Procedures

Hyperbaric Oxygen Therapy

Background

1. Hyperbaric Oxygen Therapy (HBOT) can treat a wide range of health problems
   • Hyperoxia (View image)
     • Restores neutrophil O2-mediated bacterial killing
     • Bactericidal for anaerobes and bacteriostatic for species of E. coli, Pseudomonas
     • Suppresses Clostridial production of alpha toxin
     • Stimulates angiogenesis
     • Inhibits many parts of reperfusion injury cascade, reduces local edema
     • Carbon-monoxide mediated brain lipid peroxidation
     • May also reduce neurologic sequelae after acute CO poisoning (controversial)
2. Treatment guidelines
   • Guidance
     • Patient breathes 100% O2 intermittently inside treatment chamber > sea level pressure (i.e., > 1 atm)
     • Pressurization should be ≥ 1.4 atm absolute (abs) to be considered HBOT
   • Medications recommended to be discontinued before treatment
     • Bleomycin ⇒ interstitial pneumonias
     • Sulfamylon ⇒ impairs wound healing
     • Cisplatin ⇒ impairs wound healing
     • Disulfiram ⇒ increases risk for O2 toxicity
     • Doxorubicin ⇒ cardiotoxicity

Indications

1. Hyperbaric Medical Society Hyperbaric Oxygen Therapy Indications (15th ed.)
   1. Air or gas embolism (iatrogenic or diving related)
   2. Central retinal artery occlusion
   3. CO poisoning
   4. Clostridial myonecrosis (gas gangrene)
   5. Compromised surgical grafts and flaps
   6. Crush injuries/skeletal muscle compartment syndrome/acute arterial insufficiency
   7. Decompression sickness
   8. Intracranial abscess
   9. Necrotizing soft tissue infections
   10. Significant blood loss anemia
   11. Specific acute thermal burns
   12. Idiopathic sudden sensorineural hearing loss (urgent)
   13. Delayed radiation injuries for soft tissue or bony necrosis/osteoradionecrosis
   14. Chronic refractory osteomyelitis
   15. Enhancement of healing in a problematic wound (diabetic foot ulcers Wagner grade 3-5)
2. FDA clearance
   • As of July 2021, the FDA has cleared HBOT for the following disorders:
     • Air and gas bubbles in blood vessels
     • Anemia (severe anemia when blood transfusions cannot be used)
     • Burns (severe and large burns treated at a specialized burn center)
     • Carbon monoxide poisoning
     • Crush injury
     • Decompression sickness (diving risk)
     • Gas gangrene
     • Hearing loss (complete hearing loss that occurs suddenly and without any known cause)
     • Infection of the skin and bone (severe)
     • Radiation injury
     • Skin graft flap at risk of tissue death
     • Vision loss (when sudden and painless in one eye due to blockage of blood flow)
     • Wounds (non-healing, diabetic foot ulcers)
3. HBOT and COVID-19
   • HBOT can improve the quality of life, quality of sleep, psychiatric and pain symptoms of patients suffering from long COVID
   • The clinical improvements gained by HBOT are persistent even 1 year after the last HBOT session

Contraindications

1. Absolute contraindications
   • Untreated pneumothorax
     • CXR to rule out
2. Relative contraindications
   • Uncontrolled HTN
     • BP can increase during treatment
   • DM with glucose > 300 or < 100
   • CHF with EF < 35%
     • Hyperbaric can exacerbate CHF and/or flash pulmonary edema
   • Claustrophobia/confinement anxiety
     • May require multiplace chamber or pharmacotherapy (View image)
   • Congenital spherocytosis
     • Hyperbaric oxygen can cause severe hemolysis
   • Current URI
     • Concern for ability to equalize on the descent
     • Risk of reverse sinus block on the ascent
     • Can lead to barotrauma
   • Fever
     • Lowers seizure threshold during treatment
   • Chronic sinus condition
     • Concern for ability to equalize on the descent
     • Risk of reverse sinus block on the ascent
     • Can lead to barotrauma
   • Pacemaker/implantable device
     • Risk of malfunction under pressure
     • If device delivers shock in 100% oxygen environment could ignite a fire
     • Coordinate with safety officer and call manufacturer
       • Device should be pressure tested
   • Recent eye/retinal/cataract surgery or optic neuritis
     • Buckle procedure can have air trapped
     • Other procedures can leave bubbles inside
     • Usually require a few months waiting period before initiation of treatment
   • Recent thoracic surgery
     • Recommend imaging to rule out pneumothorax
   • Obstructive lung disease/chronic obstructive pulmonary disease
     • COPD)/asthma ⇒ lose hypoxic drive to breathe
       • Screen with PFTs and xenon washout study to evaluate for risk of air trapping
   • History of seizures
     • Recommend seizures be controlled before initiation of treatment
     • Monitor therapeutic levels
     • May require lower treatment pressures
   • Untreated cancer
     • No studies show hyperbarics promote malignant cell proliferation
   • Contact lenses
     • Need to be gas permeable
     • No hard contact lenses

