For Physicians

Treatment Protocol

While every patient is different, the standard treatment protocol for most conditions is 30-40 sessions, 60 minutes each, 4-5 days/week. We recommend treating 5 days per week as an optimum frequency, although we have seen very good results with patients who were only able to receive treatment 3-4 times per week.

30 – 40 hours is the standard recommendation for:

  • Neural issues (dementia, Alzheimer’s Disease, TBI, stroke, transverse myelitis, Lyme disease, optic neuritis, Parkinson’s, ALS, MS, autism, cerebral palsy, post-concussion syndrome, etc.)  Some of these may require a series of 40 treatment sessions.

  • Congestive heart failure, avascular necrosis, non-healing wounds  in patients with comorbitities, treating radiation damaged tissue.

  • Chronic inflammatory and autoimmune disorders, including Crohn’s Disease, interstitial cystitis, RA, Lupus, Fibromyalgia, Chronic Fatigue Syndrome.

10-20 hours  at 60 minutes is recommended for:

  • Migraines, mild cognitive decline

  • Non-healing wounds, osteomyelitis, anti-biotic resistant infections in otherwise healthy patients

  • To improve surgical outcomes we recommend 5-10 pre-surgery, 5-10 post-op treatments, 60 minutes 4-5 days/week based on patient’s underlying health status.

In some cases fewer hours are required. This may include pre/post surgery in the otherwise healthy patient to enhance outcomes, enhancing athletic performance, and for specific musculoskeletal injuries in the athlete or otherwise healthy patient.

What are the different types of Hyperbaric Oxygen Therapy?

There are two types of Hyperbaric Oxygen Therapy;  high pressure and mild hyperbaric therapy. High pressure is generally referred to as hospital grade HBOT, or just HBOT.  Mild hyperbaric, or mHBOT, is hyperbaric oxygen administered at 1.3 absolute atmospheres. Each type of hyperbaric oxygen therapy has its advantages and disadvantages. The higher pressures are very useful in acute illnesses, and the lower pressures are safer, generally without side-effects, and better for chronic illnesses.

When considering the difference between hospital grade  at low pressures and mild HBOT for neurological disorders, the Quebec/McGill study is at the forefront of comparisons. The experiment was intended to test the use of low pressure HBOT in the treatment of cerebral palsy, with mild HBOT at 1.3 ATA serving as the placebo. What they found was that patients at 1.75 and 1.3 ATA were almost identical in improvement, and the patients at 1.3 ATA experienced better results with fewer side-effects (Stroller, 2004). One of the great advantages of mild HBOT is the low number of contraindications, risks and side effects. “This is one of the lowest risk procedures in all of medicine” says Paul Harch, MD,a leading expert in hyperbaric medicine.

Hyperbaric Oxygen Therapy; What are the Contraindications?

Hyperbaric oxygen therapy is one of the most benign medical treatments routinely carried out. It has few side effects that are generally easily dealt with during treatment.

We review the patient’s medical records and, if necessary, discuss the patient with you as part of our initial assessment prior to acceptance into the program. If you have any uncertainties concerning individual patients please contact our facility.

The information concerning absolute and relative contraindications given below has been summarized for your convenience; because we use lower pressure (1.3-1.5 ATA) and concentrated (90-95%) rather than 100% oxygen side effects are very rare, and we avoid concerns around seizures or oxygen toxicity.

Absolute Contraindications

Untreated Pneumothorax and Air Trapping Emphysema  – An untreated pneumothorax is considered the only absolute contraindication.  A chest drain should always be established before the patient enters the chamber. Treatment should be delayed in elective patients with a pre-existing pneumothorax until the latter has been resolved. The COPD patient with a large bleb represents a relative contraindication for similar reasons.

Relative Contraindications

Bleomycin – This drug is widely documented for its action against a variety of tumors. A personal communication from Dr. Eric Kindwall advises that newly emerging data suggest patients with a history of Bleomycin therapy may be treated with caution. The status of Bleo has hence been changed in the third edition of Hyperbaric Medicine Practice published in 2012.

Cis-Platin – This drug is used in a number of cancers because it disrupts DNA synthesis. It also delays fibroblast proliferation and collagen synthesis. A study to see if HBOT might mitigate this effect actually found that the breaking strength of wounds was adversely affected. (Nemiroff,1988). If wound strength is not an issue, such as in emergent carbon monoxide poisoning, then HBOT treatment may be administered based on the emergency indication.

