -3194-bb3b-136bad5cf58d_

The Hyperbaric Medicine Unit of the Traumatology Hospital of Seville is one of the oldest sections of the Intensive Care Service of this Center, since its date of creation dates back to 1968, in which we believe that for the first time in history from the Andalusian Community, a case of post-traumatic myonecrosis gangrenosum by HBO.

The equipment is made up of 2 English-made Vickers single-seat chambers, which reach pressures of up to 3 ATA. The number of patients treated up to 1994 amounts to 743, with the Intensive Medicine Service standing out as the first patient remitter, followed by Traumatology and in third place by Plastic and Aesthetic Surgery.

The Hyperbaric Therapy Unit of the Clínica del Angel de Málaga was created in 1988 under the sponsorship of the Submarine Installations company JACRISA

The Jacrisa hyperbaric center is a founding member of the Coordinating Committee of Centers for

Hyperbaric Medicine (CCCMH). Together with the CRIS in Barcelona and the UTH of the Marqués de Valdecilla Hospital, these hospital hyperbaric centers also have the possibility of intensive treatment.

The unit has two chambers: one for urgent indications that require individualized therapy and often intensive care, and another dedicated to the collective treatment of chronic pathologies and that allows treating 25 seated patients or 10 stretchers.

From January 1988 to October 1994, 798 patients have been treated.

It is a noteworthy fact that each hyperbaric center has a more specific dedication to certain pathologies, probably due to the different training of its managers, operational, geographical and administrative factors. Marqués de Valdecilla, from Santander has a vast experience in the treatment of necrotizing soft tissue infections. The Barcelona CRIS has treated  ten times more decompression accidents e  carbon monoxide poisoning than the other centers combined. The Malaga unit pays special attention to diabetic foot treatment. This should motivate those responsible for hyperbaric centers to scientifically disseminate the use of HBOT in pathologies less treated by each unit, since the epidemiology does not vary significantly in the different communities of our country._cc781905-5cde-3194-bb3b -136bad5cf58d_

In addition to this dissemination, scientific rigor is essential in the selection  of patients, protocols  of treatment and communication of results, for the sedimentation of a form of medical therapy such as HBO, so controversial, perhaps not so much because of its foundations as because of the loose application that has been followed in other times. Hence, the role of the CCCMH in its mission of coordination and quality control must be strengthened and valued in its proper measure

Bibliography:

1. Feldmeier JJ. Preface: Hyperbaric Oxigen 2003: indications and results. The Hyperbaric Oxygen therapy Committee report. Undersea and Hyperbaric Medical Society, 2003:p.vi

2. Boycott, AE, Damant GCC, & Haldane JS. "The prevention of compressed air illnesses", Journal of Hygiene, vol. 8, (1908): 342-443  

3. Rodriguez Villa JL. hyperbaric oxygenation. Souvenir of Boerema. Aerospace and environmental medicine. 1999; II (6)

4. Leopardi LN, Metcalfe MS, Forde A, Maddern GJ. Ite Boerema-surgeon and engineer with a double-Dutch legacy to medical technology. Surgery 2004; 135 (1):99-103 

5. Alessandro Maroni. The XIII Annual Chinese Symposium on Hyperbaric medicine. Official Newsletter. Foundation  for the International Congress on Hyperbaric Medicine, 2004, 6 (2):6-6 

6. Rodriguez Chirino MW. The HBO in Cuba, Santiago de Cuba.

7. Subbooty Nina. Hyperbaric Medicine. Buenos Aires 2006

8. Gallar Fernando, Underwater and Hyperbaric Medicine. Ministry of Labor and Social Security. Social Institute of the Navy, 3rd edition Madrid 1995 

9. Desola J. Bases and therapeutic basis of hyperbaric oxygen therapy. Janus / Medicine, Vol. LIV, no. 1260, June 5-11, 1998