State-of-the-art wound care is provided by New York Hospital Queens in the
Center for Wound Healing at Silvercrest.
The New York Hospital Queens Center for Wound Healing applies proven wound care practices and advanced clinical approaches, such as hyperbaric oxygen therapy, to help patients who suffer from chronic wounds achieve high healing rates and fast healing times.
Our wound care services, including hyperbaric medicine, are provided in an outpatient setting within our new, dedicated facility st Silvercrest.
We have assembled a multi-disciplinary team with knowledge from all the relevant medical specialties. Internists and geriatricians, surgeons and plastic surgeons, endocrinologists, vascular surgeons and podiatrists all contribute their expertise. The team at the Center for Wound Healing can treat:
- Diabetic wounds that are slow-to-heal or not healing
- Foot or leg ulcers/sores
- Surgical wounds that have opened
- Skin grafts or surgical flaps that are not healing
- Skin tears or open sores caused by radiation treatment
- Bone infection
- Crush injuries from accidents
- Radiation cystitis or proctitis
- Reconstruction of jaw or bone (related to mandibular osteoradionecrosis)
One of the unique therapy modalities available to our team is hyperbaric oxygen therapy, (HBOT).
Hyperbaric Oxygen Therapy (HBOT) is a medical treatment in which the entire body is under increased atmospheric pressure and the patient breathes 100% oxygen. This treatment is administered in a pressurized chamber.It is proven effective for a number of different medical and surgical conditions, either as a primary treatment, or in addition to other medical treatments such as antibiotics or surgery.
At the New York Hospital Center for Wound Healing at Silvercrest, we use single person ("monoplace") chambers. These chambers are approximately eight feet long and 34 inches wide. Some facilities use multi-place chambers that allow treatment of more than one person at a time.
Normally our atmosphere exerts 14.7 pounds per square inch of pressure at sea level. This is equivalent to "one atmosphere absolute," (1 ATA). In this atmosphere, we breathe approximately 20% oxygen and 80% nitrogen. During HBOT, the pressure is increased to 2-3 times normal pressure and one breathes 100% oxygen. Most patients are treated at two times the normal atmospheric pressure, (2ATA).
The combination of high oxygen concentration (100%) and increased pressure causes large amounts of oxygen to become dissolved in your blood and other tissue fluids. There can be as much as 10-15 times the usual amount of oxygen dissolved in the blood during therapy, which gets more oxygen to the rest of the body.
Many different afflictions have been shown to improve with HBOT. Some of the most common problems are non-healing wounds, (especially in diabetics), osteomyelitis, (bone infection), radiation injury to bone or soft tissue burns, decompression illness, (the "bends") and carbon monoxide poisoning.
Once you are in the chamber and the door is closed, you will hear the oxygen begin to circulate and we will then begin the gradual increase in pressure. (This is called "compression.") You may notice some warmth but this is temporary. The nurse/technician will remain with you during the treatment to adjust the rate of compression in keeping with your tolerance and to coach you in relieving the "full" sensation you may feel in your ears. This feeling is similar to what you may have felt when traveling down a mountain, flying or skin diving. We will coach you on how to clear your ears, but you may need to try several ways in order to find the one most effective for you. Depending upon how effectively you clear your ears, compression will last from 7 to 10 minutes.
When you have reached the prescribed pressure, the fullness in your ears will cease and you may rest or sleep during the remainder of the treatment. You may also watch TV or listen to music during this 1.5 to 2 hour time. The temperature in the chamber is similar to room temperature, but may be adjusted slightly.
Near the end of your treatment the nurse/technician will gradually decrease the pressure added at the beginning. This is the "decompression" phase. During this time you will experience a "popping" sensation in your ears as a result of the changing pressure. This popping is a normal adjustment in your ears, similar to what happens when you are driving up a mountain.
(Generally you will experience no other effects from HBOT. However, some patients report a "crackling" sensation in their ears between treatments. This may be relieved in the same manner used to clear your ears during compression. If "crackling" should continue, please tell your nurse/technician.
As with all medical procedures and treatments, there are some side effects that may result from exposure to hyperbaric oxygen. These are rare.
The following is a summary of potential risks and side effects:
- Bartotrauma or pain in the ears or sinuses. One may experience pain in the ears or sinuses. If one is unable to equalize the pressure within ears or sinuses, the pressurization may be slowed or halted and suitable remedies applied.
- Cerebral air embolism and pneumothorax. Whenever there is a rapid change in ambient pressure, there is the possibility of rupture of the lungs with escapes of air into the arteries or into the chest around the lung. This can only occur if the normal passage of air out of the lungs is blocked during compression. Only slow decompressions are used in hyperbaric oxygen treatment to help prevent these untoward effects.
