Harkesal 2016

Basic
Theory of HBO and EBM

As HBOT Consenssus Indica8on (CI)
Mohammad Guritno SURYOKUSUMO

Professor of Acadmie Na8onale de Mdecine, Paris
Faculty of Medicine, Indonesia University, Jakarta
Faculty of Medicine, Airlangga University, Surabaya
Ethic CommiNee of UPN VJ, Jakarta
Email: mguritno@yahoo.com

A HISTORY OF HYPERBARIC MEDICINE
Three Periods can be dis8nguished :
A Time for Discoveries : From The Renaissance to

The Age of Enlightenment

A Time for Hyperbaric Therapy : From The Middle
of The 19th Century to the beginning of The 20th
Century
A prac8ce of Hyperbaric Medicine on a Scien8c

Basis : Since The Second Half of The 20th Century
A Time for Discoveries
From the Renaissance to The Age of Enlightenment (XVII-XVIII C)
The Main Area of Scien>c Progress
1644, Torricelli invent the Barometric Tube

1643, Pascal conforms the variaBon of barometric pressure
with alBtude and establishes the law of HydrostaBcs
1661, Boyle and MarioHe (1976) both state the law relaBng
volume and pressure of an Ideal Gas
1755, Black discovers Carbon Dioxide
1775, Priestly discovers Oxygen
1789, Lavoisier discovers OxidaBon Phenomena
A Time for Hyperbaric Therapy
Between the middle of the 19th and the beginning of the 20th C
1834, Junod : Benecial eects of high-pressure oxygen on

man
1837, Pravaz (in Lyon), Tabarie (in Montpillier): PosiBve eects
of immersion in compressed air for various ailments
1841, Pol and Watelle : Recompression relieves the symptoms
of decompression illness
1855, BerBn (in Paris) : Clinical study on the use and eects of
air compressed
1876, Fontaine : The rst mobile operaBng chamber which
Pean used for surgery
From 1860 onwards, an amazing number of centers were
opened: Amsterdam, Baden-Baden, Brussels, Haarlem,
London, Malvern, Milano, Moscow, Munchen, Odessa, Vienna
(in Europe); Ashawa: the rst chamber built in Canada;
Cleveland (USA) : the largest chamber built by Cunningham
Hyperbaric-Chamber in The Word
100%
90%
80% USSR
70% South Korea
60% China
50% Erope
40%
Japan
30%
USA
20%
10%
0%
1996 2009
How is the Hyperbaric Center development in
Indonesia ?
9
8
Hyperbaric Centers
7
6
5 TNI-AL
4
NON-TNI AL
3
2
1
0
1960-1990 1991-2016
Period
Hyperbaric Oxygen Therapy (HBOT)
Hyperbaric oxygen therapy [HBOT] is a systemic
treatment which involves breathing 100% oxygen
and pressure of more than 1 atmosphere.
Treatment may be carried out either in a mono -

place chamber pressurized with oxygen 100% or
in mul>-place chamber pressurized with
compressed air, in which case the paBent receives
pure oxygen by mask, head tent (hood), or
endotracheal tube.
3rd INTERNATIONAL ANNUAL SCIENTIFIC MEETING EVIDENCE BASED MEDICINE ON HYPERBARIC OXYGEN
TREATMENT ON MEDICAL HYPERBARIC OXYGEN TREATMENT
The Stone Hotel, Legian BALI
October 15rd -16th 2015
1. Mechanical therapeuBc eect of the increased
barometric pressure (Boyles law)

2. Bio-molecular therapeuBc eects of enhanced
oxygen pressure pressure. The iniBal eects that
occur due to increased producBon ROS (H2O2 )
and RNS (NO)
1. Bio-molecular therapeuBc eects of
enhanced oxygen pressure
2. The iniBal eects that occur due to

increased producBon ROS (H2O2 ) and
RNS (NO).
HBOT reduce the volume of gas bubbles by increasing
ambient pressure.
Bubble volume will change in inverse proporBon to
ambient pressure (Boyles law)
However, the reducBon in the various bubble
dimensions will depend on the shape of bubble.
A spherical bubble compressed to 6.0 ATA (exp. 6A.
US Navy Table) will reduce to 17% of its original
volume but only 43% of its original diameter.
PO2= Pb x FiO2
PAO2=(Pb-PH2O).FiO2- PACO2 [FiCO2.(1-FiCO2)/R]
PAO =(Pb- 47).FiO - PACO - FiCO /R

