シンポジウムS2-1 Wound Healing Using Hyperbaric Oxygen Therapy

第 46 回日本高気圧環境・潜水医学会学術総会　プロシーディング
Michael B. Strauss
Department of Hyperbaric Medicine Long Beach
Memorial Medical Center
Introduction Healing presents challenges especially
for chronic non-healing wounds (CNW). For healthy
wounds these challenges go unnoticed. However, for
CNW causes for non-healing need to be identified
and corrected. Some of the factors that contribute
to non-healing of the chronic wound include external
factors such as the requirement for a moist healing
environment while others are internal such as the need
for growth factors. Inadequate wound oxygenation
is one of a triad of principal reasons CNW fail to
heal. Hyperbaric oxygen (HBO) can mitigate this
problem. Current technology provides objectivity for
determining which CNW need HBO to achieve healing.
Background After evaluating and managing thousands
of wounds for nearly 35 years, it became apparent
that there are three fundamental reasons CNW fail to
heal.1 These are 1) Deformity, 2) Unresolved infection
and 3) Ischemia/hypoxia. I have labeled these“The
Treacherous Triad.” Deformities need to be managed
with off-loading and then surgical interventions when
indicated. Unresolved infection includes osteomyelitis,
infected bursa and infected cicatrix. Often they
accompany and/or are a consequence of inadequate
management of deformities. Antibiotics alone are
usually unsuccessful in managing this component of“The
Treacherous Triad”and surgical extirpation is required. Although hyperbaric oxygen (HBO) may compliment
the other interventions for managing deformity and
unresolved infection, it is unquestionably a primary
consideration for managing the hypoxic/ischemic nonhealing wound—especially when revascularization
has been done, is not feasible and/or the results are
not sufficient to meet wound healing oxygen demands.
Evaluation of ischemia/hypoxia starts with the history
and includes information such as non–healing, persistent
infection, claudication, rest pain or combinations of
these. Examination assessments consist of evaluation of
pulses, skin coloration, skin temperature and capillary
refill. Testing procedures for ischemia/hypoxia
include Doppler blood flow information, juxta-wound
transcutaneous oxygen measurements (TCOM) and
angiography. In many respects the quantification of
the ischemia/hypoxia component of“The Treacherous
Triad”can be more objective than for the other two
components of the triad.
Strategic Elements Essential for Managing the
Problem Wound and Where Hyperbaric Oxygen
Is Utilized A problem wound is a wound that is not
healing and/or is not expected to heal in an expected
fashion.1） Chronic non-healing wounds, by the above
definition, are problem wounds. Five interventions
are needed to manage these wounds and are the
strategic elements essential for the management
of problem wou nd s. 1） T he strateg ic element s
include: 1) Management of the wound base (usually
by debridements), 2) Protection and stabilization,
3) Medical management, 4) Selection of appropriate
wound dressing agents and 5) Wound oxygenation. Interventions to manage wound oxygenation include
edema reduction, optimization of cardiac function,
revascularization, use of pharmacological agents
to improve blood rheology and hyperbaric oxygen
therapy. Whereas single interventions, that is to say
tactics, are used for managing the first four of the five
strategic elements, more than one wound oxygenation
tactic is often used to manage wound hypoxia/ischemia
with the effects being additive.
The Algorithm for Evaluation and Management of
the Chronic Non-healing Wound A logical approach
for the evaluation and management of the CNW
where ischemia/hypoxia is a crucial component can
be formulated into an algorithm (Figure 1). If the
wound is not healing and the history and examination
suggest ischemia/hypoxia is a contributing cause, juxta-wound TCOM should be obtained. If the TCOM
is greater than 40 mmHg in room air, wound healing
should occur without the need for HBO as long as the
other two components of“The Treacherous Triad”
are managed appropriately. If less than 40 mmHg in room air, a hyperbaric oxygen
challenge will differentiate which ischemic/hypoxic
wounds will be benefited by HBO. If the TCOM with
HBO at 2 atmospheres absolute exceeds 200 mmHg,
there is almost a 90 percent likelihood the wound will
heal with using HBO as an adjunct to wound healing. 2） Conclusions Five strategic interventions are needed
to manage the CNW optimally. An algorithm identifies
which CNW will be benefited by HBO. Whereas
selection of the tactics used for management of CNW
is much an art as a science, the decision to use HBO
is highly objective and correspondingly largely a
science.
