Transcutaneous oximetry in clinical practice: consensus statements from an expert panel based on evidence

Transcutaneous oximetry (PtcO2) is finding increasing application as a diagnostic tool to assess the peri-wound oxygen tension of wounds, ulcers, and skin flaps. It must be remembered that PtcO2 measures the oxygen partial pressure in adjacent areas of a wound and does not represent the actual partial pressure of oxygen within the wound, which is extremely difficult to perform. To provide clinical practice guidelines, an expert panel was convened with participants drawn from the transcutaneous oximetry workshop held on June 13, 2007, in Maui, Hawaii. Important consensus statements were (a) tissue hypoxia is defined as a PtcO2 <40 mm Hg; (b) in patients without vascular disease, PtcO2 values on the extremity increase to a value >100 mm Hg when breathing 100% oxygen under normobaric pressures; (c) patients with critical limb ischemia (ankle systolic pressure of < or =50 mm Hg or toe systolic pressure of < or =30 mm Hg) breathing air will usually have a PtcO2 <30 mm Hg; (d) low PtcO2 values obtained while breathing normobaric air can be caused by a diffusion barrier; (e) a PtcO2 <40 mm Hg obtained while breathing normobaric air is associated with a reduced likelihood of amputation healing; (f) if the baseline PtcO2 increases <10 mm Hg while breathing 100% normobaric oxygen, this is at least 68% accurate in predicting failure of healing post-amputation; (g) an increase in PtcO2 to >40 mm Hg during normobaric air breathing after revascularization is usually associated with subsequent healing, although the increase in PtcO2 may be delayed; (h) PtcO2 obtained while breathing normobaric air can assist in identifying which patients will not heal spontaneously.

Determination of ideal PtcO2 measurement time in evaluation of hypoxic wound patients

OBJECTIVE

Evaluation of ideal time for baseline PtcO2 readings in air, elevation test, and oxygen challenge during evaluation of hypoxic wound patients.

DESIGN

Retrospective analysis. IRB APPROVAL: Western IRB deemed this study exempt from requiring IRB approval.

PATIENTS

202 patients with lower extremity wounds.

METHOD

Patients had PtcO2 measurements using 6 electrodes positioned in 3 paired locations along the limb (above the knee: AK; below the knee: BK; and foot). Measurements were made from each electrode at 7 different time-event occasions: position of limb (supine or elevated), type of breathing gas (sea level air or oxygen), and time of measurement. A total of 8,484 measurements were analyzed by first examining each electrode's data, and then pooling the data for each location pair.

MAIN RESULTS

PtcO2 readings for air (10 minutes) were less than air at 20 minutes. Maximal readings were close to the 20-minute mark for AK and BK measurements, and closer to 30 minutes for the foot. Elevation test at 3 versus 5 minutes showed a continuing decline in PtcO2 values. Oxygen challenge readings at 5 and 10 minutes were significantly different: the latter always larger than the former.

CONCLUSION

Ideal times for baseline readings, leg elevation test, and oxygen challenge test are at least 20, 5, and 10 minutes, respectively.

Borg proteins control septin organization and are negatively regulated by Cdc42

The Cdc42 GTPase binds to numerous effector proteins that control cell polarity, cytoskeletal remodelling and vesicle transport. In many cases the signalling pathways downstream of these effectors are not known. Here we show that the Cdc42 effectors Borg1 to Borg3 bind to septin GTPases. Endogenous septin Cdc10 and Borg3 proteins can be immunoprecipitated together by an anti-Borg3 antibody. The ectopic expression of Borgs disrupts normal septin organization. Cdc42 negatively regulates this effect and inhibits the binding of Borg3 to septins. Borgs are therefore the first known regulators of mammalian septin organization and provide an unexpected link between the septin and Cdc42 GTPases.

