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Safety/Technical

Questions pertaining to safety and technical information. Open to the public.

Regarding the Hyperbaric Safety Director for a hospital based hyperbaric department (monoplace chambers)
Published: 04 May 2016

Regarding the Hyperbaric Safety Director for a hospital based hyperbaric department (monoplace chambers)

Published Date:   5/2016
Review Date:       5/2019
Due Review:        5/2022


Thank you for your question. The UHMS hyperbaric oxygen safety committee (SC) can provide information but the ultimate responsibility for these types of questions is with the medical director and safety director of your facility.

Question; Regarding the Hyperbaric Safety Director for a hospital based hyperbaric department (monoplace chambers):

  1. Does NFPA 99 require the Hyperbaric Safety Director to be on premise when chambers are operating?
  2. Is it ok for them to be available by phone?
  3. If someone is covering for the Hyperbaric Safety Director when they’re unavailable, i.e. on vacation:
    • Does the covering person need to have Hyperbaric Safety Director Training?
    • Would the Hospital Safety Director (not involved in daily hyperbaric operations) be an approved choice?

Regarding: Hyperbaric Safety Director (HSD) requirement to be on premises when chambers are operating.

It is the responsibility of the administration, medical director and safety director to compile a policy and procedures for the type of chambers, acuity of patients and qualifications of staff.

  1. Language requiring an individual with the responsibilities of hyperbaric safety director (HSD) has been in NFPA 99 since 1970 (56D). NFPA 99, 14.3.1.3.2 requires that each facility designate an on-site hyperbaric safety director (HSD). We are not aware of any requirement in NFPA 99 that specifies that the hyperbaric safety director be on the premises when chambers are in operation

    There is further information on this topic in the annex of NFPA 99 A14.3.1.3.2. The complexity of hyperbaric medicine is such that one person should be designated as the chamber operator. That person should be knowledgeable and have the training and experience to recognize hazards. 

    NFPA 99, 14.3.1.4.8 requires that a chamber operator be physically present and maintain visual and audible contact with the control panel or chamber occupant(s) during hyperbaric oxygen therapy.

    The UHMS facility accreditation probe HBOHR 2.2 looks for a Certified Hyperbaric Nurse or CHT on premises when chamber operations are going on.

  2. It is acceptable for the HSD to be available by phone, and in our experience, this position is most often available 24/7 for calls regarding the hyperbaric facility.

  3. If the HSD is not available, on vacation or other, there needs to be an alternate HSD named to be responsible. It is good practice to bring staffing “up” in the department and have a succession plan in place.
    • The individual covering for the HSD should have attended a hyperbaric safety director course, have knowledge and experience in hyperbaric medicine and with the equipment used at the facility. This could be the lead chamber operator with the most experience, for example.
    • Unless the hospital safety director has knowledge and experience with hyperbaric medicine and has attended a hyperbaric safety director course, we would not encourage using this resource to cover the HSD absence. We would encourage working closely with the hospital safety director so that individual has some knowledge of our unique practice.

For references see:

MEDFAQ July 07, 2015 regarding safety director training

NFPA 99, 2018 edition, chapter 14 Hyperbaric Facilities

UHMS Guidelines for Hyperbaric Facility Operations, 2nd edition

UHMS Clinical Hyperbaric Facility Accreditation Manual (Rev1)


DISCLAIMER
Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

I have a medicine/safety question. A referral came to our off campus monoplace hospital owned wound care and hyperbaric center with a diagnosis of pyoderma for 20 HBO2 treatments. Aetna has already approved this treatment. They placed a VAC on her perianal deep wound and...
Published: 31 August 2017

I have a medicine/safety question. A referral came to our off campus monoplace hospital owned wound care and hyperbaric center with a diagnosis of pyoderma for 20 HBO2 treatments. Aetna has already approved this treatment. They placed a VAC on her perianal deep wound and...

I have a medicine/safety question. A referral came to our off campus monoplace hospital owned wound care and hyperbaric center with a diagnosis of pyoderma for 20 HBO2 treatments. Aetna has already approved this treatment. They placed a VAC on her perianal deep wound and they have to give her propofol to place the VAC on her. We cannot change or apply the VAC under those conditions here at the center, so the patient will go to the GI office and have the VAC changed twice a week after her HBO2 treatment on Monday and Thursday. Is there any increased danger of toxicity or seizures with this patient with this regime and the consistent use of propofol twice a week for VAC placement?


 There is no safety issue here. We have used such a regimen routinely in some of our hyperbaric patients with large wounds. The effects of low dose propofol disappear after a few minutes.

What types of pillows can be used in the Monoplace chamber? Can we utilize reusable pillows?
Published: 01 March 2019

What types of pillows can be used in the Monoplace chamber? Can we utilize reusable pillows?

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

Regarding pillows approved for use in Monoplace chambers: One should be careful not to allow just any pillow into the monoplace chamber. The National Fire Protection Association (NFPA) 99, “Health Care Facilities Code,” 2018 edition contains a section regarding textiles (14.3.1.6.4) that provides guidance on the decision process for textiles, garments and wound care products.

We suggest that a proper risk assessment be initiated by the Safety Director of the hyperbaric program. The risk assessment found in section A14.3.1.6.4.3 is written for hyperbaric wound dressings, but the process is useful for other items as well. The Safety Director should consider using this risk assessment when making decisions about pillows to be used in the hyperbaric environment. Furthermore, section 14.3.1.6.4.4 calls for written approval by the Safety Director and Medical Director for prohibitive items to be allowed. The Safety Committee suggests that this code applies to the acceptance or disapproval of pillows.

You may wish to review these safety factors that may impact your decision:

  • The increased oxygen atmosphere in the chamber and the need to limit combustibles
  • Silk, wool and synthetic textiles are prohibited, unless approved by the medical director and safety director and based on sound and safe reasoning
  • Static producing materials should be avoided
  • Closed cell materials, such as some synthetics may retain oxygen after decompression, presenting an additional risk once the treatment has been concluded.
  • Infection prevention: Non-synthetic cotton or down pillows are relatively safe to be used in some chambers but are challenging when it comes to disinfection. Wipe-able covers are available and may need to be considered for those types of pillows.
  • The pillows need to be able to vent with the change of pressure in the chamber to avoid the pillow expanding on decompression.