References
1）Strauss, MB, IV Aksenov, SS Miller, MasterMinding
Wounds, Best Publishing Company, Flagstaff, AZ, 2010
2 ）S trauss, MB, BJ Bryant, GB Hart, Trancutaneous
oxygen measurements under hyperbaric oxygen conditions
as a predictor for healing of problem wounds. Foot &
Ankle Intl, 2002; 23(10):933-937
Figure 1 A lgorithm for Wound Healing Using Hyperbaric
Figure 1 Algorithm for Wound Healing Using Hyperbaric Oxygen Therapy
Oxygen Therapy
Wound Score
Problem Wound
(4‐7 Points)
Debridement
Protection Medical mgmt 5 Rx Strategies
Dressing agents Perfusion / O2
PPV for healing = 0.93 (~100 Cases)
Appearance
Size
Depth
Infection
Perfusion tem Pulse
pe s, D
rat op
ure ple
, ca r, c
pil olo
lar r, y r
efil
l
シンポジウムS2-1
Wound Healing Using Hyperbaric Oxygen
Therapy
Perfusion Concerns
Assessment = ½ or 1 Point
TCOM (PtcO2) Study (>200 mmHg with HBO)
PPV for Healing = 0.87 (~70 Cases)
Ischemic / Hypoxic Wound
(Perfusion Assessment <1 Point)
(Patient Goals & Function)
Special Considerations
Hyperbaric O2
+/‐ Revascularizations
MIS/KISS Surgeries
Healing of FSD Wounds
Chronic stable Wounds
50% Heal Primarily
90% Heal Secondarily
50% Fail (FSD)
Legend The Wound Score is generated by summating 5 assessments each graded from 2 (best) to 0 (worst). If 4‐7 points, we observed healing Legend
The
Wound Score is generated by summating 5 assessments each graded from
in 93% of the cases. If perfusion concerns arise because of a low perfusion grade (i.e. ½ to 1 point), then a TCOM with HBO is obtained. 2 (best) to 0Almost 90% healing was observed if the TCOM was >200 mmHg with the HBO exposure regardless of the room air TCOM
(worst). If 4-7 points, we observed healing in 93% of the cases. If perfusion
If the perfusion assessment confirms the wound is ischemic/hypoxic, the goals and function of the patient must be ascertained. If concerns arise
because of a low perfusion grade (i.e. ½ to 1 point), then a TCOM with HBO
these are satisfactory, healing with HBO occurs primarily in 50% of surgeries using MIS/KISS techniques. Of the 50% that fail, we is obtained. Almost
90% healing was observed if the TCOM was >200 mmHg with the HBO
ultimately observed healing in 90% of the motivated, functional patients exposure
of the room air TCOM
Key regardless
FSD = Failed, Sloughed Dehisced [wound], KISS = Keep it Simple & Speedy [surgery], HBO
= Hyperbaric oxygen, MIS = Minimal Invasive Surgery, PPV = Positive Predictive Value, Rx = Treatment, TCOM = Transcutaneous O Measurement If the perfusion
