International Indications For Hyperbaric Oxygen Therapy - HyperMED

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International Indications For Hyperbaric Oxygen Therapy - HyperMED

About the Author

K.K. Jain, MD, is a neurosurgeon and has held fellowships and teaching positions at Harvard, UCLA, and the University of Toronto. He

has been a visiting professor in several countries and served in the US Armv with the rank of Lieutenant Colonel. He wrote the Handbook

of Laser Neurosurgery based on his experience in microsurgery and lasers. He has been active in the field of hyperbaric medicine since

1976, starting with the application of this technique to stroke patients. The author of 15 books i including Oxygen in Physiology & Medicine,

Textbook of Gene Therapy, and Handbook ofNanomedicine), Prof. Jain, in addition to his activities in biotechnology, serves as a consultant

in hyperbaric medicine.

With contributions by

S.A. Baydin MD


Director General, Institute of Hyperbaric

Medicine and Techniques,

Post Box 853

Moscow, 119435 Russia

(Chapter 29, Pediatric Surgery)

J. Bookspan, PhD

Temple University and Jefferson Medical College,

Philadelphia, PA, USA

(Chapter 23, Headache)

T.M. Bozzuto, DO

Medical Director, Phoebe Wound Care 8c Hyperbaric Center

Phoebe Putney Memorial Hospital

Albany, GA, USA

(Chapter 41, United States)

F.K. Butler, Jr., MD

CAPT MC USN (Ret)

Chairman, Committee on Tactical Combat Casualty Care

Defense Health Board

Pensacola, FL, USA

(Chapter 32, Ophthalmology)

E.M. Camporesi, MD

Professor and Chairman, Dept. of Anesthesiology

SUNY, Syracuse, New York

(Chapter 38, Anesthesia)

C.E. Fife, MD

Associate Professor of Anesthesiology

Memorial Hermann Center for Hyperbaric Medicine

Houston, Texas 77030, USA

(Chapters 14, Chronic Lyme Disease; 23, Headache)

W.P.Fife, PhD

Professor of Hyperbaric Medicine (Emeritus)

Texas A 8c M University

College Station, Texas, USA

(Chapter 14, Chronic Lyme Disease)

P.G. Harch, MD

Director, Dept. of Hyperbaric Medicine

LSU School of Medicine at New Orleans

Harvey, LA, USA

(Chapters 19, Anoxia and Coma; 22, Cerebral Palsy; 44, Appendix)

P.B. James, MD

Professor Emeritus, Wofson Institute of Occupational Health

Medical School

Ninewells, Dundee, UK

(Chapters 10, Decompression Sickness; 21, Multiple Sclerosis;

44, Appendix)

H. Murphy-Lavoie, MD

Assistant Residency Director

Emergency Medicine Residency

Associate Program Director

Hyperbaric Medicine Fellowship

LSU School of Medicine MCLXO

New Orleans. LA. USA

(Chapter 32, Ophmahnoiogv

R.A. Neubauer, MD^

Director, Ocean Hyperbaric Center

Fort Lauderdale, FL. L'SA

(Chapters 19, Anoxia and Coma: 21, Multiple Sclerosis;

22 Cerebral Palsy: 44. Appendix

V. Neubauer

Ocean Hyperbaric Center

Fort Lauderdale, FL, L'SA

(Chapter 22, Cerebral Palsv

M.H. Sukoff

Clinical Professor of Xeiirosurgery

University of California

Irvine, CA, USA

(Chapter 20, Neurosurgery I

H. Takahashi

Professor and Chairman

Department of Hyperbaric Medicine

University of Nagoya School of Medicine

Showa-Ku, Nagoya 466-8560

Japan

(Chapter 43, Japan)

K. Van Meter, MD

Chief, Section of Emergency Medicine

Clinical Professor of Medicine, Section of Emergency Medicine

LSU Health Sciences Center in New Orleans

Harvey, LA, USA

(Chapter 39, Emergency Medicine)

J.M. Uszler, MD

Professor of Nuclear Medicine

Santa Monica-UCLA Medical Center

Santa Monica, CA, USA

(Chapter 44, Appendix)

H.A.Wyatt,MD,PhD

Clinical Instructor of Medicine

LSU Health Sciences Center

Department of Medicine and Division of Hyperbaric Medicine

Marrero, LA, USA

(Chapter 37, Organ Transplants)

