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Hiperbarična terapija kisikom kao dodatak liječenju kod traumatske ozljede mozga

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Abstract

Background

Traumatic brain injury is a common health problem with significant effect on quality of life. Each year in the USA approximately 0.56% of the population suffer a head injury, with a case fatality rate of about 40% for severe injuries. These account for a high proportion of deaths in young adults. In the USA, 2% of the population live with long‐term disabilities following head injuries. The major causes are motor vehicle crashes, falls, and violence (including attempted suicide). Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than 1 atmosphere absolute (ATA). This involves placing the patient in an airtight vessel, increasing the pressure within that vessel, and administering 100% oxygen for respiration. In this way, it is possible to deliver a greatly increased partial pressure of oxygen to the tissues. HBOT can improve oxygen supply to the injured brain, reduce the swelling associated with low oxygen levels and reduce the volume of brain that will ultimately perish. It is, therefore, possible that adding HBOT to the standard intensive care regimen may reduce patient death and disability. However, a concern for patients and families is that using HBOT may result in preventing a patient from dying only to leave them in a vegetative state, entirely dependent on medical care. There are also some potential adverse effects of the therapy, including damage to the ears, sinuses and lungs from the effects of the pressure and oxygen poisoning, so the benefits and risks of the therapy need to be carefully evaluated.

Objectives

To assess the effects of adjunctive HBOT for traumatic brain injury.

Search methods

We searched CENTRAL, MEDLINE, EMBASE, CINAHL and DORCTHIM electronic databases. We also searched the reference lists of eligible articles, handsearched relevant journals and contacted researchers. All searches were updated to March 2012.

Selection criteria

Randomised studies comparing the effect of therapeutic regimens which included HBOT with those that did not, for people with traumatic brain injury.

Data collection and analysis

Three authors independently evaluated trial quality and extracted data.

Main results

Seven studies are included in this review, involving 571 people (285 receiving HBOT and 286 in the control group). The results of two studies indicate use of HBOT results in a statistically significant decrease in the proportion of people with an unfavourable outcome one month after treatment using the Glasgow Outcome Scale (GOS) (relative risk (RR) for unfavourable outcome with HBOT 0.74, 95% CI 0.61 to 0.88, P = 0.001). This five‐point scale rates the outcome from one (dead) to five (good recovery); an 'unfavourable' outcome was considered as a score of one, two or three. Pooled data from final follow‐up showed a significant reduction in the risk of dying when HBOT was used (RR 0.69, 95% CI 0.54 to 0.88, P = 0.003) and suggests we would have to treat seven patients to avoid one extra death (number needed to treat (NNT) 7, 95% CI 4 to 22). Two trials suggested favourably lower intracranial pressure in people receiving HBOT and in whom myringotomies had been performed. The results from one study suggested a mean difference (MD) with myringotomy of ‐8.2 mmHg (95% CI ‐14.7 to ‐1.7 mmHg, P = 0.01). The Glasgow Coma Scale (GCS) has a total of 15 points, and two small trials reported a significant improvement in GCS for patients treated with HBOT (MD 2.68 points, 95%CI 1.84 to 3.52, P < 0.0001), although these two trials showed considerable heterogeneity (I2 = 83%). Two studies reported an incidence of 13% for significant pulmonary impairment in the HBOT group versus 0% in the non‐HBOT group (P = 0.007).

In general, the studies were small and carried a significant risk of bias. None described adequate randomisation procedures or allocation concealment, and none of the patients or treating staff were blinded to treatment.

Authors' conclusions

In people with traumatic brain injury, while the addition of HBOT may reduce the risk of death and improve the final GCS, there is little evidence that the survivors have a good outcome. The improvement of 2.68 points in GCS is difficult to interpret. This scale runs from three (deeply comatose and unresponsive) to 15 (fully conscious), and the clinical importance of an improvement of approximately three points will vary dramatically with the starting value (for example an improvement from 12 to 15 would represent an important clinical benefit, but an improvement from three to six would leave the patient with severe and highly dependent impairment). The routine application of HBOT to these patients cannot be justified from this review. Given the modest number of patients, methodological shortcomings of included trials and poor reporting, the results should be interpreted cautiously. An appropriately powered trial of high methodological rigour is required to define which patients, if any, can be expected to benefit most from HBOT.

Laički sažetak

Poboljšava li hiperbarična terapija kisikom preživljavanje i kvalitetu života bolesnika s traumatskom ozljedom mozga?

Traumatska ozljeda mozga značajan je uzrok smrti i invaliditeta. Ne događa se svo oštećenje mozga u trenutku ozljede; naknadno može doći do smanjenja protoka krvi i opskrbe mozga kisikom i uzrokovati daljnje sekundarno oštećenje mozga koje je i samo važan uzrok izbježive smrti i invalidnosti. Stoga je važno u ranim fazama nakon ozljede uložiti napore za smanjenje sekundarnog oštećenja mozga kako bi se pružile najbolje šanse za oporavak.

Hiperbarična terapija kisikom (HBOT) je predložena kao terapija za smanjenje sekundarnog oštećenja mozga poboljšanjem opskrbe mozga kisikom. Bolesnici koji se podvrgavaju HBOT‐u su smješteni u posebno dizajniranoj komori u kojoj se 100% kisik dostavlja pod tlakom većim od normalnog atmosferskog tlaka. Ponekad se terapija koristi za povećanje opskrbe ozlijeđenog mozga kisikom u pokušaju smanjenja područja odumiranja mozga.

Učinkovitost HBOT‐a u oporavku bolesnika s ozlijedom mozga nije jasna. Postoji i bojazan oko mogućih štetnih učinaka terapije, uključujući i oštećenje ušiju, sinusa i pluća zbog djelovanja tlaka, privremeno pogoršanje kratkovidnosti, klaustrofobiju i trovanje kisikom.

U pokušaju razrješavanja neizvjesnosti vezanih uz uporabu HBOT‐a, autori ovog Cochrane sustavnog pregleda pronašli su sve studije koje su bile randomizirana kontrolirana istraživanja a istraživala su učinke HBOT‐a kod osoba s traumatskom ozljedom mozga svih dobnih skupina.

Autori su našli sedam prihvatljivih studija koje uključuju 571 osobu. Kombinirani rezultati sugeriraju da HBOT smanjuje rizik od smrti i poboljšava razinu kome; međutim, ne postoje dokazi da su preživjeli imali poboljšani ishod u pogledu kvalitete života. Stoga je moguće da je sveukupni učinak hiperbaričnog kisika povećanje vjerojatnosti da će osobe s teškim invaliditetom nakon takvih ozljeda preživjeti. Autori zaključuju da se rutinska primjena HBOT u bolesnika s ozljedom mozga ne može opravdati rezultatima ovog pregleda.

Zbog malog broja istraživanja s ograničenim brojem ljudi, nije moguće imati pouzdane nalaze. Potrebna su daljnja istraživanja visoke kvalitete za definiranje pravog opsega koristi od HBOT‐a.