Doxorubicin (Adriamycin®) – Cardiac toxicity may occur. While doxorubicin is probably inactivated and cleared from the tissues within 24 hours it is prudent to wait for several days before beginning hyperbaric therapy. Once the drug therapy has been halted, HBOT has been successfully used as an adjunct to help heal tissue necrosis secondary to doxorubicin extravasation (Upton et al, 1986).

Disulfiram (Antabuse®) – In “Contraindications and Side Effects to Hyperbaric Oxygen Treatment” in Hyperbaric Medicine Practice, 3rd edition, Dr. Eric Kindwall clarifies that disulferam is no longer contra-indicated. It was theorized using disulfiram in the chamber might block the production of superoxide dismutase (SOD), which is the body’s major protection against oxygen toxicity. Based on the animal data, it was thought that disulfiram might pose a risk if taken in concert with HBO therapy. This was tested by Faiman, who showed that mice could be exposed to 6 ATA, exercising for one hour, without convulsing, when pretreated with intraperitoneal disulfiram. Subsequent necropsy failed to demonstrate any CNS or pulmonary oxygen damage. This work was also repeated in beagle dogs at pressures of 4 ATA with little or no evidence of oxygen toxicity. Dosages of disulfiram given in these experiments were extremely high, corresponding to 14 grams of the drug given intraperitoneally in humans, and there have been no reports of a human having a problem with HBO while taking disulfiram. Therefore, it is no longer considered a contraindication.

Mafenide Acetate (Sulfamylon®) – This antibacterial drug was developed for topical application and is still widely used in burns patients. It is a carbon anhydrase inhibitor, which tends to cause a build-up of CO2 and consequent peripheral vasodilatation. When used with HBOT, which is a vasoconstrictor, the results are worse than with either agent alone. Mafenide cream must be carefully and thoroughly removed from the patient prior to hyperbaric treatment. Silver sulfadiazene (Silvadene®) can be safely substituted.

Conditions Formerly Contraindicated

There are a number of conditions previously listed as contraindications that current research has shown are in fact treatable. Unless new data show otherwise, the conditions listed below are no longer considered to be contraindicated.

Implanted Pacemakers – Early pacemakers had void spaces; consequently they did not tolerate pressure change well, and became unstable and unreliable. Modern devices are more pressure tolerant and many are function-tested under pressure, although the test pressures and procedures vary. The maximum pressure used in our clinical hyperbaric oxygen therapy is 1.3 ATA abs. This pressure should not compromise implanted devices.

Known Malignancies – Following thorough review of the literature Feldmeier and colleagues have reported that HBOT does not enhance tumor growth and, in some cases actually produced a reduction in growth or rates of metastases (Feldmeier et al, 1994; Feldmeier, 2001; Feldmeier et al, 2003). There had been concern that occult metastases which had outgrown their blood supply would be stimulated by the growth of new blood vessels following exposure to HBOT. As hyperbaric units began treating increasing numbers of patients with radionecrosis, some were found to have residual tumor. In these patients, it was discovered that while the radionecrotic areas improved dramatically, zones containing tumor were unchanged. Subsequent studies have shown that HBOT does not increase the rate of tumor growth (Granström et al, 1990; Marx & Johnson, 1988; Nemiroff et al, 1988; Sklizovic et al, 1993).

Pregnancy – Mild HBOT is not considered to be contraindicated. Research carried out in Russia on more than 700 women treated during all stages of gestation for hypoxemia secondary to conditions such as congenital heart defects, mitral insufficiency, habitual abortion, diabetes and toxemia; and subsequent clinical experience, has shown no maternal or fetal complications or mortality. Some babies have also been delivered in a hyperbaric chamber. (Aksenova et al, 1979; Molzhaninov et al, 1981, Pobedinsky et al, 1981, Stepanyants et al, 1981; Vanina et al, 1981; Proshina 1983). Further, it has now been established that 12 continuous hours of elevated PO2 is required to initiate closure of the patent ductus. On this basis, HBOT is no longer considered to be contraindicated in the emergent treatment of the pregnant patient (VanHoesen et al, 1989). In addition, while premature infants may still be at increased risk, treatment of full-term babies has been shown to be safe.