The Use of Oxygen
in the Treatment of Pressure Ulcers
Jalil Azimian and Hossein Rafiei
1 Introduction
Wound healing consists of a series of physiologi-
cal events that occur in response to tissue dam-
ages [1, 2]. Therefore, wound healing might
progress with different pace and quality due to
local and systemic factors and also because of the
diversity among people [3, 4]. Nevertheless, it
should be noted that many vital processes of
wound healing are oxygen-dependent, and there-
fore oxygen-based therapeutic strategies for dam-
aged tissues should be based on an understanding
of the area with anoxia, hypoxia, and normoxia
[5]. In this oxygen-based model, wound healing
strategy should focus on the tissue in the hypoxia
area in order to maintain the highest level of living
tissue and stimulate the treatment process [5].
Throughout history, native healers (therapists)
found that if a wounded patient was moved from
thin air of mountainous environment to a more suit-
able climate (e.g., a very deep valley), the wounds
were healed faster [6]. Treatment of a chronic
wound requires the presence of enough oxygen.
Actually, lack of enough oxygen is a challenge for
chronic wounds’ treatment [7, 8]. The amount of
oxygen consumption in a cell depends on its type
J. Azimian, Ph.D. (*) • H. Rafiei, Ph.D.
Department of Critical Care Nursing, School of
Nursing and Midwifery, Qazvin University of
Medical Science, Qazvin, Iran
e-mail: azzimianj@yahoo.com;
Hosseinr21@gmail.com
Recent Clinical Techniques, Results, and Research in Wounds (2017)
DOI 10.1007/15695_2017_41, © Springer International Publishing AG
and biological status. Demand and consumption of
oxygen significantly increase in case of tissue dam-
age and ulcers. Since oxygen cannot be stored in
the cells, the continuous supply of oxygen to the
cells is necessary for wound healing [7]. Disruption
in oxygen supply will make many problems for the
wound healing process [7]. Therefore, oxygen ther-
apy is a logical method to increase tissue oxygen-
ation and accelerate wound healing [8].
Oxygenation of the skin may occur by two
routes: delivery from the “inside out” route via
the circulation and delivery from the “outside in”
route via the atmosphere. In the first method
(inside out), the oxygenated blood flows through
the cardiovascular system, and the oxygen
devolved is released in peripheral plasma cells
such as the skin tissue. The oxygen is transferred
from the capillaries into the interstitial space and
eventually to the skin and cells because of con-
centration differences. In the second method
(outside in), the oxygen penetrates the permeable
surface of the skin into the tissue. The amount of
oxygen diffusion into the cells and tissues
depends on its pressure amount, which forms the
basis for topical oxygen therapy (TOT) [5].
The history of using hyperbaric oxygen for
tissue repair goes back to four decades ago [9].
The advantages of using hyperbaric oxygen are:
1. It increases oxygen in the wound area and
prevents further damages.
2. It increases angiogenesis and improves
microcirculation in the wound area.

3. It improves wound healing process by reduc-
ing edema and inflammation of the area.
4. It sedates the wound area.
5. It reduces the risk of wound infections by
destroying bacteria and increasing the power
of the white blood cells.
6. It improves the microcirculation and
detoxification.
7. It improves the performance of some
antibiotics.
8. It reduces blood viscosity and its
complications.
9. It improves the blood circulation in the lym-
phatic system.
10. It prepares the skin and bone before trans-
plant surgery.
11. It improves recovery after surgery and
increases the chances of successful trans-
plantation [10, 11].
2 Hyperbaric Oxygen
Today, a new perspective has emerged in the use
of topical oxygen for the treatment of wounds by
new studies, and different everyday-developing
technologies are used to deliver oxygen to the tis-
sues [3, 12].
The ultimate goal of using the above methods
is to deliver oxygen to the depth of the tissues and
areas suffering from hypoxia where the cardio-
vascular system cannot deliver oxygen to the area
due to different causes, or environmental barri-
ers, such as an edema, prevent systemic methods
to deliver oxygen to the wound [5].
