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Safety/Technical

Questions pertaining to safety and technical information.

Can you provide a resource that outlines the inspection requirements for a monoplace chamber that has met the 10 year/10000 dive design life necessary for ongoing use of the chamber?
Published: 16 March 2015

Can you provide a resource that outlines the inspection requirements for a monoplace chamber that has met the 10 year/10000 dive design life necessary for ongoing use of the chamber?

Thank you for your question. I think you are asking about what the current ASME PVHO rules are for a monoplace chamber that has met the 10 year /  10,000 cycle point in time.

You need to purchase the 2012 edition of ASME PVHO-2. If your department has a firewall I might suggest purchasing the hard copy instead of the pdf as the pdf is actually a link to the “cloud” and I had trouble with using it with our hospitals IT security. (https://www.asme.org/products/codes-standards/pvho2-2012-safety-standard-pressure-vessels-human)

As you know, the design life is 10 years.  During that time, following PVHO-2 is optional.

There is a required 10 year Seat and Seal inspection that in the past we had to pull the end plates off the monoplace in order to inspect the seals and portion of the acrylic that cannot be seen under the seal. This normally meant sending the monoplace chambers back to the manufacturer or having someone like Reimers Eng come out and do this on site.  The current edition of the code has an alternative method that can be used without dissembling the chamber.

The service life can be longer than the design life if you follow the rules of PVHO-2.

For medical systems in a protected environment that means adding 10 years, but you need to follow the rules for Operational, Maintenance and Seat & Seal inspections years 11-20. By default the service life of monoplace chambers is currently 20 years.  A multiplace has more windows and there are destructive testing rules for those windows.

The attached document was written by one of the ASME PVHO members and is also posted on the UHMS website, you may find it helpful for the Operational inspections (daily). The annual or 18 month Maintenance inspections need to be completed by someone who has had training.

If you have not done so already I would strongly encourage you to send someone to an acrylic maintenance course.  The owner of the vessel is responsible for training, record keeping and maintenance.

We just had two of our chambers reach the 10 year mark and we decided to have Sechrist come out and verify our findings from the annual maintenance inspections.  I have not received the documentation from them yet but we wanted to have a third party inspection to include with our own. If you do not have Sechrist I suspect all the manufactures have all come up with some sort of 10 year inspection to offer. If not push them abit as they should have dealt with this.

I am looking for more info on safety and the Hyperbaric Chamber.
Published: 15 March 2015

I am looking for more info on safety and the Hyperbaric Chamber.

James Bell, Safety Director Chair: It is my opinion that most if not all we do in clinical hyperbaric medicine has some aspect of safety.  The medical director and safety director are ultimately responsible for your facility.

  • There are UHMS approved course(s) for the safety director and those are posted on line.
  • Active participation and membership in the UHMS and / or your local chapter is recommended
  • Seek UHMS accreditation for your facility
  • There are resources posted on the UHMS web site under the safety tab,  the reference list is quite extensive and was updated last year. The web site is under construction but we hope to have the safety tab available for members and non-members.
  • Seek continuing education for safety related topics: infection control, oxygen safety, safe patient handling, etc., that exist in healthcare already.
  • Maintain a library of documents such as NFPA 99 and 101, Tom Workman’s book Hyperbaric Facility Safety: A Practical Guide, Best Publishing, is out of date but has valuable information.
  • Continue to work with your co-workers to maintain a culture of safety.
  • Consider attending the 2015 safety pre-course to the UHMS ASM next summer
We are in the process of opening a Wound Care and Hyperbaric’s clinic and were looking for a few documents to have on file.  We are wondering if you had a list of approved cleaners for the acrylic?
Published: 16 March 2015

We are in the process of opening a Wound Care and Hyperbaric’s clinic and were looking for a few documents to have on file.  We are wondering if you had a list of approved cleaners for the acrylic?

The UHMS safety committee can provide information but the ultimate responsibility for these types of questions is with the  safety director of your facility.

Regarding Approved cleaners for acrylic. 

  • The manufacturers commonly specify what you can use to clean the acrylic windows on the monoplace and multiplace, Sechrist attached. We recommend that you contact the chamber manufacturer for their most current recommendation.
  • The American Society of Mechanical Engineers, Safety Standard for Pressure Vessels for Human Occupancy: In-Service Guidelines, ASME-PVHO-2-2012 edition, Mandatory Appendices V, Partial list of harmful substances and acceptable products, pg 35, lists acceptable cleaners as well.  We recommend that you obtain this document for your library.
  • Your facilities infection control needs to be engaged with this process, for example, the CDC recommends a 10% bleach solution for a C-Diff clean up.
Is there a particular company or 100% cotton blanket that you could recommend for the hyperbaric chamber?
Published: 16 March 2015

Is there a particular company or 100% cotton blanket that you could recommend for the hyperbaric chamber?

Regarding blankets for the chamber. 

  • The NFPA 99, 2015 edition 14.3.1.5.6 for fabrics in the chamber such as, sheet, pillowcases, and blankets, directs us to conform with 14.3.1.5.4.2. 14.3.1.5.4.2* specify 100% cotton or a blend of cotton/polyester are permitted in the class A chambers and 100% cotton or a blend containing no more than 50% polyester for the class B chamber. We recommend you have this document in your library. There is also free access to the NFPA codes (read only) at http://www.nfpa.org/
  • The UHMS Ad Hoc Materials Testing Advisory Committee has been looking at this type of question and we are looking forward to results available for the Pre course to the 2015 UHMS ASM in Montreal. Please consider attending.
  • The UHMS safety committee is not able to recommend one vendor over another, there are several that supply Hyperbaric blankets, and if you are in a hospital system you may even be able to utilize the hospital supplied blankets.
Is glistening free hydrophobic acrylic material lens implants able to go into the chamber? This same pt has had bilateral knee replacements and there is no available information regarding what was used. How would you clear the pt for HBO?
Published: 04 May 2015

Is glistening free hydrophobic acrylic material lens implants able to go into the chamber? This same pt has had bilateral knee replacements and there is no available information regarding what was used. How would you clear the pt for HBO?

Thank you for your question. It has provoked a stimulating conversation. The UHMS HBO2 safety committee can provide information but the ultimate responsibility for these types of questions is shared between the medical director and safety director of your facility.

Regarding whether patients with glistening free hydrophobic acrylic material lens implants are able to go into the hyperbaric chamber.

  • We are not aware of studies on this specific topic.
  • We have attached an article regarding the lens implants.
  • Our recommendation would be to work closely with the ophthalmic surgeon.
  • Each supplier has a recommended period of time to avoid pressure changes. This time frame can vary from days to weeks.
  • In practice we have seen periods of 6 months after posterior chamber ophthalmic operations (retinal detachment repairs with intraocular bubbles) to 3-5 days for anterior chamber operations such as lens implants, iris surgery, etc before starting HBO2

Regarding the bilateral knee replacements.

  • In general, inert biological implants without a closed airspace or electrical circuits are safe.
  • Individual consideration must be given as to the potential effects of pressure changes in adjacent spaces. An example would be the need to take into consideration dislodgement of stapedectomy prostheses via middle ear barotrauma.

pdfSafety and effectiveness of a single-piece hydrophobic acrylic intraocular lens (enVista®) – results of a European and Asian-Pacific study

Is it safe to treat a patient with titanium posts securing dentures in both the maxilla and mandible? These were placed 20 and 10 years respectively.
Published: 12 May 2015

Is it safe to treat a patient with titanium posts securing dentures in both the maxilla and mandible? These were placed 20 and 10 years respectively.

Titanium oral posts are safe for the hyperbaric chamber. We are not aware of any untoward events related to these devices and hyperbaric oxygen. Titanium in the hyperoxic environment is certainly a concern; however, the conditions required to create a titanium fire risk does not occur in treatments at clinical pressures. In the mouth particularly, where there is aqueous based saliva with a fairly high specific heat, it is even less likely to generate enough heat for combustion.

pdfTitanium in a Hyperbaric Oxygen Environment May Pose a Fire Risk

We are updating our HBO policies and I would appreciate your opinion on how to decompress the 2 following situations...
Published: 14 June 2015

We are updating our HBO policies and I would appreciate your opinion on how to decompress the 2 following situations...

Thank you for your question. The UHMS HBO2 safety committee can provide information but the ultimate responsibility for these types of questions is with the medical director and safety director of your facility.

We are updating our HBO policies and I would appreciate your opinion on how to decompress the 2 following situations:

    1. There is a fire in a chamber, how do you decompress the NEIGHBORING chamber?
    2. Oxygen pressure is lost, how do you decompress the chamber? Do you shut off the Master Valve first or leave it alone and turn the Pressure Set to zero and allow it to decompress?

We interpret your question to be about monoplace chambers and since we do not know the manufacture our response will be generic and may not apply to your chamber. The manufacturer of your chamber will have recommendations for emergency operation of the chamber. Check the operator’s manual and call the manufacturer. NFPA 99 Health Care Facilities Code, 2015 edition, annex material B.14.3 Suggested Procedures for Hyperbaric Chamber Operator to Follow in the Event of Fire in a Class B chamber is a valuable resource.