H.Yagi.MD

Director, Hyperbaric Medicine

Fukuoka Yagi Kosei-Kai Hospital

(2-21-25, Maidashi, Higashi-Ku,

Fukuoka, Japan

(Chapter 43, Japan)


fable of Contents

rord by J. Toole

)rd to the Third Edition by E. Teller

to the Fifth Edition

to the Fourth Edition

ce to the Third Edition

to the Second Edition

• to the First Edition

IX

X

XII

XII

XIII

XIII

XIV

' J: Basic Aspects

.The History of Hyperbaric Medicine

.Ifiysical, Physiological, and Biochemical Aspects of Hyperbaric Oxygenation

(.Effects of Diving and High Pressure on the Human Body

bflivsical Exercise Under Hyperbaric Conditions

t&rpoxia

|Oxvgen Toxicity

>aric Chambers: Equipment, Technique, and Safety

Lfcdkations, Contraindications, and Complications of HBO Therapy

Ufcug Interactions with Hyperbaric Oxygenation

3

9

21

31

37

47

59

75

81

II: Clinical Applications

>mpression Sickness

>ral Air Embolism

LCawbon Monoxide and Other Tissue Poisons

i Therapy in Infections

Therapy in Chronic Lyme Disease

1 Therapy in Wound Healing, Plastic Surgery, and Dermatology

1 Therapy in the Management of Radionecrosis

87

103

111

135

149

157

177


VIII

17. The Use of HBO in Treating Neurological Disorders 189

18. The Role of Hyperbaric Oxygenation in the Management of Stroke 205

19. HBO Therapy in Global Cerebral Ischemia/Anoxia and Coma 235

20. HBO Therapy in Neurosurgery 275

21. HBO Therapy in Multiple Sclerosis 291

22. HBO in the Management of Cerebral Palsy 299

23. HBO Therapy in Headache 311

24. HBO Therapy in Cardiovascular Diseases 319

25. HBO Therapy in Hematology and Immunology 339

26. HBO Therapy in Gastroenterology 347

27. HBO and Endocrinology 357

28. HBO and Pulmonary Disorders 361

29. HBO Therapy in Pediatric Surgery 367

30. Hyperbaric Oxygenation in Traumatology and Orthopedics 375

31. HBO Therapy in Otolaryngology 387

32. HBO Therapy and Ophthalmology 399

33. Hyperbaric Oxygenation in Obstetrics and Neonatology 421

34. Hyperbaric Oxygenation in Geriatrics 425

35. HBO as an Adjuvant in Rehabilitation and Sports Medicine 431

36. The Role of HBO in Enhancing Cancer Radiosensitivity 435

37. HBO Therapy and Organ Transplants 443

38. Anesthesia in the Hyperbaric Environment 447

39. HBO in Emergency Medicine 453

40. Hyperbaric Medicine as a Specialty: Training, Practice, and Research 483

41. Hyperbaric Medicine in the United States 491

42. Hyperbaric Medicine in Japan 495

43. Hyperbaric Medicine in the Rest of the World 499

PART III: Appendix, Bibliography, Index

44. Appendix: Diagnostic Imaging and HBO Therapy 505

45. Bibliography 521

46. Index 571


76 Chapter 8

Table 8.1

Uses of HBO Approved by the Undersea and Hyperbaric Medical

Society

• Air or gas embolism

• Carbon monoxide poisoning and carbon monoxide poisoning

complicated by cyanide poisoning

• Clostridial myonecrosis (gas gangrene)

• Crush injury, the compartment syndrome, and other acute

traumatic ischemias

• Decompression sickness

• Enhancement of healing in selected problem wounds

• Exceptional anemia resulting from blood loss

• Necrotizing soft tissue infections (of subcutaneous tissue,

muscle, or fascia)

• Refractory osteomyelitis

• Intracranial abscess

• Radiation tissue damage (osteoradionecrosis)

