Hyperbaric Patient Selection


Article Author:
Kyle DuBose


Article Editor:
Jeffrey Cooper


Editors In Chief:
Joshua Gibson
Jim Powers
Kermit Huebner


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
3/21/2019 12:55:48 AM

Introduction

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.

Issues of Concern

Indications

There are currently 15 approved indications accepted by the Undersea and Hyperbaric Medical Society. There are both urgent and non-urgent indications[1][2], and they are as follows:

Urgent

  • Air or gas embolism (can be the iatrogenic or diving related type of injury)[3]
  • Central retinal artery occlusion
  • Enhancement of healing in a problematic wound (diabetic foot ulcers Wagner grade 3, 4, or 5)[4][5][6]
  • Carbon monoxide poisoning [7]
  • Clostridial myonecrosis (gas gangrene)
  • Compromised surgical grafts and flaps[8]
  • Crush injuries/skeletal muscle compartment syndrome/acute arterial insufficiency[9]
  • Decompression sickness[10]
  • Intracranial abscess
  • Necrotizing soft tissue infections
  • Exceptional blood loss anemia
  • Specific acute thermal burns[11]
  • Idiopathic sudden sensorineural hearing loss (urgent)

Non-Urgent Indications

  • Delayed radiation injuries for soft tissue or bony necrosis/osteoradionecrosis[12][13]
  • Chronic refractory osteomyelitis

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.

Contraindications

The one absolute contraindication to hyperbaric oxygen treatment is a patient with an untreated pneumothorax. 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:  

  • Uncontrolled hypertension (blood pressure can increase during treatment)
  • Diabetes mellitus with glucose levels greater than 300 or less than 100
  • Congestive heart failure with ejection fraction less than 35% (hyperbaric can exacerbate congestive heart failure and/or flash pulmonary edema)
  • Claustrophobia/confinement anxiety (more common in monoplace chambers, may require multiplace chamber or pharmacotherapy to tolerate treatments)
  • Congenital spherocytosis (hyperbaric oxygen can cause severe hemolysis)
  • Current upper respiratory infection  (concern for ability to equalize on the descent, or risk of reverse sinus block on the ascent, both of these situations can lead to barotrauma)
  • Fever (can lower the seizure threshold during treatment)
  • Chronic sinus condition (concern for ability to equalize on the descent, or risk of reverse sinus block on the ascent, both of these situations can lead to barotrauma)
  • Pacemaker/implantable device (possibility of malfunction under pressure, if device delivers a shock in 100% oxygen environment could ignite a fire, need to coordinate with the safety officer and call manufacturer to make sure device has been pressure tested to the treatment depth you are going to recommend)
  • Recent eye/retinal/cataract surgery or optic neuritis (buckle procedure can have air trapped, other procedures can leave bubbles inside and 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 the hypoxic drive to breathe, can screen with pulmonary function tests and xenon washout study to evaluate for risk of air trapping)
  • History of seizures (recommend that the seizures need to be controlled before initiation of treatment, monitor therapeutic levels, may require lower treatment pressures)
  • Untreated cancer (controversial topic, but there are no studies to date showing that hyperbarics promote malignant cell proliferation)
  • Contact lenses (need to be gas permeable, no hard contact lenses)

Clinical Significance

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. [14]

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.

Enhancing Healthcare Team Outcomes

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. The healthcare team including clinicians and nurses must work together to educate the patients on the risks and benefits of hyperbaric therapy, maintaining safety during treatment, and provide coordinated care.


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Hyperbaric Patient Selection - Questions

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A consult is requested to evaluate a patient in an emergency room. The patient is accompanied by his dive buddy and ship captain. His diving buddy reports they were spearfishing at 80 feet and the patient got spooked by a shark that came to investigate their catch. The buddy reports that the patient panicked and surfaced in under one minute. At the surface, the boat captain reports the patient complained of chest pain, change in sensation, coughed up blood, and then had a syncopal event once on the boat. He is now tachycardic and hypotensive. The chest x-ray is reportedly normal. Should the patient be treated with hyperbaric oxygen?



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Which of the following diabetic foot ulcer descriptions should be considered for hyperbaric oxygen therapy?



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What is an indication for hyperbaric oxygen therapy post fasciotomy?



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Which of the following conditions is an absolute contraindication to treating a patient in a hyperbaric chamber?



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Which of the following conditions causing vision loss is an indication for treatment in a hyperbaric chamber?



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Hyperbaric Patient Selection - References

References

An Update on the Appropriate Role for Hyperbaric Oxygen: Indications and Evidence., Fife CE,Eckert KA,Carter MJ,, Plastic and reconstructive surgery, 2016 Sep     [PubMed]
The use of hyperbaric oxygen therapy for carbon monoxide poisoning in Europe., Mutluoglu M,Metin S,Ibrahim Arziman,Uzun G,Yildiz S,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2016 Jan-Feb     [PubMed]
A clinical practice guideline for the use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers., Huang ET,Mansouri J,Murad MH,Joseph WS,Strauss MB,Tettelbach W,Worth ER,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2015 May-Jun     [PubMed]
Principles and practice of hyperbaric medicine: a medical practitioner's primer, part I., Perdrizet GA,, Connecticut medicine, 2014 Jun-Jul     [PubMed]
Hyperbaric oxygen treatment for air or gas embolism., Moon RE,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2014 Mar-Apr     [PubMed]
Hyperbaric oxygen treatment for decompression sickness., Moon RE,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2014 Mar-Apr     [PubMed]
Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants., Esposito M,Worthington HV,, The Cochrane database of systematic reviews, 2013 Sep 30     [PubMed]
Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns., Cianci P,Slade JB Jr,Sato RM,Faulkner J,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2013 Jan-Feb     [PubMed]
The effect of hyperbaric oxygen in the enhancement of healing in selected problem wounds., Warriner RA 3rd,Hopf HW,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2012 Sep-Oct     [PubMed]
The effect of hyperbaric oxygen on compromised grafts and flaps., Baynosa RC,Zamboni WA,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2012 Jul-Aug     [PubMed]
The effect of hyperbaric oxygen in crush injuries and skeletal muscle-compartment syndromes., Strauss MB,, Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc, 2012 Jul-Aug     [PubMed]
Hyperbaric oxygen therapy for late radiation tissue injury., Bennett MH,Feldmeier J,Hampson N,Smee R,Milross C,, The Cochrane database of systematic reviews, 2012 May 16     [PubMed]
Wound care: the role of advanced wound healing technologies., Wu SC,Marston W,Armstrong DG,, Journal of vascular surgery, 2010 Sep     [PubMed]
Howell RS,Criscitelli T,Woods JS,Gillette BM,Gorenstein S, Hyperbaric Oxygen Therapy: Indications, Contraindications, and Use at a Tertiary Care Center: 1.3 www.aornjournal.org/content/cme. AORN journal. 2018 Apr;     [PubMed]

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