Timed emergency drills as required by NFPA 99 2015, edition, section 14.3.1.4 Rules and Regulations will provide your team valuable information for development of your emergency procedures.

1. We suggest that if there is a fire in a chamber all chambers in the department should be immediately decompressed and the patients / staff relocated to a safe place.

2. Without knowing the manufacturer of your chamber it is hard to be specific. In general, if gas supply is lost, many class B chambers are designed to decompress. You may have enough driving pressure in the lines to emergently decompress the chamber. We would suggest trying operation of the chamber during an emergency drill by shutting off the main supply to an un-manned chamber and develop your management plan based on the results of the drill.

What is the accepted time to establish a clinically relevant dose of O2 in a class B chamber when initially compressed with near 100% O2 (USP grade A medical O2)?
Published: 12 July 2015

What is the accepted time to establish a clinically relevant dose of O2 in a class B chamber when initially compressed with near 100% O2 (USP grade A medical O2)?

This is a great question and one that we should all be asking. The UHMS safety committee is not in a position to be able to state what a clinically relevant dose of HBO2 would be. We can try to answer how long a typical class B chamber would take to achieve near 100% oxygen.

The definition of Hyperbaric Oxygen Therapy (HBO2), in the UHMS Hyperbaric Therapy Indications 13th edition, is “An intervention where a person breathes near 100% (USP medical oxygen) while inside a hyperbaric chamber that is pressurized to a greater than sea level pressure. Current information indicates that the pressure be at least 1.4 atmospheres absolute (ATA). Common treatment pressures range between 2.0 and 3.0 ATA with typical treatment times of 90 -120 minutes of oxygen breathing at pressure.  USP medical oxygen is at least 99% oxygen. The time required to achieve near 100% oxygen in the chamber is dependent in part, on the size of the chamber, gas supply to the chamber, ventilation rate and pressure in the chamber. The time frame to achieve near 100% O2 in the class B chamber can range between 10 to greater than 30 minutes, depending on the variables involved. This subject has not been adequately studied.

You should also contact your chamber manufacturer to see what their response to this question is. We would like to see more chambers available that provide information at the control panel for O2% in the chamber and accurate pressure in atmospheres absolute as well as gauge.

HBO2 therapy is a combination of time, pressure and O2%, we need to be as accurate as possible.

  1. Undersea and Hyperbaric Medical Society, Hyperbaric Oxygen Therapy Indications, 13th edition, Weaver, Best Publishing.
  2. CGA G-4.3-2007 Commodity Specification for Oxygen, 6th edition, Compressed Gas Association
  3. UHMS ASM meeting abstracts, Worth ER: Cochran, SK; Dale HM Oxygen Concentration Rise in a Monoplace chamber
  4. Journal of Hyperbaric Medicine, Vol. 3, No. 1, 1988, Air Breaks in the Sechrist Model 2500-B Monoplace Hyperbaric Chamber, G.W. Raleigh, Rubicon Foundation Archive (http://rubicon-foundation.org)
  5. [abstract] Interval to achieve 100% oxygen of monoplace chamber pressurization to 1.5 ATA, Weaver LK, Petty L, Bell J, Deru K, Churchill S, (http://rubicon-foundation.org)
  6. UHM 2013, Vol. 40, No.2 – Hyperbaric Oxygen and Chronic Brain Injury, A Prospective trial of hyperbaric oxygen for chronic sequelae after brain injury (HYBOBI), figure 7, Churchill S, Weaver L, Deru K, Russo A, Handrahan D, Orrison W, Foley J, Elwell H, (http://rubicon-foundation.org)
Do you have to attend a safety director course to be a safety director of a hyperbaric program? In other words, is attending the course a recognized standard?
Published: 07 July 2015

Do you have to attend a safety director course to be a safety director of a hyperbaric program? In other words, is attending the course a recognized standard?

The short answer is that the safety committee is not aware of a code that requires attending a safety director course.  For centers seeking UHMS accreditation, there are several survey probes specific to the responsibilities and qualifications of a safety director.  One of which is to have successfully completed a UHMS or NBDHMT approved hyperbaric safety course.  Following UHMS accreditation criteria would be considered best practice for a facility safety director.  It is our suggestion that even the most experienced individual would benefit from attendance in a course.  The matter of validating “qualified person” to be the safety director and “qualified safety course” is the responsibility of the hyperbaric facility.  The NFPA definition of a qualified person is:  “A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge, training, and experience, has demonstrated the ability to perform the work.”  This can be altered to fit assessing a safety course as well.

Regarding the position of safety director for the hyperbaric facility.

  • A safety director is required by the NFPA 99, Health Care Facilities Code.  This applies even if your state has not adopted NFPA 99 and if you are not in a Health Care Facility. The NFPA 101 Life Safety Code refers us to 99 and states that as far as the Life Safety Code is concerned, all hyperbaric facilities must meet 99, therefore it is a law and enforcement would be from the local authority having jurisdiction.
  • NFPA 99, 2015 edition, chapter 14.3 Administration and Maintenance, entire, and specifically 14.3.1.3.2 and A14.3.1.3.2 outlines the requirement for someone to be designated as the safety director.  A Safety Director course is not required.
  • You need to have the NFPA books in your library, if you do not have these two, there is, read only, free access to all the NFPA codes at http://www.nfpa.org/ .
  • The Canadian standard has language regarding the SD position but does not require a course. 18.2.2 Safety director, The safety director shall be appropriately knowledgeable, qualified and competent by training or experience, in the operation, maintenance, and repair of all the mechanical, electrical, liquid, and gas systems of the hyperbaric facility and shall be acceptable to the regulatory authority having jurisdiction. This person should be involved in all aspects of planning regulations and use of the hyperbaric facility.
  • Note: While not necessarily one of the chamber operators, it is suggested that the safety director be the senior of the chamber operators and a certified hyperbaric technologist or equivalent.
  • A UHMS accreditation survey expects that there is a safety director.
  • We are not aware of a certification available for the safety director, this is in part because there are many different types of operations. You may work for a large complex multi lock chamber with critical care, inpatients, outpatients, etc. You may work for a small wound care operation with a couple of monoplace chambers. The safety director needs to be someone with experience and training to meet the needs of the facility. The UHMS Guidelines for Hyperbaric Facility Operations is available from the on line store at UHMS.org and contains information regarding minimum qualifications. https://www.uhms.org/
  • The person designated as the safety director should be certified or working on certification as Certified Hyperbaric Registered Nurse (CHRN) or Certified Hyperbaric Technologist (CHT) and have or will be, attending a safety director course.
  • The National Board of Diving and Hyperbaric Medicine has a position statement regarding the safety director, (http://www.nbdhmt.org/position_statements.asp#c03)
  • Please see the UHMS web site for listings of safety director courses.

 

In Denver, CO with an atmospheric pressure less than sea level, how should the ordering physician compensate when prescribing hyperbaric oxygen therapy for a standard wound care table 2.0 ATA for 90 minutes? Please provide a detailed explanation.
Published: 26 July 2015

In Denver, CO with an atmospheric pressure less than sea level, how should the ordering physician compensate when prescribing hyperbaric oxygen therapy for a standard wound care table 2.0 ATA for 90 minutes? Please provide a detailed explanation.

The decision whether or not to compensate for deferential pressure due to altitude is the medical directors responsibility. The US Navy requires altitude corrections for divers starting at 1000 feet of altitude. We are not aware of conclusive data that indicates the outcomes are better or worse for patients because they were treated using gauge pressure versus atmospheres absolute (ATA) at altitude. We suggest that the chamber pressure should be as accurate as possible. There are certainly MD’s who choose to compensate for the differential pressure at altitude and those that do not.

We are not aware of any hyperbaric chambers with absolute pressure monitoring installed by the manufacturer. Most chamber pressure monitors use a gauge scale such as; feet of sea water /fsw, pounds per square inch /psig, atmospheres /atm, bar, kilo pascals / Kpa).  These gauges inform the user what the pressure is inside the chamber with no regard to the outside ambient pressure.  (note: the ATA or ATM marking from the manufacturer on your chamber is most likely a gauge pressure and not accurate above sea level ). To calculate absolute pressure one needs to include the surrounding ambient pressure.  This pressure differs from facility to facility due to differences in altitude and a constantly varying local barometric pressure. Therefore if one is to be accurate in the use of atmospheres absolute (ATA) an absolute gauge must be added to the chamber.

Denver is at an altitude of 5,924 feet and has an average barometric pressure of 12.2 pounds per square inch absolute (psia), 0.83 ATA. If a chamber at that altitude is compressed to 14.7 pounds per square inch gauge (psig) to achieve 2.0 ATA there will be an error of 2.5 psig or 0.17 ATA. The absolute pressure in the chamber would be 26.9 psia / 1.83 ATA not 29.4 psia / 2.0 ATA. The physician in Denver, CO wanting to achieve 2.0 ATA in the chamber will need to compensate for altitude by adding back the differential between altitude and sea-level by compressing the chamber to 17.2 psig.

