Hyperbaric oxygen therapy
- C Crawford Mechem, MD, FACEP
C Crawford Mechem, MD, FACEP
- Professor of Emergency Medicine
- Perelman School of Medicine, University of Pennsylvania
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Section Editor
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Hyperbaric oxygen (HBO) serves as primary or adjunctive therapy for a diverse range of medical conditions (table 1) [1-4]. In the United States, over 500 hyperbaric facilities offer either single occupant ("monoplace") or multiple occupant ("multiplace") chambers. Information regarding the location of hyperbaric facilities can be accessed through the Undersea & Hyperbaric Medical Society website (www.uhms.org) or via the Divers Alert Network Emergency Hotline (United States phone number: 919-684-8111; website: https://www.uhms.org/resources/chamber-directory.html).
The mechanisms of action, administration, risks, and outcomes of HBO therapy for its currently accepted indications will be reviewed here. Smoke inhalation, carbon monoxide poisoning, and diving complications are discussed separately in greater detail. (See "Carbon monoxide poisoning" and "Complications of SCUBA diving" and "Inhalation injury from heat, smoke, or chemical irritants".)
MECHANISMS OF ACTION
Most of the benefits of hyperbaric oxygen (HBO) are explained by the simple physical relationships determining gas concentration, volume, and pressure . HBO is most commonly used under conditions of tissue hypoxia or to treat decompression sickness or gas embolism, in which gas bubbles obstruct blood flow.
Increased oxygen delivery — Henry's Law states that the amount of an ideal gas dissolved in solution is directly proportional to its partial pressure. Thus, the dissolved plasma oxygen concentration of 0.3 mL/dL at sea level (1.0 atm) increases to 1.5 mL/dL upon administration of 100 percent oxygen, while hyperbaric oxygen delivered at 3.0 atm yields a dissolved oxygen content of 6 mL/dL. The latter figure is sufficient to meet resting tissue oxygen extraction requirements irrespective of the adequacy of the hemoglobin-bound oxygen pool. The ability of HBO to augment oxygen content and independently meet resting tissue oxygen requirements has led to its use in conditions of compromised oxygen delivery, such as profound anemia, carbon monoxide (CO) poisoning, and both acute and chronic ischemia [2,6-9].
Reduction of gas bubble size — The use of hyperbaric oxygen therapy for decompression illness is based upon Boyle's Law, since the volume of nitrogen bubbles is inversely related to the pressure exerted upon it. At 3.0 atm, bubble volume decreases by approximately two-thirds. Further bubble dissolution is accomplished by the replacement of inert nitrogen within the bubbles with oxygen, which is then rapidly metabolized by tissues .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Gill AL, Bell CN. Hyperbaric oxygen: its uses, mechanisms of action and outcomes. QJM 2004; 97:385.
- Leach RM, Rees PJ, Wilmshurst P. Hyperbaric oxygen therapy. BMJ 1998; 317:1140.
- Undersea & Hyperbaric Medical Society. www.uhms.org (Accessed on August 09, 2005).
- Medicare Coverage Issues Manual. Publication no. HCFA-Pub6 Transmittal 129, Department of Health and Human Services (DHHS), Health Care Financing Administration (HCFA), 2000. www.cms.hhs.gov/manuals/pm_trans/R129CIM.pdf.
- Camporesi EM, Bosco G. Mechanisms of action of hyperbaric oxygen therapy. Undersea Hyperb Med 2014; 41:247.
- Wattel F, Mathieu D, Nevière R, Bocquillon N. Acute peripheral ischaemia and compartment syndromes: a role for hyperbaric oxygenation. Anaesthesia 1998; 53 Suppl 2:63.
- Hart GB, Lennon PA, Strauss MB. Hyperbaric oxygen in exceptional blood-loss anemia. J Hyperb Med 1987; 2:205.