In order to facilitate the understanding, the
categories use oxygen for wound healing. The
first category is related to the amount of pressure
used in the system. Considering that, systems are
divided into two categories of hyperbaric (a sys-
tem with a pressure higher than atmospheric
pressure) and normobaric (a pressure equal to
atmospheric pressure). Hyperbaric oxygen
(HBO) and topical hyperbaric oxygen (THBO)
methods are in the hyperbaric category and trans-
dermal continuous oxygen therapy (TCOT) is in
the normobaric category. The systems can also be
J. Azimian and H. Rafiei
classified according to their systemic or topical
application. In this case, the HBO method is in
the systemic category (oxygen is systemically
delivered to the patients), and TCOT and THBO
are in the local category (oxygen is delivered to
the wound topically).
Although the ultimate goal of all three meth-
ods of HBO, THBO, and TCOT is to increase the
oxygen available to the damaged tissue and speed
up wound healing, as noted, the three methods
are different in their functional structure. In the
HBO method, the patients are placed in a big
chamber where they receive oxygen with high
flow rate and pressure systemically. In this
method, the patient receives 100% oxygen in a
chamber at a pressure greater than atmospheric
pressure for 90–120 min per day. In this method,
treatment continues on a daily basis until the
wound heals [13]. Since oxygen is not used topi-
cally, the chance of oxygen reaching the wound
area is much reduced which is the main disadvan-
tage of this method. The method has also some
risks such as oxygen toxicity, barotrauma, and
pneumothorax. There is a risk of explosion and
fire threatening the patient, too. Due to the limita-
tion of the patient inside the chamber and non-­
portability of the device, the method is used with
less enthusiasm on the part of clinicians.
Many patients do not tolerate the side effects
of systemic HBO. They do not have the access to
the facilities necessary to carry out the procedure.
In some cases, the cardiovascular system of the
patient does not have enough power to deliver
oxygen to the tissues of the patient’s wound. In
some cases, edema existed and oxygen cannot
reach it through the circulation [3, 14]. In these
cases, TOT as a preferred method is able to carry
oxygen through the body surface to the wound,
and since the oxygen reaches the wound directly
and not through vascular capillaries, it minimizes
the complications of oxygen therapy. Therefore,
the topical hyperbaric oxygen therapy method is
used. TOT can reach the outer surface of the body
in the form of gas or dissolved in body fluids.
However, biologically, the administered oxygen
in the form of gas must be dissolved to be effec-
tive so that the target tissues can absorb it [5, 15].
The Use of Oxygen in the Treatment of Pressure Ulcers
3 Topical Oxygen
Topical oxygen gas system (oxygen boot) was
proposed in 1932. In this method, the oxygen is
delivered to the wound or affected limb in form
of pure gas, or it is delivered to the wound through
a machine that produces oxygen gas. In the
THBO method, the 100% oxygen is directly
delivered to the wound with a pressure more than
atmospheric pressure [13]. In the THBO, the
used pressure and time depend on factors such as
the type of pathogen in the wound and the amount
of angiogenesis around the wound.
A review study has suggested evidence-based
recommendations for TOT. There are obstacles
for carrying the oxygen in the form of gas bub-
bles to the target cells in the wound that must be
overcome since these internal factors limit the
performance of systemic TOT. Studies have
shown encouraging results in the treatment of
wounds using TOT with low pressure. In this
method, the 100% oxygen is used at the atmo-
spheric pressure or slightly higher with or with-
out the use of high-pressure chambers. This
method is more accessible than HBO and can be
used by the patient at home.
Due to complications of HBO and THBO
methods, the TCOT method was proposed which
did not need the patient to remain still. In this
method, the patient can receive other cares. This
will reduce the costs, enable the patient to be
active, and receive other cares. In the TCOT
method, oxygen is directly delivered to the
wound which is covered and moist at low flow
rates (3–12 mL/h). In this method, the oxygen
flow rate is 40 L per minute. TCOT might not be
effective in wounds covered with scar tissue [7].
Few side effects are reported for using oxygen in
chronic wound healing some of which are myo-
pia, ear damage, and oxygen poisoning in rare
cases [9]. The HBO method has contraindica-
tions in patients with deep vein thrombosis and
severe heart failure. The method is not recom-
mended for pregnant women [8].
Using this method has resulted in wound heal-
ing through angiogenesis in various studies on
the wound healing of animals as well as human
clinical studies. The use of a topical tool for
administration of streams of 100% oxygen bub-
bles on the wound has healed the wound through
epithelial healing.