assessment confirms the wound is ischemic/hypoxic, the goals and function
of the patient must be ascertained. If these are satisfactory, healing with HBO occurs
primarily in 50% of surgeries using MIS/KISS techniques. Of the 50% that fail, we ultimately
observed healing in 90% of the motivated, functional patients
Key FSD = Failed, Sloughed Dehisced [wound], KISS = Keep it Simple & Speedy [surgery],
HBO = Hyperbaric oxygen, MIS = Minimal Invasive Surgery, PPV = Positive Predictive
Value, Rx = Treatment, TCOM = Transcutaneous O2 Measurement
2
203
日本高気圧環境・潜水医学会雑誌
シンポジウムS2-3
当院における創傷治癒の治療戦略
田村裕昭　川嶌眞人　永芳郁文　本山達男
古江幸博　川嶌眞之　尾川貴洋　樋高由久
清水正嗣　高尾勝浩　山口　喬　宮田健司
特定医療法人玄真堂　川嶌整形外科病院
【はじめに】創傷治癒は，損傷された部分に生体の持
つ修復と再生能力が引き出された結果であるが，糖
尿病患者の増加に伴う足病変や，高齢化に伴う閉塞
性動脈硬化症などの血管病変による下腿潰瘍の難治
例が増加しており，この創傷治癒に苦しむことが少な
くない。当院では，局所的には，壊死組織の除去，
創傷部の湿潤環境の維持，感染管理などを行い，全
身要因への配 慮をしながら高気 圧酸素治療（以下
HBOT）を積極的に併用し治療に取り組んでいる。
【慢性創傷の原因と診断】慢性創傷の原因として最も
多いのは糖尿病性足病変があげられ，次いで動脈性
あるいは静脈性の潰瘍，血管炎，褥創，外傷後の創
治癒遅延，熱傷，骨髄炎に合併した潰瘍や 孔，ガ
ス壊疽や壊死性筋膜炎後など種々の原因がある。治
療に当たっては，これらの原因を考慮しながら，全身
状態や局所所見の評価を行う。血液検査では，創治
癒を遅らせる原因になる貧血や低蛋白血症などの評
価，CRPや赤沈値，白血球数などの炎症状態，血糖
やHbA1Cなどで血糖コントロールを評価する。画像
診断は，Ｘ線像で骨髄炎やガス像の有無を確認し，
MRIで炎症や損傷範囲の程度，骨内変化の状況を
確認し，血管超音波や造影MRI，CTアンギオグラフィ
ー
（他施設依頼）などで血管形態評価をする。血流の
評価は，超音波ドップラー，ABI，経皮的酸素分圧な
どを測定している。
【治療】当院での治療方針を表 1に示す。初期では，
日々の観察を密にして，病変の変化に注意しながら
壊死組織や不活性組織の除去することが重要で，外
科的デブリドマンは創傷の基底部が出血するまで行
う。創部の湿潤環境を保持しながら，必要に応じ
感受性のある抗菌薬を用いて感染の鎮静を図るとと
もに，早期からHBOTを開始する。通常の創傷では
2ATA下純酸素吸入 60分1日1回を原則とし，ガス壊
疽や壊疽性筋膜炎などの重症感染症の急性期では
2.8ATA下純酸素吸入 60分 1日1～2回で治療する。
HBOTは，血管新生の促 進，線 維芽 細胞の増殖，
浮腫の改善などの虚血性軟部組織の治癒促進作用
や，白血球の殺菌作用の増強，抗菌薬の抗菌作用の
増強などにより，創傷治癒に有効に働く。2～3週間
HBOTを継続すれば治療評価が可能になるので，創
状態が改善傾向であればさらに継続か植皮を行うか
などの検討をし，改善が得られない場合は血行再建
や切断の検討をしている。
204
Vol.46（ 4 ）, Dec, 2011
当院での難治性潰瘍 240例のHBOTのみの治療成
績は，創が閉鎖したのが 62.1％，50％以上改善したの
が18.2％，50％以下または不変が15.9％であった。骨
髄炎を伴った糖尿病性足病変は難治であるが，HBOT
の併用で手術することなく治癒する例も経験した。
最近は，創部の洗浄や湿潤環境保持にオゾンナノ
水を使用している。オゾンナノ水は，強力な組織保
存能，組織修復力，殺菌力を有し創傷治癒に有効で，
オゾンそのものは液中で分解消滅するため活性酸素
としての生体への酸素毒性をほとんど生じないことが
眞野により報告されている1）。症例数はまだ少ないが，
難治性潰瘍の閉創率は，HBO単独群は 23例中13例
（56.5％）に対し，オゾンナノ水併用群は 27例中 20例
（74.1％）と改善を認めた（図１）。
感染創を手術で一期的に閉鎖する場合は，閉鎖的
持続洗浄療法を１週間行い感染の確実な鎮静に努め
ている。また，治療効果なく切断に至る場合は，す
でに当院の安倍が報告しているが，2ATA純酸素吸入
下で経皮的酸素分圧が300㎜ Hg以上あることを切断
部位の一つの指標としている 2）。
【結語】難治性創傷の治療は総合的な治療が必要に
なるが，HBOTは極めて有効な治療手段の一つと思わ
れる。オゾンナノ水と併用することで創傷治癒効果が
さらに改善することが期待され，今後も検証していき
たい。
【文献】
1 ）眞
野喜洋：ナノバブルウオーターの医療応用．マイクロ
バブル・ナノバブルの最新技術Ⅱ．シーエムシー出版．
2010；pp.237-245.