- McLoughlin PL, Cope TM, Harrison JC. Hyperbaric oxygen therapy in the management of severe acute anaemia in a Jehovah's witness. Anaesthesia 1999; 54:891.
- Van Meter KW. A systematic review of the application of hyperbaric oxygen in the treatment of severe anemia: an evidence-based approach. Undersea Hyperb Med 2005; 32:61.
- PACE N, STRAJMAN E, WALKER EL. Acceleration of carbon monoxide elimination in man by high pressure oxygen. Science 1950; 111:652.
- Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med 1998; 339:1603.
- Nylander G, Lewis D, Nordström H, Larsson J. Reduction of postischemic edema with hyperbaric oxygen. Plast Reconstr Surg 1985; 76:596.
- Zamboni WA, Wong HP, Stephenson LL. Effect of hyperbaric oxygen on neutrophil concentration and pulmonary sequestration in reperfusion injury. Arch Surg 1996; 131:756.
- Luongo C, Imperatore F, Cuzzocrea S, et al. Effects of hyperbaric oxygen exposure on a zymosan-induced shock model. Crit Care Med 1998; 26:1972.
- Thom SR. Hyperbaric oxygen: its mechanisms and efficacy. Plast Reconstr Surg 2011; 127 Suppl 1:131S.
- Marx RE, Ehler WJ, Tayapongsak P, Pierce LW. Relationship of oxygen dose to angiogenesis induction in irradiated tissue. Am J Surg 1990; 160:519.
- Roth RN, Weiss LD. Hyperbaric oxygen and wound healing. Clin Dermatol 1994; 12:141.
- Kaye D. Effect of hyperbaric oxygen on Clostridia in vitro and in vivo. Proc Soc Exp Biol Med 1967; 124:360.
- Hill GB, Osterhout S. Experimental effects of hyperbaric oxgen on selected clostridial species. I. In-vitro studies. J Infect Dis 1972; 125:17.
- Mader JT, Brown GL, Guckian JC, et al. A mechanism for the amelioration by hyperbaric oxygen of experimental staphylococcal osteomyelitis in rabbits. J Infect Dis 1980; 142:915.
- Moon RE, Sheffield PJ. Guidelines for treatment of decompression illness. Aviat Space Environ Med 1997; 68:234.
- Shupak A, Melamed Y, Ramon Y, et al. Helium and oxygen treatment of severe air-diving-induced neurologic decompression sickness. Arch Neurol 1997; 54:305.
- Toklu AS, Korpinar S, Erelel M, et al. Are pulmonary bleb and bullae a contraindication for hyperbaric oxygen treatment? Respir Med 2008; 102:1145.
- Torp KD, Carraway MS, Ott MC, et al. Safe administration of hyperbaric oxygen after bleomycin: a case series of 15 patients. Undersea Hyperb Med 2012; 39:873.
- Karagoz B, Suleymanoglu S, Uzun G, et al. Hyperbaric oxygen therapy does not potentiate doxorubicin-induced cardiotoxicity in rats. Basic Clin Pharmacol Toxicol 2008; 102:287.
- Bessereau J, Tabah A, Genotelle N, et al. Middle-ear barotrauma after hyperbaric oxygen therapy. Undersea Hyperb Med 2010; 37:203.
- Hadanny A, Meir O, Bechor Y, et al. Seizures during hyperbaric oxygen therapy: retrospective analysis of 62,614 treatment sessions. Undersea Hyperb Med 2016; 43:21.
- Hyperbaric Oxygen Therapy, Undersea & Hyperbaric Medical Society. http://membership.uhms.org/?page=Indications (Accessed on July 29, 2014).
- Germonpré P. Patent foramen ovale and diving. Cardiol Clin 2005; 23:97.
- Moon RE. Hyperbaric oxygen treatment for air or gas embolism. Undersea Hyperb Med 2014; 41:159.
- Leitch DR, Green RD. Pulmonary barotrauma in divers and the treatment of cerebral arterial gas embolism. Aviat Space Environ Med 1986; 57:931.
