D.J. Wallace 1,2 S. Silverman.2* J.Goldstein 3,and D.
- Department of Medicine Cedar-Sinai Medical Center
- UCLA School of Medicine, Los Angeles, CA.
- The Chronic Fatigue Syndrome Institute. Anaheim CA.
- The Hyperbaric Oxygen Institute, San Bernardino, CA
Hyperbaric Oxygen has been used in patients with Rheumatic
Disease for many years with out reports of untoward or unusual
complications for a variety of Non Rheumatic indications. Recent
evidence that hyperbaric oxygen inhibits the actions of certain
cyctokins. Acts as an immune doculator and may help cognitive
dysfunction has resulted in a re-examination of its potential role
in rheumatic diseases. A case report of a LUPUS/ Scleroderma
crossover patient is presented whose cognitive dysfunction improved
after hyperbaric oxygen therapy. The history of hyperbaric oxygen
and its physiology are related, along with a focused review of its
effects on the immune and central nervous systems. Areas, which
might warrant further consideration by Rheumatologists, are
outlined, as well of areas of concern.
Keywords: hyperbaric oxygen: Scleroderma: rheumatic Diseases
Hyperbaric Oxygen Therapy is defined as the
subjecting of patients to pure oxygen breathing at ambient
temperatures, which are greater than normal atmospheric pressure.
Although concepts of hyperbaric oxygen therapy were first
employed in 1662, its modern use other than for decompression dates
from 1956 when hyperbaric oxygen was used to perform cardiac surgery
in Holland 1 . Mechanically, the most common applications of
hyperbaric oxygen are to dissolve air or gas emboli and treat divers
with "bends" or decompression illness.
New insights into the
biochemical and immune interactions of hyperbaric oxygen have
increased interest in its potential applications over the past
decade. The United States Medicare System has approved hyperbaric
oxygen for 13 indications ranging from acute Carbon Monoxide
intoxications, Gas gangrene, and osteroradionecroisis to acute
arteriolar insufficiency. Over the last 20 years, patients with a
variety of conditions, especially Multiple Sclerosis, have reported
cognitive improvement after undergoing hyperbaric oxygen. One Lupus/
Scleroderma crossover patient, whose case is reported here,
underwent hyperbaric oxygen therapy specifically for cognitive
impairment. And experienced subjective and objective improvements.
Her case is presented and our concepts of hyperbaric oxygen and the
immune and central systems are reviewed.
A 53 year old Caucasian Woman flight attendant
who was in her usual state of health in 1979 when she underwent
Thyroidectomy and inadvertent parathyroidectomy for Graves disease.
In February of 1980, her Heyer Schulte saline breast implants (place
in 1977 for cosmetic purposes) were replaced with Cox-Uphoff
Silicone prostheses. She was well until 1986 when she presented to
UCLA Medical Center with subcutaneous arthritis, Raynaud's
phenomenon, Sclerodactyly, inflammatory arthritis, and erythermatous
rashes. A work-up demonstrated an ANA of 1:40 (speckled), elevated
sedimentation rates (averaging in the high 30's) and persistently
decreased IgA levels. She was diagnosed as having a Lupus/
Scleroderma crossover. Although the possibility of Eosinophilic
fascuiitis was considered. (It was ultimately ascertained that she
occasionally took L-troptophan to sleep after long fights.) No
disease modifying therapy was given: supportive diuresis and not
steroidal anti- inflammatory agents were prescribed. Over the
following 7 seven years, Her ANA rose to 1:1280 (homogeneous) a
positive IgG anticardiolipin antibody was found and her course was
complicated by percarditis and supraventrocular tachyarrhythmias.
The latter of the two items were felt to be suggestive of cardiac
sclerodrema: anti RNP was negative and her inflammatory arthritis
subsided. CD3 levels. B cell and natural killer cell values do not
change. Similar findings have been found in mice in two separate
studies. 9.10 Interestingly, the administration of Immunoglobulin
production by spleen cells 9 Long terms hyperbaric oxygen delayed
the development of Proteinuria, facial erythema, and lymphadenopathy
in MRI/ 1pr. Mice. Iamoto et al showed that hyperbaric oxygen has
immunosuppressive properties modulated by decreasing interluekin 1
and prostaglandin E2 production, but interleukin 6 in production was
not altered. 11
How does Hyperbaric Oxygen Affect the
Central Nervous System?
Studies of hyperbaric oxygen on the central
nervous system show that at tensions of 1.2- 1.5 atmospheres
absolute (ATA), it decreases blood flow by 1-20% (mean of various
studies is about 10%), 2 other physiologic changes occur. These
include greater permeability of the blood brain barrier to
medications and increased oxygen tensions tissues that far outweigh
the net effects of mild vasoconstriction. The deformability of
erythrocytes is increased resulting in improved transportation in
the microvasculature circulation and lactate removal. 12 Hyperbaric
oxygen stimulates the metabolism of nerve cells deprived of oxygen.
