The USAF Hyperbaric Center: A Look Through the Porthole
CPT John J. Feldmeier, USAF, MC·
CPT Wilbur T. Workman, USAF, SSC··
T he unlikely combination of diving chambers and the
USAF School of Aerospace Medicine (USAFSAM) was
a direct outgrowth of the first successful hyperbaric treat-
ment of a military aviator in 1959 for severe altitude decom-
pression sickness.! Once the pathophysiology of altitude
decompression sickness was recognized to be virtually
identical to diving decompression sickness, the Air Force
became intimately involved in compression therapy. Ini-
tially, eight double-lock chambers were purchased from the
Navy and geographically distributed across the globe, to
provide prompt treatment for decompression sickness. Seven
of these eight original chambers are still in use today for
treatment and training. Shortly thereafter, in the early
1960s, a large double-lock hypo-hyperbaric chamber was
installed at the USAF School of Aerospace Medicine. With
this sophisticated tool, investigators pursued research into
the etiology and treatment of decompression sickness and
air embolism.
Meanwhile, within the civilian community in Amster-
dam, Brummelkamp, Boerema, and others' were investi-
gating the effects of hyperbaric oxygen (HBO) on anerobic
infections. In hopes of oxygenating myocardial tissues, es-
pecially in cases of congenital defects, open heart surgery
was being accomplished in large hyperbaric operating the-
aters in Europe and in the States." At about the same time,
Ledingham in Great Britain proposed the use of HBO in
treating carbon monoxide poisoning." During the decade
of the 1960s, HBO was utilized with mixed results as a ra-
diation sensitizer, in the attempt to enhance the therapeutic
effect of radiation at a lower dose. 12
In 1965, physicians at the USAF School of Aerospace
Medicine began to accept emergency cases of gas gangrene
and CO poisoning for HBO. By the early 1970s, accumu-
lated clinical data from multiple centers had shown the
benefit of HBO in the treatment of chronic osteomyelitis,
radiation necrosis, failing skin flaps, and nonhealing hy-
poxic wounds.
In 1974, the USAF Hyperbaric Medicine Center was es-
tablished at the USAF School of Aerospace Medicine to in-
vestigate the efficacy of HBO in a wide range of disorders.
In the intervening years, HBO has become an accepted
therapeutic modality in a number of pathologic situations.
The Hyperbaric Medicine Division has continued to pursue
clinical investigation, and a wealth of possible applications
remains to be explored. In areas of established efficacy, the
Division stands alone as the military clinical hyperbaric
medicine center. Within the civilian sector, approximately
From the Hyperbaric Medicine Division, USAF School of Aerospace
Medicine, Brooks AFB, Tex 78235.
*Chief, Medical Operations.
**Chief, Diving Operations.
Military Medicine, Vol. 148, February 1983
100 departments of hyperbaric medicine have been estab-
lished and are actively providing HBD for therapeutic pur-
poses.
Basic Hyperbaric Physiology
The efficacy of hyperbaric oxygen is based on two phys-
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ical factors: (1) the mechanical compression of gas-filled
bubbles; and (2) the elevation of the partial pressure of in-
spired gases which, in tum, determines the degree to which
these gases are in solution in body fluids. These factors are
applied through the use of pressures up to six Atmospheres
Absolute (ATA) and the use of oxygen breathing at pres-
sures up to three AT A.
The mechanical compression of gas-filled bubbles is ac-
complished by the application of Boyle's Law. The degree
of bubble-size reduction is a direct function of the total
pressure applied during compression. This gaseous volume
reduction is of primary importance in the treatment of gas
embolism and decompression sickness.
Henry's Law serves as the basis of the second physiologi-
cal factor: that of dissolved gases. As the partial pressure
of each inspired gas increases within the alveoli during
compression, the amount of that gas dissolved in the blood
plasma will likewise increase. This increase in the relative
quantity does not determine the absolute amount of gas
that will be dissolved for any given pressure. This is deter-
mined by the solubility coefficient of that gas in a fluid.