We have seen facilities that have calculated the pressure to equal ATA for the various treatment schedules and posted these at the control panel. These are based on the average barometric pressure in their area. There are other facilities that have added absolute gauges to the chamber systems and verify the absolute pressure in the chamber daily.

Confirming pressure by calculation:
When limited to a pressure gauge using a gauge scale, the absolute pressure can be calculated (with reasonable accuracy) by adding the average barometric pressure for your facility found from a reliable source such as the blood gas lab, TcpO2 monitors or weather sources. If using weather sources, confirm the pressure scale they are using is the same as your gauge. Note that airports report a standardized barometric pressure relative to sea level and it may not be the actual barometric pressure for your location. It is easier than one might think to get this wrong!

Confirming pressure mechanically:
The most accurate way to confirm your chamber is at the absolute pressure prescribed is to install a calibrated absolute pressure gauge.

Modifications to the chamber(s) manual and/or automated control systems:

  1. Seek the support of the chamber manufacturer.
  2. Seek the support of your facility’s bio-medical department.
  3. Validate that the person/company doing any modifications to your chamber is qualified.

Things to consider:

  1. The pressure relief valves should be checked to make sure that the ones installed will accommodate the increased pressure. Example, Denver to achieve 44.1 psia / 3.0 ATA, the chamber will be compressed to approx. 32 psig. Monoplace chambers are designed for 30 psig working pressure.
  2. The chamber manufacturer may need to be engaged as your chamber gauges are designed for sea level use and a monoplace may not display a value above 30 psig and in fact the controls for a monoplace may not allow a pressure greater than 30 psig without adjustment.
  3. If this is a multiplace chamber the increased chamber pressure to achieve ATA will affect the inside attendants sea level equivalent depth and this must be accounted for in your procedures.
  4. Is this undertaking warranted for your facility’s altitude?  There is no right answer.  Each facility needs to determine what is best for their situation.
  5. Perform a risk assessment if chamber modifications are not supported by the chamber manufacturer.
  6. Will this modification void your warranty?
  7. Need for enhanced staff training.
  8. Updating your maintenance program to address the modifications, as appropriate.
  9. Issues not discussed that are specific to your facility’s chamber(s).


References:

  • U.S. Navy Diving Manual. Revision 6. Washington, D. C.: U.S. Government Printing Office; 2008.
  • UHMS 2013 ASM, Abstract, Absolute Pressures for monoplace and multiplace chambers, Bell JE, Weaver LK, Churchill S, Haberstock D
  • UHM 2014, Vol. 41, No. 6 – Altitude Decompression tables for HBO2 Attendants, James Bell, CHT/EMT/CFPS, Paul A Thombs, M.D., William J. Davison, CHT, Lindell K Weaver, M.D.,FACP, FCCP, FCCM, FUHM
  • FAQ HBO Treatment at altitude Hamilton Research, LTD, David J. Kenyon, Glen Butler

pdfUHM_41-6_Altitude_deco_tables_for_IAs.pdf

pdfComment on FAQ: “How would an MD compensate for altitude in a monoplace chamber”

pdfAbsolute Pressures for monoplace and multiplace chambers

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, who 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 are in need of reference materials to come up with a no/go list for our chamber. What are the best resources for this information? ...
Published: 03 August 2015

We are in need of reference materials to come up with a no/go list for our chamber. What are the best resources for this information? ...

We are in need of reference materials to come up with a no/go list for our chamber. What are the best resources for this information? We mainly did emergency patients in the past but are now seeing more and more wound care patients with different types of dressings.


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

References for this question include:

  • NFPA 99, 2015 edition, chapter 14 and annex material
  • Manufacturer’s Instructions for Use statements
  • NFPA 53 Recommend Practice on Materials, Equipment, and Systems Used in OEA
  • ASTM G04 Committee: Compatibility and Sensitivity of Materials in Oxygen Enriched Atmospheres
  • ASTM Safe Use of Oxygen and Oxygen Systems
  • Safety Data Sheet (SDS) :Note these are for 1 ATA testing in an air atmosphere.
  • Food and Drug Administration (FDA) …E-mail Alerts…Manufacturer and User Facility Device Experience Database (MAUDE)
  • Approved and Prohibited Items (local Go / Go list)
  • Product Manufacturer (Tech Support)​
  • Peers
  • https://www.ecri.org
  • Hyperbaric Facility Safety: A Practical Guide, Wilbur Workman, Best Publishing
  • Attendance and involvement in the UHMS chapter, annual meetings and pre-courses. Example of a lecture from the 2013 UHMS Safety Pre-course (Attached)
  • UHMS Web site, https://www.uhms.org/ , Safety Documents, posts an extended list of references

pdfMaterial Selection for the Oxygen Enriched Atmosphere - 2013 - Richard C. Barry, BBA, CHT-A 

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, who 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.

How long do we need to keep maintenance logs/records/annual preventative maintenance records? We have kept records since we opened in 1998.
Published: 07 August 2015

How long do we need to keep maintenance logs/records/annual preventative maintenance records? We have kept records since we opened in 1998.

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

This is not a one size fits all question and we suggest that you will need to work with your Authority having Jurisdiction (AHJ), facility administration, Quality, Risk and clinical engineering departments to make this determination. The National Fire Protection Association, glossary of terms defines the AHJ as “An organization, office, or individual responsible for enforcing the requirements of a code, or for approving equipment, materials, an installation, or a procedure.” There is more than one AHJ that would have interest in the records kept. List of possible AHJs would include: NFPA, ASME (PVHO-1 and PVHO-2), UHMS, FDA, TJC, OSHA, CMS, State specific Department of Health, Local Fire Authority, Interest specific Insurance Carriers/Underwriters, and Institution imposed standards.

It must also be understood that a lot of standards only have the force of law if recognized by a governmental agency with authority in your area. The others are only enforceable if agreed to by the institution, for example insurance carrier/underwriter rules.

There are valid legal reasons for not maintaining records past 7 years. The Joint Commission has typically asked for preventive maintenance history & service history back 3 years. Other regulatory agencies may go back a little further in time, if it is a pediatric/neonatal/L&D/Maternity area, ideally 21 years. Some facilities we are aware of never really purge the data base and the records are kept indefinitely.

There are specific regulations regarding record retention in code, example references below.

ASME PVHO-2-2003, 4.5 QUALITY ASSURANCE (c) retain all maintenance inspection forms and all window repair forms, as applicable, throughout each window's service life.

ASME PVHO-2-2003 7.1.2 Written records of the results of maintenance inspections shall be retained throughout the service life of each window.

ASME PVHO-2-2003 7.5 ..... All records including the original PVHO-1 documentation package, the maintenance inspection reports, and all repair-related forms set forth in this Standard (plus any additional documentation that the cognizant jurisdictional authority may require) shall be retained by the user for the duration of the widow's service life, plus 1 year.

NFPA-25, 2011 ed. 4.3 Records 4.3.4 As-built system installation drawings, hydraulic calculations, original acceptance test records, and device manufacturer's data sheets shall be retained for the life of the system.

NFPA-25 2011 ed. 4.3.5 Subsequent records shall be retained for a period of 1 year after the next inspection, test, or maintenance of that type required by the standard.

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, who 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 have been told about the affects of titanium in the chamber - what about aluminum? Nowadays patients have aluminum eyeglasses. Are these safe in a monoplace chamber?
Published: 16 August 2015

We have been told about the affects of titanium in the chamber - what about aluminum? Nowadays patients have aluminum eyeglasses. Are these safe in a monoplace chamber?

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.

The UHMS SC is not aware of any concerns regarding aluminum eyeglasses in the monoplace chamber.

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, who 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 with hyperbaric oxygen therapy with a spinal stimulator?
Published: 05 October 2015

Is it safe to treat a patient with hyperbaric oxygen therapy with a spinal stimulator?

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

Neuromodulators from different companies may not carry the manufacturer’s full endorsement. Boston Scientific and Medtronic provide differing information regarding spinal stimulators. We would encourage you to contact the manufacturer for each patient to insure the most up to date recommendation. 

The medical decision making would be the responsibility of the medical director.  A risk assessment of the importance of hyperbaric medicine versus the possible malfunction or damage to the stimulator must be completed. The device may be able to be turned down or off for the treatment. Informed consent should be obtained from the patient and documented. If the decision to treat is made, limit the exposure to 2 ATA and monitor the patient.  Document the reasoning and why the benefit outweighs any possible injury or damage to the patient or the stimulator. The patients’ medical team should be involved with the process.

We can provide general information on stimulators as in Medtronic’s and Boston Scientific.

Medtronic: (Copied from the Instructions For Use)

image004

Boston Scientific:

In a confidential written reply from the company; they state that while functional testing was performed after storing the device at 2 ATA, they do not have human subject data and do not support the use of the device within a hyperbaric chamber.