- Murphy BP, Harford FJ, Cramer FS. Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen. Ann Surg 1985; 201:242.
- Evans DE, Catron PW, McDermott JJ, et al. Effect of lidocaine after experimental cerebral ischemia induced by air embolism. J Neurosurg 1989; 70:97.
- Hallenbeck JM, Leitch DR, Dutka AJ, et al. Prostaglandin I2, indomethacin, and heparin promote postischemic neuronal recovery in dogs. Ann Neurol 1982; 12:145.
- Uhl E, Sirsjö A, Haapaniemi T, et al. Hyperbaric oxygen improves wound healing in normal and ischemic skin tissue. Plast Reconstr Surg 1994; 93:835.
- Kolski JM, Mazolewski PJ, Stephenson LL, et al. Effect of hyperbaric oxygen therapy on testicular ischemia-reperfusion injury. J Urol 1998; 160:601.
- Greensmith JE. Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg 2004; 12:376.
- Bouachour G, Cronier P, Gouello JP, et al. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial. J Trauma 1996; 41:333.
- Brannen AL, Still J, Haynes M, et al. A randomized prospective trial of hyperbaric oxygen in a referral burn center population. Am Surg 1997; 63:205.
- Villanueva E, Bennett MH, Wasiak J, Lehm JP. Hyperbaric oxygen therapy for thermal burns. Cochrane Database Syst Rev 2004; :CD004727.
- Mustoe TA, Porras-Reyes BH. Modulation of wound healing response in chronic irradiated tissues. Clin Plast Surg 1993; 20:465.
- Spiegelberg L, Djasim UM, van Neck HW, et al. Hyperbaric oxygen therapy in the management of radiation-induced injury in the head and neck region: a review of the literature. J Oral Maxillofac Surg 2010; 68:1732.
- Feldmeier JJ, Heimbach RD, Davolt DA, et al. Hyperbaric oxygen as an adjunctive treatment for delayed radiation injury of the chest wall: a retrospective review of twenty-three cases. Undersea Hyperb Med 1995; 22:383.
- Feldmeier JJ, Heimbach RD, Davolt DA, et al. Hyperbaric oxygen an adjunctive treatment for delayed radiation injuries of the abdomen and pelvis. Undersea Hyperb Med 1996; 23:205.
- Feldmeier JJ, Heimbach RD, Davolt DA, et al. Hyperbaric oxygen in the treatment of delayed radiation injuries of the extremities. Undersea Hyperb Med 2000; 27:15.
- Carl UM, Feldmeier JJ, Schmitt G, Hartmann KA. Hyperbaric oxygen therapy for late sequelae in women receiving radiation after breast-conserving surgery. Int J Radiat Oncol Biol Phys 2001; 49:1029.
- Bui QC, Lieber M, Withers HR, et al. The efficacy of hyperbaric oxygen therapy in the treatment of radiation-induced late side effects. Int J Radiat Oncol Biol Phys 2004; 60:871.
- Gothard L, Stanton A, MacLaren J, et al. Non-randomised phase II trial of hyperbaric oxygen therapy in patients with chronic arm lymphoedema and tissue fibrosis after radiotherapy for early breast cancer. Radiother Oncol 2004; 70:217.
- Denton AS, Maher EJ. Interventions for the physical aspects of sexual dysfunction in women following pelvic radiotherapy. Cochrane Database Syst Rev 2003; :CD003750.
- Feldmeier JJ, Hampson NB. A systematic review of the literature reporting the application of hyperbaric oxygen prevention and treatment of delayed radiation injuries: an evidence based approach. Undersea Hyperb Med 2002; 29:4.
- Mayer R, Klemen H, Quehenberger F, et al. Hyperbaric oxygen--an effective tool to treat radiation morbidity in prostate cancer. Radiother Oncol 2001; 61:151.