This is the basic rationale behind the use of hyperbaric
oxygen therapy for wound-healing enhancement.
Since the gas of primary concern is oxygen, a quick re-
view of oxygen transportation is appropriate to establish
its response to the hyperbaric environment. The primary
mechanism of oxygen transportation is via the hemoglobin
molecule. One gm of hemoglobin can combine with 1.36 ml
of oxygen. At normal sea level pressure (Pa02 of 100 mm
Hg), with an average hemoglobin of 15 gm per 100 cc and
approximately 97 per cent saturation, the oxygen content
is about 19.4 volumes per cent. If the partial pressure of ar-
terial oxygen is increased to between 100-200 mm Hg, then
the hemoglobin becomes 100 per cent saturated. Any in-
crease in arterial oxygen pressures will not increase the
amount of oxygen transported via the hemoblogin, Any
additional oxygen carried to the tissues is done so in physi-
cal solution.
Under normal sea level conditions (Pa02 of 100 mm Hg),
there is 0.31 ml of oxygen dissolved in each 100 ml of whole
blood, or 0.31 volumes per cent. Unlike the S-shaped curve
of hemoglobin saturation, the amount of oxygen actually
dissolved in plasma is linearly related to the oxygen partial
pressure. By increasing the inspired oxygen pressure, the
amount of oxygen dissolved in plasma can be significantly
118
The USAF Hyperbaric Center: A Look Through the Porthole
increased. This amount can be easily calculated for any
given oxygen pressure, since 0.0031 volumes per cent of
oxygen will dissolve in plasma per mm Hg P02 (at body
temperature). Each additional atmosphere of pressure ac-
counts for an extra 2.2 volumes per cent of oxygen dissolved
in plasma. For example, a three ATA [66 feet of sea water
(FSW)] an additional 6.6 volumes per cent of oxygen is dis-
solved in plasma.
The two above factors combine to provide very high
levels of oxygen to the tissues. At three ATA, for example,
breathing 100 per cent oxygen, PA02 is 2,193 mm Hg (cor-
rected for CO2 and H 20 vapor partial pressures), thus pro-
viding for an arterial P02 of 1,900 mm Hg. This pressure
equivalent of 66 FSW represents the maximum depth at
which 100 per cent oxygen is administered. At 2.4 ATA (45
FSW), the resulting arterial oxygen tension would be 1,707
mmHg.
One of the most critical links in the hyperbaric oxygen
chain is the oxygen delivery system itself. The USAF Hy-
perbaric Center utilizes a manual pressure demand oxygen
breathing regulator, in combination with a properly fitted
aviator's breathing mask. This assembly provides 100 per
cent oxygen to the patient while exposed to elevated baro-
metric pressures in a compressed air diving chamber. To
obtain the oxygen values referred to above, it is essential
that the breathing mask be properly sized and correctly
used by the patient. Sheffield'? reported that even a slight
leak could reduce tissue oxygen tensions by as much as 50
per cent. When the patient's condition does not permit the
use of an aviator's breathing mask, alternate methods of
oxygen delivery are provided. These include a plastic hood
assembly which is secured around the patient's neck, and
the use of endotracheal or tracheostomy tubes when in
place.
Clinical ApplicatiQns
Some 1,400 patients have now received treatment in Air
Force hyperbaric chambers. In order to insure the appro-
priate administration of HBO, division members actively
participate in the Undersea Medical Society (UMS). The
UMS is recognized as the professional society which over-
sees clinical applications and investigation, in order to guar-
antee that HBO is delivered only when properly indicated.
A'panel of experts working under the aegis of the UMS has
classified disorders into four categories according to the
relative benefit of HBO in their management. 7 Category I
disorders are those in which the weight of clinical evidence
overwhelmingly establishes HBO as an indicated part of
therapy. In Category II disorders, there is abundant clini-
cal and research data to support a role for HBO but the
weight of evidence is not as compelling as in Category I.