Verbal discovery with Boston Scientific and the IFU posted on the web site does not include this statement. A phone call with Boston Scientific indicated that there are two models that perform up to 2 ATA in the manufacturing process. The technician stated that they had no human data and could not endorse the use of the device in the chamber or scuba diving. There is a warning even for swimming as the change in muscle use may have some effect on the stimulator. A formal request for a letter could take as long as 3 weeks and has to come from an MD or medical facility.

Documents:

pdfMEDTRONIC PAIN THERAPY Using neurostimulation for chronic pain

pdfSYNCHROMED® ISOMED® Implantable infusion systems

pdfBoston Scientific: Precision Plus Implantable Pulse Generator (IPG)

pdfBoston Scientific: Precision Spinal Cord Stimulator System - Clinician Manual - Directions for Use

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, who 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 "standard" ascent rate for a class A chamber from 2.4ATA or what is the suggested rate? Currently we bring it up between 10-15 minutes.
Published: 04 August 2015

Is there any "standard" ascent rate for a class A chamber from 2.4ATA or what is the suggested rate? Currently we bring it up between 10-15 minutes.

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.

The UHMS SC is not aware of any a standard decompression rate for a clinical class A chamber. Your current practice is typical of our experience.

When planning the treatment profiles, the decompression obligation for the inside attendant as well as patient air trapping are concerns that must be addressed. Patient comfort and chamber design are factors as well. The decompression rate in the USN Air Decompression table of 30 fsw / minute (13.4 psig / minute) is fairly aggressive for patient care in the clinical chamber and should be reserved for emergencies. The NFPA 99, 2015 edition, chapter 14, requires class A chambers to be able to decompress from 3 ATA to ambient pressure in 6 minutes (11 fsw or 4.9 psig per minute) The USN and USAF have tables with standardized decompression rates such as the USN table 5 decompression rate of 1 fsw / minute (0.445 psig /minute).

For your consideration we have posted responses from several members of the committee related to this question;

  • Linear decompression of 10 minutes at 2 psig / minute. The attendant wears an oxygen mask for 5 minutes at 2.4 ATA and during the 10 minutes linear decompression. We have no recollection of any DCS incidents with inside attendants since we switched to this protocol. Part of our reasoning for the linear decompression was, our previous profile included a 10 fsw (4.45 psig) decompression stop, the decompression rate was faster and the chamber became uncomfortably cold. Our chamber heating system at that time was not up to the task. If we have a patient with pulmonary air trapping issues the physicians usually ask for a 15 minute ascent instead of 10 minutes (1.4 psig / minute). All of our treatment tables use oxygen breathing by the attendant but not all treatment tables have a linear ascent.
  • 2.4 ATA protocol for multiplace decompresses at 9.4 kPa /min (1.4 psig / minute) from 141 kPa (20.45 psig) for a total 15 min decompression time. Attendants go on oxygen 5 min prior to starting decompression to provide a total of 20 min on oxygen for decompression of inside attendants. Note this exceeds USN that requires no stop or oxygen deco for this exposure but was selected for inside attendant safety.
  • Typically decompression rate of 7 fsw / minute (3.11 psig / minute) from 2.4 ATA to 10' (4.45 psig). Complete a 3 minute stop at 10 fsw (4.45 psig) for attendant decompression & a rate of 5 fsw / minute ( 2.25 psig / minute) from 10 fsw (4.45 psig) to surface. A total decompression time of 10 minutes. Our attendants breathe O2 for 15 minutes before starting decompression. Decompression is extended at the physician’s discretion for patients with lung issues, CHF, etc.
  • Our attendants breathe oxygen for 30 minutes prior to decompression. Has to do with our altitude (3000 ft). Decompression is over 10 minutes from 45 fsw (20.0 psig). I always hesitate to put in ATA since we only use gauge pressure. It's approximately 2.2 ATA by the standard definition.
  • Our typical decompression rate is 2 psig per minute. Our attendants were oxygen for 30 minutes of the treatment and during the 10 minute decompression. The decompression rate is extended by the MD if there are patient care concerns.

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, who 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 new patient we are considering for HBO that has a hair weave.
Published: 04 October 2015

I have a new patient we are considering for HBO that has a hair weave.

I have a new patient we are considering for HBO that has a hair weave. I don\'t know anything about hair weaves, but she says it is glued on. Any information on this matter would be helpful, whether to treat patient with weave or other precautions that may help.

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.

Regarding information concerning patients wearing hair extensions during hyperbaric therapy.

  • We are not aware of any specific information regarding hair extensions in the chamber monoplace or multiplace.
  • NFPA 99, 2015 edition chapter 14 , 14.3.1.5.4.3 and the annex material relate to textiles and wound dressing not specifically for hair extensions. The risk assessment process may be useful to you.
  • While the UHMS SC would not be in a position to recommend practice in this specific case our general consensus is that if the wig or extension is easily removed then we recommend removing the item. If it is not easily removed consider a tight fitting cap to cover the extension or wrapping with a damp cloth to mitigate any static concerns. Our concern is primarily regarding hair products that are applied soon before a hyperbaric treatment and not enough time was allowed for off gassing of any flammable fumes. Not all hair extensions are glued in and not all are synthetic. This is a local decision to make.
  • Multiplace: see if patient can tolerate a mask.
  • Monoplace or hood: Research the details; they will lead you to an answer.
    1. Volume of weave/hair extensions (understand there is a difference between the two! Although some people use the two synonymously)
    2. Volume of real hair.
    3. List of Material(s) involved: real hair, synthetic hair, metal(s), glues, cure time of adhesive(s), etc.
    4. Washing history, chemical(s) used on it, etc.
    5. Does the facility have the ability to humidify a hood circuit? If so, and research data doesn’t bring up any major RED flags, consider humidifying the hood. As always, the facility needs to determine the definition of RED flags.
    6. For some types of weaves/hair extensions there is a service life (recommended to be changed out every “X” amount of time). If non-emergent, when does the patient plan on getting them removed/changed out anyway?
    7. Last but not least, encourage the patient to have it removed. However, sometimes that can be a financial and/or vanity deal breaker.

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, who 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 polyurethane undergarments for compression therapy, an acceptable product in a monoplace chamber?
Published: 06 November 2015

Is polyurethane undergarments for compression therapy, an acceptable product in a monoplace chamber?

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.

The SC does not have enough information to answer this question. We can provide information for your consideration while you complete the due diligence required for this topic. In general unless there is a compelling medical necessity the consensus is that we would not allow this product in the class B chamber.

  • NFPA 99, 2012 edition, 14.3.1.5.4.1, Except where permitted by 14.3.1.5.4.1, synthetics are prohibited in class A or class B chambers.
  • NFPA 99, 2012 edition, 14.3.1.5.4.3 allow for the physician or surgeon in charge, in concurrence with the safety director to allow synthetic materials
  • NFPA 99, 2012 edition, A14.3.1.5.4.3 includes a risk assessment that outlines the process where one could decide whether or not to allow a synthetic such as a polyurethane undergarment.
  • What is the medical necessity? If there is no medical necessity then it would be a No Go.
  • This product would be a fuel if ignition were to occur, how much of the material would be allowed if used? This product probably has a relatively low flammability rating.
  • Polyurethane can be produced as an antistatic product, most are not. There is a static risk with dissimilar materials. How do you manage the static concern?
  • What information can be obtained from the manufacturer, safety data sheets, your peers, etc regarding static producing properties and flammability.


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, who 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 a requirement for how much humidity is required in the room that houses monoplace chambers? I have looked at the NFPA and it addresses multiplace chambers.
Published: 07 November 2015

Is there a requirement for how much humidity is required in the room that houses monoplace chambers? I have looked at the NFPA and it addresses multiplace chambers.

Thank you for the interesting question.

There are no codes we are aware of specifically regarding humidity control in the monoplace hyperbaric suite.

There is language in NFPA 99 for the class A chamber, non-mandatory in the annex A 14.2.4.3.2 and humidification allowed 14.2.4.3.5. These do not answer your question and are specifically for the class A chamber not the room housing the chamber.

It is accepted that 50-60 percent humidity will pretty much eliminate static potential. 14.3.1.5.3* Personnel , states that antistatic procedures are under the safety directors responsibilities whenever atmospheres greater than 23.5 % O2 are used. In our opinion this relates to the class A chamber not the room housing the chamber. A14.3.1.5.4.3 (3) discusses static and humidity in regards to a risk assessment for a wound dressing.

Grounding is a critical part of operating monoplace hyperbaric chambers. Insure the chamber and patient are grounded and document the findings.

Humidity is mentioned in an out of print UHMS guideline (pdf on the UHMS web site under Safety) and in the 2005 edition of the 101 Handbook for anesthetizing locations. Some monoplace facilities have added humidity controls to their rooms; some facilities have humidity as a function of the as built design of the HVAC system. The majority of monoplace hyperbaric suites we are aware of do not do anything in regards to controlling humidity in the room.


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, who 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.

Have there been any studies looking at the safety and efficacy of utilizing nitroglycerin patches in the hyperbaric environment to assist or improve circulation flow to a wound?
Published: 15 January 2016

Have there been any studies looking at the safety and efficacy of utilizing nitroglycerin patches in the hyperbaric environment to assist or improve circulation flow to a wound?