2 ）安
倍基幸：下肢血行障害に対する高圧酸素下の経皮的
酸素分圧評 価．日本災害医学会会 誌　1990；Vol.38
No.4.pp.225-230.
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第 46 回日本高気圧環境・潜水医学会学術総会　プロシーディング
シンポジウムS2-4
重症軟部組織感染症に対する当院の治療戦略
―陰圧閉鎖療法と高気圧酸素治療の併用―
とを確認できた時点からHBOを開始。また日々局所
の所見を観察しつつ，十分な肉芽形成が得られた時
点で，植皮または皮弁などの創傷閉鎖手術を施行。
術後約１週間程度の，初回創傷処置の時点まで継続
山田法顕　土井智章　豊田　泉　田中義人
した。この時点で創傷および潰瘍面の治癒状態から
三宅喬人　谷崎隆太郎　中島靖浩　吉田隆浩
HBOの継続が望ましいと判断した例はHBOを継続し
吉田省造　白井邦博　小倉真治
た。これまで 6例（症例は表のとおり）に施行し，2次
岐阜大学医学部附属病院　高度救命救急センター
感染例はなく，創閉鎖手術は１例を除き2回以上の
手術を必要としておらず，良好な治療成績を挙げてい
感染症学や抗菌化学療法が発達した現在でも，壊
死性筋膜炎に代表される重症軟部組織感染症は，難
治性感染症の一つである。これらの感染症に対して
る。これらは，HBO，NPWTおのおのが持つ効果の
相乗効果によるものと考えられる。1,2)
HBO，NPWT各々の主たる治癒機転のtagetが，重
の基本的な治療の原則は，適切な全身管理とともに，
症軟部組織感染症および治療に伴う潰瘍の特徴であ
迅速かつ十分なドレナージ・外科的デブリードメントと
ることを考慮すると，本疾患の亜急性期から慢性期
適切な抗菌化学療法である。しかし軟部組織感染症
こそ，NPWTとHBOの併用が最もその治療効果を発
ではしばしば十分なドレナージが不可能であったり，
揮するといえる。今後最適な治療頻度や圧力の設定，
病変部位には血流が途絶していることも多く抗菌化
治療機序の詳細の更なる解明など，解決すべき問題
学療法が不十分となりやすい。また十分なデブリード
は多いが，今後救急領域で標準的治療となりうる可
メントを行うが故に治療過程で広範な軟部組織欠損
能性を秘めているのではないだろうか。
を生じるために，経過が遷延することも多く，重症軟
部組織感染症の局所創傷管理の上で大きなジレンマ
となる。
我々はこれまで外傷・熱傷による軟部組織欠損に
対し陰圧創傷閉鎖療法（Negative Pressure Wound
Therapy：NPWT）を施行し，良好な肉芽形成が得ら
れることを確認し，またこれまでにこれらの創傷管理
については，多くの報告がある。しかし一方で創傷
によってはNPWTのみでは効果が不十分 である例も
これまで経験し，また報告されてきた。また当院では
外傷による軟部組織欠損を伴う開放骨折（GustiloⅢA
以上）すなわち挫滅・汚染創に対し創傷治癒の促進
効果，感染に対する効果を期待して高気圧酸素治療
（Hyperbaric Oxygen therapy：HBO）を行い，良好な
経過が得られることを確認している。 これらの知見・
【参考文献】
1 ）Weiland D. Fasciotomy closure using simultaneous
Vacuum-assisted closure and hyperbaric oxygen. Am
Surg. 2007;73: 261-6.