Procedure

1. Fill balloon-filled equipment/devices (e.g., Foley, ET tube) with fluid to avoid rupture
2. Pretreat with decongestants if sinus congestion present
3. Avoid with severe peripheral vascular disease because of vasoconstrictive effects
4. May need emergent myringotomy or tympanostomy tubes if high-grade barotrauma (blood, severe erythema, pain) occurs
5. Diabetics should receive pre- and post- compression blood sugar checks, since HBO2 can induce hypoglycemia
6. Pre-treat 30 min prior to HBO2 with lorazepam or diazepam for confinement anxiety
7. Wedge pillow in monoplace chamber: to reduce pulmonary blood flow and risk of pulmonary edema in class patients at high risk for CHF
8. Cardiac monitoring for patients with active CAD or hypotension
9. Those at risk for seizures should have anticonvulsant levels checked and an IV for rapid administration of anticonvulsants

Complications

1. Most are benign and resolve with discontinuation of HBOT
2. Effects of Pressure
   • Barotrauma (e.g., hyperemia of tympanic membrane, rupture of TM, etc.)
   • Sinus pain
   • Bronchospasms
   • Alveolar rupture
   • Damage to devices and prostheses
3. Oxygen Toxicity
   • Tracheobronchitis
   • Tunnel vision
   • Tinnitus
   • Nausea
   • Fasciculations
   • Irritability
   • Dizziness
   • Generalized tonic-clonic seizure
   • Retinopathy of prematurity
   • Cataract formation
   • Transient myopic change in vision

References

1. FDA. Hyperbaric Oxygen Therapy: Get the Facts. Available at: https://www.fda.gov/consumers/consumer-updates/hyperbaric-oxygen-therapy-get-facts. [Accessed November 2024]
2. In: Huang ET (eds). UHMS Hyperbaric Medicine Indications Manual, 15th ed., Best Publishing Co, Undersea and Hyperbaric Medical Society, 2023
3. Hadanny A, Zilberman-Itskovich S, et al. Long term outcomes of hyperbaric oxygen therapy in post covid condition: longitudinal follow-up of a randomized controlled trial. Sci Rep. Feb 15, 2024; 14(3604): https://doi.org/10.1038/s41598-024-53091-3
4. Robbins T, Gonevski M, et al. Hyperbaric oxygen therapy for the treatment of long COVID: early evaluation of a highly promising intervention. Clin Med (Lond). Nov 2021;21(6):e629-e632
5. Sharma R, Sharma SK, et al. Efficacy of hyperbaric oxygen therapy for diabetic foot ulcer, a systematic review and meta-analysis of controlled clinical trials. Sci Rep. Jan 26, 2021; 11(2189): https://doi.org/10.1038/s41598-021-81886-1
6. Edwards M, Cooper JS. Hyperbaric Treatment of Thermal Burns. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470524/. [Accessed November 2024]
7. Buboltz JB, Robins M. Hyperbaric Treatment of Carbon Monoxide Toxicity. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470531/. [Accessed November 2024]
8. Weaver LK, Hopkins RO, et al. Hyperbaric Oxygen for Acute Carbon Monoxide Poisoning. N Engl J Med. Oct 3, 2002; 347: 1057-1067
9. Moon RE. Hyperbaric oxygen treatment for decompression sickness. Undersea Hyperb Med. Mar-Apr 2014;41(2):151-7
10. Shah J. Hyperbaric Oxygen Therapy. J Am Col Certif Wound Spec. Apr 24, 2010;2(1):9-13
11. DuBose KJ, Cooper JS. Hyperbaric Patient Selection. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK499820/. [Accessed November 2024]
12. Sadri RA, Cooper JS. Hyperbaric Complications. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459191/. [Accessed November 2024]

Contributor(s)

1. Ho, Nghia, MD

Updated/Reviewed: November 2024