Thank you for your question, it has provoked a stimulating conversation. The UHMS HBO2 safety committee can provide information but the ultimate responsibility for these types of questions is with the medical director and safety director of your facility.

Regarding studies about patients wearing nitro patches for increased circulation at the affected site during hyperbaric oxygen therapy.

  • We are not aware of studies on this specific topic.

Since you did not identify what type of chamber we will respond to both class A and class B. The NFPA 99 2015 edition 14.3.1.5.2.2 describes how flammable agents could be allowed in class A chambers. 14.3.1.5.2.3 Prohibits flammable liquids, gasses or vapors in a class B chamber. The risk assessment on whether or not to allow transdermal patches has to be made by the medical director and safety director for each type of chamber and if the risk outweighs the benefit then the patch would not be allowed. A common example of this would be the nicotine patch where we can usually get by for 2 hours or so without nicotine and the patches are not expensive therefore we would prohibit them in the chamber. On the other hand fentanyl patches are expensive and there are facilities that have decided to use them in both class A and class B chambers. While we most commonly see single-layer & multi-layer drug-in patches, there are others to consider. First, reservoir patches, which have a larger open space for medication storage. As this medication absorbs into the skin, the leftover air pocket needs to become a consideration when entering the HBO environment. Second, is the vapor type patch, which by NFPA standards 14.3.1.5.2.2 and 14.3.1.5.2.3 are most likely not compatible with the HBO environment.

Other factors need to be taken into account when performing a risk assessment of patches that both the safety director and physician should complete together. Some patches have "rate-controlled" membranes that may be affected by chamber pressure. The medical decision to continue or discontinue the use of a patch should to be weighed equally with its safe use in a chamber.

One of the most concerning to us are Nicotine patches and their potentially extreme degree of vasoconstriction. This has been noted to cause significant differences in TCOMS and LUNA There is very little real data on the fire risk of the transdermal patches. We have anecdotal experience that indicates a small risk for fire. Hopefully the UHMS Ad Hoc Materials Acceptability and Testing committee will be able to provide more information on these types of questions. More case reports are needed regarding this topic.

The medical necessity of the patch then becomes the driving factor. If there is compelling reason and there is no safer alternative then the medical director may decide that the transdermal patch should be allowed. This decision and the risk assessment need to be documented and the exception signed by both the medical director and the safety director. If the decision is that the patch is medically necessary then a daily pretreatment inspection of the patch must be performed to insure that it has not become contaminated with a prohibited substance.

References below regarding topical nitroglycerin and for general discussion

1. Treatment with Topical Nitroglycerine may Promote the Healing Process of the Diabetic Foot Ulcers. Mikaili P, Moloudizargari M, Aghajanshakeri S. Med Hypotheses. 2014 Aug;83(2) 172-174. doi: 10.1016/j.mehy.2014.05.002. Epub 2014 May 17.

2. Effectiveness of Topical Application of Nitoglycerin Spray to Increase Survival of Cuaneous Flaps and Grafts. P Coto-Segura, J Ingelmo, Talonso, P Sanches. Actas Demosifilogr. 2007, 98:291-5

3. Effect of Topical Nitroglycerine on the Survival of Ischemic Flow-through Venous Flaps in Rabbits. Coruh A, Abaci K, Gunay GK. J Reconstruction Microsurg. 2004 Apr, 20(3):261-6

• Lavonas, EJ … abstract found in the Rubicon Foundation collection of UHMS presentations “CONCLUSION: Transdermal medication delivery systems do not produce an excessive fire risk in the hyperbaric environment. However, because of erratic drug absorption, use of patch medications should be avoided in patients undergoing hyperbaric oxygen therapy when possible.”

• Pawasauskas J, Perdrizet. Case Report. Journal of Pain & Palliative Care Pharmacotherapy (Sept 2014). The institutional policy prevents transdermal patches in the chamber. So, they applied a new fentanyl patch daily.

• Hopf H, West JM, Hunt TK. 1996. Rubicon Foundation abstract. EFFECT OF CLONIDINE ON TISSUE OXYGEN LEVELS IN PATIENTS WITH LOCAL TISSUE HYPOXIA IN CHRONIC NON-HEALING WOUNDS. “CONCLUSION: Clonidine increases PtcO2 in patients whose wounds demonstrate low PtcO2 unresponsive to supplemental oxygen. Excess sympathetic activation likely contributes to the impaired healing demonstrated by such patients.”

 

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, who 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.

Does the patient air mask and ground bracelet need to be disposed of after the patient finishes their HBO treatment cycle or can they be cleaned with disinfectant and used again?
Published: 23 January 2016

Does the patient air mask and ground bracelet need to be disposed of after the patient finishes their HBO treatment cycle or can they be cleaned with disinfectant and used again?

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.

Regarding: Disposal or disinfection of the patient air break assembly and ground bracelet.

The instructions for use from the manufacture of the device, the facilities infection control and hyperbaric medicine staff will all be utilized to determine the procedure based on the type of device used. The answer(s) will depend on the type of air break assembly and patient grounding device used. The type of patient treated may affect your infection control procedure for these devices as well. For example, if you are hospital based and have a patient that is in isolation your procedures will most likely be different that if you are an out patient facility.

  1. If using a disposable mask and/or grounding bracelet: it is single patient use (label it for that patient, clean as per infection control and dispose of it at the end of the care plan).
  2. If using a reusable air break assembly and/or grounding bracelet: have it cleaned per your institution’s cleaning procedures.
    1. With the demand valve style of air break mask, there is a recommendation that a bio-filter to be inserter between the oral/nasal mask or mouth piece and the demand valve. Consider issuing the re-usable oral/nasal mask or mouth piece to the patient for the duration of the patient care plan, then send the device to Central Sterilization before placing back into service for the next HBO2 patient.

 

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 the Lap Band device with a filling port, approved for the hyperbaric chamber?
Published: 07 February 2016

Is the Lap Band device with a filling port, approved for the hyperbaric chamber?

The SC is not aware of an “approval” of this device for hyperbaric conditions. This decision would be the responsibility of the medical director in concurrence with the safety director and communications with the manufacturer.

The Directions for use (DFU) from the manufacturer, attached, do not specifically list hyperbaric conditions. This would therefore need to be a medical decision based on the required patient care. The SC is not familiar with this device; however, based on the information in the DFU, there is probably no safety issue with the implanted device under hyperbaric conditions. The device should be filled with saline liquid, per the instructions, and there should no air in the system. Any small bubble will make little difference in changing the bands size. Under Adverse Events, the DFU states “Deflation of the band may occur due to leakage from the band, the port or the connecting tubing. Nausea and vomiting may occur . . ." Therefore, if the medical director and safety director agree that this device may be allowed in the chamber, the staff need to be aware of the concerns. As always, consider the whether there are patient as well as any other considerations that the medical director might have.

pdfLAP-BAND® Adjustable Gastric Banding System with the Access Port II Directions For Use (DFU)

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.

My understanding is that air breaks are uncommon anymore in the HBO2 community and I understand that there is a greater risk of O2 toxicity @ 2.4 ATA or greater. Is there any documented evidence for the need of air breaks during the hyperbaric treatments?
Published: 29 January 2016

My understanding is that air breaks are uncommon anymore in the HBO2 community and I understand that there is a greater risk of O2 toxicity @ 2.4 ATA or greater. Is there any documented evidence for the need of air breaks during the hyperbaric treatments?

My understanding is that air breaks are uncommon anymore in the HBO2 community and I understand that there is a greater risk of O2 toxicity @ 2.4 ATA or greater. Is there any documented evidence for the need of air breaks during the hyperbaric treatments? Please include any publications or resources? Thank you, I appreciate your guidance.


Regarding: Air breaks in the HBO2 Community

The SC cannot recommend medical practice. The hyperbaric treatment protocol is the responsibility of the medical director and the safety director.
Air breaks are used in the clinical setting for two primary reasons. The first to reduce oxygen toxicity involving the central nervous system. The second is to reduce oxygen toxicity to the pulmonary system. Due to the complexity of our patients and the underlying disease processes, the clinical patient may present with conditions that could possibly lead to a lower threshold limits for oxygen toxicity (i.e. fever, low blood sugars, medications). Seizure occurrences have been reported at 1 in 10,000 (1), 1 in 3,388 in one series (1), and 1 in 1,650 in another (2). Another article reported zero per 10,000 at 2.0 ATA, 15 per 10,000 at 2.4/2.5 ATA and 51 per 10,000 at 2.8 ATA (3). Patients treated for CO poisoning or decompression illness have an incidence as high as 0.5-2% (4), presumably due to a combination of CNS injury and higher PO2 (2.8-3.0 ATA) used for treatment of those conditions.

Major pulmonary oxygen toxicity has not been reported during routine clinical hyperbaric treatment, although there is a theoretical risk in patients who receive oxygen within a short interval after certain chemotherapeutic agents such as bleomycin and mitomycin C.

