XV Jornadas N.

Medicina Maritima, 18-10-2013 Cadiz

Usosylimitacionesdelaoxigenacinhiperbrica
(OHB/HBOT)enlaactualidad:
perspectivasdesdelaevaluacindetecnologas,yla
medicinabasadaenlaevidencia.
Jordi M.GolFreixa
jmgol@isciii.es
INSTITUTODESALUDCARLOSIII
AGENCIADEEVALUACINDETECNOLOGASSANITARIAS
(AETS)

OHBparaquienen2013?
Cualessonlasindicaciones
Robustezdelasmismas
Implicaciones

OHBparaquienen2013?
Cualessonlasindicaciones:
Lgicafisiopatolgica.
Experienciaclnica:seriesclnicas.
Quieneshanhecholaslistas:

Sociedadescientficas
Aseguradoras
Organismosreguladores
Otros

Comosehanhecholaslistas
Evolucinhistrica

[Robustezdelasmismas]
[Implicaciones]

IndicacionescubiertasporMEDICARE

20.29 HyperbaricOxygenTherapy

(Rev.48,Issued:031706;Effective/ImplementationDates:061906)CIM3510ForpurposesofcoverageunderMedicare,hyperbaric
oxygen(HBO)therapyisamodalityinwhichtheentirebodyisexposedtooxygenunderincreasedatmosphericpressure.

A.CoveredConditions:ProgramreimbursementforHBOtherapywillbelimited tothatwhichisadministeredinachamber(including
theonemanunit)andislimitedtothefollowingconditions:

l.Acutecarbonmonoxideintoxication,
2.Decompressionillness,
3.Gasembolism,
4.Gasgangrene,
5.Acutetraumaticperipheralischemia.HBOtherapyisavaluableadjunctivetreatmenttobeusedincombinationwithaccepted
standardtherapeuticmeasureswhenlossoffunction,limb,orlifeisthreatened.
6.Crushinjuriesandsuturingofseveredlimbs.Asinthepreviousconditions,HBOtherapywouldbeanadjunctivetreatmentwhenloss
offunction,limb,orlifeisthreatened.
7.Progressivenecrotizinginfecctions (necrotizingfasciitis),
8.Acuteperipheralarterialinsufficiency,
9.Preparationandpreservationofcompromisedskingrafts(notforprimarymanagementofwounds),
10.Chronicrefractoryosteomyelitis,unresponsivetoconventionalmedicalandsurgicalmanagement,11.Osteoradionecrosis asan
adjuncttoconventionaltreatment,
12.Softtissueradionecrosis asanadjuncttoconventionaltreatment,
13.Cyanidepoisoning,
14.Actinomycosis,onlyasanadjuncttoconventional therapywhenthediseaseprocessisrefractorytoantibioticsandsurgical
treatment,
15.Diabeticwoundsofthelowerextremitiesinpatientswhomeetthefollowingthreecriteria:
a.PatienthastypeIortypeIIdiabetesandhasalowerextremitywoundthatisduetodiabetes;
b.PatienthasawoundclassifiedasWagnergradeIIIorhigher;and
c.Patienthasfailedanadequatecourseofstandardwoundtherapy.
TheuseofHBOtherapyiscoveredasadjunctivetherapyonlyaftertherearenomeasurablesignsofhealingforatleast30days of
treatmentwithstandardwoundtherapyandmustbeusedinadditiontostandardappropriateoffloading,andnecessarytreatmentto
resolveanyinfectionthatmightbepresent.Failuretorespondtostandardwoundcareoccurswhentherearenomeasurablesigns of
healingforatleast30consecutivedays.Woundsmustbeevaluatedatleastevery30daysduringadministrationofHBO
therapy.Continued treatmentwithHBOtherapyisnotcoveredifmeasurablesignsofhealinghavenotbeendemonstratedwithinany
30dayperiodoftreatment.

NocubiertasporMEDICARE

20.29 HyperbaricOxygenTherapy

B.Noncovered Conditions
Allotherindicationsnotspecifiedunder270.4(A)arenotcoveredundertheMedicareprogram.Noprogrampaymentmaybemade
foranyconditionsotherthanthoselistedin
270.4(A).
NoprogrampaymentmaybemadeforHBOinthe treatmentofthefollowingconditions:
1.Cutaneous,decubitus,andstasisulcers
2.Chronicperipheralvascularinsufficiency
3.Anaerobicsepticemiaandinfectionotherthanclostridial
4.Skinburns(thermal).
5.Senility.
6.Myocardialinfarction.
7.Cardiogenic shock.
8.Sicklecellanemia.
9.Acutethermalandchemicalpulmonarydamage,i.e.,smokeinhalationwith
pulmonary
10.Acuteorchroniccerebralvascularinsufficiency.
11.Hepaticnecrosis.
12.Aerobicsepticemia.
13.Nonvascularcausesofchronicbrainsyndrome(Picksdisease,Alzheimersdisease,Korsakoffs disease)
14.Tetanus.
15.Systemicaerobicinfection.
16.Organtransplantation.
17.Organstorage.
18.Pulmonaryemphysema.
19.Exceptionalbloodlossanemia.
20.MultipleSclerosis.
21.ArthriticDiseases.
22.Acutecerebraledema.

The7thEuropeanConsensusConferenceonhyperbaricMedicine,Lille.
(ECC7)2004.
INDICACIN

NIVEL DE EVIDENCIA

Intoxicacin por monxido de carbono (ICO)

Sndrome de aplastamiento
Prevencin de la osteorradionecrosis despus de extraccin dental
Osteoradionecrosis de mandbula
Cistitis radica
Accidente por descompresin
Embolia gaseosa
Infeccin bacteriana anaerbica o mixta
Pie diabtico
Compromiso en injertos de piel y msculo cutneos
Osteoradionecrosis de otros huesos
Proctitis/enteritis radioinducido
Lesin de tejidos blandos, radioinducido
Sordera sbita
Ulcera isquemica
Osteomielitis crnica refractaria
Neuroblastoma en estadio IV
Encefalopata anoxica
Radionecrosis de laringe
Lesin radioinducida del SNC
Reimplante de extremidades
Quemaduras de 2grado y >20% de la superficie

B
B
B
B
B
C
C
C
B
C
C
C
C
C
C
C
C
C
C
C
C
C

The7thEuropeanConsensusConferenceon
HyperbaricMedicine,Lille. (ECC7).
Indicacionesaceptadas,segnnivelde
evidencia:
NivelA: Dobleciego,aleatorio,muestras
grandes
NivelB: Dobleciego,aleatoriodeunasola
muestraopequeosestudios
NivelC: Seriesclnicas,opininoconsensode
expertos

Aspectosmetodolgicosyde
robustez:
Validezdelasseriesclnicas.
Validezexterna:generalizabilidad,estimacinde
efectopoblacional.Seleccindecasos
Validezinterna:controldesesgos.Calidad
metodologica deldiseo
Validezdeconstructo,oconceptual.

Calidaddelaevidenciaversus fuerzadelas
recomendaciones

Qu hacerantelaevidenciainadecuada?

NICE
Aseguradoras
Proveedoreslibres
Profesionaleslibres
Sociedadescientificas yprofesionales