Hyperbaric oxygen therapy (HBOT) is defined as placement of the entire body in an increased pressure environment of a minimum 1.4 atmospheres (atm) absolute, with 100% oxygen inspiration. Many factors are involved when choosing a course of therapy for a patient. The best choice for the patient balances the risks and rewards. HBOT is generally well tolerated by most patients, although there are a few clinical scenarios that must be screened before starting HBOT.
There is currently only one absolute contraindication to hyperbaric oxygen therapy, which is untreated pneumothorax. Placing a patient in a chamber and changing the pressure around them can result in a tension pneumothorax occurring on ascent, which could quickly become life-threatening. Any patient with pneumothorax should have it treated (likely with some form of thoracostomy tube) before hyperbaric oxygen therapy.
These were previously thought to be absolute contraindications:
These have long been held to be relative contraindications, and risks versus benefit should be addressed accordingly:
Not a Contraindication
It had been hypothesized that active cancer would be a contraindication to hyperbaric oxygen therapy. The proposed mechanism was that hyperbaric oxygen causes the release of vascular endothelial growth factor (VEGF) and could cause increased tumor growth. However, given the difference in tumor growth cycles versus wound healing and review of the literature, the evidence shows a net neutral effect on gene expression related to tumor growth.
HBOT can be used for emergent or elective interventions. The primary emergent indication for HBOT is decompression sickness from gas embolism and decompression illness. It is also used for acute management of carbon monoxide toxicity, chronic refractory osteomyelitis, radiation injuries to soft tissue, and clostridial myonecrosis, although evidence for HBOT use is less clear. It has also been used in necrotizing wounds, retinal artery occlusion, and acute trauma, though clear evidence of efficacy for these conditions is somewhat lacking. In some of these conditions, HBOT is an adjuvant for patients unresponsive to traditional treatment methods alone. Additional research indicates that patients who have recovered from head and neck tumors after radiation and surgical intervention may experience progressive fibrosis of soft tissues within the jaw. Studies have shown that patients who receive coadministered HBOT experience better outcomes than those without, and conclude that patients who are irradiated for head and neck tumors should be referred to HBOT centers and physicians should coordinate this effort with planned surgeries to optimize tissue healing. Delayed radiation sequelae for the treatment of neurologic, gynecologic, urologic, and colorectal cancers have all shown responsiveness to concurrent HBOT. There is also evidence that HBOT for treatment of severe anemia where transfusions are refused (observant Jehovah’s Witnesses) or are unable to be safely performed. Evidence for this has been established at the basic science level and has been corroborated in healthy patients. One of the main drawbacks of this treatment method is the relative lack of access. There is a national shortage of HBOT centers in the United States, limiting its use and study as a mainstay treatment.
Indications for HBOT use should be carefully weighed against the patients' potential contraindications for treatment to ensure that patients’ benefit outweighs associated risks. Interprofessional collaboration is crucial to ensure that patients’ contraindications are considered and ruled out while ensuring that HBOT is used with a reasonable indication of benefit. As HBOT can be used emergently or electively, interprofessional roles vary considerably for each use. In emergent situations, earlier HBOT initiation is correlated with improved outcomes. While emergency department (ED) physicians may have the final say in recommending emergent HBOT, nurses, radiologists, emergency medical service personnel, and pharmacists play a critical role in ruling out contraindications for HBOT use.
Emergency medical service personnel is responsible for producing the initial history which may include indications that emergency HBOT is needed, such as a diving injury or evidence of carbon monoxide toxicity. Radiology staff must evaluate past radiographs for evidence of pulmonary nodules or other pulmonary abnormalities that may contraindicate elective HBOT. In addition, radiology will have a critical role in emergent situations to rule out tension pneumothorax, the single absolute contraindication to HBOT. Pharmacists and pharmacy staff have an important role in considering the patient’s current medications and medication schedules so that patients undergoing chemotherapy can also utilize elective HBOT safely and without risk of medication effects. Nurses play an important role in monitoring patients undergoing HBOT for an adverse reaction and are essential to the maintenance of patient safety and wellbeing during HBOT treatment. For elective HBOT, primary care providers must carefully note medical conditions that may relatively contraindicate HBOT, including claustrophobia, upper respiratory infections (URIs), diabetes, eustachian tube malformations, and chronic respiratory diseases. When considering HBOT, the primary care staff must continuously review potential comorbidities that may introduce additional risk to the patient.
Oxford CEBM Evidence Levels for HBOT by Condition
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