The rationale for air breaks is based upon a study in which volunteers breathed 100% O2 at 2.0 ATA for up to 19 hours (5). Use of 5-minute air breaks after every 20 minutes of 100% O2 delayed the onset of a measurable reduction in vital capacity (-5%) from 6 hours (without air breaks) to 17 hours. We are not aware of any specific studies that look at the influence of air breaks on CNS O2 toxicity. Such a study would be difficult to perform since O2 toxicity is rare.

Air breaks are prescribed in some standard treatment procedures such as USN Treatment Tables for decompression illness. Routine use of air breaks for other hyperbaric treatment algorithms is at the discretion of the treating physician and is often implemented when treatment pressure exceeds 2.0 ATA. The time or length of the air break can vary from five to ten minutes (up to 15 minutes for treatment protocols used for decompression illness), typically after 100% O2 breathing periods of 20-30 minutes.

1) Hampson N, Atik D. Central nervous system oxygen toxicity during routine hyperbaric oxygen therapy. Undersea Hyperb Med. 2003;30(2):147-53

2) Banham ND. Oxygen toxicity seizures: 20 years' experience from a single hyperbaric unit. Diving Hyperb Med. 2011;41(4):202-10

3) Heyboer M, 3rd, Jennings S, Grant WD, Ojevwe C, Byrne J, Wojcik SM. Seizure incidence by treatment pressure in patients undergoing hyperbaric oxygen therapy. Undersea Hyperb Med. 2014;41(5):379-85

4) Hampson NB, Simonson SG, Kramer CC, Piantadosi CA. Central nervous system oxygen toxicity during hyperbaric treatment of patients with carbon monoxide poisoning. Undersea Hyperb Med. 1996;23(4):215-9

5) Hendricks PL, Hall DA, Hunter WL, Jr., Haley PJ. Extension of pulmonary O2 tolerance in man at 2 ATA by intermittent O2 exposure. J Appl Physiol. 1977;42(4):593-9

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 level and credentials due HBO technicians need? I heard EMT, Paramedic, LPN, RN... can you clarify?
Published: 25 January 2016

What level and credentials due HBO technicians need? I heard EMT, Paramedic, LPN, RN... can you clarify?

Thank you for your question. The UHMS hyperbaric oxygen safety committee (SC) can provide information, but ultimately the responsibility lies with the hyperbaric Medical Director and hyperbaric Safety Director of your facility.

Regarding credentials for personnel staffing hyperbaric chambers:
The level of training and experience of the hyperbaric chamber operators and inside attendants varies depending on the country of origin, complexity of the chamber(s) and level of care provided. There are Physicians, Nurse Practitioners, Life Support Technicians, Chamber Technicians, Physiologist, Researchers (medical), Respiratory Therapist, Diver Medics, Physician Assistants, Corpsman, Medical Services Specialist, EMTs, Paramedics, Registered Nurses or LPNs, and others that are employed as hyperbaric chamber operators and inside attendants. The list of resources below is not all inclusive, but it is a sampling of some available qualifications and standards.

  • The National Fire Protection Association, NFPA 99, Health Care Facilities Code, 2015 edition, 14.3.1.4.2 “The medical director of hyperbaric medicine and the safety director shall jointly develop the minimum staff qualifications, experience, and complement based on the following:
    1. Number and type of hyperbaric chambers in use
    2. Maximum treatment capacity
    3. Type of hyperbaric therapy normally provided
  • The National Board of Diving and Hyperbaric Medical Technology (http://www.nbdhmt.org/), Scope of practice for Certified Hyperbaric Technologists states” The purpose of this document is to describe the training and competencies necessary to become certified as a hyperbaric technologist. CHT® is not an entry-level qualification, rather an additional certification beyond the applicant’s qualifying profession (refer to qualifying pathway list).
  • The Undersea and Hyperbaric Medical Society (https://www.uhms.org/) has recommendations on staffing qualifications in the most recent UHMS Guidelines for Hyperbaric Facility Operations, and there are hyperbaric staffing requirements listed in the UHMS Facility Accreditation documents.
  • Certified Hyperbaric Technologist is not required in Canada if they are trained and certified as a chamber operator such as what is offered under the Divers Certification Board of Canada and the CSA standard for Hyperbaric Chamber. The Canadian Undersea and Hyperbaric Medical Association (CUHMA) (formally the Canadian Chapter UHMS) has a "Guidelines to the Practice of Clinical Hyperbaric Medicine and Provision of Hyperbaric Oxygen Treatment" with references on qualifications of staff.
  • The Australian Standard AS 4774.2-2002 lists requirements for personnel staffing hyperbaric facilities.
  • The European Code of Good Practice for Hyperbaric Oxygen Therapy lists requirements for personnel staffing hyperbaric facilities. Also reference the Educational and Training Standards for the Staff of Hyperbaric Medical Centers, European Committee for Hyperbaric Medicine / European Diving Technical Committee.
  • South Africa uses the Risk Assessment Guide for Installation and Operation of Clinical Hyperbaric Facilities publication, under the authority of national hyperbaric association (SAUHMA), and specifies registered healthcare providers with appropriate hyperbaric training for attendants with current BLS training. Chamber operators require appropriate training, certified by SAUHMA.
  • We are aware of others such as Mexico and Japan that have standards for chamber operators and inside attendants as well.
  • Reference Hyperbaric Facility Safety: A Practical Guide, Best Publishing, Workman
  • There are military, commercial diving and tunneling competencies and standards for chamber operators and inside attendants in those ocupations.

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 recommended and or necessary to designate a Medical Director for each location that HBO2 is administered or does it suffice to designate a Medical Director for an organization that administers HBO2 at multiple sites?
Published: 12 March 2016

Is it recommended and or necessary to designate a Medical Director for each location that HBO2 is administered or does it suffice to designate a Medical Director for an organization that administers HBO2 at multiple sites?

Thank you for your question. Unfortunately this response does not include the international community and is predominantly from a perspective of the USA. The safety committee is of the consensus that in general it is best practice to have a designated medical director at each facility. This position would assume the responsibility and champion day to day activity at that site. The staffing guidelines in the 2nd edition of the UHMS Guidelines for Hyperbaric Facility Operations contain language specifically for a licensed medical facility. We would expect to see a medical director for the hyperbaric service to be credentialed at the facility with all of the appropriate state medical licensure. This does not mean that there could not also be another level of medical supervision for organizations with multiple sites. Having a medical director over all the sites would provide continuity between the sites.

There is no “pat” answer for this question. For example we are aware of at least two locations in the USA where one medical director and staff operate out of two separate hospitals. The procedures, personnel, patients and equipment are shared between the hospitals as if they were simply on separate floors of the same hospital. In this scenario we would agree that one medical director would suffice. Local jurisdictions and medical privileges differ between states and Advanced Practioners such as Physician’s assistant and Nurse Practioners play a role in the process as well.

The 2005 UHMS accreditation manual lists the requirements for the medical director. This is also available on the web site https://www.uhms.org/

The UHMS has position statements for Clinician Attendance of Hyperbaric Oxygen Therapy, March 2009 and, Standards for Clinical Hyperbaric Treatment Facilities, March 2009. Physician oversight is certainly a condition for reimbursement as well as good practice.

The National Board of Diving and Hyperbaric Medical Technology has a position statement regarding Physician Attendance and Supervision of Hyperbaric Oxygen Therapy (2010-01) April 2010 (Rev. July 2013) http://www.nbdhmt.org/index.asp

The SC is not aware of a specific code requiring a single medical director. The NFPA 99 Health Care Facility’s Code puts the responsibility for this decision on the governing body. NFPA 99 has specified a safety director since 1968. The NFPA 99 Health Care Facility’s Code Handbook (page 544) has a corollary to the question of a requirement for a medical director in section 14.3.1.3.2: “Can a single safety director be responsible for multiple facilities in different locations?” The answer:  “Some organizations manage multiple hyperbaric facilities in different regions and have designated a single safety director for all their facilities.  The intent of the requirement is not to discourage that type of support structure, but there must be an individual at each facility who assumes the responsibilities of the safety director described in this chapter.”
The medical director for the hyperbaric facility is cited in NFPA-99.  There are two mentions, 14.3.1.4.2 - The medical director of hyperbaric medicine and the safety director shall jointly develop the minimum staff qualifications, experience, and compliment based on the following….” And - A.14.3.1.3.2 …. Due to a conflict of responsibility, the same individual should not serve as both medical director and safety director.  There are also a few other mentions of “hyperbaric physician”.


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.

pdfClinical Hyperbaric Facility Accreditation Manual 2005 Edition ( Revision 1)

pdfCredentialing and Privileging Requirements For Hyperbaric Medicine Physicians

I would like to use a BIS monitor in our monoplane chamber. What steps are important to clear this device for our use?
Published: 22 February 2016

I would like to use a BIS monitor in our monoplane chamber. What steps are important to clear this device for our use?

I would like to use a BIS monitor in our monoplace chamber. What steps are important to clear this device for our use? It is a current 4 Chanel BIS monitor. Resistance free cable can be fabricated in conjunction with electrical 19 pin penetrator. Inside the chamber we would only have the BIS sensor and the cable.


