For years, many healthcare professionals considered hyperbaric oxygen therapy (HBOT) a treatment in search of diseases. However, in recent years, medical studies have found more than a dozen health conditions for which it is considered a valuable – and occasionally life-saving – treatment.

More than 5 million individuals in the United States have chronic, slow-healing wounds – usually the result of an underlying medical condition, such as diabetes, neuropathy, arthritis, venous insufficiency, autoimmune disease, and factors associated with immobility. For these patients, healing cuts, scratches, and sores requires specialized care.

While for years HBOT has taken a backseat to more conventional medical approaches, its stalwart presence on the fringe of accepted medicine, as well as its growing number of committed practitioners, has gradually ushered it into the spotlight as a useful therapeutic tool.

“HBOT is still fairly new in terms of medical treatment,” says Eric Shapiro, CHT, DMT, EMT, the Hyperbaric Oxygen Unit manager and safety officer at Northwest Hospital in Randallstown, Md. “Hopefully, in
the not-so-distant future, HBOT will be recognized as a primary
treatment, as opposed to a last resort therapy. While it is not a guarantee or a ‘miracle cure,’ there are just too many people who have benefited from HBOT use when all other traditional methods of treatment failed.”

Approved for Air

As with many medical interventions, Medicare guidelines determine a patient’s eligibility for hyperbaric oxygen therapy. To qualify for Medicare reimbursement for HBOT, a patient must have been treated for 30 to 45 days, with care including good debridement of the wound, nutrition control, and – in the case of diabetics –glucose control.

Despite the availability of portable or home hyperbaric oxygen units, Medicare will cover HBO therapy only when it is administered in a chamber and used to treat the following conditions:

• Acute carbon monoxide intoxication
• Decompression illness
• Gas embolism
• Gas gangrene
• Acute traumatic peripheral ischemia
• Crush injuries and suturing of severed limbs
• Progressive necrotizing infections
• Acute peripheral arterial insufficiency
• Treatment of compromised skin grafts
• Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management
• Osteoradionecrosis as an adjunct to conventional treatment
• Soft tissue radionecrosis as an adjunct to conventional treatment
• Cyanide poisoning
• Actinomycosis

“HBOT can also be put to use if a patient experiences exceptional blood loss, and ‘uncross-matched blood’ is not accessible, or the patient cannot take blood as in the case of Jehovah’s Witnesses,” says Peter Allinson, MD, medical director of hyperbaric medicine at Baltimore, Md.-based Good Samaritan Hospital. “Hyperbarics may be able to buy some time until either the patient can make enough blood cells or they can receive the necessary blood transfusion.”

He adds, “Hyperbarics is especially useful in diabetics with non-healing wounds that have persisted for more than 30 days, despite good wound care, and despite doing everything possible to improve the vascular supply to the wounds. For Medicare reimbursment of HBOT, these wounds need to be of certain severity, namely Wagner 3, in which you have some exposed bone or tendons and there is an infection present.”

While Medicare does seem to present an obstacle, or at the very least, a hindrance for practitioners to provide a helping hand to the healing process, these Medicare specifications also ensure that this costly treatment is not administered unnecessarily, as a majority of patients’ wounds will eventually heal without it.

According to Sharon Hannum, RN, program director of The Wound Healing Center at Pa.-based Bryn Mawr Hospital, Medicare continues to be a considerable barrier for HBOT applications. While the medical community in southeastern Pennsylvania has become more receptive to HBOT in the past 10 years – particularly for diabetic wound lower extremity indication – there remain certain stipulations under Medicare, which limit The Wound Healing Center’s abilities.

For example, under current specifications, the total number of treatments a patient can receive is 40, a cut-off which in turn makes it difficult to obtain an extension of HBOT for exceptional cases.

Training for Treatment

Despite the relative ease and calm that seems to surround the noninvasive practice of hyperbaric oxygen therapy, proper training and strict protocols are critical when dealing with 100-percent oxygen. In May of 2009, a Fort Lauderdale, Fla.-woman was killed and her 4-year old grandson critically injured when a hyperbaric chamber caught fire, supposedly due to modifications intended to increase the pressure and oxygen levels.

“You need to be specially trained in hyperbarics to administer the problems and also diagnose certain conditions,” says Allinson. “For example, I’m board-certified in hyperbarics. Some of our nurses are certified by the Hyperbaric Nursing National Association, but all the nurses that deal with the chamber are required to have gone through specialized training.”

