Hyperbaric Oxygen Therapy and it’s role in Anemia

Our body typically fulfills its Oxygen demand from Air, which is present at 21% concentration and one atmospheric pressure. What if our body suddenly requires more Oxygen in a lesser time and blood transfusions are not a viable option? Then Hyperbaric Oxygen therapy comes to the rescue. Severe Anemia is one of such conditions that is highly prevalent in India and this new therapy could be a promising adjunctive to help reduce this problem.

What is Hyperbaric Oxygen Therapy?

Hyper means “increased” and baric means “pressure”. Hyperbaric Oxygen Therapy is a promising means of therapy which involves providing pure Oxygen at twice or thrice the normal air pressure and at a much higher concentration than normal atmosphere (100% as compared to 21% in Air). This allows more Oxygen to be transported to cells and tissues of body in a lesser time, for them to continue their normal metabolic activities.

What is the procedure for Hyperbaric Oxygen Therapy?

Patient is placed in a special chamber called hyperbaric chamber designed to sustain high pressures of Oxygen. Therapy is divided in sessions, usually 20, but may vary for each patient. Each session lasts 90-120 min but can be varied according to specific needs.
Chamber fills up with a much a higher pressure than normal, almost twice, containing pure Oxygen. Any flammable objects and electronic devices are taken from the patient to avoid fire hazard. Patients usually pass time by listening to music, watching movies or simply by taking a nap!

What are different conditions for which Hyperbaric Oxygen Therapy is recommended?

Food and Drug Administration Agency (FDA) has recommended it for many conditions including the following:
• Embolism (Air and gas bubbles in Blood)
• Carbon Monoxide poisoning due to fires, idling vehicles etc
• Decompression sickness (in scuba divers)
• Burns
• Crushing injuries
• Gangrene
• Severe Anemia (Hemoglobin count less than 7.0 g/dl)
Today we will specifically be talking about role of Hyperbaric Oxygen Therapy in treating Severe Anemia.

What is Anemia?

Before going into details of treatment modalities, let’s talk about what Anemia actually is? Simply put, Anemia is a condition in which body is unable to supply vital organs and tissues with adequate amount of Oxygen to maintain normal metabolic activities.
Anemia is diagnosed by a low level of Hemoglobin in blood (below 11g/dl)
Anemia results in patient feeling multiple symptoms:
• Feeling of weakness
• Fatigue
• Light-headedness
• Cold clammy feet and hands
• Yellowish discoloration of skin
• Cramps
• Headaches
• Chest pain
• Irregular heartbeats

What causes Anemia?

Anemia can be due to 2 main biological reasons:
1. Lack of Oxygen carrying red blood cells or
2. Lack of Oxygen carrying pigment known as haemoglobin, both of which are directly related to deficiency of one element: IRON.
Iron deficiency is hence the leading cause of Anemia, whether due to decreased consumption, increased loss or inadequate absorption from gut.
Other causes of Anemia include deficiency of Vitamin B12, Folic acid & infections such as malaria which causes increased breakdown of Red Blood Cells.

Anemia in India?

Anemia is getting increasingly prevalent in India. According to the National Family Health Survey 5 (NFHS-5) of 2019 almost 67% of children under 5 years of age are anemic, which is a rise from previous figure of 59% in 2015.
This means more than 110 thousand Indian children are suffering from concerning effects of Anemia including:
• stunted growth
• slow mental development
• weakened immune system leading to increased morbidity from Infections.
Anemia is not only affecting infants, but also severely affecting their mothers i.e. Women. Anemia in women has seen a rise of 4% in 4 years (from 53 to 57% in 2019). This increase has many reasons:
• Lack of diet rich in Iron, Folic acid or vitamin B12
• Less Iron consumption than other family members
• Frequent pregnancies
• Heavy periods
• Social reasons of not seeking medical advice
• Chronic infections i.e. Parvovirus infection
• Genetic conditions i.e. Hemolytic anemias such as Sickle Cell Anemia
Not only women, but Indian men also seem to suffer increasingly from Anemia, with an increase of about 2% prevalence from 23 to 25% owing mainly to lack of iron rich diet.

What is Treatment of Anemia?

So far, we have discussed causes and prevalence of Anemia in India, but the question arises that how can it be cured. Basic treatment consists of reversal of causes i.e. integrating more Iron in diet through beans, spinach, nuts, figs etc. Other options to overcome iron deficiency include iron pills and injections.
If deficiency is due to other causes such as infections, abrupt treatment followed by nutritional support is suitable. Checking for other deficiencies like Vitamin B12 and Folic acid is also of utmost importance in overcoming Anemia.
In severe cases i.e. Anemia due to blood loss, transfusions are important in overcoming deficiency. If matching blood type can’t be made available or person rejects blood transfusions due to religious or Immunologic reasons, then Hyperbaric Oxygen Therapy is the next best suitable option for overcoming this condition.