It may be beneficial to inquire of your chamber manufacturer when seeking options for pillows. The UHMS website below contains links to many chamber vendors that may offer pillows. However, the Hyperbaric Oxygen Safety Committee suggests that your own risk assessment be performed regardless of the pillow manufacturer.

https://www.uhms.org/resources/links/11-chamber-equipment-manufacturers.html

Please let us know if we can provide any additional guidance or information.

Respectfully,

The UHMS Safety Committee

 

DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

We recently stated using maggots in wound care. Have you guys used these? I looked into the product and I wondered your thoughts of the Dacron screen that holds them in place? We do not currently have any HBO patients using this therapy but trying to get prepared if it comes up.
Published: 25 March 2019

We recently stated using maggots in wound care. Have you guys used these? I looked into the product and I wondered your thoughts of the Dacron screen that holds them in place? We do not currently have any HBO patients using this therapy but trying to get prepared if it comes up.

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

The UHMS HBO2 Safety Committee is well aware that maggot therapy is a viable and common practice in wound care. We have evaluated the Dacron screen utilized for this therapy and can find no evidence that this item poses a significant risk in the hyperbaric environment. We must reiterate that the decision to allow foreign materials into the chamber rests upon the safety director and medical director of your facility.

It was observed by members of our committee that several articles regarding maggot therapy are available for your review and may contribute to the decision-making process for your facility.

https://www.ncbi.nlm.nih.gov/m/pubmed/24224280/

http://dx.doi.org/10.1155/2014/592419

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3233395/

Respectfully,

The UHMS Safety Committee

 

DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

Is it safe to treat a patient in hyperbaric oxygen therapy when they have an indwelling peritoneal dialysis catheter that has a minicap that has a iodine impregnated sponge and titanium adapter? The minicap is not able to be substituted at all per manufacturer guidelines.
Published: 23 April 2019

Is it safe to treat a patient in hyperbaric oxygen therapy when they have an indwelling peritoneal dialysis catheter that has a minicap that has a iodine impregnated sponge and titanium adapter? The minicap is not able to be substituted at all per manufacturer guidelines.

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

The iodine within the minicap of this type of catheter does not pose an increased risk of fire. Since no flammable materials are otherwise identified, the remaining concern is the titanium adapter. For more information regarding this material, please refer to previously answered questions regarding titanium and peritoneal dialysis catheters.

Respectfully,

The UHMS Safety Committee

REFERENCES:

Material Safety Data Sheet – Iodine (Ratings listed are for the 1ATA environment)

http://dept.harpercollege.edu/chemistry/msds/Iodine%20Fisher.pdf  

________________________________________

MEDFAQ Published: 03 May 2016

Can patients be safely treated with an existing peritoneal dialysis catheter? Are there any precautions that need to be taken prior to therapy?

https://www.uhms.org/resources/medfaqs-frequently-asked-questions-faq/53-safety-technical.html

________________________________________

MEDFAQ Published: 20 June 2016

Can safety committee provide and update on titanium in HBO. Dr. Weaver answered a question about this at the Winter Symposium in SLC.

https://www.uhms.org/resources/medfaqs-frequently-asked-questions-faq/53-safety-technical.html

 


DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

One of our researchers has a hyperbaric oxygen chamber. We had a question about appropriate paint to use for a HBO chamber. I am having a hard time finding information on where to find paint that is high oxygen rated. Can you help point me in the right direction?
Published: 15 July 2019

One of our researchers has a hyperbaric oxygen chamber. We had a question about appropriate paint to use for a HBO chamber. I am having a hard time finding information on where to find paint that is high oxygen rated. Can you help point me in the right direction?

Date:  7/15/2019

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility. If you are a safety officer responsible for this chamber and you have not attended a Hyperbaric Safety Director’s course as described by the National Board of Diving and Hyperbaric Medical Technology (NBDHMT.org), this committee would highly recommend it.

The UHMS Safety Committee cannot specify a specific brand, product, or chemical makeup for paint that would be suitable for a 100% oxygen environment. The action of painting a hyperbaric chamber is not something that should be taken lightly, as mishaps have been recorded in the literature (ref. 1), and failure to address fire safety concerns could result in unsafe conditions. This committee would strongly suggest that you reach out to your chamber manufacturer for further guidance. You should consider the design life of the particular chamber and consider all of the risks prior to an undertaking of this nature. There is guidance from the Department of Defense related to air-filled chambers that may be considered as a reference point, but these documents do not address 100% oxygen environments. (ref. 2, 3)

In general terms, chamber manufacturers will consider a number of safety factors when choosing paint for air-filled chambers, to include:

  • Is the paint low-VOC?
  • Are there residual flammable vapors that haven’t off-gassed?
  • Is it water-based (where fire is concerned)?
  • Is this product eco-friendly or non-toxic?
  • Is the product corrosion-inhibiting?
  • Is there as unpleasant or residual smell?

The safety of this process should be carefully respected and thoroughly planned, ensuring that:

  • The safety of this process should be carefully respected and thoroughly planned, ensuring that:

    • All of the manufacturer’s application instructions are followed
    • Staff applying paint are safe and the area is well ventilated
    • The location of the chamber is suitable to paint on site – If not, consider moving the chamber to a commercial site
    • The paint has had enough time to off-gas potentially harmful vapors. To validate this, it may be necessary to follow the application with high precision gas analysis and contamination scrubbing before the chamber can be used. Follow the chamber manufacturer’s guidance and study the data provided from the product’s SDS. (ref. 2, 3).

