1) The document discusses using transdermal carbon dioxide (CO2) delivery via a handheld device called D'Oxyva to increase microcirculation and promote wound healing. 2) It provides background on how CO2 acts as a vasodilator and how increased CO2 levels via this device can boost oxygen delivery and tissue perfusion. 3) Several case studies and observations are presented showing accelerated wound healing in patients using the D'Oxyva device to deliver transdermal CO2.

1. Introduction: New Prospect of
treatment of wound healing
Ito Puruhito, MD
Thoracic, Cardiac and Vascular Surgery, Medical Faculty, Universitas Airlangga , Surabaya,
Indonesia
Presented at : 6th Surabaya Vascular Update (SURVUE-6) , Surabaya, July 22-23, 2016

2. DISCLOSURE
The author disclosed that the investigation is
sponsored by Circularity Healthcare, LLC

3. Introduction
The recognition of the importance of proper
microcirculatory function has been growing
rapidly in recent years, suggesting that improved
microcirculatory health can support better
outcomes in a wide variety of conditions, both
localized and systemic.
Optimal microvascular function is critical in
regulating blood flow and tissue perfusion,
blood pressure, oxygen delivery, and waste
removal.

4. The clinical application :
Proper functioning of these processes can have
a beneficial effect on prevention and
treatment of disease states such as sepsis ,
non-healing wounds, diabetes , hypertension ,
obesity , metabolic syndrome , respiratory
disorders, sexual dysfunction, and age-related
syndromes.

5. The basic knowledge :
• Increased microcirculation with CO2 is widely known to
increase the perfusion of oxygen throughout the body
based on the Bohr effect.
• CO2 is widely accepted as a natural vasodilator.
• Increased oxygen-rich microcirculatory tissue perfusion
throughout the body is widely reported in medical
research to improve physiological processes including
but not limited to healing, performance, stamina, sleep
quality, skin health, and much more.

6. In addition, when the Bohr
effect is stimulated, the
increase in blood CO2
concentration causes
greater oxygen unloading
by hemoglobin proteins,
thereby increasing oxygen-
rich blood flow in the local
microcirculatory system

8. According to Bohr’s Law, increased CO2 leads to a shift to the right
of the curve balance of he Oxygen Dissociation curve, and this will
increase the release of Oxygen to red blood cells. So increased
CO2 content has a positive benefit to wound healing due to
increased release of Oxygen to tissues.

9. Wound healing process by
Transdermal CO2 Delivery
• Soft vapor of water and CO2 readily and safely dissolves
in the skin to increase skin perfusion pressure or
microcirculation
• D`OXYVA delivers the highest possible concentration of
CO2 and has been clinically studied to significantly
increase lasting blood flow volume that reportedly results
in a long-term increase of blood flow in the body's
microcirculatory system.
• It is non-electrical, handheld, painless, easy to use, and
safe, with no detrimental or adverse side effects,
according to years of user feedback and the results of
past clinical trials with D`OXYVA

10. the effect of transdermal CO2 delivery on
remote microvascular perfusion in subjects
with and without diabetes by assessing skin
perfusion pressure of the foot after bathing
the thumb in CO2.
D’oxyva device
Inside : CO2 cartridge
thumb
Foot with wound

11. Scientific reasoning
• Introduction Medical gases have historically been
delivered via the inhalation route of administration.
However, in light of the physiology of human skin, it
may be possible to deliver medical gases transdermally.
• Transdermal gas delivery is non-invasive and can
interact with dermal capillary and cellular receptors
near the skin, producing a desired systemic effect.
• The work (using D’oxyva device) (*) studied a novel
method for boosting microcirculation using diffusive
non- invasive transdermal delivery of a supersaturated
solution of carbon dioxide (CO2) in water.
(*) Lee C. Rogers, D.P.M., Judy M. Muller-Delp, Ph.D.,
Topy A. Mudde, MSc.

12. Conclusion of the study for clinical use
• Application of transdermal CO2 produces a remote
vasodilation that may be mediated through release of a
circulating humoral agent
• Transdermal Delivery of Carbon Dioxide Boosts
Microcirculation (Lee C. Rogers1, D.P.M., Judy M. Muller-Delp3, Ph.D., Topy A. Mudde2, MSc.)
• Impairments in microcirculation are detrimental to skin
repair and regeneration
• the D`Oxyva® delivery system of transdermal carbon
dioxide improves parameters of dermal
microcirculation.
• using the D’Oxyva® device shows promise for
improving the microcirculation in multiple disease
states and may improve skin repair or delayed wound
healing.

13. First Case report
• Case : 48yrs M with prolonged wound healing after bone fracture of tibia, more than 2 years of classical wound
treament, received D’oxyva treatment in 4 weeks’ session, 7x per week, twice daily (total 60 cartridges) :
1st week 2nd week 3rd week 4th week
• Case-2 : 65 yrs F with Diabetes and open wound treated by herself at home for 4 weeks, then consulted to me :
After 7 days of
treatment
with D’oxyva
(1x per day) –
same wound
dressing as
before
(unfortunately the
patient did not
appear again at my
practice office
since then..)