Category III disorders are those in which preliminary re-
ports and studies show promise, but conclusive studies are
yet to be accomplished. Finally, Category IV· disorders in-
clude those in which there is no theoretical basis for treat-
ment, and support for HBO as a modality of treatment is
no more than hearsay or anecdote.
At the USAF School of Aerospace Medicine, HBO is ad-
119
ministered in four emergency situations, all of which are
UMS Category I disorders. These disorders are decompres-
sion sickness, air embolism, carbon monixide poisoning,
and gas gangrene.
To date, 377 cases of decompression sickness (DCS) and
30 cases of air embolism have been treated in Air Force
chambers. Recall that in both instances HBO is designed to
reduce intravascular bubble-size, while increasing the avail-
ability of oxygen to vital tissues by creating a large motive
force to drive oxygen into solution in the plasma. Whereas
prior to 1959 at least 18 fatalities resulted due to altitude
DCS, since the inauguration of early aggressive HBO ther-
apy no deaths have occurred, and only one patient has
been left with any permanent neurologic deficit. 2
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A total of 242 cases of carbon monoxide poisoning have
been treated in Air Force chambers. Here HBO is effective
in reducing carboxyhemoglobin half-life to 23 minutes, as
compared with half-lives of 90 minutes breathing 100 per
cent oxygen at sea level or five hours and 20 minutes
breathing air. In addition, HBO can deliver enough oxygen
dissolved in plasma to supply the central nervous system
and myocardium. In this fashion, the usual transport of
oxygen bound to hemoglobin is bypassed until the CO
molecule can be displaced and purged from the body. By
utilizing its vasoconstrictive properties, HBO also reduces
cerebral edema that results secondary to hypoxia."
It remains to be established in what fashion HBO may
also be effective in reversing the disruption of intracellular
respiration by displacing the CO molecule from the cyto-
chrome oxidase chain.
The cases of gas gangrene include 119 patients treated at
the USAF School of Aerospace Medicine and the other Air
Force Chambers. Although the causative organism is a
clostridium and classed as an anerobe, tissue levels high
enough to be bactericidal are unlikely to be achieved. In-
stead, the aim of HBO here is to attain tissue oxygen ten-
sions of 250 mm Hg or more. At this point, further exotoxin
production is halted. Once the local and systemic toxic ef-
fects of the exotoxin are removed, antibiotics and less
radical surgical debridement can be effective in irradicating
the infecting organism. In this instance, HBO has been a
life-or-limb saving adjunct to the time honored principle of
surgical debridement and amputation."
In non-emergency situations at the USAF School of Aero-
space Medicine, HBO is administered adjunctively in the
treatment of chronic osteomyelitis, hypoxic wounds, and
failing grafts. For the most part, routine treatments are de-
livered in UMS Category II and III disorders.
One-hundred and twenty-two cases of chronic osteomy-
elitis have been treated to date. Success rates in cases of
chronic osteomyelitis run at an arrest rate of approxi-
mately 75 per cent. This figure should not be directly com-
pared with other series where acute cases of osteomyelitis
are reported. It must be pointed out that the overwhelming
majority of patients treated at the Hyperbaric Medicine Di-
vision have already been failures to antibiotic and surgical
treatment alone. Only after HBO is added as an adjunct to
antimicrobial therapy and adequate and appropriate de-
bridements, sequestrectomies, and bone grafts can success
Military Medicine, Vol. 148, February 1983
120
be achieved in the population of patients afflicted by
chronic osteomyelitis.'?