• Compromised skin grafts and flaps

Table 8.2

Summary of International Indications for HBO

1. Decompression sickness

2. Air embolism

3. Poisoning: carbon monoxide, cyanide, hydrogen sulfide, carbon

tetrachloride

4. Treatment of certain infections: gas gangrene, acute necrotizing

fascitis, refractory mycoses, leprosy, osteomyelitis

5. Plastic and reconstructive surgery:

- for nonhealing wounds

- as an aid to the survival of skin flaps with marginal circulation

- as an aid to reimplantation surgery

- as an adjunct to the treatment of burns

6. Traumatology: crush injuries, compartment syndrome, sof

tissue sports injuries

7. Orthopedics: nonunion of fractures, bone grafts, osteoradionecrosis

Indications

Indications for hyperbaric oxygen (HBO) therapy vary in

different countries and are described in Chapter 43. The

indications approved by the Undersea and Hyperbaric

Medical Society (Table 8.1) are very limited and rely on the

prooi ot erdcacy otHBOby controWed studies. X summary

c?i I'lTcrrctfiiYjiTS rs SITCTWYT rrr isotc o.Z. i ue iduic irsis a"u uic

conditions where HBO has been shown to be useful, although,

to date, few of these have been proven by controlled

studies.

Contraindications

Contra-indications for HBO therapy are shown in Table

8.3.

to catfoac sut^exy

9. •Pei\pr\eia\r disease, ischemic gangrene, iscYien

pain

HI. Neurological: stroke, multiple sclerosis, migraine, c

edema, multi-inlarct dementia, spinal cord injury a

cuiar diseases of the spinai cord, brain abscess, pe

neuropathy, radiation myelitis, vegetative coma

11. Hematology', sickle cell crises, severe blood loss an

12. Ophthalmology: occlusion of central artery of ret;

13. Gastro-intestinal: gastric ulcer, necrotizing enteroco

lytic ileus, pneumotoides cystoides intestinalis, hepa

14. For enhancement of radiosensitivity of malignanl

15. Otorhinolaryngology: sudden deafness, acute acoi

ma, labyrinthitis, Meniere's disease, malignant oti

(chronic infection)

16. Lung diseases: lung abscess, pulmonary embolisr

to surgery)

17. Endocrines: diabetes

18. Obstetrics: Complicated pregnancy - diabetes, e

heart disease, placental hypoxia, fetal hypoxia. C

heart disease of the neonate

19. Asphyxiation: drowning, near hanging, smoke inh

20. Aid to rehabilitation: spastic hemiplegia of stroke

gia, chronic myocardial insufficiency, periphera

disease.

Pneumothorax. The only absolute contraindication for

HBO is untreated pneumothorax. Surgical relief of the

pneumothorax before the HBO session, if possible, removes

the obstacle to treatment.

The contraindications listed below are not absolute but relative.

The potential benefits should be weighed against the

condition of the patient and any ill-effects that may occur.

Upper Respiratory Infections. These predispose to otobarotrauma

and sinus squeeze.

Emphysema with C0 2 Retention. Patients with this problem

may develop pneumothorax due to rupture of an em-

Table 8.3

Contraindications for HBO Therapy

Absolute

• Untreated tension pneumothorax

Relative

• Upper respiratory infections

• Emphysema with CO? retention

• Asymptomatic air cysts or blebs in the lungs seen

X-ray

• History of thoracic or ear surgery

• Uncontrolled high fever

• Pregnancy

• Claustrophobia (see complications of HBO)


196 Chapter 17

The favorable results of HBO on cerebral edema in experimental

animals have been confirmed by the clinical use of

HBO for the relief of traumatic cerebral edema (Sukoff &

Ragatz 1982). HBO (1.5 ATA) treatment of patients with severe

brain injury reduces raised intracranial pressure and improves

aerobic metabolism (Rockswold et al 2001; Sukoff 2001).

Application of HBO during the early phase of severe

fluid percussion brain injury in rats significantly diminished

ICP elevation rate and decreased mortality level (Rogatsky

etal 2005). In conclusion, it can be stated that HBO

relieves cerebral edema by the following mechanisms (Figure

17.3):

• Reduction of CBF but maintenance of cerebral oxygenation.

• HBO counteracts the effects of ischemia and hypoxia associated

with cerebral edema and interrupts the cycle of

hypoxia/edema.

HBO lowers raised ICP in traumatic cerebral edema as long

as the cerebral arteries are reactive to C0 2. It is ineffective in

the presence of vasomotor paralysis and is contraindicated in

terminal patients with this condition. The effects of HBO can

persist after the conclusion of a session and there is no rebound

phenomenon, as is the case with the use of osmotic

diuretics. If the ICP is elevated due to obstruction in the CSF

pathways, as is the case in intraventricular hemorrhage, HBO

and dehydrating agents have only a temporary effect in lowering

ICP. Ventricular drainage is important in these patients,

not only to lower the ICP but also to improve the CBF that

decreases as an effect of raised ICP. Persistence of raised ICP

can cause further cerebral damage. Studies of the effect of

HBO on raised ICP in patients with brain tumors and cerebrovascular

disease indicate that reduced ICP is initially due

to direct vasoconstriction caused by hyperoxia but tends to

rise again. However, the secondary rise can be prevented by

induced hypocapnia.