- Bennett MH, Feldmeier J, Hampson NB, et al. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev 2016; 4:CD005005.
- Wilkinson D, Doolette D. Hyperbaric oxygen treatment and survival from necrotizing soft tissue infection. Arch Surg 2004; 139:1339.
- Pizzorno R, Bonini F, Donelli A, et al. Hyperbaric oxygen therapy in the treatment of Fournier's disease in 11 male patients. J Urol 1997; 158:837.
- Hollabaugh RS Jr, Dmochowski RR, Hickerson WL, Cox CE. Fournier's gangrene: therapeutic impact of hyperbaric oxygen. Plast Reconstr Surg 1998; 101:94.
- Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest 1996; 110:219.
- Brown DR, Davis NL, Lepawsky M, et al. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg 1994; 167:485.
- Riseman JA, Zamboni WA, Curtis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990; 108:847.
- Demello FJ, Haglin JJ, Hitchcock CR. Comparative study of experimental Clostridium perfringens infection in dogs treated with antibiotics, surgery, and hyperbaric oxygen. Surgery 1973; 73:936.
- Soh CR, Pietrobon R, Freiberger JJ, et al. Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample. Intensive Care Med 2012; 38:1143.
- Mindrup SR, Kealey GP, Fallon B. Hyperbaric oxygen for the treatment of fournier's gangrene. J Urol 2005; 173:1975.
- Bentur Y, Shupak A, Ramon Y, et al. Hyperbaric oxygen therapy for cutaneous/soft-tissue zygomycosis complicating diabetes mellitus. Plast Reconstr Surg 1998; 102:822.
- Esterhai JL Jr, Pisarello J, Brighton CT, et al. Adjunctive hyperbaric oxygen therapy in the treatment of chronic refractory osteomyelitis. J Trauma 1987; 27:763.
- Sharifi M, Fares W, Abdel-Karim I, et al. Usefulness of hyperbaric oxygen therapy to inhibit restenosis after percutaneous coronary intervention for acute myocardial infarction or unstable angina pectoris. Am J Cardiol 2004; 93:1533.
- Stavitsky Y, Shandling AH, Ellestad MH, et al. Hyperbaric oxygen and thrombolysis in myocardial infarction: the 'HOT MI' randomized multicenter study. Cardiology 1998; 90:131.
- Rusyniak DE, Kirk MA, May JD, et al. Hyperbaric oxygen therapy in acute ischemic stroke: results of the Hyperbaric Oxygen in Acute Ischemic Stroke Trial Pilot Study. Stroke 2003; 34:571.
- Yildiz S, Kiralp MZ, Akin A, et al. A new treatment modality for fibromyalgia syndrome: hyperbaric oxygen therapy. J Int Med Res 2004; 32:263.
- Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database Syst Rev 2011; :CD004818.
- Cifu DX, Walker WC, West SL, et al. Hyperbaric oxygen for blast-related postconcussion syndrome: three-month outcomes. Ann Neurol 2014; 75:277.
- Boussi-Gross R, Golan H, Fishlev G, et al. Hyperbaric oxygen therapy can improve post concussion syndrome years after mild traumatic brain injury - randomized prospective trial. PLoS One 2013; 8:e79995.
- Higdon B, Youngman L, Regehr M, Chiou A. Deep Frostbite Treated With Hyperbaric Oxygen and Thrombolytic Therapies. Wounds 2015; 27:215.
- Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database Syst Rev 2015; :CD004818.
- MECHANISMS OF ACTION
- Increased oxygen delivery
- Reduction of gas bubble size
- Antagonism of carbon monoxide
- Improved wound healing
- CLINICAL USE
- Carbon monoxide or cyanide poisoning
- Decompression sickness and air embolism
- Acute traumatic or thermal injury
- Radiation injury
- Nonhealing ulcers, skin grafts, and wound healing
- Future directions
- SUMMARY AND RECOMMENDATIONS