2 ）Thaddeus S,et al. The Evaluation of Subatmospheric
Pressure a nd Hy perba ric Oxygen in Ischemic
Fu l l -T h i c k n e s s Wo u n d H e a l i n g A m S u r g . 2000;66:1136-43.
当院での診療経験をふまえ，重症軟部組織感染症に
おける局所の管理にNPWTとHBOの併用を行った。
一連の戦略として，まずは十分なドレナージ・外科
的デブリードメントと適切な抗菌化学療法，全身管
理を行い，全身状態の安定化を最優先とする。創
部の浸出液がNPWTに対応できる量になった時点で
NPWTを開始。 さらに呼吸・循環動態が安定したこ
205
日本高気圧環境・潜水医学会雑誌
シンポジウムS2-5
Hyperbaric oxygen therapy plays a key
role in the development of wound care
center in Taiwan
Tsai Wen-Ping
Division of Plastic Surgery, Department Surgery,
Department of Hyperbaric Oxygen and Wound Care
Center, Shuang-Ho Hospital, Taipei Medical University,
Taipei, Taiwan.
Wound care is now recognized as an interdisciplinary
approach to problem or chronic wounds. Integration
of different experts into wound care, including
infection physician, endocrinologist, vascular
surgeon, plastic surgeon, nutritionist, wound care
nurse specialist, etc., is one important point to the
success of wound center development. Hyperbaric
oxygen (HBO) treatment, a proved powerful
adjuvant therapy in wound healing, plays a key role
in the establishment of wound care center. During
the treatment course of HBO, patients can receive
regular follow up for wound evaluation as well as
wound dressing change. Treatment strategies can
also be adjusted or modified accordingly without
delay. Interdisciplinary consultation and meeting
can also be held frequently.
In Taiwan, there are about 35 multi-chamber
HBO centers. About one fourth of the centers
focused on problem wound and the number is still
increasing. Our wound care center, hyperbaric
oxygen treatment and wound care center in
Shuang-Ho Hospital, is a newly established HBO
center focused on wound care in Taiwan. The
characteristics of our center are multidisciplinary
wound care team, individualized wound care
treatment plan and smartphone-based telemedicine.
Our wound care team includes plastic surgeon,
vascular surgeon, cardiovascular physician,
endocrinologist, infection physician and wound
care nursing staff, etc. Weekly case discussion
and bi-weekly interdisciplinary meeting are held
consistently. Every patient visited our center
will be suggested an individualized treatment
plan for wound healing recorded in a “wound
care passport”. The patient can involve more
into their treatment progress by checking one’s
own“passport”at hand. The“smart-phone based
telemedicine”
, with the help of worldwide increasing
popularity of smartphone, is a newly developed
206
Vol.46（ 4 ）, Dec, 2011
system for real-time interaction between patients
and medical staffs. Patient can send the pictures
of wound taken from their smartphone to our
wound care data base. And our medical staff will
advise adequate management to patient or family
immediately online (Fig 1). It will not only improve
the compliance of patients and also save more
time and labor especially for disabled patients.
Besides, we also established a blog and forum of
our wound care center for education and discussion
with patient and their family (Fig 2). All those
characteristics are derived from“patient-oriented”
concept. On HBO treatment course, patient can
receive other ancillary treatments or dressing
change at the same time in our center. After HBO
treatment course, patient can finish their wound
care treatment in our center or receive online
follow-ups by“smart-phone based telemedicine”
till the wound heals. Though the HBO treatments to improve wound
healing is not covered by public health insurance
in Taiwan, the number of patients came for this
indication is increasing greatly. We believe and
hope that our model of hyperbaric oxygen and
wound care center is helpful to facilitate wound
healing and also improve patient care.
Fig 1. S
mart-phone based telemedicine to
facilitate wound care.
Fig 2.“Wound-care
blog”for education and
discussion with patient and their family.
(http://i-woundcare.com/blog)