The injured brain is susceptible to oxygen toxicity if high

pressures are used. This is usually not a problem as the

pressures seldom exceed 2.5 ATA; 1.5 ATA is used for most

neurological indications.

Table 17.4

Neurological Indications for the Use of HBO Therapy

1. Cerebrovascular disease

Acute cerebrovascular occlusive disease

Chronic poststroke stage

Treatment of spasticity

Aid to rehabilitation

Adjunct to cerebrovascular surgery

Selection of patients for IC/EC bypass operation on the ba

of response to HBO

Postoperative complications of intracranial aneurysm su

gery: cerebral edema and ischemia

Carotid endarterectomy under HBO as a cerebral protec

measure

2. Cerebral air embolism

3. Head injuries: cerebral edema and raised intracranial pressu

4. Spinal cord lesions

Acute traumatic paraplegia within 4 h of injury

Spinal cord decompression sickness (spinal cord "hit")

Ischemic disease of the spinal cord

Aid to the rehabilitation of paraplegia and quadriplegia

Residual neurological deficits after surgery of compressii

spinal lesion

5. Cranial nerve lesions

Occlusion of the central artery of the retina

Facial palsy

Sudden deafness

Vestibular disorders

6. Peripheral neuropathies

7. Multiple sclerosis

8. Cerebral insufficiency (decline of mental function): mi

infarct dementia

9. Infections of the CNS and its coverings: brain abscess, me

ingitis

10. Radiation-induced necrosis of the CNS: radiation myelopathy

and encephalopathy

11. CO poisoning

12. Migraine headaches

13. Cerebral palsy

Indications for the Use of HBO in

Neurological Disorders

Various neurological conditions where HBO has been reported

to be useful are listed in Table 17.4. Most of these

are based on a review of the literature. There are few controlled

clinical studies. The Undersea and Hyperbaric

Medical Society USA does not list any of these conditions

(with the exception of cerebral air embolism) as approved

for payment by third-party insurance carriers.

There are several good reviews of the use of HBO ::

neurological disorders (Hayakawa 1974; Kapp 1982; Su? -

off 1984). The role of HBO in cerebrovascular disease

described in Chapter 18. HBO for the management of

oxic encephalopathies is dealt with in Chapter 19, neur

surgical disorders in Chapter 20, HBO as an adjunct

the management of multiple sclerosis is discussed

Chapter 21, cerebral palsy in Chapter 22, and migraine

headaches in Chapter 23. The rationale for the use

HBO is discussed, along with the indications.


500 Chapter 43

Introduction

The practice of medicine varies around the world and so

does hyperbaric medicine. It was considered appropriate to

include a brief description of trends in the practice of

hyperbaric medicine around the world. It was not possible

to include all the countries. Only those countries outside

of the United States where hyperbaric medicine is practiced

on a significant scale are included. A brief description of

hyperbaric medicine in United States was given in Chapter

41. This chapter will briefly describe the current state of

hyperbaric medicine in Germany, Russia and China. HBO

in Japan is described in detail in Chapter 42.

Hyperbaric Medicine in Germany

Germany has played an important part in the development

of modern hyperbaric medicine, particularly in the applications

for neurological disorders. Important work in this area

was done in the late 1960s and early 1970s at the University

Neurosurgical Clinic, Bonn, by Professor K.H. Holbach and

colleagues, of whom Prof. Wassmann continued this work.

The author (KKJ) had an opportunity to work with this

team. HBO was applied to patients with head injuries and

stroke and the important contribution was the response to

HBO for selecting patients for extra-intracranial bypass operation.

This application of HBO did not spread in clinical

practice for the next decade when the group in Bonn moved

to other centers and followed other interests in neurosurgery.

In 1980s research was done into the applications of

HBO for inner ear disorders, particularly sudden deafness.

In 1986, the author returned to Germany and during the

following three years had a chance to work on the clinical

applications of HBO in a rehabilitation clinic. This is where

the work on treatment of chronic stroke patients was carried

out. In 1989, there were only four active hyperbaric chambers

for clinical HBO therapy in Germany.