Preparation and crystal structure of the recombinant alpha(1)/alpha(2) catalytic heterodimer of bovine brain platelet-activating factor acetylhydrolase Ib

The intracellular form of mammalian platelet activating factor acetylhydrolase found in brain (PAF-AH Ib) is thought to play a critical role in control in neuronal migration during cortex development. This oligomeric complex consists of a homodimer of the 45 kDa (beta) LIS1 protein, the product of the causative gene for type I lissencephaly, and, depending on the developmental stage and species, one of three possible pairs of two homologous approximately 26 kDa alpha-subunits, which harbor all of the catalytic activity. The exact composition of this complex depends on the expression patterns of the alpha(1) and alpha(2) genes, exhibiting tissue specificity and developmental control. All three possible dimers (alpha(1)/alpha(1), alpha(1)/alpha(2) and alpha(2)/alpha(2)) were identified in tissues. The alpha(1)/alpha(2) heterodimer is thought to play an important role in fetal brain. The structure of the alpha(1)/alpha(1) homodimer was solved earlier in our laboratory at 1.7 A. We report here the preparation of recombinant alpha(1)/alpha(2) heterodimers using a specially constructed bi-cistronic expression vector. The approach may be useful in studies of other systems where pure heterodimers of recombinant proteins are required. The alpha(1)/alpha(2) dimer has been crystallized and its structure was solved at 2.1 A resolution by molecular replacement. These results set the stage for a detailed characterization of the PAF-AH Ib complex.

Protein crystallization by rational mutagenesis of surface residues: Lys to Ala mutations promote crystallization of RhoGDI

Crystallization is a unique process that occurs at the expense of entropy, including the conformational entropy of surface residues, which become ordered in crystal lattices during formation of crystal contacts. It could therefore be argued that epitopes free of amino acids with high conformational entropy are more thermodynamically favorable for crystal formation. For a protein recalcitrant to crystallization, mutation of such surface amino acids to residues with no conformational entropy might lead to enhancement of crystallization. This paper reports the results of experiments with an important cytosolic regulator of GTPases, human RhoGDI, in which lysine residues were systematically mutated to alanines. Single and multiple mutations were introduced into two different variants of RhoGDI, NDelta23 and NDelta66, in which the first 23 and 66 residues, respectively, were removed by recombinant methods. In total, 13 single and multiple mutants were prepared and assessed for crystallization and all were shown to crystallize using the Hampton Research Crystal Screens I and II, in contrast to wild-type NDelta23 and NDelta66 RhoGDI which did not crystallize. Four crystal structures were solved (the triple mutants NDelta23:K135,138,141A and NDelta66:K135,138,141A, and two single mutants NDelta66:K113A and NDelta66:K141A) and in three cases the crystal contacts of the new lattices were found precisely at the sites of mutations. These results support the notion that it is, in principle, possible to rationally design mutations which systematically enhance proteins' ability to crystallize.

Expression, purification, and crystallization of the RGS-like domain from the Rho nucleotide exchange factor, PDZ-RhoGEF, using the surface entropy reduction approach

Lsc-homology domains are found in several eukaryotic nucleotide exchange factors which act on Rho-family GTPases. They show limited amino acid sequence similarity to RGS proteins, which down-regulate the cellular signaling by the alpha-subunits of trimeric G-proteins and have been shown to interact with Galpha12 and Galpha13. It is believed that the RGS-like (RGSL) domain constitutes the functional link between G-protein-coupled receptors and cytosolic Rho-GTPases. We report here the expression, purification, and crystallization of the RGSL domain from the PDZ-RhoGEF. To obtain X-ray-grade crystals we have used the recently proposed approach of crystallization by mutational surface entropy reduction, in which selected Lys --> Ala, Glu --> Ala, and/or combined point mutations are introduced into the target protein to reduce the cumulative conformational entropy of surface residues. Of the five mutants that were designed and prepared, the second one tried (K463A, E465A, E466A) yielded crystals suitable for further analysis and diffracted X-rays to 2.8 A resolution on a home source. The crystals exhibit hexagonal symmetry, space group P6(1) 22 or P6(5) 22, with unit cell parameters a = b = 63.1 A, c = 202.1 A, and contain one molecule in the asymmetric unit.