    Additionally, we encourage you to reference the following codes and standards for further guidance:

    • Section 14.2.2.5 through 14.2.2.5.3, National Fire Protection Agency (NFPA). (2018). NFPA 99 2018 Edition: Health Care Facilities Code. Quincy, Massachusetts.
    • Fire Hazard Classification, ASTM E-84 (NFPA 255), Class “A” (Class A (or 1) is the lowest flame spread rate)
    • ASTM E-84 (UL 723) provides flame spread ratings/classes: "Test for Surface Burning Characteristics of Building Materials."
    • NFPA 255 (describes the test to provide a comparative measurement of surface flame spread and smoke development of materials under specific fire exposure conditions).
    • “U.S. NAVY GENERAL SPECIFICATION FOR THE DESIGN, CONSTRUCTION, AND REPAIR OF DIVING AND HYPERBARIC EQUIPMENT,” Revision 1, August 23, 2006 https://www.navsea.navy.mil/Portals/103/Documents/SUPSALV/Diving/General%20Specifications%20Hyperbaric%20Equip.pdf?ver=2016-02-10-114010-800
    • U.S. ARMY CORPS OF ENGINEERS, NAVAL FACILITIES ENGINEERING COMMAND (Preparing Activity), AIR FORCE CIVIL ENGINEERING SUPPORT AGENCY, “UNIFIED FACILITIES CRITERIA (UFC), UFC 4-159-01N, DESIGN: HYPERBARIC FACILITIES,” 16 January 2004 https://www.wbdg.org/ffc/dod/unified-facilities-criteria-ufc/ufc-4-159-01n

    Citations:

    Respectfully,

    The UHMS Safety Committee


DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

 

“Are diapers with synthetic material (infant and adult) allowed in the Monoplace hyperbaric chamber, pressurized with 100% oxygen?”
Published: 13 August 2019

“Are diapers with synthetic material (infant and adult) allowed in the Monoplace hyperbaric chamber, pressurized with 100% oxygen?”

Thank you for your question. The UHMS HBO safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the Medical Director and Hyperbaric Safety Director of your facility.

The UHMS Hyperbaric Safety Committee understands the advantage that absorbent diapers offer to the patient and the caregiver. Regarding the allowance of synthetic materials in Class A or Class B chambers, one must weigh the risks carefully and consider any opportunity for risk mitigation. For guidance concerning risk assessment and mitigation, we refer you to the National Fire Protection Association® (NFPA) 99, Health Care Facilities Code, 2018 Edition, which contains a section regarding textiles (14.3.1.6.4) offering guidance on the decision process for textiles, garments and wound care products.

We suggest that you know the types of materials commonly used to manufacture these products and their potential flammability. Typically, disposable diapers contain several layers of material Consisting of::

  • The inner layer or top sheet rests against the skin of the wearer and can be made from polypropylene material. Some top sheets include a skin-care lotion, which can protect the skin from overhydration and reduce irritation.
  • The absorbent core layer is designed to hold fluids. To enhance absorbency, most disposable diapers include a matrix of fluff material and a chemical compound known as Super Absorbent Polymer (SAP) that holds up to three hundred times its weight. This material forms into a gel as it absorbs fluids, and is known by other names, including hydrogel, sodium polyacrylate, polyacrylate absorbents, or Absorbent Gel Material (AGM).
  • The fluff in the absorbent core is usually made from wood pulp and may include wheat/corn-based materials. It is designed to distribute fluid across the diaper surface, while the SAP is intended to absorb and lock liquids in its core.
  • The waterproof outer shell is most often a petroleum-based plastic or polyethylene-treated material.
  • Bands made of elastic Lycra® or spandex to keep the diaper close to the wearer.
  • Non-woven refastening tape which holds the diaper in place and allows for adjustment.

We suggest the Hyperbaric Safety Director initiate a risk assessment. The risk assessment found in section A.14.3.1.6.4.3 is written for hyperbaric wound dressings, but the process is useful for other items as well. The Hyperbaric Safety Director should consider using this risk assessment when deciding which materials may be allowed in the hyperbaric environment. Furthermore, section 14.3.1.6.4.4 calls for written approval by the (Hyperbaric) Safety Director and Medical Director for prohibitive items to be allowed. The Safety Committee suggests that this code applies to the acceptance or disapproval of diapers.

You may wish to review these safety factors that  impact your decision:

Material Considerations

  • The increased oxygen atmosphere in the chamber and the need to limit combustibles
  • Silk, wool and synthetic textiles are prohibited unless approved by the Medical Director and (Hyperbaric) Safety Director based on sound and safe reasoning
  • Avoid static producing materials
  • Closed-cell materials, such as some synthetics may retain oxygen after decompression, presenting an additional risk once the treatment has been concluded. Patients must avoid contact with any naked flames for approximately 30 minutes after therapy.
  • Although most codes regarding textiles are not written for 100% oxygen environments, garments are required to comply with UL requirements and A Guide to the Undited States Apparel and Household Textiles Compliance Requirements; NISTIR 8115, https://nvipubs.nist.gov
  • The Safety Committee is aware of practices that have utilized cotton towels to fashion a cloth diaper as well.

Static Considerations

  • Confirmation of the continuity of ground between the patient and the chamber before each therapy.
  • Consider placing a damp cotton towel over the garment to lessen static capacity.

References

https://www.babygearlab.com/expert-advice/what-is-inside-those-disposable-diapers

https://tapes.averydennison.com/en/home/solutions/personal-care/baby-diaper.html

https://nvlpubs.nist.gov/nistpubs/ir/2016/NIST.IR.8115.pdf

Please let us know if we can provide any additional guidance or information.

Respectfully,

The UHMS Safety Committee


 

DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

What is the proper management of gastric tubes in the Monoplace HBO chamber?
Published: 21 September 2019

What is the proper management of gastric tubes in the Monoplace HBO chamber?

Date posted:  9/21/2019


Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

For the Monoplace environment, it is reasoned that Gastrostomy tubes (commonly known as G-Tubes) may remain either closed or open during therapy and throughout pressure changes. Your facility’s Hyperbaric Medical Director should make the determination based upon the needs of your program. Here are several considerations that may aid you in determining the best approach for your facility:

  • It is recommended that the disposition of the tube remain static (open or closed) throughout therapy to reduce the potential for air trapping and rapid release of air and fluid (Boyle’s Law).
  • Open G-tube ends may be wrapped with sterile gauze to contain any potential drainage.
  • Closed G-tube ends may also be wrapped, in the event of accidental opening.
  • Closed G-tube ends may reduce the amount of drainage, but require an additional step to complete before and after therapy. You may wish to adjust your pre/post therapy checklists accordingly.
  • After therapy, you may wish to check the tube for patency and proper function prior to departure.