In recent years there has been a rapid expansion of hyperbaric

facilities in Germany and in 2008 there are approximately.

These are all multiplace chambers (monoplace chambers

are not approved in Germany currently) and over 50,000

patients were treated in the year 2007. Most of these patients

(about 85%) are treated on an ambulatory basis for indications

related to the inner ear (tinnitus and hearing loss). Most

of these chambers are outside of university centers and are

mostly business enterprises with little research activity. Efforts

are being made to expand the indications to other areas

and some of these chambers may be used for the treatment

of patients in acute stroke trials that are planned in conjunction

with US centers.

Hyperbaric Medicine in China

The first Chinese hyperbaric chamber was built in

Dr. Wen-ren Li, Hyperbaric medicine has developed i

ly in China during the past decade and there are i

18000 hyperbaric chambers in the country. Tk

including physicians, nurses, technicians and re

entists is over 35,000. The number of patients treate

with HBO exceeds 2.5 million. Apart from the

practice, research is being carried out on the mecr.

of action of HBO and its role in the managemen:

following conditions:

• Stroke

• Persistent vegetative state

• Autoimmune diseases

• Cancer

• Rejection in transplants

Indications and contraindications for hyperbaric o:

China are shown in Table 43.1.

Table 43.1

Indications for HBO in China, Chinese Society of Hyperbaric

Oxygen Medicine

Emergency indications, first line

1. Acute CO poisoning and its delayed neurological sequel

2. Acute decompression sickness

3. Acute air embolism

4. Acute cerebral dysfunction after cardiopulmonary res_>c:

tation (electric injury, drowning, hanging)

5. Anaerobic infections (Gas gangrene, tetanus, etc)

6. Shock

7. Chemical and gas poisoning (hydrogen sulfide, petroleiM

gas etc)