Structure of the BH domain from graf and its implications for Rho GTPase recognition

Cellular signaling by small G-proteins is down-regulated by GTPase-activating proteins (GAPs), which increase the rate of GTP hydrolysis. The GTPase regulator associated with focal adhesion kinase (Graf) exhibits GAP activity toward the RhoA and Cdc42 GTPases, but is only weakly active toward the closely related Rac1. We determined the crystal structure of a 231-residue fragment of Graf (GrafGAP), a domain containing the GAP activity, at 2.4-A resolution. The structure clarifies the boundaries of the functional domain and yields insight to the mechanism of substrate recognition. Modeling its interaction with substrate suggested that a favorable interaction with Glu-95 of Cdc42 (Glu-97 of RhoA) would be absent with the corresponding Ala-95 of Rac1. Indeed, GrafGAP activity is diminished approximately 40-fold toward a Cdc42 E95A mutant, whereas a approximately 10-fold increase is observed for a Rac1 A95E mutant. The GrafGAP epitope that apparently interacts with Glu-95(Glu-97) contains Asn-225, which was recently found mutated in some myeloid leukemia patients. We conclude that position 95 of the GTPase is an important determinant for GrafGAP specificity in cellular function and tumor suppression.

The functional implications of the dimerization of the catalytic subunits of the mammalian brain platelet-activating factor acetylhydrolase (Ib)

The mammalian brain contains significant amounts of the cytosolic isoform Ib of the platelet-activating factor acetylhydrolase (PAF-AH), a unique type of PLA2. This oligomeric protein complex contains three types of subunits: two homologous (63% identity) 26 kDa catalytic subunits (alpha(1) and alpha(2)) which harbor all the PAF-AH activity, and the 45 kDa beta-subunit (LIS1), a product of the causal gene for Miller-Dieker lissencephaly. During fetal development, the preferentially expressed alpha(1)-subunit forms a homodimer, which binds to a homodimer of LIS1, whereas in adult organisms alpha(1)/alpha(2) and alpha(2)/alpha(2) dimers, also bound to dimeric LIS1, are the prevailing species. The consequences of this "switching" are not understood, but appear to be of physiological significance. The alpha(1)- and alpha(2)-subunits readily associate with very high affinity to form homodimers. The nature of the interface has been elucidated by the 1.7 A resolution crystal structure of the alpha(1)/alpha(1) homodimer (Ho et al., 1997). Here, we examined the functional consequences of the dimerization in both types of alpha-subunits. We obtained monomeric protein in the presence of high concentrations (>50 mM) of Ca2+ ions, and we show that it is catalytically inactive and less stable than the wild type. We further show that Arg29 and Arg22 in one monomer contribute to the catalytic competence of the active site across the dimer interface, and complement the catalytic triad of Ser47, Asp192 and His195, in the second monomer. These results indicate that the brain PAF-acetylhydrolase is a unique PLA2 in which dimerization is essential for both stability and catalytic activity.

Homologs of the alpha- and beta-subunits of mammalian brain platelet-activating factor acetylhydrolase Ib in the Drosophila melanogaster genome

The mammalian intracellular brain platelet-activating factor acetylhydrolase, implicated in the development of cerebral cortex, is a member of the phospholipase A2 superfamily. It is made up of a homodimer of the 45 kDa LIS1 protein (a product of the causative gene for type I lissencephaly) and a pair of homologous 26-kDa alpha-subunits which account for all the catalytic activity. LIS1 is hypothesized to regulate nuclear movement in migrating neurons through interactions with the cytoskeleton, while the alpha-subunits, whose structure is known, contain a trypsin-like triad within the framework of a unique tertiary fold. The physiological significance of the association of the two types of subunits is not known. In an effort to better understand the function of the complex we turned to genomic data mining in search of related proteins in lower eukaryotes. We found that the Drosophila melanogaster genome contains homologs of both alpha- and beta-subunits, and we cloned both genes. The alpha-subunit homolog has been overexpressed, purified and crystallized. It lacks two of the three active-site residues and, consequently, is catalytically inactive against PAF-AH (Ib) substrates. Our study shows that the beta-subunit homolog is highly conserved from Drosophila to mammals and is able to interact with the mammalian alpha-subunits but is unable to interact with the Drosophila alpha-subunit. Proteins 2000;39:1-8.