Respectfully,

The UHMS Safety Committee


 DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

Is there any literature or consensus about treating patients less than 5 days a week on a regular basis? We have a patient who can only come 3 days a week due to his work. Is it only the total number of treatments received that matters or does the time frame in which it is received also important? (not referring to Marx protocol patients).
Published: 21 September 2019

Is there any literature or consensus about treating patients less than 5 days a week on a regular basis? We have a patient who can only come 3 days a week due to his work. Is it only the total number of treatments received that matters or does the time frame in which it is received also important? (not referring to Marx protocol patients).

Date posted: 9/21/2019


Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

There is significant interest in this question throughout the hyperbaric community as there are a number of occasions where circumstances often prohibit consecutive hyperbaric therapy. The committee refers you to resources such as Pubmed and the Rubicon Foundation. A literature search has revealed the following result:

Rate of delivery of hyperbaric oxygen treatments does not affect response in soft tissue radionecrosis.

Given that this study represented a response rate in soft tissue radionecrosis only, the committee does not propose that this logic be applied universally to all other indications for hyperbaric oxygen therapy.

Respectfully,

The UHMS Safety Committee


 DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

In the Monoplace chamber, is it always proper to turn off oxygen supply if there is a fire in the chamber? It is very logical to cut off O2 which is fueling fire, however at another class we were told never to turn off O2 because you then lose control of chamber. Which is correct?
Published: 21 September 2019

In the Monoplace chamber, is it always proper to turn off oxygen supply if there is a fire in the chamber? It is very logical to cut off O2 which is fueling fire, however at another class we were told never to turn off O2 because you then lose control of chamber. Which is correct?

Posted: 9/21/2019


 

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

It is well known that the reduction of pressure is proven to decrease the rate and intensity of an oxygen-enriched fire. It is this committee’s opinion that in the event of a fire in the Monoplace chamber, maximum decompression should not be delayed as the heat of combustion will significantly contribute to increasing pressure in the chamber. As such, rapid evacuation of the patients and staff in the immediate and surrounding areas is critical.

Additionally, it is imperative that each hyperbaric facility contact their chamber manufacturer to understand the behavior of their emergency ventilation controls associated with their particular chamber model and system design. When describing the system to the manufacturer, consider any potential system modifications that may have occurred since installation.

You may also consider:

  • A test of your system with and without gas supply during decompression to understand how the system behaves. Consider the time required to decompress and the impact on facility evacuation and perform fire drills with each of these scenarios in mind.
  • Develop your emergency procedures to reflect the behavior of your particular system. NFPA 99, Annex B.14.3.2 contains guidance in drafting the emergency procedures for fire in a Class B chamber.
  • It is also important to perform a timed test of the emergency ventilation function periodically per the manufacturer’s maintenance recommendations.
  • Once all chambers have been decompressed, it is common for emergency procedures to include the shutdown of oxygen supply at the zone valves prior to evacuation or relocation.

Lastly, the Safety Committee has reached out to two Monoplace chamber manufacturers to address this question. Each of them confirmed that the emergency ventilation function installed on their chambers require a gas supply in order to operate normally. These manufacturers also stated that when the emergency ventilation function is activated, the inflow of oxygen to the chamber ceases.  The gas supplying the actuating valves that keep the exhaust valve open will remain, so that the chamber can fully decompress. Again, it is important to confirm and test the function of your particular chamber, as there are many variations of this design. Your understanding of this design will lead to a procedure that will dictate a series of life saving events. Therefore, this question is one that should be asked and answered by every Hyperbaric Safety Director and Medical Director.

Respectfully,

The UHMS Safety Committee


 DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

I would like to ask you regarding one of our patient’s device (Ahmed glaucoma valve implant/ glaucoma drainage implant). Is he allowed to enter the hyperbaric chamber with this device without any concern?
Published: 05 February 2020

I would like to ask you regarding one of our patient’s device (Ahmed glaucoma valve implant/ glaucoma drainage implant). Is he allowed to enter the hyperbaric chamber with this device without any concern?

Posted Date:       2/5/2020


MEDFAQ Question: I would like to ask you regarding one of our patient’s device (Ahmed glaucoma valve implant/ glaucoma drainage implant). Is he allowed to enter the hyperbaric chamber with this device without any concern?

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

The safety committee understands this item to be surgically attached to the sclera of the eye and free of air. Therefore it is reasonable to consider that pressure would have no effect on the functionality of the device. However, we strongly suggest that a risk assessment be performed by the hyperbaric physician aided by the patient’s ophthalmologist, as there may be the potential for intraocular changes during and after hyperbaric oxygen therapy.

Literature review reveals a handful of studies and commentary on the application of hyperbaric oxygen therapy, intraocular pressure, and glaucoma-related procedures, but there are no known studies specifically related to the Ahmed valve and hyperbaric oxygen therapy.

The following references may assist you in completing the risk assessment and determining the proper course of action for your particular case. Again, we strongly suggest consulting the patient’s ophthalmologist prior to the decision to proceed with hyperbaric oxygen therapy:

Ersanli D, Akin T, “The effect of hyperbaric oxygen on intraocular pressure,”  Vol 33: Journal of the Undersea and Hyperbaric Medical Society, 2006

McMonnies CW, “Hyperbaric oxygen therapy and the possibility of ocular complications or contraindications” Journal of clinical and experimental optometry, 2015, Volume 98, Issue 2, Pages 122-125

Official site: “Ahmed Glaucoma Valve,” New World Medical, 2020

Animation: “How does the Ahmed Valve Work,” New World Medical, 2014

Animation: “(Surgical Placement of the) Ahmed Valve model PC7,” New World Medical, 2010

Respectfully,

The UHMS Safety Committee


DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.




We would like to start treatment in the monoplace chamber for a patient that currently has a Denali Vena Cava Filter in place. Called manufacturer, no hyperbaric testing has been done for this device. Does anyone have experience with these devices or know of any contraindications?
Published: 05 February 2020

We would like to start treatment in the monoplace chamber for a patient that currently has a Denali Vena Cava Filter in place. Called manufacturer, no hyperbaric testing has been done for this device. Does anyone have experience with these devices or know of any contraindications?