As HBOT is finally breaking into accepted medicine, portable hyperbaric oxygen units are becoming more widely used, not by those with serious medical conditions, but by those who simply want to be more healthy or looking for a physical edge in competitive sports. Several of today’s athletes are utilizing a foldable, zip-up chamber and an attached generator that pumps pure oxygen into it, medical professionals not included.


“At our hospital, treating physicians, technicians, and nurses are
certified in the use of hyperbaric oxygen therapy,” says Shapiro. “HBOT physicians coordinate patient care directly with the referring physician and other specialists. Unfortunately, not all places are that offer HBOT are like this. Anyone with the money to afford a chamber can go out and buy one and start using it. To me, that is no different than playing Russian Roulette.”

He continues “There are so many safety measures that need to be put in place, not to mention the proper training to run the chambers. The bottom line is that you've only got one life, and in my opinion, if
you are going to receive HBOT treatments, make absolutely sure that
whoever is running the chamber has been both trained and passed an
approved Undersea and Hyperbaric Medical Society and/or the National Board of Diving and Hyperbaric Medical Technology 40-hour introductory course to HBOT medicine.”

The burgeoning home HBOT market has sparked interest not only among athletes, but also among homebound individuals with medical conditions who purchase these systems without a full understanding of the possible dangers, or whether or not they actually attain the pressure levels necessary for effective treatments.

“Unless you are receiving 100-percent oxygen under atmospheric pressure, you are not receiving true HBOT,” says Shapiro. “Patients should make sure that whoever is administering it is trained properly, has all the safety requirements set in place, and that their chambers are from legitimate companies.”

High-Pressure Risks

While HBOT does provide a medically approved intervention for various conditions, there remains a viable risk when working in a high-pressure, oxygenated environment. In an effort to reduce the risk of combustion in hyperbaric conditions, patients are often asked to remove any device that may produce a spark.

Likewise, make-up, hairspray, perfume, Vaseline, and other petroleum-based products are banned inside many of these hyperbaric chambers. Some patients are even advised to avoid applying lotions – many of which have a petroleum base – to the skin on the day of the procedure.

“We do extensive chamber safety training with patients,” says Hannum. “They sign off on a safety check list as part of their education. There are reminder safety signs in the dressing rooms that the patients read after changing and before every treatment. The hyperbarist, before putting the patient in the chamber, extensively reviews with the patient the contraband that they are not to bring into the chamber. Safety in the hyperbaric area is an integral part of the hyperbaric program.”

At the start of the treatment, as pressure builds, it is common for patients to feel pressure in their ears. Usually, by the end of the treatment, as the pressure is released, the ears “pop” automatically.

“Most people are probably familiar with this problem, called barotrauma,” says Hannum. “It occurs naturally during activities such as flying or driving in the mountains. You can usually take care of it yourself by yawning or chewing gum, which forces your ears to ‘pop’ and equalize the pressure. During hyperbaric oxygen therapy, the discomfort may be more severe and lead to pain.”

Also, as a result of high pressure inside the hyperbaric chamber, patients are susceptible to damage of the middle and inner ear, nasal sinuses, lungs, and teeth. Also, some medical professionals believe HBOT may affect the eyes as well, as patients become increasingly myopic during treatments, but this condition gradually reverses itself when treatments end.

“There is also some risk of oxygen toxicity,” says Allinson. “Oxygen is a drug, and at higher pressures, it can excite the brain to the point you could get a grand mal seizure. We do take some several precautions to prevent this, and therefore, we rarely see it occur. The likelihood of occurrence is about 1 in 20,000 patients, which translates to an episode every three to four years.”

As medical professionals and hyperbaric practitioners continue to push the envelope in hyperbaric oxygen therapy, many new conditions are being considered for usage, including neurological issues in both adult and pediatric patients, the multi-faceted pediatric autism spectrum, increasing a tumor’s sensitivity to radiation treatments, and other currently non-reimbursed indications.

However, until clinical studies confirm the long-term effectiveness and improved quality of life following oxygen treatments for these conditions, for many of today’s medical professionals, HBOT will continue to flounder on the controversial border between accepted and placebo medicine.

– Bob Stott is the senior editor for Therapy Times. Questions and comments can be directed to bstott@therapytimes.com.