Regarding: Important steps to consider before using equipment in the hyperbaric chamber.

The question of how to approve medical equipment for hyperbaric use comes up quite often. The UHMS safety committee can provide resources and information but the responsibility for testing and evaluating equipment for use with the clinical chamber is with the medical director and safety director of the facility. There are very few medical devices that have hyperbaric medicine listed as one of the “approved” conditions. The UHMS has presented a Safety Pre-Course to the 2013 and 2015 Annual Scientific Meetings that included lectures on approval of equipment.

In regards to the question of the BIS 4 channel monitor. It sounds as though you have managed getting the patient lead through the hull. You will need a proper, pressure proof thru-hull connector, and matching plug ends for the cable. The “sensors’ appear to transmit signals out the chamber and if there is no current flow into the chamber, it appears to be safe. The manufacturer needs to be contacted to confirm that the signals pass out and are not amplified in the chamber. There is neither, sufficient evidence in the brochure, nor on the website to clarify this. 

Some thoughts to consider are:

  • The National Fire Protection Association 99 Health Care Facilities Code, 2015 edition, Chapter 14, lists the temperature, electrical limits and responsibilities of the safety director regarding equipment used in class A and class B chambers. You should have this reference in your library and refer to it when considering the use of non-approved equipment under hyperbaric conditions.
  • At least one major academic tertiary referral institution’s legal team has experience in medical device modification across its entire complex, and the constantly changing needs of subspecialty patient care which include hyperbaric medicine, interprets the current FDA regulations in the following fashion. “The program (modification and testing of medical devices for safe use in the hyperbaric environment) is not subject to FDA regulation. FDA regulates manufacturers and not the practice of medicine. Physicians are able to use FDA approved products other than under the labelled indications as long as the physician meets certain criteria."
  • The FDA’s statement on this off-label use is as follows:
    “Good medical practice and the best interests of the patient require that physicians use legally available drugs, biologics and devices according to their best knowledge and judgment. If physicians use a product for an indication not in the approved labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain records of the product's use and effects. Use of a marketed product in this manner when the intent is the "practice of medicine" does not require the submission of an Investigational New Drug Application (IND), Investigational Device Exemption (IDE) or review by an Institutional Review Board (IRB).”
  • It should be noted that any modifications to the device or use other than as recommended by the manufacturer risks voiding any warranty on the product.

References:

  1. NFPA 99, Health Care Facilities Code, 2015 edition
  2. Food and Drug Administration, http://www.fda.gov/default.htm
  3. Burman F., “Risk Assessment Guide,” Fifth Edition, 2015, (Ref. 1.6.1 - 1.6.21)
  4. Burman F., Sheffield R., Posey, K., “Decision process to assess medical equipment for hyperbaric use.” UHM 2009, Vol. 36, No. 2

pdfBIS™ Brain Monitoring Solutions - Enhance perioperative outcomes with patient-targeted anesthesia.

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.

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)

  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?

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.

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.
    1. 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.
    2. 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, 2015 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.

Are there current guidelines pertaining to the number of HBO2 technicians that need to be present during a hyperbaric treatment?
Published: 04 May 2016

Are there current guidelines pertaining to the number of HBO2 technicians that need to be present during a hyperbaric treatment?

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.

Regarding: Guidelines for number of HBO2 technicians that need to be present during hyperbaric oxygen therapy.

The National Fire Protection Association (NFPA) 99 Health Care Facilities Code, 2015 edition 14.3.1.4.2 States that the medical director and safety director shall jointly develop the minimum staffing qualifications, experience, and complement based on the following.

  1. Number and type of hyperbaric chambers in use
  2. Maximum treatment capacity
  3. Type of hyperbaric therapy normally provided

The UHMS Guidelines for Hyperbaric Facility Operations, 2nd edition provides guidance in section 3, Staffing Guidelines.

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.

An external fixator is on a patient that has been referred for treatment, the doctor states the metal is a hydrocarbon, is this safe in a monoplace chamber?
Published: 03 May 2016

An external fixator is on a patient that has been referred for treatment, the doctor states the metal is a hydrocarbon, is this safe in a monoplace chamber?

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.

Regarding: Hydrocarbon External fixators in a monoplace chamber.

We are not aware of any Hydrocarbon external fixators and without more information we are offering a generic statement with regards to fixators. External fixators are, in general, safe in the monoplace chamber, but they should be padded to protect the chamber from damage if the patient has a seizure or if the fixator has contact with the chamber window in some manner.

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.

If a facility performs off-label treatment is a separate informed consent recommended or required?
Published: 18 May 2016

If a facility performs off-label treatment is a separate informed consent recommended or required?

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.

Regarding: Informed consent required for off label use.

Informed consent is required for any medical procedure. This is the responsibility of the medical director.

 
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.

Have we definitively proven any tapes to be safe in the monoplace environment, and can the data be viewed?
Published: 18 May 2016

Have we definitively proven any tapes to be safe in the monoplace environment, and can the data be viewed?

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.

Regarding: Proof of any tape being safe in the monoplace environment:

The SC has posted several manufacturer notices regarding materials on the UHMS web site under; Publications, Safety Documents, Manufacturer Notices. These are under review and need to be updated. Please contact the manufacturer for the most recent information.

The UHMS Ad Hoc Material Testing Advisory Committee is working on this type of question and we hope to have something to use from that project soon.


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.

Can chambers be used for off-label treatment if it is not listed on the chambers 510K approval?
Published: 17 March 2016

Can chambers be used for off-label treatment if it is not listed on the chambers 510K approval?

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.

Regarding: Use of chambers for off label treatment not listed on the 510K

The Food and Drug Administration does not practice medicine, the 510K is a manufacturer’s document and a physician may use a device outside of the parameters listed on the 510K. Any physician may use any drug or device in an off-label manner.  This is what their license allows them to do.  However, they cannot advertise or market the fact that they are using the drug or device for an off-label indication.  The marketing restriction applies not only to the manufacturer but to the user of the device.  The FDA has issued warning letters to facilities to promoting the use of a hyperbaric chamber for off-label indications. A medical doctor may, if in the best interests of the patient, use a device for something for which its approval was not given

Physicians have a responsibility to justify, including the risk management, all their decisions and they need to answer to these before their peers. For example; using a ventilator in a chamber which does not have FDA clearance is not in itself wrong as long as the device is a medical one and the physician has assessed all the risks.

Considerations for using a “bag” chamber or any HBO2 chamber for non-approved indications: If a physician does this, his controlling body should surely sanction this? If advertised as medicine, then surely there are consequences if there is no healthcare practitioner? If the chamber is in a public place, surely the local fire marshal or pressure vessel inspector has some jurisdiction? In the USA the National Fire Protection Association (NFPA) 101 Life Safety Code refers any occupancy to the NFPA 99 Health Care Facility Code for hyperbaric medicine.

Then, as expressed by the European College of Hyperbaric Medicine at their recent conference: “If it is a non-recognized treatment, you can only do this as part of an ethically approved project and not for reimbursement.”


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 am unable to find documentation regarding specifications for the required smoke hood for multiplace chambers. The ones we have on hand are about to reach their expiration date & that particular brand does not seem to be available at this time. There is
Published: 18 May 2016

I am unable to find documentation regarding specifications for the required smoke hood for multiplace chambers. The ones we have on hand are about to reach their expiration date & that particular brand does not seem to be available at this time. There is

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.

Regarding: Required alternative source of breathing air for multiplace and monoplace chambers.

The National Fire Protection Association, NFPA 99 Health Care Facilities Code, 2015 edition, chapter 14: 14.2.4.5.3* states, “A means for respiratory and eye protection from combustion products allowing unrestricted mobility shall be available outside a Class A or Class B chamber for use by personnel in the event the air in the vicinity of the chamber is fouled by smoke or other combustion products.”

This requirement may be met by several different devices; these range from umbilical-supplied smoke hoods and self-contained breathing apparatus, to the emergency escape hoods. Whichever device you choose, you must also meet any OSHA and local authority requirements for training, maintenance, documentation and medical fitness to wear the device.

NFPA does not specify the type of device only that you have one.

We suggest that the selection of the device depends on the type of chamber and patients treated at your facility, together with the degree of emergency support to the unit, the distance to the nearest area of safety and the number of patients that need to be evacuated. These factors have a bearing on the length of time that the operator needs to be able to remain in a smoke-filled area. Emergency drills with the various devices should be carried out to evaluate how they will work in your environment. Work with the manufacturer of your facility and engage the industrial hygienist in your hospital. Document your decision process, maintenance and training.

The UHMS accreditation survey probes HBOV 2.0, 2.1, 2.2, 2.3, 2.4 and 2.5 addresses this question as well. The survey does not specify the type of alternative breathing air apparatus.