Hyperbaric oxygen in the treatment of delayed radiation injuries of the extremities

Hyperbaric oxygen (HBO2) is used as an adjunct in the treatment of radiation injury at many sites, including the mandible, larynx, chest wall, bladder, and rectum. In these disorders, HBO2 is effective in stimulating neovascularization and reducing fibrosis. No previous publications report the application of HBO2 to radiation injuries of the extremities. From 1979 until 1997, 17 patients were treated at the Southwest Texas Methodist and Nix Hospitals for nonhealing necrotic wounds of the extremities within previously irradiated fields. All but one wound involved a lower extremity. Most of the patients had been irradiated for soft tissue sarcomas or skin cancers. The rest were irradiated for a variety of malignancies. HBO2 was delivered in a multiplace chamber at 2.4 atm abs daily for 90 min of 100% oxygen at pressure. This report is a retrospective, uncontrolled review of these patients. Eleven patients (65%) healed completely whereas five (29%) failed to heal and one (6%) was lost to follow-up. Three (60%) of those who failed were found to have local or distant recurrence of their tumor early in their course of hyperbaric treatment and were discontinued from therapy at that time. When last seen in the clinic, the wound of the patient who was lost to follow-up was improved but not completely healed. Four of those who failed (including the two with local tumor recurrence) required amputation. If we exclude those with active cancer and the patient lost to follow-up, the success rate was 11 of 13 or 85%. HBO2 was applied successfully with complete wound healing and the avoidance of amputation in a majority of these patients. The consequences of failure in patients suffering from radiation necrosis of the extremities (some complicated by the presence of tumor) are significant, with 80% of the five failures requiring amputation. In radiation injuries of the extremities as in delayed radiation injury at other sites, HBO2 is a useful adjunct and should be part of the overall management.

Probing the substrate specificity of the intracellular brain platelet-activating factor acetylhydrolase

Platelet-activating factor acetylhydrolases (PAF-AHs) are unique PLA2s which hydrolyze the sn-2 ester linkage in PAF-like phospholipids with a marked preference for very short acyl chains, typically acetyl. The recent solution of the crystal structure of the alpha(1) catalytic subunit of isoform Ib of bovine brain intracellular PAF-AH at 1.7 A resolution paved the way for a detailed examination of the molecular basis of substrate specificity in this enzyme. The crystal structure suggests that the side chains of Thr103, Leu48 and Leu194 are involved in substrate recognition. Three single site mutants (L48A, T103S and L194A) were overexpressed and their structures were solved to 2.3 A resolution or better by X-ray diffraction methods. Enzyme kinetics showed that, compared with wild-type protein, all three mutants have higher relative activity against phospholipids with sn-2 acyl chains longer than an acetyl. However, for each of the mutants we observed an unexpected and substantial reduction in the V(max) of the reaction. These results are consistent with the model in which residues Leu48, Thr103 and Leu194 indeed contribute to substrate specificity and in addition suggest that the integrity of the specificity pocket is critical for the expression of full catalytic function, thus conferring very high substrate selectivity on the enzyme.

Expression, purification and crystallization of a BH domain from the GTPase regulatory protein associated with focal adhesion kinase

Signaling by small GTPases is down-regulated by GTPase activating proteins (GAPs) which enhance the rate of GTP hydrolysis. The activity of GAPs specific for Rho GTPases resides in the BH domain, many homologues of which are found in any mammalian genome. One of them was identified in the GTPase regulator associated with focal-adhesion kinase (GRAF). It shares approximately 20% sequence identity with p50RhoGAP. This GAP activates RhoA and Cdc42Hs, but not Rac. In order to dissect the molecular basis of this specificity, a 231-residue-long fragment corresponding to the BH domain of GRAF has been expressed, purified and crystallized. Trigonal crystals, of space group P3(1)21 or P3(2)21, with unit-cell dimensions a = b = 63.5, c = 90.38 A were grown from solutions of PEG 6000. Data to 2.15 A were collected from a flash-frozen sample on an R-AXIS IV imaging-plate detector mounted on a rotating anode X-ray generator.