Posted Date:       2/5/2020


MEDFAQ Question: We would like to start treatment in the monoplace chamber for a patient that currently has a Denali Vena Cava Filter in place. Called manufacturer, no hyperbaric testing has been done for this device. Does anyone have experience with these devices or know of any contraindications?

Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

Several members of the committee have expressed no concerns allowing this type of device. This is mainly due to the fact that the item is solid and contains no air-filled spaces. The UHMS Safety Committee considers this device to be compatible in either the Monoplace or Multiplace hyperbaric environment.

Respectfully,

The UHMS Safety Committee

 


 DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

Could any of you experts discuss the effects (if any) of implanted/impregnated radiation seeds/beads radiation emission in a hyperbaric patient being treated and the possible adverse effects on the chamber acrylic windows. Thank you.
Published: 06 February 2020

Could any of you experts discuss the effects (if any) of implanted/impregnated radiation seeds/beads radiation emission in a hyperbaric patient being treated and the possible adverse effects on the chamber acrylic windows. Thank you.

Date Posted:       2/28/2020


MEDFAQ Question: Could any of you experts discuss the effects (if any) of implanted/impregnated radiation seeds/beads radiation emission in a hyperbaric patient being treated and the possible adverse effects on the chamber acrylic windows.


Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

For the sake of clarity, there are two main sources of therapeutic radiation emission that have potential reference here: external beam and brachytherapy.

It is well known that external beam radiation, used for treatments commencing around the 1960’s, had a detrimental effect on acrylic windows, shortening the life span to approximately 3 years (1).

The PVHO limits(2) of radiation exposure to acrylics and described in acrylic testing (1) refer to external beam radiation, which  are exponentially higher than levels seen in brachytherapy.

  • PVHO-1, 2-1.2 Exclusions (f) The exposure to nuclear radiation shall not exceed 4 Mrad.
    • 4 Mrad = 40 kGy (kiloGray)

Brachytherapy is given in two different forms, namely high dose-rate (HDR) and low dose-rate (LDR) brachytherapy.

  • The isotopes used in HDR brachytherapy emit radiation at greater than 12 Gy/hour. This is provided by the insertion of a higher energy isotope into the body in order to provide an intense dose to the tumour or affected area. The isotope is then removed after a short-term exposure (usually about 20 minutes). This form of radiation therapy would not be done inside a chamber. However, it would be safe to treat such a patient in a hyperbaric immediately after each dose.
  • LDR brachytherapy is achieved by inserting or locating isotopes into the tumour or affect area in the form of seeds or beads. There can be up to 100 seeds implanted at a time. These seeds then emit radiation continuously to achieve the required dose. These isotopes are selected based on their emission energy and half-life. It is important to account for this as the radiation intensity is highest right after being inserted, then decays until the half-life has been reached, where-after the intensity falls to below any levels of concern.
  • In order to determine whether an acrylic window could be damaged by the emission of the gamma rays, the dose rate – indicated as Grays (Gy) per unit time, treatment time and number of treatments given in a specific chamber need to be considered. This would enable a computation to be done to determine the likely absorbed dose by the acrylic window.
  • In the case of LDR brachytherapy, the radiation emitted by the isotopes is conservatively quantified as safe to other humans at distance of less than one foot.
  • At this distance, depending on the typical isotopes in use, the total absorbed radiation by any acrylic window, located one foot from the actual isotope and assumed to be given continuously for a full 8-hour day, for every day of the year, would require between 40 and 150 years to achieve the PVHO limit of 4 Mrad. Well beyond any envisaged service life of an acrylic window.

Although considered safe for acrylic windows, any user should always record all events where such patients are treated, together with information from the radiation oncology department as to the isotopes in use and their maximum dose rate, and the total treatment time. This will enable any future decisions on service life to be more accurately determined based on actual, estimated absorbed radiation.

References:

  • Stachiw JD, “Handbook of Acrylics for Submersibles, Hyperbaric Chambers and Aquaria," Best Publishing, 2003
  • American Society of Mechanical Engineers, “Safety Standard for Pressure Vessels for Human Occupancy. ANSI/ASME PVHO-1, 2-1.2 Exclusions,” 2019

Respectfully,

The UHMS Safety Committee


 DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

It seems that COVID-19 has now reached the shores of Europe in full swing and although the UK has left Europe, Europeans are still plentiful in the UK and UK travellers and visitors are exposed to this new virus. What PPE has been tested to be safe under pressure? What cleaning products would be recommended after treating an infected patient? .
Published: 25 February 2020

It seems that COVID-19 has now reached the shores of Europe in full swing and although the UK has left Europe, Europeans are still plentiful in the UK and UK travellers and visitors are exposed to this new virus. What PPE has been tested to be safe under pressure? What cleaning products would be recommended after treating an infected patient? .

Date Posted: 3/17/2020


 

Thank you for your question. The UHMS HBO2 safety committee (UHMS-SC)  can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the Medical Director and Hyperbaric Safety Director (MD & HSD) of your facility.

The UHMS-SC directs all hyperbaric practices to follow the guidance of the Centers for Disease Control (CDC) along with guidance from the Hyperbaric Chamber Manufacturer, State and local health agencies, and your hospital infection prevention and control group. All of these sources will impact the decision for your practice. Your choice should be a decision made between the MD & HSD of your program. The UHMS-SC can provide guidance based upon existing literature available to the public, but does not endorse a particular product or procedure.

The CDC has released a list of items as identified by the Environmental Protection Agency (EPA) that can be utilized for disinfection, stating that:

“Products with EPA-approved emerging viral pathogens are expected to be effective against COVID-19 based on data for harder to kill viruses. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.).”

It is important to note that many of the items within the EPA’s list may be unsafe to utilize on acrylic surfaces. It is important to reach out to your specific chamber manufacturer for further guidance. In all cases, it is important to follow the guidance of the product’s manufacturer for application and contact time.

For non-acrylic surfaces, The UHMS-SC advises you follow the guidance of your hospital’s infection prevention and control department to identify a particular product that is known to be effective against COVID-19.

Regarding protocols for cleaning chamber surfaces, hyperbaric facilities should follow the protocols set forth by their institution. Dr. Jim Chimiak, Medical Director at the Divers Alert Network states: “There are no special recommendations that we are aware of for chamber attendants or for disinfection of the hyperbaric chamber and BIBs in light of the COVID-19 pandemic. The usual disinfection protocols are more than sufficient to kill COVID-19, in the unlikely event that it would be present.”