- Oxygen toxicity. The risk of oxygen toxicity is minimized by exposing the patient to only those pressures and treatment times known to be safe for the body and its organs.
- Risk of fire. With the use of oxygen in any form there is an increased risk of fire. However, strict precautions are taken to prevent this and our systems comply with all applicable codes. There has never been a fire involving a patient in any hospital-based hyperbaric wound center in the United States.
- Worsening of Near-sightedness ("myopia"). After 20 or more treatments, (and especially if you are over 40 years old), it is possible to experience diminution of your ability to see things that are far away. This is believed to be temporary and vision usually returns to its pretreatment level about six weeks after the cessation of therapy. Understand that it is not advisable to get a new prescription for your glasses until at least 8 weeks have passed following your last HBOT treatment.
- Maturing or ripening of cataracts. Occasionally, individuals with cataracts will experience a ripening or maturing of the cataract.
- Temporary Improvement in far-sightedness ("presbyopia"). After 20 or more treatments, (and particularly if you are over 40 years of age), there is a possibility that you may experience an improvement in your ability to see objects that are close by, or may be able to read without reading glasses. This is believed to be temporary and vision usually returns to its pretreatment level about six weeks after the cessation of therapy.
- Numb fingers. A small number of patients notice a numb feeling in the fourth and fifth fingers of the hands after 20 or more treatments. This need not be a concern, and will disappear in about 6 weeks following the completion of treatment.
- Ear fluid. Fluid sometime accumulates in the ears as a result of breathing high concentrations of oxygen. It may sometimes feel like having a pillow over your ears. This disappears after treatment ceases and can often be eased with the use of decongestants.
- Fatigue. Some people may experience fatigue after HBOT treatments, but this is not a consistent finding.
Diabetic Foot Ulcers: A Special Problem
Leg ulcers are a well known complication for patients with diabetes. With nearly 200 million diabetics world-wide, each with a 25% lifetime risk for loot ulcer, the enormity of the problem is clear. Once an ulcer occurs in a diabetic, there is an increased risk of wound progression that may ultimately lead to amputation. However, nearly half of amputations in diabetics can be prevented through use of a team approach to wound care.
Diabetic foot ulcers tend to result from the co-existence of peripheral neuropathy and ischemia from peripheral vascular disease.
In more than 60% of diabetic patients with foot ulcers there is underlying neuropathy. Neuropathy is known to result from hyperglycemia-induced metabolic abnormalities. It affects the motor, autonomic, and sensory systems. Damage to the nerves serving the intrinsic foot muscles leads to an imbalance between flexion and extension. This generates foot deformities with abnormal bony prominences and pressure points that cause skin breakdown and ulceration. Autonomic neuropathy produces a loss of sweat and oil gland function, which causes the foot to lose its ability to moisturize the skin. The skin becomes dry and more susceptible to injury. Finally, loss of sensation from peripheral neuropathy makes ulcer development and progression more likely. As the foot is traumatized, the patient may be unable to detect the insult, leaving some wounds to go unnoticed and progressively worsen over time.
Peripheral arterial disease (PAD) is a contributing factor in half of leg ulcer cases. For diabetics, it commonly affects the tibial and peroneal arteries of the calf. Smoking, high blood pressure and high cholesterol also contribute to the development of PAD. Blockage of arteries results in poor blood supply ("ischemia") in the lower extremity and an increased risk for ulceration. Established ulcers also have more difficulty healing.
The results of the foot evaluation should aid in developing an appropriate management plan. If an ulcer is discovered, the description should include characteristics of the ulcer, including size, depth, appearance, and location. There are many classification systems used to describe ulcers that are based on a variety of physical findings. One of the most popular systems is the Wagner Ulcer Classification System. It is based on wound depth and the extent of tissue necrosis. Some have suggested a deficiency in this system, since it only accounts for wound depth and appearance and does not consider the presence of ischemia or infection. The University of Texas has proposed another classification system that addresses ulcer depth and includes the presence of infection and ischemia.
Offloading and debridement are considered vital to the treatment process for diabetic foot wounds. The goal of offloading is to redistribute force from ulcers sites and pressure points at risk to a wider area of contact. Debridement, treatment of infection and local wound care are always essential, and arterial revascularization will decrease the likelihood of amputation in many PAD patients. Among the adjunctive wound care treatments being used is hyperbaric oxygen therapy (HBOT). HBOT has been shown to increase oxygen diffusion to the tissues and stimulate neovascularization and fibroblast replication. It can also increase phagocytosis and leukocyte-mediated killing of bacteria. The Center for Medicare & Medicaid Services has approved reimbursement of HBOT for 14 conditions, including diabetic ulcers. Diabetic ulcers that are Wagner Grade 3 wounds and that have failed to resolve after a 30-day course of standard treatment are considered candidates for HBOT.