In hyperbaric medicine, it is important that healthcare professionals understand that the approved indications are not common knowledge amongst those that do not practice it. Some healthcare professionals may be aware of hyperbaric medicine if the facility they work in has a chamber, but they still may not know the indications or when it is appropriate to refer patients. Part of being a hyperbaric physician is to educate colleagues in the community to collaborate and provide the best care to patients. When evaluating patients, healthcare professionals must first determine if they have an indicated diagnosis. Healthcare professionals must also educate patients during the consultation and make sure they are willing to comply with safety regulations and rules of the chamber environment, the number of treatments recommended, and the frequency of treatments indicated by their plan of care.
There are currently 15 approved indications accepted by the Undersea and Hyperbaric Medical Society. There are both urgent and non-urgent indications, and they are as follows (Weaver, 2014):
After confirming that a patient has an indicated diagnosis, the next step is to perform a thorough history and physical to determine if the patient is an appropriate candidate for hyperbaric chamber treatment. The first ethical obligation to a patient is nonmaleficence ("do no harm"). Healthcare professionals need to review any contraindications or relative contraindications for hyperbaric oxygen treatment.
The one absolute contraindication to hyperbaric oxygen treatment is a patient with an untreated pneumothorax (Weaver, 2014; Latham, 2013). All patients should have lung imaging before treatment. If a patient receives treatment for a pneumothorax, the risk-benefit ratio would need evaluation before placing the patient in the chamber based on their indication. During pneumothorax management, a chest tube with the Heimlich valve open prior to initiation of treatment would be an acceptable approach for pre-chamber management in an emergency clinical situation.
Relative contraindications to evaluate before treatment include, but are not limited to, the following (Latham, 2013):
In assessing a patient’s medications, clinicians need to remember the following pharmacotherapy interactions with hyperbaric oxygen treatments. Bleomycin can lead to interstitial pneumonitis (recent exposure, usually within a 12-month period), pulmonary fibrosis. Sulfamylon and cisplatin impair wound healing. Disulfiram blocks superoxide dismutase, which is protective against oxygen toxicity, and doxorubicin can cause cardiotoxicity (must wait a minimum of 72 hours from the last dose). Thus these medications are recommended to be discontinued before treatment (Latham, 2013).
After a healthcare professional take a history and performs a physical evaluation of a patient, they need to keep in mind the type of treatment plan recommended for the patient. For urgent indications, the sooner hyperbaric treatment sessions usually start, the better the benefit from treatments. Other considerations include the type of chamber available and limitations of the chamber based on clinical requirements of the patient, the amount of staff available, mixed gas capabilities, and time needed for treatment. If a multiplace chamber is accessible, there is usually no limitations as a practitioner or tender will be available to the patient during treatment. For monoplace chambers, there can be limitations based on clinical requirements. For example, some monoplace chambers do not have air hoses to allow for air breaks during treatment. Others do not have ports to allow for monitoring heart rate or other vitals, and for intubated patients, there needs to be a special ventilator available with a respiratory therapist to control settings during treatment (Bove, 2004; Kindwal & Whelan, 2008).
In conclusion, appropriate hyperbaric patient selection will include patients that will follow all safety protocols, patients with approved indications, confirmation of diagnosis, no contraindications and minimal to no relative contraindications to hyperbaric oxygen treatment, a chamber and crew that is suitable to the patient’s clinical needs, and consent to treatment from the patient or a legal representative.
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