Promoter analysis of the acetate-inducible isocitrate lyase gene (acu-3) from Neurospora crassa

Analysis of the promoter region of the acetate-induced isocitrate lyase gene (acu-3) of Neurospora crassa was undertaken. A series of deletions in the 5' non-transcribed region were constructed and the effects of these mutations on the enzyme levels following growth on sucrose and transfer to acetate were measured. Sequences within the region -603 to -271 relative to the transcription start site appear essential for transcription. The region -950 to -1278 is required for sucrose repression, which is consistent with previous protein/DNA gel retardation results of protein extracts from N. crassa cultured on sucrose. Protein extracts from acetate-induced mycelia identify alternative promoter regions apparently involved in acetate-induced gene transcription.

Measuring tissue oxygen tension: a review

Because of technological advances in tissue oximetry, clinicians and scientists have a better understanding of the role of oxygen in wound healing. In wound care and hyperbaric medicine applications, an oximeter is principally used with vascular assessment to help determine amputation level and to estimate healing potential. With the current emphasis on cost savings in the managed care setting, transcutaneous oximetry (PtcO2) has gained importance as a tool for predicting potential candidates for hyperbaric oxygen (HBO2) therapy. It is used to identify the presence of hypoxia in wounded tissue, to predict the responders to hyperoxia and in some instances to determine when HBO2 treatment is complete. This literature review describes the principal current methods for measuring tissue O2 and the values obtained in normal and wounded tissue under both normobaric and hyperbaric conditions. The review includes the Jefferson C. Davis Wound Care and Hyperbaric Medicine Center protocol for PtcO2 assessment of potential HBO2 candidates and suggestions for obtaining reproducible PtcO2 data.

Hyperbaric and hypobaric chamber fires: a 73-year analysis

Fire can be catastrophic in the confined space of a hyperbaric chamber. From 1923 to 1996, 77 human fatalities occurred in 35 hyperbaric chamber fires, three human fatalities in a pressurized Apollo Command Module, and two human fatalities in three hypobaric chamber fires reported in Asia, Europe, and North America. Two fires occurred in diving bells, eight occurred in recompression (or decompression) chambers, and 25 occurred in clinical hyperbaric chambers. No fire fatalities were reported in the clinical hyperbaric chambers of North America. Chamber fires before 1980 were principally caused by electrical ignition. Since 1980, chamber fires have been primarily caused by prohibited sources of ignition that an occupant carried inside the chamber. Each fatal chamber fire has occurred in an enriched oxygen atmosphere (> 28% oxygen) and in the presence of abundant burnable material. Chambers pressurized with air (< 23.5% oxygen) had the only survivors. Information in this report was obtained from the literature and from the Undersea and Hyperbaric Medical Society's Chamber Experience and Mishap Database. This epidemiologic review focuses on information learned from critical analyses of chamber fires and how it can be applied to safe operation of hypobaric and hyperbaric chambers.

Hyperbaric oxygen an adjunctive treatment for delayed radiation injuries of the abdomen and pelvis

Radiation therapy is often utilized as adjunctive or primary treatment for malignancies of the abdomen and pelvis. Radiation complications are infrequent, but can be life threatening or significantly diminish the quality of life. Radiation necrosis is an approved indication for hyperbaric oxygen (HBO2). Previous publications have reported results in treating delayed radiation injuries involving many sites. This paper reports the experience of a single physician group in treating delayed injuries of the abdomen and/or pelvis. Forty-four such patients have been treated since 1979. Of the 41 patients available for follow up, 26 have healed; 6 failed to heal; and 9 patients had an inadequate course of therapy (fewer than 20 treatments). Especially encouraging was the resolution of fistulae in six of eight patients with only three requiring surgery for closure. Overall, the success rate in patients receiving at least 20 HBO2 treatments was 81%. Hyperbaric oxygen is a useful adjunct in treatment of delayed radiation injuries of the pelvis and abdomen.

Gel mobility shift scanning of the acetate-inducible promoters from Neurospora crassa reveals a common co-inducible DNA-binding protein

The promoter regions of four acetate-inducible genes of Neurospora crassa, acu-3, acu-5, acu-8 and acu-9, have been sequenced. Using a scanning gel mobility shift assay particular DNA regions in each promoter have been shown specifically to bind partially purified protein extracted from acetate-induced mycelia. The protein-binding regions so defined have common sequence motifs, elements of which are similar to those required for acetate induction in aspergillus nidulans.