8. Acute retinal artery occlusion

9. Acute cerebral edema and pulmonary edema

10. Crush injury and its syndrome

11. Acute peripheral circulatory failure

12. Severe spinal cord injury.

Second line indications, adjunctive

1. Coronary heart disease

2. Myocardial infarction

3. Myocarditis

4. Bronchial asthma and asthmatic bronchitis

5.: Ischemic cerebrovascular disease

6. Migraine

7. Bell's palsy

8. Peripheral nerve injuries and neuropathies

9. Mountain sickness

10. Brain trauma

11. Brain tumor, post-operative

12. Cerebrovascular disease, post-operative

13. Multiple sclerosis

14. Epilepsy

15. Reimplantation of severed limb, post-operative


Hyperbaric Medicine in Rest of the World 501

16. Myelitis

17. Bone fractures and non-union of fracture

18. Aseptic osteonecrosis

19. Chronic skin ulcer

20. Congenital heart disease surgery

21. Coronary artery bypass operation

22. Paralytic ileus

23. Peripheral vascular disease

24. Chilblain

25. Burns

26. Cosmetic surgery, post-operative

27. Post skin grafting

28. Sudden deafness

29. Acoustic deafness

30. Vertigo

31. Retinal venous thrombosis

32. Central serous retinopathy

33. Retinal concussion

34. Optic atrophy

3 5. Diabetic retinopathy

36. Viral encephalitis

37. Infectious hepatitis

38. Chronic hepatic insufficiency

39. Peptic ulcer

40. Ulcerative colitis

41. Sports injuries

42. Radiation injury

45. Pharmaceutical and chemical intoxications

44. Pityriasis rosea

45. Shingles

46. Erythema nodosum

4". Periodontal disease

4?. Recurrent aphthous ulcer

49. Cancer (combined with radiotherapy and chemotherapy)

30. Pneumonia in children

• -.onatal asphyxia

52. Fetal distress

5 5 Cerebral palsy in children

iaiestigative indications

1. Meningitis

2. Arrhythmia

3L Chronic heart failure

4. Glaucoma

.inganese poisoning

4. Autoimmune diseases

7. Diabetes mellitus

• : -i.a::on-induced vasculitis

9L Cervical spondylopathy

ML Mycosis

•. • • • - n"> disease

i >z-..z dementia

13L Pyocephalus

14. Progressive myodystrophy

15- Rheumatoid arthritis

ML Adah respiratory distress syndrome

-Jdbirth in women with heart disease

Ml mutual abortion

AdbK contraindications

xested pneumothorax and mediastinal emphysema

2. Active bleeding and hemorrhagic disease

3. Positive reaction to oxygen tolerance test

4. Tuberculous cavitation in lungs and hemoptysis

5. Second degree heart block

Relative contraindications

1. Severe upper respiratory tract infection

2. Severe pulmonary emphysema and bullae of lungs

3. Severe sinusitis

4. Untreated malignant tumor

5. Detachment of retina

6. Sick sinus syndrome

7. Bradycardia

8. Otitis media suppurativa

9. Eustachian tube occlusion

10 Hypertension

Hyperbaric Medicine in Russia

Russia has extensive hyperbaric facilities. There are over

60 centers with hyperbaric facilities and approximately

1300 hyperbaric chambers are currently in use. Russia had

one of the longest lists of indications for hyperbaric oxygen

therapy. These indications are shown in Table 43.2.

Table 43.2

Hyperbaric Oxygen Indications in Russia

Vascular diseases

Arterial obstructions in the limbs before and after surgery

(embolism, traumas, thrombosis)

Arteriosclerosis

Gas embolism in the blood vessels

Ulcers caused by defective blood circulation

Cardiac disorders

Heart strain

Heart rhythm disturbances

Irregular heartbeat

Paroxysmal extrasystole

Cardiac insufficiency

Cardiosclerosis decompensation

Cardiac insufficiency after heart surgery

Heart contraction disturbances

Cardio-pulmonary insufficiency

Pulmonary disorders

Lung abscess before and after surgery

Nonspecific chronic lung affections with cardiopulmonary

insufficiency signs

Gastrointestinal disorders

Stomach and duodenal ulcers

Intestinal obstruction

Liver diseases

Acute viral hepatitis

Hepatic encephalitis

Liver cirrhosis

Obstructive jaundice

Hepatic insufficiency after resuscitation

Toxic hepatitis


502 Chapter 43

Table 43.2 (continued)

Central nervous system diseases

Cerebral gas embolism

Brain ischemia

Cranial traumas

Posthypoxic encephalopathy

Botulism

Cervical spinal cord trauma

Eye disorders

Acute retinal ischemia

Retinal dystrophy

Diabetic retinopathy

Optic neuritis by methanol intoxication

Endocrine disorders

Diabetic arteriopathy

Diabetic ulcers and polyneuritis

Toxic goitre

Facial and maxillary pathology

Paradontosis

Facial phlegm

Maxillary osteomyelitis

Necrotic gingivitis and stomatitis

Facial actinomycosis

Orthopedics

Fractured limbs with blood circulation disturbances

Fractures in an arteriopathic or diabetic patient

Delayed fracture union

Osteomyelitis

Obstetrics

Abortion by placental ischemia

Threatened abortion due to endocrine disorders

Placental hypoxia

Fetal hypoxia

Pregnancy neuropathy (stage 1,2)

Pregnancy with immunological disorders

Pregnancy complications by extragenital pathology

Cardiac malformation: acquired or congenital

Diabetes

Pregnant or delivered mothers in critical state

Coma after eclampsia

Diseases of newly born

Asphyxia during delivery

Cerebrovascular disturbance

Hemolysis

General surgery infections

General septic abscess unresolved in spite of incision

Infectious peritonitis with surgical removal of initial lesion

Wound pathology

Clostridial infection

Wound abscess in spite of drainage

Prophylactic treatment of wound infected after open trauma

Granular wound

Wound with superficial burn

Postsurgery wound

Exogenous poisoning

Carbon monoxide poisoning

Cyanide poisoning

Chloroxide poisoning

Organic phosphate poisoning

World Distribution of Hyperbaric

Facilities

Some idea of the quantity of hyperbaric medical 1

the world can be obtained by a review of the statistics

ing the distribution of hyperbaric chambers in

countries. Accurate information on this subic.

obtain, but the available figures are shown in Figu

The largest number of chambers are located in Chir i

1800) and Russia with 1300 chambers is next. Eur

about 475 hyperbaric chambers, and the distnDo

these is shown in Figure 43.2. The number of chamb

not necessarily correlate with the number of patient

number of treatments given. There is no separation

tiplace and monoplace chambers in the statistics.

South

Korea

8°/<

Figure 43.1

World distribution of hyperbaric chambers.

Benelux

Switzerland

2%

Scandinavia

2%

Figure 43.2

Distribution of hyperbaric chambers in Europe.

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