Objectives: To assess the effect of adjunctive HBOT in improving neurological outcome in people with DOC with subacute brain injury & to find out the safety of using HBOT in patients with severe DOC.
Design: Retrospective study of persons with traumatic/non traumatic brain injury, underwent rehabilitation and adjunctive HBOT from April 2017-March 2019. HBOT was given in Perry TM Monoplace Chamber 1.5 ATA for 60 minutes each session when neurologically and medically stable. Neurological status was assessed by Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) before and after the intervention. Medical complications observed in HBOT file was noted.
99 persons (M:F:82:17) with brain injury (TBI : ICH : IS = 49 : 35 : 15), age 8 – 86 years (48.8) were included. 57 persons underwent surgery (24 TBI; 27 ICH; 6 IS). HBOT was started 10 days–240 days after the injury (mean 61days). HBOT sessions varied from 12 – 68 (mean 18).
GCS score pre-intervention improved from E1M1VT – E4M4V2 (m 5.94) to E4M3VT – E4M6V5 (m 9.91). The post HBOT GOS was Grade- II-44, III - 34, IV-6 and V–12.
6 of 84 persons in GOSII pre intervention improved to GradeV, 2 to IV, 29 to III, 44 in II and 3 in GradeI. Of 12 in GOS III: 5 improved to GradeV, 2 to IV and 5 in Grade III. Of 3 in Grade IV GOS: 1 improved to Grade V and 2 in GradeIV. Complications during HBOT were Dysautonomia, hypoglycaemia and increased tracheal secretions.
Disorders of Consciousness(DOC) are common after severe brain Injuries. In more severe conditions like coma and persistent vegetative state, where there is little a physician can offer to alter the natural course of the brain insult, any new treatment modality to improve the state of mind is appealing, both to the clinician as well as the family of patients. The effectiveness of Hyperbaric oxygen therapy (HBOT) in brain injury is being debated for the last few decades and the outcomes though promising are not conclusive.
Since early 2015, HBOT has been used in patients with DOC following brain injury as an adjunct to intensive neurorehabilitation. Four years down the line with more than a hundred patients with severe DOC being treated with HBOT, we undertook this study to assess the effect of adjunctive HBOT in improving neurological outcome in people with subacute brain injury & to find out the safety of using HBOT in patients with severe DOC with tracheostomy and multiple co-morbidities.
Material and Methods
A Retrospective analysis of persons with traumatic & non traumatic brain injury with DOC who underwent HBOT in our hospital from April 2017 - March 2019 was done.
All person disorders of consciousness irrespective of duration, who had no ventilatory requirement for last 3 days , could maintain Blood glucose level > 100 m/dl before the HBOT session, had at least 90 minutes suction free period were taken for HBOT. Those with Tympanic Membrane rupture, Active inner middle ear diseases, Pneumothorax, Aggressive behaviour and recent uncontrolled seizures were contraindicated for HBOT. Patients who failed the HBOT trial, took less than 12 sessions or whose Glasgow Coma Scale ( GCS ) or Glasgow Outcome Scale (GOS) scoring was not available were excluded from the study. A total of 99 patients met the criterion. Case sheets and HBOT notes were examined from medical records for finding out the complications that occurred during the period.
HBOT was given in Perry TM Monoplace Chamber as per the brain protocol of 1.5 ATA for 60 minutes for each session for a minimum of 12 session . HBOT was started when patients were neurologically stable and out of Intensive Care Unit. All the persons also received comprehensive neurorehabilitation including neurocognitive pharmacotherapy, physical therapy, occupational therapy, swallow therapy and robotic assisted treadmill training.
Neurological status which was assessed by GCS to measure Eye opening, Verbal and motor responses at the time of starting HBOT and at the time of discharge was evaluated. Those with tracheostomy was given a score zero for verbal response for scoring purpose. Functional outcome was measured using GOS which was recorded at the time of HBOT Trial and at time of discharge. GOS has 5 levels; Level 1 is death, Level 2 describes Persistent Vegetative state, Level 3 is Severe Disability, Grade 4 is Moderate disability and Grade 5 is Good recovery.
A total of 99 persons were included in this study . There were 82 male and 17 females.
Among them, 49 had Traumatic brain injury ( TBI ), 35 had Intracerebral haemorrhage ( ICH ) and 15 had ischemic stroke . Age varied from 8 to 86 years with a mean age of 48.8 .
57 persons had underwent decompression surgery at the time of insult, of which 24 were TBI, 27 were ICH, 6 were IS. HBOT was started as early as 10 days and up to 240 days after the initial brain insult (mean 61 days ). Number of HBOT sessions varied from 12 to 68 (mean 18).
GCS score pre-intervention ranged from a minimum of E1M1VT and maximum of E4M4V2 ( mean 5.94 ) which improved to at least E4M3VT and a maximum of E4M6V5 ( mean 9.91). The maximum improvement in GCS was in the component of spontaneous eye opening.
GOS score pre-intervention were Grade II in 84, Grade III in 12 and Grade IV in 3 persons. The post HBOT GOS was Grade II in 44, grade III in 34, Grade IV in 6 and Grade V in 12 persons.
Out of 84 persons in GOS Grade II pre-intervention, 6 persons improved to Grade V ( 7% ), 2 persons improved to Grade IV ( 2.3 % ), 29 persons improved to Grade III (35% ) and 44 persons remained in II (52%) . 3 persons died due to underlying medical condition. Of 12 persons in GOS Grade III, 5 persons improved to Grade V (41%) , 2 persons improved to grade IV (16%) and 5 persons remained same in Grade III (41%). Of 3 persons in GOS Grade IV, 1 person improved to Grade V (33%) and 2 persons remained same in Grade IV (66%) post intervention.
Among the stroke patients, the post HBOT, GOS was Grade I - 0%, Grade II -52% , Grade III - 38% , Grade IV - 2% and Grade V - 8% .
Among the TBI patients, the post HBOT, GOS was Grade I - 6% , Grade II -36% , Grade III - 30%, Grade IV - 10% and Grade V - 16% .
Most common reasons for stopping an HBOT sessions were autonomic hyperactivity, hypoglycaemia and increased tracheal secretions.
HBOT is tolerated well by persons with subacute brain injury. It can contribute to neurological and functional outcome of persons with DOC due to subacute brain injury when used as an adjunctive measure to intensive neurorehabilitation. 46% of patients had change of at least 1 level in GOS.
Improvements were noticed in even patients with GCS as low as 2T. Maximum improvement was observed in component of spontaneous eye opening.
HBOT is safe and can be used in persons with any grade of DOC. No mortality or significant adverse effects were encountered due to HBOT use in our centre.
Effects of higher pressure ( more than 1.5 ATA ) and longer duration ( more than 1 hour ) needs to be evaluated. Large scale randomized control studies are required to prove the findings unequivocally.