The methods that deliver dissolved oxygen to
the wound work in two ways. In the first way,
these tools include portable dissolved oxygen to
tissues and cells such as fluorocarbon. In the sec-
ond way, these tools allow a gas tank of oxygen
to deliver oxygen to the tissues [5]. Although
there are reports of difficulty in stable fluorocar-
bon emulsion production, the results of some
studies have been encouraging. The most impor-
tant challenge in this method is delivering oxy-
gen with high pressure gradient to the cells and
tissues with hypoxia. If this challenge is resolved,
TOT will be a complementary tool to systemic
oxygen therapy report used by physicians in
wound healing [5, 15].
Several previous studies have examined the
effects of oxygen on the treatment of chronic
wounds. In a study in 2016, Yu et al. [16] exam-
ined the effects of THBO in the treatment of
chronic diabetic foot ulcers resistant to standard
treatments. They divided 20 patients with dia-
betic foot ulcers into two groups of intervention
and control. Oxygen therapy continued for 8
weeks in that study. Their results showed that the
use of THBO significantly improved healing of
chronic ulcers resistant to conventional treat-
ments. In another study in this regard in 2017,
Niederauer et al. [17] examined the effect of
TCOT on wound healing in patients with diabetic
foot ulcers. They divided 100 patients into two
groups of intervention and control. The patients
in the intervention group received TCOT for 12
weeks, and the patients in the control group were
treated with standard methods. Their results
showed that the rate of wound healing in patients
treated with TCOT was significantly higher com-
pared to the standard methods. They also showed
that the rate of complete wound healing in
patients treated with TCOT was higher compared
to patients treated with standard methods.
The healing of pressure ulcers is very complex
and costly. The use of THBO as an easy and cost-­
effective therapy in the treatment of pressure

ulcers is increasing [10]. Although there are few
studies in this regard, they all suggest that the use
of oxygen can enhance wound healing in pres-
sure ulcers. One of the first reports on the appli-
cation of HBO in the treatment of pressure ulcers
is that of Fisher in 1990. Fisher [18] reported that
the use of THBO increased granulation speed,
reduced microbial growth, and enhanced wound
healing. Fisher did not observe any side effects of
the treatment. In another study published as a
poster, Berlin et al. [19] examined the effects of
TCOT on four patients with chronic ulcers resis-
tant to conventional treatments. One patient in
that study had a pressure ulcer in the heel.
In 2008, Bank and Ho [20] investigated the use
of THBO on the healing of pressure ulcers in three
patients with spinal cord injury with a grade 4
wound in the pelvic area. The results showed that
in all three cases, the wound healing had improved
significantly after treatment. In another study in
2015 in Japan, Sano [21] examined the effect of
topical oxygen in the treatment of six patients with
chronic wounds. One of the patients had a pressure
ulcer in the sacral region. Their results showed that
treatment with THBO has led to an increase in the
partial pressure of oxygen in the area around the
wound. A significant tissue granulation was also
observed in the cells in that area. In another study
in this regard in 2015 in Iran, Azimian et al. [3]
examined the effect THBO on wound healing of
pressure ulcers grades 2–4 in the sacral and ischium
areas. They examined 100 patients in the two
groups of intervention (n = 50) and control (n = 50).
The patients in the investigation group received
topical oxygen with a rate of 10 L per minute for
20 min, three times a day. The treatment continued
for 12 consecutive days. They used the push crite-
ria to study the wound healing process. At the end
of the 12th day after the start of the study, the
wounds of 16 patients in the intervention group
healed completely, while the wound of only one
patient healed completely in the control group.
Their results also showed that the wound healing
J. Azimian and H. Rafiei
process in the intervention group had better condi-
tions during the 12 days. Finally, they concluded
that the use of THBO therapy is an effective and
harmless method of pressure ulcer healing.
Conclusions
Generally, it can be said that the use of oxygen
in the treatment of different chronic ulcers such
as diabetic foot ulcers is very effective. Its appli-
cation for patients with pressure ulcers requires
further studies, although all the few studies on
the effect of oxygen in the treatment of pressure
ulcers indicated that this method will accelerate
the healing process of pressure ulcers.
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