Role of Hyperbaric Oxygen Therapy in Anemia

100% pure Oxygen provided in Hyperbaric Oxygen Therapy allows more Oxygen to be carried by a lower concentration of Hemoglobin in a given time. This increased Oxygen concentration encourages normal levels even after end of therapy session.
Apart from it, increased dissolved Oxygen in blood also aids in regulating normal metabolic activities of all vital organs and tissues of body, according to a 2012 research {1} Not only this, but also that this high-pressure Oxygen is adequate to meet body’s demands alone without any transport from haemoglobin. [3]
Anemia triggers your body’s compensatory mechanisms by inducing heart to pump faster in attempt to provide more Oxygen through a lower concentration of haemoglobin, this results in irregular or faster heartbeats. Research suggests healthy effects of Hyperbaric Oxygen Therapy on Anemia associated complications i.e. heart rate. Breathing 100% pressurized Oxygen reduced anemia-induced increased heart rate, with an effect equal to that of transfusion or increasing blood haemoglobin by 3g/dL. This benefit was attributed to usefulness of Oxygen rather than increased concentration in blood. [2]
Perhaps the most interesting effect of Hyperbaric Oxygen Therapy is its ability to initiate formation of new blood vessels, the process known as angiogenesis, over course of multiple therapy sessions. More vessels allow better perfusion of vital organs and especially tissues. It is said to mediate angiogenesis through stem cells which then differentiate into blood vessel forming endothelial cells.
Hyperbaric Oxygen Therapy also promotes formation and release of crucial factors needed for vessel formation such as VEGF (Vasculo-Endothelial Growth factor) and HIF-1 alpha (Hypoxia Inducible Factor-1 alpha). [4]
Apart from angiogenesis, Hyperbaric Oxygen Therapy also induces increase in Hemoglobin and Red blood cell mass in Acute and Chronic Anemia patients.

How safe is Hyperbaric Oxygen Therapy?

Hyperbaric Oxygen Therapy is a generally very safe procedure with little or no side effects and very rarely any complications. Side effects could be kept to a minimum if therapy time is less than 2 hours and pressure doesn’t build up beyond 3 times the normal atmospheric pressure.
As patient is placed inside a high-pressure chamber, he or she may feel ear or sinus pain. Patient may also feel fatigue or light headedness due to prolonged sessions.
Dose of Oxygen for each therapy session should be determined for each indivual specifically by a medical practitioner. Patient may require breaks in between sessions and breath normal Air to prevent buildup of abnormally high levels of Oxygen.
In very rare and severe cases, patient may also get seizures due to Oxygen toxicity. According to a research, patients experiencing seizures, had risk factors for it including narcotic withdrawal, alcohol withdrawal, antidepressant, cephalosporin, ceftriaxone or tramadol use. Hence medical practitioners should carefully evaluate patients for these risk factors before starting Hyperbaric Oxygen Therapy.

Conclusion:

Hyperbaric Therapy is a very safe, effective and cost-friendly adjunct treatment for Severe Anemia which is getting increasingly popular in India with many new centres in urban and metropolitan cities. It is also highly recommended for many other conditions described above.
However, it is not completely risk free and should by carefully modified by the medical practitioner for each and every patient. Hyperbaric Oxygen therapy opens new avenues for the treatment of patients who couldn’t get blood transfusions before due to allergies, religious reasons or simply due to lack of availability of matching blood.

Citations:

1.Van Meter KW. The effects of hyperbaric Oxygen on severe Anemia. Undersea Hyperb Med. 2012 Sep-Oct;39(5):937-42. PMID: 23045922.
2.Feiner JR, Finlay-Morreale HE, Toy P, Lieberman JA, Viele MK, Hopf HW, Weiskopf RB. High Oxygen partial pressure decreases anemia-induced heart rate increase equivalent to transfusion
3. Hart GB. HBO and exceptional blood loss anemia. In:Kindwall EP, ed. Hyperbaric medicine practice. Flagstaff, Ariz.: Best, 1994:517-24.

4.Thom SR, Bhopale VM, Velazquez OC, Goldstein LJ, Thom LH, et al. Stem cell mobilization by hyperbaric oxygen. Am J Physiol Heart Circ Physiol. 2006;290:H1378–86.

5. Seidel R, Carroll C, Thompson D, Diem RG, Yeboah K, Hayes AJ, Hall B, Whelan HT. Risk factors for oxygen toxicity seizures in hyperbaric oxygen therapy: case reports from multiple institutions. Undersea Hyperb Med. 2013 Nov-Dec;40(6):515-9. PMID: 24377194.