References:

EPA.gov, “List N: Disinfectants for Use Against SARS-CoV-2,” Accessed 3/17/2020

https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

Sechrist Industries, “CARE AND DISINFECTION OF THE CHAMBER AND GURNEY,” Accessed 3/17/2020

https://sechristusa.com/wp-content/uploads/2018/09/Approved-Chamber-Disinfectants.pdf

Perry Baromedical, “PERRY GUIDANCE ON COVID-19,” Accessed 3/17/2020

https://perrybaromedical.com/uncategorized/perry-guidance-on-covid-19/

Divers Alert network, “DAN ENCOURAGES DIVERS AND DIVE OPERATORS TO PROPERLY DISINFECT DIVE GEAR,” Accessed 3/17/2020

https://www.diversalertnetwork.org/news/dan-encourages-divers-and-dive-operators-to-properly-disinfect-dive-gear

Respectfully,

The UHMS Safety Committee


 DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

Lung damage and ARDS in COVID 19 infection has implicated immune modulation as a possible treatment. IL-6 inhibitors are now in trials. From Medscape article: "Interleukin-6 (IL-6) inhibitors may ameliorate severe damage to lung tissue caused by cytokine release in patients with serious COVID-19 infections. This treatment doesn't necessarily alter the course of viral infection but would mitigate long term lung damage to those severely affected by COVID. So HBO doesn't impact IL-6 per se but
Published: 23 March 2020

Lung damage and ARDS in COVID 19 infection has implicated immune modulation as a possible treatment. IL-6 inhibitors are now in trials. From Medscape article: "Interleukin-6 (IL-6) inhibitors may ameliorate severe damage to lung tissue caused by cytokine release in patients with serious COVID-19 infections. This treatment doesn't necessarily alter the course of viral infection but would mitigate long term lung damage to those severely affected by COVID. So HBO doesn't impact IL-6 per se but

Posted: 3-24-2020


Q: Lung damage and ARDS in COVID-19 infection have implicated immune modulation as a possible treatment. Interleukin-6 (IL-6) inhibitors are now in trials. A Medscape article notes: 

"Interleukin-6 (IL-6) inhibitors may ameliorate severe damage to lung tissue caused by cytokine release in patients with serious COVID-19 infections.

This treatment doesn't necessarily alter the course of viral infection but would mitigate long-term lung damage to those severely affected by COVID.  So HBO doesn't impact IL-6 per se but does suppress IL-1 and PGE-2 as well as macrophages.  Additionally, the use of HBO in ARDS would help in oxygenation in these patients.  Difficulties in providing ventilatory support during HBO could be a limitation."


A: Using HBO2 to treat someone with subacute, ongoing hypoxemia (due to any cause) would work in the short term but would be time-limited due to pulmonary oxygen toxicity, which would then cause further deterioration. If adequate blood oxygenation cannot be achieved using supplemental O2 (up to around 50% FiO2) and manipulation of ventilator settings (e.g. I:E ratio, positive end-expiratory pressure/PEEP level), then the only option is extracorporeal membrane oxygenation (ECMO).

.

Richard Moon, MD
Professor of Anesthesiology
Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine
Medical Director, Center for Hyperbaric Medicine & Environmental Physiology


DISCLAIMER
Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally. 

I work in a clinic setting with wound care on one side of the building and I am alone on my side with HBO2. My boss would like to put a push button code lock on my door and I'm wondering if this is permitted? If there was a fire I'm concerned about the Fire Department not being able to get in. Does anyone have a similar issue? Is it ok to have this type of device on the HBO2 room door? We need some type of Safety policy and procedure for an active gunman in the building and I’m not sure how to go about th
Published: 30 March 2020

I work in a clinic setting with wound care on one side of the building and I am alone on my side with HBO2. My boss would like to put a push button code lock on my door and I'm wondering if this is permitted? If there was a fire I'm concerned about the Fire Department not being able to get in. Does anyone have a similar issue? Is it ok to have this type of device on the HBO2 room door? We need some type of Safety policy and procedure for an active gunman in the building and I’m not sure how to go about th

Published Date:      02/2017
Review Date:         02/2020


Question:  I work in a clinic setting with wound care on one side of the building and I am alone on my side with HBO2. My boss would like to put a push button code lock on my door and I'm wondering if this is permitted? If there was a fire I'm concerned about the Fire Department not being able to get in. Does anyone have a similar issue? Is it ok to have this type of device on the HBO2 room door? We need some type of Safety policy and procedure for an active gunman in the building and I’m not sure how to go about this.


Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

Security is a real concern and we agree that Hyperbaric Facilities need to develop Policy and Procedures to manage active shooter / Code Silver, Bomb threats and other security concerns. We are required by NFPA 99, chapter 14, to have emergency drills on a regular basis. These threats should be added to your emergency response plans.

The SC would refer you to your local Authority Having Jurisdiction (AHJ). There are codes and regulations regarding locked doors. For guidance you can start with NFPA 101 Life Safety Code, 2018 edition, 5-2.1.5 Locks, Latches and Alarm Devices and NFPA 99, 2018 edition, Chapter 13, Security Management. Work with your local AHJ and Safety and Security department, possibly Emergency Management, to complete a threat assessment. These resources will help decide if a key pad is necessary.

In general, we see no issue with a cipher lock on the entrance to the hyperbaric suite. In fact, we are aware of many facilities with ID badge, card access, push button locks and even keyed doors entering the room housing the chamber(s). The Fire Department will be able to gain access in the event of an emergency. Consideration should be given to enabling not only the Fire Department, but other responders such as code teams or security. The chamber room can be considered a restricted area with authorized entry only. The concern is that evacuation in the event of an emergency is not hindered. There must always be an exit path, and the lock mechanism must not impede egress (or ingress of authorized personnel).