2 2 2 2
CaO2= (Hb x SaO2 x 1.34) + (0.003 x PaO2)
TaO2= IC x CaO2 x 10
[Guritno, 1997]
Enhanced Atmospheric Pressure vs
FiO2, PAO2, PaO2, HbO2, CaO2
Pb (ata) 1.0 1.0 2.0 3.0
FiO2 (%) 0,21 1.0 1.0 1.0
PAO2 (mmHg) 104 673 1433 2195
PaO2 (mmHg) 100 627 1267 2000
HbO2 (%) 19,7 20,1 20.1 20.1
CaO2 (ml/100ml) 0,3 1,88 3.8 6.0

[Guritno, 1984]

6.0 ml O2/100ml plasm
[%]
3,8 ml O2/100ml plasm

PLASM
20,1
19,7 HbO2
21% O2
100% O2 100% O2
1.0 2.0 3.0 [ata]

[Guritno, 1984]
How hyperbaric oxygen can be beneficial for treatment ?
THE APPROACHES OF 3 HYPOTHESES
[ HYPERBARIC OXYGEN HYPOTHESES]
GURITNO, 2010
[Qiang Zhang at al, 2008]
[Calabresse and Baldwin 1997, Calabresse and Blain 2005]
PosiBve Response
Therapeu8c Doses Over Doses

NegaBve Response
Toxic Doses
[Guritno, 2010 (Modica8on Qiang Zhang at al., 2008)]
Pressure
Fraction O2
Duration
Sesion
Apoptosis
Necrosis
Atrophy
Controlled Less Controlled Catastrophic
[Miguel Blanco, Ignacio Lizasoain, Toas Sobrino, Jose Vivancos, 2006]
HBOT Ischemic Precondition
Duration-Interval
Session - interval
Cure-Interval
Ischemic Tolerance
Early Phase Delayed Phase

Hours Days
Activation of existing protein Gen expression

De novo protein synthesis
Regulation of normal processes Down regulation of genes expression
during ischemia
2.4 ATA
Oxygen
Air
Depth
Oxygen 100 %
30 5 30 5 30
Time
Guritno, 1997
[Miguel Blanco, Ignacio Lizasoain, Toas Sobrino, Jose Vivancos, 2006]

ATP dependent receptor K+ HSP 70
Ionotropic Glutamate Receptor HSP 27
Immediate Early Genes HSP 90
Nitric Oxide
Guanylil Cyclase
P21 Ras Protein
Phosphorylation Protein Muskelin
Apoptosis Regulating Genes Platelet Activating Factor Receptor
Neurotropic Factors Actin
Erythropoietin
Inflammatory Cytokines
Nuclear Factors
TREATMENT ON MEDICAL HYPERBARIC OXYGEN TREATMEN
Reverse hypoxia
Alter ischemic eect
Inuence vascular reacBvity
Reduce edema
Modulate NO producBon
Modify growth factor & cytokine eect by
regulaBng their level and/or receptor
Induce changes in membrane proteins aecBng
ions exchange and gaBng mechanism
Promote cellular proliferaBon
Accelerate collagen deposiBon
SBmulate capillary budding and arborizaBon
Accelerate micro bio-oxidaBve killing
Improve select anBbioBc exchange across
membranes
Interfere with bacterial disease propagaBon by
denaturing toxins
Modulate the immune system response
Enhance oxygen radical scavengers thereby
decreasing ischemia-reperfusion injury
An agreement was reached on indicaBons during the
Consensus Conference (ECHM), Lille, Sept. 1994 and up-date
in Dec. 2004, April 15-16 th 2016
In fact, one of the ways of assessing the eciency of HBO:
basic research, animal studies with control groups and
human studies following EBM procedures (prospecBve,
controlled, randomized clinical studies)
EBM: IntegraBon of best research evidence with clinical
experBse and paBent values .
The 5 Steps EBM: 1. FormulaBon of answerable clinical
quesBons, 2. Searching for evidence, 3. CriBcal appraisal, 4.
Applicability of evidence, 5. EvaluaBon of performance.

