Introduction
The effects of barometric pressure on human physiology and cognition date back to Evangelista Torricelli's invention of the barometer in 1643. In 1644, Torricelli observed, “We live submerged at the bottom of an ocean of the element air.”(1) Altitude ascents and descents in air have an effect on human physiology due to changes in both oxygen pressure and barometric pressure. The positive effects of descent from altitude on human pulmonary, rheumatic, and cardiac diseases have been documented during relocations of people from the Rocky Mountains (5000–10,000 ft above sea level) to the lower Missouri River Basin of the United States (~1000 ft above sea level) (2, 3). Kramer et al. (4) quantified and showed the durability of this phenomenon in chronic obstructive pulmonary disease (COPD) patients who relocated for 3 weeks from Jerusalem (altitude 800 m, 2500 ft, 13.4 psi, 0.91 ATA) to the Dead Sea (altitude 402 m of air below sea level 15.4 psi, 1.05 ATA). At the end of the Dead Sea relocation, parameters such as walking distance and maximum oxygen consumption improved and persisted for 2 weeks after returning to Jerusalem at 0.91ATA (4). The findings by Kramer et al. were substantiated by 50 years of physiological evidence of the bioactivity induced by pressure changes in the same range as his COPD patients who relocated from Jerusalem to the Dead Sea, moving from 1.0015 ATA to 1.3 ATA (5).
The opposite effect, i.e., worsening of COPD on ascent in “the ocean of air,” was observed by Dr. Orval Cunningham, professor of anesthesiology (University of Kansas), the specialty of gas physiology. While on a vacation to the Colorado Rocky Mountains during the Spanish flu pandemic of 1918, he became aware of the increased mortality of Spanish flu victims at higher altitude (6). He reasoned that, since a descent to lower elevations has a therapeutic effect on patients (2, 3), a further increase in pressure beyond sea level, i.e., to below “the ocean of air,” would have further benefit. Using a converted boiler as a hyperbaric chamber in Kansas City, Missouri (altitude 909 ft), Cunningham replicated this improvement caused by altitude descent on human disease when he treated an agonal Spanish flu patient in 1918, achieving complete recovery with four daily 1-h 1.6 ATA hyperbaric air treatment (HBAT) sessions (6, 7) Countless Spanish flu patients followed, and Cunningham extended his clinical treatment benefits to a variety of conditions (7–9). After a hundred years, his reasoning and success were replicated in the application of hyperbaric oxygen therapy (HBOT) to COVID-19 (10–12). and post-COVID “Long Haulers Syndrome.” (13–15).
The results obtained by Kramer et al.. (4) and Cunningham with compressed air (2, 3, 6–9) have been replicated in cerebral palsy children (16, 17), a drowned child (18), and two persistent postconcussion syndrome studies (19, 20). The pressure changes observed in these studies were in the range of the pressure changes observed in the Rocky Mountain/Great Plains relocators (2, 3) and the pressure changes experienced by our dementia patient on weekend trips from his home in the Rocky Mountains to western Nebraska. During these trips, he experienced clinical deteriorations and improvements that tracked altitude changes. Based on the above literature, the authors' personal experience, and the patient's clinical travel experience, the primary author replicated the clinical benefits experienced on the weekend trips to lower altitude (higher pressure) by treating his patient in a portable hyperbaric chamber. In this study, we report the sustained improvement in dementia with repetitive hyperbaric air therapy, using pressure similar to that used by others who have used altitude descent to improve their medical conditions (2–4).