We also note that a chamber operator working alone is concerning. NFPA 99, 2018 edition, chapter 14 requires that there be a qualified chamber operator at the control panel with visual and audible communication with the occupants any time the chamber is in use. We would encourage the use of the UHMS Guidelines for Hyperbaric Facility Operations, 2nd edition, Section 3, Staffing Guidelines, to staff the chamber operation. Consider how to ensure the safety and security of the single operator and any patients being treated, as described in this question. Is there a communications link for immediate help? Consider a panic button or regular rounding (closed circuit video feed?) by someone to check on the chamber operator and patients to provide support as needed. During your emergency drills, do you have the help you need to manage the number of patients? 

Is there any contraindications on a patient receiving Etoposide Chemotherapy Drug and HBOT treatments?
Published: 30 April 2020

Is there any contraindications on a patient receiving Etoposide Chemotherapy Drug and HBOT treatments?

Posted: 05-01-2020


Question:  Is there any contraindications on a patient receiving Etoposide Chemotherapy Drug and HBOT treatments?

Answer: 

Etoposide (VP-16) and Hyperbaric Oxygen

Mechanisms: This drug directly interferes with cancer cell duplication directly by interfering with DNA replication and recombination by preventing the uncoiling of DNA. There are no indications that it is an oxygen dependent process.

Tumors Treated: Germ cell tumors, lung cancers, lymphomas including Hodgkin’s disease, gastric cancer, breast and ovarian cancer

Routes of Administration: Oral and IV

Common Toxicities: Bone marrow suppression with decreased blood counts (mostly white cells and platelets), nausea and vomiting, loss of appetite, hair loss, mucositis including lower GI tract leading to diarrhea, allergic reactions including chills, fever, bronchospasm, shortness of breath, tachycardia, swelling of face and tongue and low blood pressure (less than 2% of patients have these reactions, local inflammatory reactions, risk of secondary malignancies

 Metabolism: Metabolized primarily by the liver. Serum half life is up to 30 hours.

Recommendations with HBO2:

  • There is no published experience of HBO2 with Etoposide.
  • Based on mechanisms of action and common complications, it is unlikely that there are frequent or severe harmful interactions.
  • Because it is cleared from the serum to about 3% of peak concentrations in 5 half lives (i.e. 5X30 hours), one could postulate that an interval of about 6 days would be prudent before initiating or re-starting HBO2 after a dose of Etoposide.
  • Without published experience, of course the decision is the decision to treat or not treat concurrently with HBO2 and Etoposide is the purview of the managing physician and the UHMS cannot make a firm recommendation to treat or not to treat.

John J. Feldmeier, D.O., FACRO, FUHM

 

What is the risk of airborne droplet transmission from the exhaust of a Monoplace chamber? What elements of risk mitigation (i.e. filters, distance, exhaust location) should be considered?
Published: 05 May 2020

What is the risk of airborne droplet transmission from the exhaust of a Monoplace chamber? What elements of risk mitigation (i.e. filters, distance, exhaust location) should be considered?

Date:       5/5/2020


 

Question: What is the risk of airborne droplet transmission from the exhaust of a Monoplace chamber? What elements of risk mitigation (i.e. filters, distance, exhaust location) should be considered?

Answer:  Thank you for your question. The UHMS HBO2 safety committee can provide information to assist you in answering your question, but the ultimate responsibility for these types of questions rests with the medical director and safety director of your facility.

It must first be known that the UHMS Safety Committee cannot definitively answer your specific question of risk without knowing a myriad of factors surrounding the construction of your facility’s exhaust system. Other factors such as the height of the exhaust, wind, temperature, humidity, and variations in ventilation rate may impact the ability of the droplets to travel the length of the exhaust. Even with these factors, we assume there may remain an element of uncertainty, as serial cultures and viral concentration measurements in several locations would be necessary to validate any mitigation measures. In any case, we would encourage you to work with your chamber manufacturer, infection prevention specialists and facilities management teams to determine the best course of action.

We encourage you to review these additional comments from the committee that may assist you in the risk assessment (1) and decision-making process:

  • There is speculation that the droplets will likely salt out on the inside of the exhaust pipe.
  • The exhaust point is typically found on the rooftop of a building, and should not be considered a serious concern, as the location is usually a great distance from the general population.
  • Monoplace chambers have moisture and particulate filtration on the supply side to protect pneumatic gauges, regulators and valves (PVHO-1, 4-4.3). On the exhaust side, PVHO-1 requires a screen to prevent exhaust blockage, and NFPA 99, 14 14.2.11.2.4 calls for the installation of a 0.3cm2 screen to protect the exhaust endpoint. Neither of these items would serve as filters in the infection control sense.
  • If the user were to add exhaust-side filters of the same materials used in the N95 respirator, there would be a risk to the chamber’s ability to ventilate and decompress capably. Any attempt to modify the existing exhaust system should be done only with approval of the chamber manufacturer. Alterations like these would also require testing of the decompression capability and documentation describing the testing measures used, along with approval from the manufacturer. The measure is possible, but may be seen as excessive, as this measure is not a current requirement concerning the delivery of Hyperbaric Oxygen to patients with other highly infectious diseases.
  • It is noted that sea-level negative pressure rooms within hospitals require the point of exhaust, without HEPA filtration, to be 25 feet away from potentially contacting the general population (Ventilation of Healthcare Facilities - ASHRAE Standard 170).
  • Other factors include particulate size. The Diver’s Alert Network has investigated this to understand the effectiveness of face masks and the output of compressed breathing air filter systems. The particles range from 4µm down to 0.5µm. From the research found on virus particles (not specifically SARS CoV2), 42% of particles were smaller than 1µm. Here is one source. To quote: “RNA was detected in coughs from 38 (81%) of the 47 subjects who had flu. The RNA was found in 35% of particles larger than 4 microns in diameter, 23% of particles 1 to 4 microns in diameter, and 42% in particles smaller than 1 micron.” Compressed air filters don’t really remove particles smaller than 1µm. However, the N95 respirator can remove up to 95% of particles as small as 0.3 µm. 99.5% for particles down to 0.75µm.
  • Transmission of droplets: there would need to be some studies, but firstly the air/oxygen leaving the chamber is going to be cooler due to the pressure drop from chamber pressure to the 1 psi regulated outlet pressure (adiabatic cooling from the pressure change and some Joule-Thompson cooling from orifices in the flow path). We have actually seen this when decompressing a monoplace chamber rapidly – ice forming at the exhaust screen. This will/should cause droplets to fall out faster and rest on the piping (and associated pressure controls in the exhaust system). Secondly, the longer they travel, the more of them are going to fall out – friction on the piping, temperature, impact at the bends and so on; however, some particles will likely make it to the exhaust outlet. Lastly, this argument is with respect to droplets and does not address airborne transmission. Droplets, which have greater mass, will be more likely to settle at some stage due to the gravitational effects.
  • Exhaust outlet concerns: Physical distancing of at least 6 feet is generally accepted; however this may be insufficient as some claim these droplets can exist in the air for up to 30 minutes before dropping. Additionally, temperature and turbulence will affect these results as will the exit speed of the droplets and wind effects which may carry them further. A higher temperature at the exit will also serve to keep them from coalescing.
  • It is perceived that a safe distance from the exhaust point could be 30 feet. This is based upon comments from infectious disease specialists including Dr. Anthony Fauci, who stated that in extreme cases, sneezing in patients with significant viral loading can project particles into the air up to 27 feet. A typical monoplace chamber exhaust ranges from 85 to 400 lpm, and human exhalation may deliver 6 – 25 lpm (rest to active). In the chamber you’d expect a dilution of 6/85 at the minimum flow rates. Ventilating the chamber at 250 lpm may provide a dilution of approximately 3%. This in combination with the adiabatic and Joule-Thompson cooling, and the length of the exhaust piping (which if it has any metallic section is going to cause the droplet to stick to the wall more easily), would make it highly unlikely for someone to be significantly exposed.
  • It is likely that the exhaust from a monoplace chamber is akin to hospital HVAC exhaust due to its general location (rooftops in most instances). Because of this, there should be minimal exposure to patients, staff or the public at large. If the facility and the safety director have done their due diligence and ensured that NFPA-99 guidelines have been followed for installation of the chamber exhaust, then there should be minimal risk due to this distancing. While the intent of NFPA-99 regarding exhaust requirements was for fire safety, they also serve to help mitigate infection control risks.

