Pearls in Hyperbaric Oxygen Therapy: A Challenging Case Series

Richard Simman, MD, FACS, FACCWS; Aurel Mihani, MD; Jill Michalak, DNP, APRN, NP-C, CWOCN; Marvin Heyboer III, MD


Wounds. 2022;34(9):e78-e84. 

In This Article

Abstract and Introduction


Introduction: Providers involved in treating patients who would benefit from HBOT need to be knowledgeable about the absolute and relative contraindications to HBOT.

Objective: This case series evaluates several challenging clinical scenarios in which HBOT was administered. Patients who may benefit from HBOT can present with relative contraindications, and it is the responsibility of the members of the health care team to know what additional information may be required to determine if the patient can safely undergo HBOT. However, such information is sparse in some cases.

Materials and Methods:Nine patients underwent HBOT to manage diverse presentations, some for which there was no or scant published information on the potential interaction between in situ devices and HBOT.

Results: All patients demonstrated clinical improvement, and there were no adverse events.

Conclusion: Providers may encounter uncommon or unique situations when considering whether or not to administer HBOT, and it may be necessary to consult with others (eg, experts in other specialties, device manufacturers or vendors) to provide optimal patient care.


Most of the 15 indications for the use of HBOT can be lifesaving and limb sparing.[1] Providers who assist in treating patients who would benefit from HBOT need to be knowledgeable about the absolute and relative contraindications to its use. Untreated pneumothorax is clearly an absolute contraindication to HBOT. Relative contraindications include administration of doxorubicin during HBOT, use of bleomycin within the previous 6 months, use of disulfiram, the presence of implanted devices, the presence of epidural pain pumps, pregnancy, high fever or epilepsy, inability of an individual to clear their ears, history of thoracic surgery, eustachian tube dysfunction, claustrophobia, a history of eye surgery, and upper respiratory or sinus infection.[1] Urgent and emergent circumstances in which HBOT is administered include arterial or venous gas embolus, decompression illness, acute arterial insufficiency (including central retinal arterial occlusion), gas gangrene, certain necrotizing soft tissue infections, crush injury and compartment syndrome, intracranial abscess, compromised tissue flaps and skin grafts, severe anemia, thermal burns, idiopathic sudden sensorineural hearing loss, and carbon monoxide poisoning.[2]

The 2 primary mechanisms of action of HBOT are pressure and hyperoxygenation.[3] The presence of a hyperbaric ambient pressure is in itself therapeutic in some instances, such as, gas embolus and decompression illness. In both cases, gas bubbles in blood and soft tissues contribute to the condition and the additional ambient pressure reduces the size of the bubbles, which ameliorates the condition.

Hyperoxygenation of tissues is the other primary mechanism of action in HBOT and is in itself therapeutic in several of the indications for HBOT. In severe anemia and carbon monoxide poisoning, for example, blood plasma is supersaturated with oxygen, which allows adequate oxygenation of tissues throughout the body even though the usual hemoglobin oxygen transportation system is unavailable.

However, HBOT also has several secondary effects owing to synergy between the high pressure and high oxygen content. It has an antimicrobial effect, which explains the use of HBOT in refractory osteomyelitis and necrotizing soft tissue infections. Additionally, HBOT blunts ischemia reperfusion injury, which is helpful in treating decompression illness, crush injuries, and carbon monoxide poisoning; it blunts vasoconstriction, which is directly related to edema control in several indications; and it improves wound healing via the aforementioned mechanisms as well as independent mechanisms that improve both the growth of new blood vessels from local endothelial cells, angiogenesis, and the recruitment of stem cells to form new blood vessels (ie, vasculogenesis).

Patients may have relative contraindications to HBOT, and it is the responsibility of the health care team to know what additional information is required to determine whether HBOT can be safely administered. Information on relative contraindications may be sparse, however. The cases presented herein include patients with relative contraindications who would otherwise benefit from HBOT.

Several scenarios are presented in this case series, including the use of ketamine for sedation in a patient undergoing HBOT. Other scenarios include the use of HBOT in the setting of cerebral vasoconstrictive syndrome, in a patient with an antimicrobial tracheal-esophageal device who had recently undergone thoracic surgery, in a pregnant woman with carbon monoxide poisoning, and in patients with various types of implantable devices. The purpose of this article is to educate providers on uncommon or unique situations in which HBOT may be indicated and to note the additional steps taken to manage each patient safely and successfully.