As early as the 1960's, Meijne reported cognitive improvement in
patients to performing mathematical calculations and demonstrated
increased typewriter skills after hyperbaric oxygen 13 An area of
controversy among Hyperbaricists concerns the possibility that once
1.5 ATA is exceeded, anaerobic metabolism is favored and thus
cognitive do not improve as well as they would at lower pressures.
Di Sabato et al 14 performed a controlled study (with Sham
hyperbaric controls) on patients with cluster headaches. The
dramatic improvement was attributed to vasoconstriction, decreased
edema, increased serotoin synthesis, and decreased cerebral hypoxia.
Additionally, in the central nervous system hyperbaric oxygen
decreases adrenaline and monoamine oxidase levels as well as
promoting axonal regeneration 15.
Hyperbaric Oxygen for Multiple
Sclerosis and other autoimmune diseases:
As hyperbaric oxygen decreases demyelination
from per-vascular edema, over 6000 patients with multiple sclerosis
have undergone this therapy in the past 10 years. A published trial
by The New England Journal of Medicine Suggesting improvement with
hyperbaric oxygen in 40 patients in 1983 stimulated considerable
interest. 16 However, it was evident that even though hyperbaric
oxygen increased helper T lymphocyte levels, patient liked the
treatment and reported subjective improvements (especially in the
sense of well-being, cognitions and bladder function), Four
separated placebo -controlled double -blind trials failed to
demonstrate any objective benefits of using the Kutz Disability
status Scale or any other parameters 17-20 This was also confirmed
in a 22 institution multicenter registry 312 patients followed for 2
Occasionally patient with other rheumatic
syndromes and associated complications have been held to respond to
hyperbaric oxygen. Aseptic necrosis complicating system lupus, for
example, appears to be worthy of greater scrutiny. Abstracts and
presentations at seminars and meetings of hyperbaric oxygen claim
benefits for pneumatosis cystoid intestinal in sclerodrema, livedo
reticularis with Vasculitis and Raynaud's phenomenon. Articles have
appeared advocating hyperbaric oxygen for Crohn's disease and
cyclophophadmide-associated hemorrhagic cystitis
How save is hyperbaric oxygen?
Hyperbaric Oxygen is generally quite safe, but
serious complications can occur.24 Absolute contraindications to
hyperbaric oxygen include pregnancy, underlying malignancy,
untreated PNEUMOTHORAX, concomitant therapy with doxorubicin,
cis-platinum, or disulfiram. Special considerations need to be taken
into account if the patient has upper respiratory tract infections
or chronic sinusitis (which make clearing of the ears and sinuses
problematic) low seizure thresholds (with high fevers or epilepsy,
emphysema with CO 2 retention (which suppresses breathing). And
congenital spherocytosis (hempolysis can result) The most common
complication of hyperbaric oxygen is barotrauma to the ears and
sinuses caused by pressure changes, which has been reported in about
5% of the cases. Occurring in 0.1- 5% of the patients are
hypersensitivity reactions confinement anxiety, central nervous
system oxygen toxicity, pulmonary oxygen toxicity and temporary
changes in eyesight. To minimize risks, patients are advised to have
an ear, nose and throat examination by the treating Physician before
therapy, not to drink alcohol or take any medication for 4hours
prior to treatment, and to wear 100% cotton clothing.
Is there a potential role for
hyperbaric oxygen in Rheumatic Diseases?
Very little is known about the influence of
hyperbaric oxygen on the immune system. Animal models of autoimmune
disease and normal mice are conductive to hyperbaric oxygen studies.
Hyperbaric oxygen might be useful in combination with other
therapeutic modalities. Further study is needed in these areas
before proceeding to human trials. Nevertheless, anecdotal
testimonials that hyperbaric oxygen helps people think more clearly
should be taken seriously and ultimately subjected to a prospective
Systemic lupus erthematosus (SLE) is an
autoimmune disorder that affects several hundred thousand Americans.
Nearly half manifest in similar cognitive deficits that do not
respond to CORTICOSTEROIDS. 26 In the past few years, the
development of single photon emission computerized tomography
(SPECT) has shown hypoperfusion abnormalities bitemporally and
bifrontally in patients with SLE and incidentally, with fibromyalgia
/ Chronic Fatigue syndromes. 26-29
Hyperbaric Oxygen is a well -characterized, old
technology whose immunodulatory properties and effects on cognition
have never been adequately studied. Although relatively expensive,
this reasonably safe procedure might have potential
heretofore-unrealized applications to the patients with rheumatic