14.2.11.2* Exhaust from all classes of chambers shall be piped outside of the building.

14.2.11.2.1 Each Class B chamber shall have an independent exhaust line.

14.2.11.2.2 The point of exhaust shall not create a hazard.

14.2.11.2.3 The point of exhaust shall not allow reentry of gases into the building.

References

Burman, F. (2019). Risk Assessment Guide for Installation and Operation of Clinical Hyperbaric Facilities. San Antonio, TX: International ATMO, Inc.

The American Society of Mechanical Engineers. (2019). ASME PVHO-1-2019: Safety Standard for Pressure Vessels for Human Occupancy. Two Park Avenue, New York, NY

National Fire Protection Agency (NFPA). (2018). NFPA 99 2018 Edition: Health Care Facilities Code. Quincy, Massachusetts.

N Engl J Med (2020). “Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1,” April 16, 2020, 382:1564-1567, DOI: 10.1056/NEJMc2004973

Bourouiba, L. (2020), “Turbulent Gas Clouds and Respiratory Pathogen Emissions: Potential Implications for Reducing Transmission of COVID-19,” Published online March 26, 2020, Journal of the American Medical Association, doi:10.1001/jama.2020.4756

Lindsley, W. (2010). “Measurements of Airborne Influenza Virus in Aerosol Particles from Human Coughs,” November 30, 2010, PLOS One, https://doi.org/10.1371/journal.pone.0015100

American Society of Heating, Refrigeration, and Air-Conditioning Engineers (2017), “Ventilation of Healthcare Facilities - ASHRAE Standard 170 -2017,” American Society of Heating, Refrigeration, and Air-Conditioning Engineers, www.ashrae.org

 

 

Respectfully,

The UHMS Safety Committee


DISCLAIMER

Neither the Undersea and Hyperbaric Medical Society (UHMS) staff nor its members are able to provide medical diagnosis or recommend equipment over the internet.  If you have medical concerns about hyperbaric medicine you need to be evaluated by a doctor licensed to practice medicine in your locale, which can provide you professional recommendations for hyperbaric medicine based upon your condition. The responsibility of approving the use of equipment resides with the physician and safety director of the facility.  Information provided on this forum is for general educational purposes only.  It is not intended to replace the advice of your own health care practitioner and you should not rely upon it as though it were specific medical advice given to you personally.

 

 

I was wondering where UHMS stands on patients that take herbal supplements doing hyperbaric therapy. Also estriol vaginal cream and progesterone gel. Can the patient use it 20 hours before HBO therapy?
Published: 13 May 2020

I was wondering where UHMS stands on patients that take herbal supplements doing hyperbaric therapy. Also estriol vaginal cream and progesterone gel. Can the patient use it 20 hours before HBO therapy?

Posted: 5/20/2020


Question:I was wondering where UHMS stands on patients that take herbal supplements doing hyperbaric therapy. Also estriol vaginal cream and progesterone gel. Can the patient use it 20 hours before HBO therapy?

Answer: This MEDFAQ asks whether the UHMS has a blanket policy on herbal supplements during HBO2 treatment and more specifically whether it is an issue for a patient to use a vaginal estriol cream and/or progesterone gel concurrently or even up to 20 hours before HBO2 treatment.

The UHMS has no across the board policy on herbal supplements. There are hundreds if not thousands of these. Each of them would have to be looked at individually. For the most part, they actually are likely to make little or no difference. On-line resources or one of several paperback references can provide the specific potential side effects or the putative beneficial effects of these supplements. For cancer patients, some of whom are receiving hormonal suppressive therapy as part of their cancer treatment, it is important to determine whether these supplements might be increasing levels of the very hormones the oncologist has set out to suppress. Studies have shown that there is not much systemic absorption of vaginal estrogens typically used to decrease dyspareunia by supporting the vaginal epithelium in postmenopausal women or women receiving anti-estrogen treatment. Progesterone is a frequently used appetite stimulant in cancer patients. In wound healing, it is possible that it might actually have a benefit in supporting nutrition for asthenic patients and by providing an anabolic effect.

Our recommendation is that herbal products and various nutritional supplements be considered like other medications the patient may be taking and considered individually for any negative interaction with hyperbaric oxygen. Because there are so many different products with many different ingredients, no general recommendation can be made.