Hyperbaric oxygen as an adjunctive treatment for delayed radiation injury of the chest wall: a retrospective review of twenty-three cases

Since 1979, 23 cases of radiation-induced chest wall necrosis have been treated in the Hyperbaric Medicine Departments of Southwest Texas Methodist Hospital and the Nix Hospital, San Antonio, Texas. Eight cases involved soft tissue only. Six of eight (75%) patients with soft tissue involvement healed without requiring surgical debridement, although four patients (50%) did have flaps or grafts. Fifteen patients had bony and soft tissue necrosis. Eight of these patients (53%) resolved with adjunctive hyperbaric oxygen (HBO), but all required aggressive surgical debridement including skeletal resection. Four (27%) had reconstructive flaps as well. Six patients (40%) with bony necrosis who had either no or incomplete debridement failed to heal. Three patients (13%)(two soft tissue and one bony) were found to have residual tumor during HBO and were discontinued from treatment. HBO is an effective adjunctive therapy for soft tissue chest-wall, radiation-induced necrosis, but must be coupled with appropriate debridement to include surgical removal of all necrotic bone to ensure a successful outcome of bony plus soft tissue necrosis.

Increased activity of porcine pancreatic phospholipase A2 by designed long-range electrostatic stabilisation of the transition state

Stabilisation of the catalytic transition state by long-range charge interactions has been tested with mutagenesis for porcine pancreatic phospholipase A2. Electrostatics calculations were used to determine locations which would interact preferentially with one part of the dipolar charge separation that is believed to develop in the transition state. Experiment shows increased enzyme activity relative to wild-type recombinant enzyme for mutants N97D and N101D, consistent with the design.

Hyperbaric oxygen therapy for diabetic wounds

Hyperbaric oxygen can be a useful adjuvant in the management of diabetic foot wounds when coordinated with medical-surgical management of the patient. Elevated tissue oxygen tensions improve leukocyte bacterial killing efficiency and enhance connective tissue regenerative systems for wound healing. An algorithm for the management of diabetic foot wounds is proposed in this article.

Does hyperbaric oxygen have a cancer-causing or -promoting effect? A review of the pertinent literature

We reviewed all known published reports or studies related to a possible cancer-causing or growth-enhancing effect by hyperbaric oxygen. Published articles were retrieved using Medline searches for the period 1960-1993. Additional references were obtained from bibliographies included in those articles discovered in the computer search. Also, hyperbaric medicine text books and the published proceedings of international hyperbaric conferences were visually searched. Studies and reports discovered in this fashion and related to the topic were included in the review. Twenty-four references were found: 12 were clinical reports, 11 were animal studies, and 1 reported both an animal study and a clinical report. Three clinical reports suggested a positive cancer growth enhancement, whereas 10 clinical reports showed no cancer growth enhancement. Two animal studies suggested a positive cancer-enhancing effect, and 10 animal studies showed no such effect. (The report that included both animals and humans is counted in both groups). The vast majority of published reports show no cancer growth enhancement by HBO exposure. Those studies that do show growth enhancement are refuted by larger subsequent studies, are mixed studies, or are highly anecdotal. A review of published information fails to support a cancer-causing or growth-enhancing effect by HBO.

Flying after diving guidelines: a review

Recreational divers face a difficult choice when trying to select the appropriate surface interval between diving and flying. Differences in diving techniques and lack of readily available hyperbaric treatment make guidelines for commercial and military divers inappropriate for recreational divers. A literature review revealed that proposed surface intervals ranged from zero to 24 h, but few were human-tested. On 24 February 1989, the Undersea and Hyperbaric Medical Society (UHMS) Workshop formalized guidelines for recreational divers. Do not push the tables, i.e., do not go to the maximum exposures allowed by the tables. For no-decompression dives: (1) With less than 2 h total dive time (surface to surface) during the previous 48 h, divers should wait 12 h before flying; (2) With multiday, unlimited diving, wait 24 h before flying. Recreational divers should not make dives that require decompression stops, but if such dives should occur, delay flying for at least 24 h and, if possible, for 48 h. Divers with DCS symptoms should not fly, unless it is required to obtain hyperbaric treatment. The UHMS guideline is based on current scientific information and expert opinion, and is anticipated to be conservative, safe surface intervals for the vast majority of divers.