Case description
The patient was a 78-year-old man with dementia who lived for 16 years in Gypsum, Colorado at 6400 feet (1944 m, 0.79 ATA, 11.6 psi) and was a summertime vacation home neighbor of the primary author in Lake McConaughy, Nebraska (3330 feet altitude, 972 m, 0.89 ATA, 13.0 psi). He was cognitively intact until a cerebral injury from an urgent cholecystectomy in the spring of 2019. Post-operatively, the family noticed an immediate cognitive change (“he was no longer himself”). The patient was reduced to social withdrawal, infrequent smiles, and little intelligible speech. He was subsequently diagnosed with dementia. In May 2019, his son-in-law attended a baseball game with the patient in Denver, Colorado (21) (altitude of 5200 feet, 1544 m, 0.83ATA, 12.1 psi) and noticed that he had become incoherent (delirious) around 4:00 PM during the middle innings of the game. Attendance at this game included travel from his home at an elevation of 6400 feet (0.79 ATA) over the Continental Divide (Eisenhower Tunnel, 11,111 feet, 3401 m, 0.66 ATA, 9.6 psi) and a pressure change of−0.13 ATA (see Figure 1). This was the first episode where the patient's sundowning had occurred well before its typical evening time.
Figure 1. Schematic of relevant altitudes discussed in the case report.
Travel to the baseball game entailed 90 min of increasing hypobaric hypoxia from his home at 6400 ft (0.79 ATA) to the Eisenhower Tunnel (11,111 feet, 0.66 ATA) before descent to the baseball stadium at 5,280 ft (0.83 ATA). This included a peak stress of 15–20 min at the Eisenhower Tunnel. The early sundowning was confirmed by additional family members and the primary author's observations on multiple occasions during the summer of 2019 while traveling on the same route to his vacation home in Nebraska for weekend trips (3,330 ft., 0.89 ATA). After staying for a number of days at the decreased altitude (higher pressure), typically on the third day (Sunday afternoons), the family observed behavioral and symptomatic improvement. The primary author also witnessed the patient's cognitive deterioration post cholecystectomy, his further deterioration during visits of summer 2019, and rebounding by Sunday afternoons during vacation home visits.
The observations during the baseball game travel suggested that the hypobaric/hypoxic stress induced by road travel through Eisenhower Tunnel (0.66 ATA) on the patient's dementia (22, 23), a 0.13 ATA decrease in pressure and oxygen pressure, was similar to Cunningham's observations of Spanish flu patients in the Rocky Mountains (6). The lower-altitude higher-pressure rebound improvement observed in the mental status of the patients during Sunday afternoons, a 0.10 ATA increase from his hometown and a 0.23 ATA (3.4 psi) increase from the hypobaric/hypoxic stress zone of Eisenhower Tunnel (0.66 ATA), was in the range of bioactive pressure changes described by Kramer and Godfrey (4) (0.14 ATA increase in pressure), effects of altitude descent from the Rocky Mountains to the Great Plains (2, 3), recompression effects on patients with altitude sickness (24, 25), and the MacDonald–Fraser review of bioactivity in the micropressure range of 1.015–1.3 ATA (5). Based on the authors' previous low-pressure hyperbaric therapy experience with an Alzheimer's patient (26), a drowned child (18), and the medical literature (vide supra), the primary author proposed that the beneficial pressure changes experienced by the patient could be replicated in a portable chamber. Given the effects of HBOT on Nrf2 upregulation (27–29) and of NRF2 effects on intracellular glutathione (GSH) (30), supplemental GSH precursors were recommended adjunctively during hyperbaric treatment.
Treatment
The patient was initiated on daily 1.6 g sublingual glutathione amino acid precursors 3 weeks prior to hyperbaric treatment. The primary author and his wife trained the patient's spouse, children, and adult grandchildren on chamber operations, and hyperbaric treatment was commenced on 20 October 2019, approximately 6 months after cholecystectomy-induced cerebral injury. The treatments were carried out once/daily, 5 days/week, at 1.09 ATA/45–60 min of total treatment time for 20 treatments, 1-week break, repeat 20 treatments. The 0.3 ATA increase in pressure in each hyperbaric treatment was the same increase in pressure used in hyperbaric air treatment of a sub-acutely drowned 2-year-old girl in which global regrowth of brain tissue was demonstrated (18).
Outcome and follow-up
The patient received 14 hyperbaric treatments in 20 days. After the first four treatments, the improvements in speech, cognition, and activities of daily living were so significant that two television news stations in two different US states reported the patient's progress in separate broadcasts. See broadcast news links shown in Figures 2, 3 and Supplementary material.
Read The Full Case Study And Report Here:https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1356662/full