Another broad area of intervention in which HBO has
proven to be an invaluable adjunct is treatment of chronic
wounds. A total of 445 patients have now had treatment in
this category. In spite of meticulous wound care and ade-
quate nutritional therapy, a number of patients with arteri-
osclerotic peripheral vascular disease, vasculitis secondary
to radiation or collagen vascular disease, diabetes mellitus,
and venous stasis present otherwise insurmountable prob-
lems of wound healing. How is it that HBO can stimulate
healing in a hypoxic wound when the patient receives only
one treatment daily encompassing a total of 90 oxygen
minutes? Hunt" has shown that a critical level of oxygen
tension, approximately 30 mm Hg , must be exceeded be-
fore fibroblasts proliferate and actively elaborate collagen.
Once this level is achieved in the wound, a network of
newly elaborated collagen strands act as a framework for
capillary budding. When this neovascularity is established,
the baseline oxygen tension of the wound is increased and
the healing process becomes self-perpetuating.
This premise is borne out by tissue oxygen measurements
done most frequently now at USAFSAM in a noninvasive
manner, utilizing a transcutaneous electrode. A single clin-
ical example will serve to illustrate this point (Fig. 1). Pa-
tient 1278 is a 46 year old female who is afflicted with
scleroderma and secondary vasculitis. It was her misfor-
tune to be bitten by fire ants over the lateral malleolar area,
with resultant nonhealing ulcers . These had been present
for a period of three months when she was referred for ad-
junctive HBO. Initial oxygen tensions at the wound site
demonstrated a hypoxic condition with a measured tension
of 17 mm Hg. However, after the third week, wound oxy-
gen tens ions were maintained consistently at levels of 50
mm Hg or more while breathing room air . In the presence
of patent large vessels, in this case as in many others, HBO
has been successful in initiating collagen production and
eventual epithelization . After seven weeks of treatment the
ulcers had completely resolved.
Although adjunctive HBO is not universally successful
in wound healing, even in the diabetic where success rates
. ment and, as referred to earlier, the impact of carbon mon-
.
60
50
~P'T1EHTlm
(INSECT BITE ULCERS)
:r 4'
! '"
i ..
.
!!- '"
20
15
.
10
oo~-:---:---~_-L_-~--!---~--!----
,
TIME (WEEKS)
Fig. 1. Changes in baseline transcutaneous P0 2 during air breathing at
one ATA across weeks of hyperbaric oxygen treatment.
Military Medicine, Vol. 148, February 1983
The USAF Hyperbaric Center: A Look Through the Porthole
are lowest at around 60 per cent, eventual wound closure is
accomplished in a majority of cases .
In the irradiated patient, successful mandibular and
maxillary bone grafts have been achieved in 93 per cent of
cases.' HBO here is used pre- and post-operatively to pro-
mote graft take. These results are unexcelled, even in series
where the complex surgical technique of microvascular
anastomosis has been employed . Success in grafting bone
into irradiated fields has led to the application of a similar
protocol in the reanastomosis of irradiated bowel. Early
results with this protocol appear to be just as promising.
Clinical Investigation
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With the disorders discussed above, there is a wealth of
scientific data to support the usefulness of hyperbaric oxy-
gen therapy. Even so, a tremendous amount of research is
still needed to further its position in the physicians' arma-
mentarium. In this regard, the USAF Hyperbaric Center is
deeply involved in an ever-expanding clinical investiga-
tions function .
As briefly discussed above, one major area of concen-
tration is evaluating the technique of transcutaneous tis-
sue-oxygen measuring in a hyperbaric environment. One
recently completed study focused on the differences in tissue
oxygen tensions in healthy smokers and nonsmokers under
normobaric and hyperbaric conditions." It was found that,
under normobaric conditions, tissue oxygen tensions in
smokers were 18 per cent below those for nonsmokers. Un-
der hyperbaric conditions, no significant difference was
detected . This study suggested that patients who smoke
while undergoing HBO therapy could reduce the compro-
mise in tissue oxygen tensions by refraining from smoking
during their course of therapy.