Altitude decompression sickness: hyperbaric therapy results in 145 cases

Most cases of decompression sickness that occur at altitude resolve upon descent to lower altitudes. Before the use of hyperbaric therapy, cases that did not resolve accounted for some of the most difficult medical management problems in military aerospace medicine. On 27 March, 1941, the U.S. Navy Diving School successfully used hyperbaric therapy for a case of altitude-induced decompression sickness that did not resolve on return to ground level. Since then, over 145 such cases have been treated by hyperbaric therapy. At first, treatments involved using compressed air, with varying success. Current medical management of altitude-induced decompression sickness requires immediate compression to 2.8 ATA, equivalent to 60 ft of sea water (FSW) pressure, and a series of intermittent oxygen and air breathing periods during the subsequent slow decompression to surface. This report confirms the treatment recommendations set forth by Behnke and Downey, and crystallized by Goodman in 1964. Conclusions are based on treatment experience in the management of 120 cases in U.S. Air Force hyperbaric chambers, and a survey of hyperbaric facilities which have treated 25 other cases.

Application of hyperbaric oxygen therapy in a case of prolonged cerebral hypoxia following rapid decompression

The first known and previously unpublished report of the use of hyperbaric oxygen (HBO) in the treatment of prolonged cerebral hypoxia is reported in an incident involving a USAF T-39 aircraft that underwent rapid decompression from 753 mb (2,438 m or 8,000 ft) to 148 mb (13,716 m or 45,000 ft). Within 5 to 8 s, the pilot lost consciousness because he did not don his oxygen mask and, therefore, was unable to obtain supplemental oxygen immediately. After a delay of 6 to 8 min, he was given supplemental oxygen at and below 697 mb (3,048 m or 10,000 ft). On the ground, the pilot was blind and disoriented. This condition persisted for 6.5 h, at which time HBO was administered. Orientation and vision were regained; neurologic findings were negative. It is concluded that HBO therapy was effective in treating this case of prolonged cerebral hypoxia. The report shows 1) the potential application of HBO in the treatment of prolonged cerebral hypoxia, and 2) the need for developing safe procedures for descent of passenger aircraft following such decompressions.

Effects of long-term exposures to 100% oxygen at selected simulated altitudes on the pulmonary surfactant in mice

The purpose of this investigation was to evaluate the effects on pulmonary surfactant in mice after long-duration exposure to 100% oxygen at various partial pressures equivalent to 842 mb (632) mmHg) or less. Six-month-old female CBA mice, weighing 25-35 g, were exposed to the pure oxygen environment. The effect on pulmonary surfactant was evaluated in two groups of 16 experimental animals and compared with control groups which were maintained in a similar environmentally controlled chamber at sea level conditions. Group I was exposed to pure oxygen at 842 mb (632 mmHg), a level known to be toxic and lethal. Group II was initially exposed for 60 d to pure oxygen at 420 mb (315 mmHg), a level not expected to be lethal, and the oxygen partial pressure gradually increased in steps over a 150-d period until an oxygen partial pressure at 842 mb (632 mmHg) was reached. In Group I, 12 out of 16 mice died of respiratory distress within 7 d. One died on the 10th day and three survived to complete 15 d of exposure but were euthanized because of severe despiratory distress. Mice in Group II which were exposed to pregressively increasing oxygen partial pressures survived. Pulmonary surfactant was obtained by saline lavage of the lungs. Chloroform/methanol extracted samples from oxygen-exposed mice in Group I displayed lower surfactant activity than Group II or controls. In fact, surfactant activity of mice dying in respiratory distress after 7 d was markedly lower than that of all other animals. Mice in Group II exhibited significantly lower(p less than 0.05) surfactant activity than controls, X = 34.71 and 38.58 respectively. This lower surfactant activity was consistent for Group II throughout the 150-d exposure except at the 90-d and 150-d exposures. The findings of this investigation support preceding studies which contend that the lung is the most vulnerable target for oxygen toxicity at altitude. It appears that an adaptive process involving both quantitative and qualitative changes in the pulmonary surfactant enabled animals in Group II to survive the progressively increasing ocygen partial pressures in an environment where survival would not normally be possible.