10th ECHM
Consensus Conference
on Hyperbaric Medicine
April 15-16th 2016

Lille
www.echm-lille-consensus-2016.org
Condi8on Accepted Non Accepted Comment
Level Level
TYPE 1
Evidence Evidence
A B C D E F
CO Poisoning X
Open fracture with crush injury X
PrevenBon of osteoradionecrosis
X
aser dental extracBon
Osteoradionecrosis (mandibula) X
Sos Bssue radionecrosis (cysBBs, ProcBBs changed
X from T2 to T1
ProcBBs)
Decompression Ilness X
Gas embolism X
Anaerobic or mixed bacterial
X
infecBons
Sudden deafness Upgrade from
X C to B and
from T2 to T1
TYPE II Level Evidence Level Evidence

A B C D E F
Crush injury without fracture X Added
DiabeBc foot lesions X
Compromised skin grass and musculocutaneous
X
aps
Osteoradionecrosis (bones other than
X
mandibula)
Radio induced lesions of Sos Bssue (other than
X
cysBBs, ProcBBs)
Surgery and implant in irradiated Bssue
X
(prevenBve treatment)
Ischemic ulcer X
Refractory chronic osteomyeliBs X
Burn 2sd degree more than 20 % BSA X
Central reBnal artery occlusion (CRAO) X
Peumatosis cystoides intesBnallis X
Stage IV neuroblastoma X
Femoral head necrosis
X
TYPE 3 Level Evidence Level Evidence
A B C D E F
Brain injury (acute and chronic stroke, TBI is news,
post anoxic encephalopathy) in highly stroke is
selected paBents X upgraded, post-
anoxic no
change
Radio induced lesions of larynx X
Radio induced lesions of the CNS X
Post vascular procedure reperfusion
X
syndrome
Limb replantaBon X
Selected non healing wound secondary
X
to systemic processes
Sickle cell disease Upgraded from
X
NA
Anaerobic or mixed bacterial infecBons X
IntersBBal cysBBs Upgrade from
X
NA, from E to
Nega8ve Recommenda8ons (Type 1) Level Evidence Level Evidence
A B C D E F
AuBsm spectrum disorders X Added
Placental insuciency X
MulBple sclerosis X
Cerebral palsy X
Tinnitus X
Acute phase of stroke X
Conclusion
Hyperbaric oxygen therapy [HBOT] is a systemic treatment which
involves breathing 100% oxygen and pressure of more than 1
atmosphere.
The Pivotal therapeu8c eect of HBOT : Mechanical therapeu3c eect
of the increased barometric pressure (Boyles law), and Bio-
molecular therapeu3c eects of enhanced oxygen pressure
pressure. The iniBal eects that occur due to increased producBon
ROS (H2O2 ) and RNS (NO)
An agreement was reached on indicaBons during the Consensus
Conference (ECHM), Lille, Sept. 1994 and up-date in Dec. 2004, April 15-16
th 2016
How the mechanism of hyperbaric oxygen can be benecial for treatment ? ,

The approaches of 3 Hypotheses (Guritno 2010) : Redox Hypothesis,
Hormesis and Ischemic Tolerance or Hypoxia Precondi3on
TERIMAKASIH

Harkesal 2016

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Basic

Theory of HBO and EBM

A Time for Discoveries : From The Renaissance to

A prac8ce of Hyperbaric Medicine on a Scien8c

1644, Torricelli invent the Barometric Tube

1834, Junod : Benecial eects of high-pressure oxygen on

Treatment may be carried out either in a mono -

2. The iniBal eects that occur due to

PAO2=(Pb-PH2O).FiO2- PACO2 [FiCO2.(1-FiCO2)/R]

PAO =(Pb- 47).FiO - PACO - FiCO /R

CaO2= (Hb x SaO2 x 1.34) + (0.003 x PaO2)

Pb (ata) 1.0 1.0 2.0 3.0

FiO2 (%) 0,21 1.0 1.0 1.0

PAO2 (mmHg) 104 673 1433 2195

PaO2 (mmHg) 100 627 1267 2000

HbO2 (%) 19,7 20,1 20.1 20.1

CaO2 (ml/100ml) 0,3 1,88 3.8 6.0

3,8 ml O2/100ml plasm

1.0 2.0 3.0 [ata]

Therapeu8c Doses Over Doses

Controlled Less Controlled Catastrophic

HBOT Ischemic Precondition

Early Phase Delayed Phase

Activation of existing protein Gen expression

April 15-16th 2016

TYPE II Level Evidence Level Evidence

How the mechanism of hyperbaric oxygen can be benecial for treatment ? ,

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