This noninvasive method of measuring tissue oxygen
tensions is currently being used as one parameter in the pa-
tient selection process. Once a patient has been entered into
therapy, this technique is used to track the changes in
transcutaneous tissue oxygen tensions, and to correlate
those findings with the clinical presentation.
Current investigational thrusts include such studies as the
effectiveness of the administration of 100 per cent oxygen
under normobaric conditions for wound healing enhance-
oxide poisoning on cellular metabolism. A great deal of
SCLERODERMA
attention is also being focused on whether HBO may pro-
vide oxygen for energy requirements to actively transport
chemotherapeutic agents intracellularly to the core of a hy-
I SUCCESS I
poxic, malignant tumor.
Two areas highlighted for near-term research are the role
that HBO plays in the treatment of war-related injuries (for
example, crush injuries and blunt trauma) and the poten-
tial immunosuppressive effect of HBO.
Operational Support
In addition to its clinical investigation mission, it is also
the responsibility of the Center to evaluate new techniques
for the application of HBO . This covers the testing and
The USAF Hyperbaric Center: A Look Through the Porthole
evaluation of new equipment and chamber design, as well
as increasing the availability of HBO to the military medi-
cal community.
In that regard, established plans call for the construction
of five "new generation" clinical hyperbaric treatment fa-
cilities at selected regional locations. The first of these new
facilities is to be operational at Wright-Patterson AFB,
Ohio, by 1984. This new facility is to house a complex con-
sisting of three interconnected hyperbaric chambers. Each
will be an upright cylinder, the largest being 22 feet in di-
ameter with accommodations for up to 18 patients. When
completed, this hyperbaric treatment center will be the
most technologically advanced in the United States.
Another stated mission of the USAFSAM Hyperbaric
Medicine Division is to provide consultation to physicians
on specific cases related to the usefulness of HBO. The re-
questing physician should contact the hyperbaric medicine
physician on call at Brooks AFB, Texas. During duty hours
(0730-1615 hours) call (512) 536-3281. After normal duty
hours, consultation may be obtained by calling the Brooks
AFB Command Post at (512) 536-3278, 24 hours a day,
seven days a week. The Autovon prefix for the above num-
bers is 240.
Conclusion
As the hyperbaric medicine program of the United States
Air Force comes of age, the Division of Hyperbaric Medi-
cine of the USAF School of Aerospace Medicine will con-
tinue in the forefront of advancing research, providing
education and consultation, and delivering clinical treat-
ments in indicated disorders. HBO is here to stay in the Air
Force and within the civilian community. The days ahead
will be particularly exciting for members of the Division,
for, in areas of research, nowhere are prospects more prom-
ising than in the battlefield injury. The Division of Hyper-
baric Medicine will continue to contribute directly to the
vital mission of national defense by providing support to the
aviator and the ground troop as well, when decompression
sickness, blunt trauma, crush injury, radiation injury, clos-
Book Reviews (Continued)
Pulmonary Emergencies. S. A. Sahn, M.D. (Ed.), Associate Prof.
of Medicine, Division of Pulmonary Diseases, Univ. of Col-
orado Health Sciences Center, Denver. Churchill Livingstone,
New York, Edinburgh, London, and Melbourne, 1982,415 pp.,
$42.00.
At first glance one wonders why a book on pulmonary emergen-
cies. However, Dr. Sahn, with excellent contributions from an im-
pressive group of authors, has produced an excellent, pertinent
book. Two initial chapters on cardiopulmonary resuscitation and
tracheal intubation cover these topics very extensively, and then
there are separate chapters on 12 topics easily fitting into the gen-
eral category of pulmonary emergencies. Each of these chapters is
excellently done with a practical approach to the subject. Most of
121
tridial myonecrosis, or chronic osteomyelitis compromise
the ability to respond to the threat of foreign aggression.
References
1 Boerema, I. et al: High Tension Oxygen Therapy. Arch. Chir. Neerl.
(Den Haag), 8:193, 1956.