14. Observation 1 (14 February 2015)
Location : Left Foot-plantar
OBSERVATIONS DONE AT SANGLAH HOSPITAL, BALI (Courtesy : Dr.I.N.Semadi)
Case:
diabetic foot,
left plantar
and toe

15. Observation 2 : (21 February 2015)
Location : Plantar pedis sinistra
Treatment with D’oxyva device, twice daily,
5 days per week 1st week’s appearance

16. Observation 3 : (7 March 2015)
Location : Plantar pedis sinistra
2nd week (20 x treatment)

17. Observation 4 : (28 March 2015)
Location : Plantar pedis sinistra
3rd week (30 x treatment)

18. Observation 1 : (14 Februari 2015)
Location : 1st digiti pedis sinistra
Wound of the toe (same side of foot)

19. Observation 2 : (21 Februari 2015)
Location : 1st digiti pedis sinistra
1st week (10 x treatment)

20. Observation 3 : (7 March 2015)
Location : 1st digiti pedis sinistra
2nd week (20 x treatment)

21. Observation 4 : (28 March 2015)
Location : 1st digiti pedis sinistra
3rd week (30 x treatment) :
toe completely healed

22. Result of our experience using D’oxyva
apparatus for Diabetic foot ulcer
• 6 patients, observed for 5 consecutive days,
treatment with D’oxyva app. 2x/ day
• Perfusion Index (PI) observed (Masimo) (*)
• Same wound dressing treatment
• Observer : Dr.Chiquita
(*) Perfusion index (PI) is a ratio between pulsatile blood flow or static blood flow to
nonpulsatile in peripheral tissues. PI is a non-invasive and continuous mean to measure
peripheral perfusion obtained pulse oximetry.
The measuremen t of PI is not influenced by physiologic variables susch as heart rate, SaO2,
oxugen consumption, and temperature. Change of PI is parallel to peripheral perfusion.
Location with high pulsatile (high PI) is an optimal place to measure with pulse oximetry and
pulse CO-Oximetry. The best location is the tip of the toe.

23. Measurement of PI (Perfusion Index) Masimo® by
means of gadget (Android or Apple)
Finger / toe tip

24. Result of preliminary observations
taken from our Ambulatory patients :
• N : 6
• Status : - Wagner-1 = 2
- Wagner-2 = 3
- Wagner-3 = 1
• Indication of improved wound healing :
significant increase of PI
• Improved healing (after 5 days) = 6 (100%)

25. Pat.1
Day-1 (PI : 0,29) Day-5 (PI : 0,41)

26. Pat.2
Day-1 (PI : 4,2)
Day-5 (PI : 7,8)

27. Pat.3
Day-1 (PI : 2,9)
Day-5 (PI : 5,6)

28. Pat.4
Day-1 (PI : 1,8)
Day-5 (PI : 2,4)

29. Pat.5
Day-1 (PI : 0,52)
Day-5 (PI : 3,9)

30. Pat.6
Day-1 (PI : 2,6) Day-5 (PI : 4,6)

31. Practical tips
• if they use their D'Oxyva less frequently, the supply of
cartridges will last longer, saving them money. I try to
stress to my patients that the first box of 25 cartridges
should last two months. The second box of 25 should
last about three months.
• These estimates are based on using the device 5 times
a week for the 1st month (5 days a week), and then
using it 3 times a week for the second month, for a
total of 32 treatments. As the first box of cartridges is
nearing empty, the patient should purchase the next
box. This box would be used for at least 3 treatments
per week for roughly the next 6 weeks  50 cartridges

32. Recommended use and benefit
• Increase in muscle mass
• Increase in skin collagen
• Improvement in circulation
• Increase in overall energy
• Increase in body/digestive track eliminations
• Increase in blood oxygen levels
• Improvement in my digestive system
• Improvement in absorption of nutritional supplements
• Decease in overall pain and inflammation in bones,
muscles, and joints
• Reduction in spider veins
• Reduction in body fat
Dr. Jim Bledsoe PhD. N.S
My personal experience using D’oxyva
in 50 consecutive session (5x per week
in 10 weeks) – 50 cartridges :

33. D'Oxyva impacts the body in much
the same way as supplements do.
• The reason for using D’Oxyva more often in the first
month is that, similar to most nutritional
supplements, it is necessary to upload at a higher
dosage in the initial stages of usage. This uploading
allows the supplementation process to have a greater
effect on the body, jump- starting the beneficial
effects.
• For more severe conditions, it is usually possible to
see meaningful results by using D’Oxyva about twice
a day, or roughly ten applications a week, for the first
two months. Once the desired improvement has been
achieved, the treatments can be scaled back to a
maintenance mode of 3 – 5 times a week.