2Davis, J. C., Sheffield, P. J., et al: Altitude Decompression Sickness:
Hyperbaric Therapy Results in 145 Cases. Aviat. Space Environ. Med.,
48:722-730, 1977.
3Douglas, T. A. et al: Carbon Monoxide Poisoning. First Int. Con-
gress on the Clinical Applications of Hyperbaric Oxygen, Boerema, I.,
Brummel Kamp, W. H., and Meijne, N. G. (Eds.), Amsterdam, 1963.
4Feldmeier, J. J., Marx, R. E., and Heimbach, R. D.: Hyperbaric Oxy-
gen as an Adjunct to Mandibular and Maxillary Grafts in the Irradiated
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Patient. Presented at the Undersea Medical Society Annual Scientific
Meeting, Pacific Grove, Calif., 25-29, May 1981.
sHeimbach, R. D., Boerema, I., Brummelkamp, W. H. , et al: Current
Therapy of Gas Gangrene. In Davis, J. C., Hunt, T. K. (Eds.), Hyperbaric
Oxygen Therapy. Bethesda, Md., Undersea Medical Soc., 1978, pp. 153-
176.
6Hunt, T. K.: Fundamentals of Wound Management in Surgery.
Wound Healing: Normal Repair. Chirurgecom, Inc. N.J., 1976, p. 62.
7Kindwall, E. P. (Ed): Categorized Diseases/Conditions. Hyperbaric
Oxygen Review, Vol. 1, Jan. 1980, p. 5.
8 : Carbon Monoxide and Cyanide Poisoning. In Davis, J. C.,
Hunt, T. K. (Eds.), Hyperbaric Oxygen Therapy. Bethesda, Md., Under-
sea Medical Soc., 1978, pp. 177-190.
9Meijne, N. G., Schoemaker, G., and Bulterijs, A.: The Value of
Hyperbaric Oxygen in Cardiovascular Surgery. First Int. Congress on the
Clinical Applications of Hyperbaric Oxygen, Boerema, I., Brummel-
kamp, W. H., and Meijne, N. G. (Eds.), Amsterdam, 1963.
l~orrey, B. F., Dunn, J. M., Heimbach, R. D.,et al: Hyperbaric Oxy-
gen and Chronic Osteomyelitis. Clin. Orthop. 144:121-127, 1979.
l1Sheffield, P. J.: Tissue Oxygen Delivery. Presented at the Annual
Scientific Meeting of the Aerospace Med. Assoc., San Antonio, Tex.,
May 7,1981.
12Yan Den Brenk, H.A.S., Madigan, J. P., and Kerr, R. C.: Experience
with Megavoltage Irradiation of Advanced Malignant Disease Using High
Pressure Oxygen. First Int. Congress on the Clinical Applications of
Hyperbaric Oxygen, Boerema, I., Brummelkamp, W. H., and Meijne,
N. G. (Eds.), Amsterdam, 1963.
13Workman, W. T. and Sheffield, P. J.: Continuous Transcutaneous
Oxygen Monitoring in Smokers Under Normobaric and Hyperbaric Oxy-
gen Conditions. Prested at the Second Int. Symposium on Continuous
Transcutaneous Blood Gas Monitoring, Zurich, Switzerland, October 16,
1981.
these subjects are covered in other textbooks; e.g., acute respira-
tory failure, acute asthma, pulmonary infection, immunocompro-
mised patient, inhalation injury of the lungs, but even these
chapters add something to the usual approach and there are chap-
ters such as those on massive hemoptysis, pneumothorax, chest
trauma, and superior vena cava syndrome which give excellent
reviews on topics which are more difficult to find in the standard
pulmonary textbooks.
I highly recommend this book for any practitioner involved with
the pulmonary management of patients.
COL KEITH K. HUNT, JR., MC, USA
(Continued on page 144)
Military Medicine, Vol. 148, February 1983