For references see:
Rubicon, http://rubicon-foundation.org/

  • NFPA Mandated SCBA Type Capability Within Clinical Hyperbaric Facility: An Analysis of the Types and Frequency of use, Canterbury B; Baker B
  • Chamber Fire Safety, Schmidt, TC; Dorr VA; Hamilton JR RW
  • Selecting Smoke Hoods for Hyperbaric Facilities, Wood S
  • NFPA 99, 2015 edition, chapter 14 Hyperbaric Facilities
  • UHMS Clinical Hyperbaric Facility Accreditation Manual (Rev1)
  • NIOSH, “NIOSH RESPIRATOR SELECTION LOGIC,” 
  • OSHA Regulations standard 29 CFR personal protective equipment 1910.134 respiratory protection

 
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.

If a metered dose inhaler was to be used in a chamber would the dose delivered be the same as if given at 1 ATA?
Published: 30 June 2016

If a metered dose inhaler was to be used in a chamber would the dose delivered be the same as if given at 1 ATA?

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.

There is an article on the topic of the use of MDI in a multiplace chamber, UHM 2009, Vol. 36, No.1 Inhaler Performance under Hyperbaric Conditions. The conclusion was “We conclude that the weight change per actuation of albuterol and the sizes and numbers of aerosol particles emitted from albuterol MDI’s actuated in a hyperbaric environment varied by canister type.

This paper can be a useful reference when evaluating asthmatic – COPD patients. The final decision needs to be made by the medical director after a thorough risk assessment & weighing other options.

There are some additional thoughts the SC would include on this topic.

  • The Mechanical Delivery, which is adequately addressed by the referenced study.
  • The Pharmacological component which is also addressed by the study.
  • Due to delivery variations associated with MDI’s, a random survey of facilities indicates that there are a number of approaches which often include additional “puffs”, especially when delivery is through an ETT.
  • The use of a spacer or holding chamber is highly recommended for MDI delivery as it improves particle deposition in the airway.
  • The Safety Data Sheet for the propellant indicates that it is non-flammable and has a flammability rating of zero.
  • In personal communications, at least one manufacturer indicates that their MDI’s do deliver the prescribed dose at various barometric pressures, admittedly this has not been tested by the manufacturer at 2-3 ATA.
  • This device should not be used during compression or decompression to avoid barotrauma

pdfMaterial Safety Data Sheet

pdfAlbuterol metered dose inhaler performance under hyperbaric pressures

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.

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

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.

The 2015 NFPA 99 Health Care Facilities Handbook, 14.3.2.5* prohibits equipment made from cerium, magnesium and magnesium alloys in the hyperbaric chamber.  There is concern expressed within the handbook annex, A14.3.2.2 regarding the potential risk of many products. Iron alloys, aluminum, human skin, plastic tubing etc may not self-extinguish. Titanium and Titanium alloys are not specifically prohibited in the hyperbaric chamber by NFPA 99.

Oxygen compatibility testing is complicated and there is little data available for materials in clinical chambers, self-ignition temperatures are generally unknown in special atmospheres. The concern is that if a piece of titanium is broken, enough energy could be produced by the stress fracture to ignite the titanium in a high oxygen environment. 

All equipment taken into a hyperbaric chamber should be evaluated for any associated risk. 

Equipment made of titanium and titanium alloys should be evaluated before use in the hyperbaric chamber. Each product should be evaluated before use.  A common example is the titanium eyeglass frames. It is unlikely that a patient wearing eye glasses made from a titanium alloy would be able to break the frames with enough energy to initiate combustion at 30 psig and near 100% oxygen. Further, multiplace and monoplace chambers operate under the threshold temperatures for a flammability concern with solid titanium.  The loose powder or fines of titanium that are a concern are not present with this device.   Any amount of powder, or filings, should never be allowed into the chamber. Manipulation of eyeglass frames or jewelry while in the hyperbaric chamber should be prohibited.

  1. Evaluate each piece of equipment containing titanium or titanium alloys before using in the chamber.
  2. Document the process
  3. Solid titanium is safe to use in the chamber during normal operations.

References

NFPA 99 Health Care Facilities Handbook 2015 edition

Corrosion Resistance of titanium, Titanium Materials Corporation, TIMET, pp20 figures 13 & 14

Electronics Space Products International, MSDS Sheet, Titanium, (Ti)

Safety-Related Problems in the Titanium Industry in the last 50 years, Poulsen, JOM, 52 (5) (2000), Safety Guidelines, pg 5 & 6, #5 

pdfA study of the mechanism of the titanium – liquid oxygen explosive reaction, Technical Report ASD-TR-61-479, Directorate of Materials and Process Aeronautical Systems Command, Wright-Patterson Air Force Base, Ohio

pdfTitanium in a Hyperbaric Oxygen Environment May Pose a Fire Risk, AviatSpace Environ Med 2003; 74:1301-2

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.

Can laptop computers be safely operated inside a Class A multiplace environment? What precautions must be taken? Can the computer be operated on battery power? Can the computer be operated on 120 V power? Please explain all safety related issues and regulatory compliance issues.
Published: 20 July 2016

Can laptop computers be safely operated inside a Class A multiplace environment? What precautions must be taken? Can the computer be operated on battery power? Can the computer be operated on 120 V power? Please explain all safety related issues and regulatory compliance issues.

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.

Regarding: Laptop computers in the multiplace

Thank you for the question, this has provided a stimulating conversation. With electronic charting being mandated in the USA it would be attractive to be able to have a laptop in the chamber for patient care purposes. We would not consider a laptop for patient or staff entertainment as this purpose would not be necessary for the treatment and therefore would be prohibited by 2015 edition of NFPA 99, 14.2.8.3.3, Only portable equipment necessary for the safe operation of the chamber and for required patient care shall be permitted in the chamber.

This question is not one that the SC can provide a definitive answer for. A careful risk assessment provided by a competent person must be completed. We are able to provide some general thoughts on the matter; we had opposing viewpoints within the committee. The USN has evaluated two commercial off the shelf “ruggedized” laptops for use in disabled submarines in hyperbaric conditions up to 5 bar. One failed, one worked, we have attached the study for your convenience. There is at least one manufacturer that provides a laptop for use in saturation diving chambers to 450 MSW or 18 msw in 25% O2 in hyperbaric chambers. Therefore, yes it can be done; and no, not all the SC members agreed that we would allow laptops in the clinical multiplace chamber. A detailed risk assessment and testing of the device would need to happen before this was considered. We are not aware of any clinical chambers that are providing laptops in the chamber. We are aware of facilities in the USA and Europe that have installed the monitor, key board and mouse inside the chamber with the CPU outside the chamber. There is at least one facility that installed the CPU inside the chamber as well. So there are alternatives to consider.

Things to consider:

  • The battery pack should be removed. Lithium – cobalt is the most unstable of all the lithium – ion chemistries and Lithium batteries are currently prohibited in the NFPA 99. Please see that attached reference articles. The devise should be able to operate on the multiplace 24 volt supply without the battery pack.
  • The fan helps keep the CPU cooled down.  The fan is designed to operate in a 1 atmosphere environment.  When used at elevated pressures they are trying to move dense air and the additional work load may cause the fan motor to overheat and shut down, causing the CPU to overheat. The SC had differing views on this topic; air density may in fact cause the CPU to run cooler, although we do not know if this increased density would cause the fan motor to overheat.
    NFPA-99 14.2.8.3.12 TEMPERATURE
    No electrical equipment installed or used in the chamber shall have an operating temperature in excess of 85⁰C (185⁰F)
  • The battery and 120V considerations, we are not allowed to charge batteries while the chamber is in use. Many devices are designed to charge the batteries if they are plugged into a 120 V supply. Removing the batteries and providing a 12V supply may be an option for some devices
    NFPA-99 14.2.8.3.17.5 Battery-operated devices
    (4) Batteries or battery-operated equipment shall not undergo charging while located in the chamber.
    (7) Lithium and Lithium ion batteries shall be prohibited in the chamber during chamber operations, unless the product has been accepted or listed for use in hyperbaric conditions by the manufacturer or a nationally recognized agency.
  • NFPA-99 14.2.8.3.10*Concern noted in meeting the requirements of Receptacles inside the chamber, specifically that interruption of power, even low voltage, could produce a spark with enough energy to ignite a flammable agent.
  • Consider inert gas purging of the device.

We hope this helps and look forward to seeing your abstract at a future ASM or UHM journal article on this topic.

pdfDanMedical Analysis System1.94 MB

pdfDanMedical Product Information September 2014554.68 KB

pdfHydra Engineering D-MAS HyperSat250.33 KB

pdfNSMRL TECHNICAL REPORT #1220965.05 KB

pdfFlammability Assessment of Bulk-Packed, Rechargeable Lithium-Ion Cells in Transport Category Aircraft752.02 KB

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.

Can one use and/or obtain a third party (AEM) maintenance company for servicing and repair of their hyperbaric chambers and still meet current accreditation requirements as well as keep in compliance with the Joint Commission?
Published: 11 August 2016

Can one use and/or obtain a third party (AEM) maintenance company for servicing and repair of their hyperbaric chambers and still meet current accreditation requirements as well as keep in compliance with the Joint Commission?

Regarding: The use of a 3rd party or in-house staff to provide Alternative Equipment Maintenance (AEM), or the necessity to use the Original Equipment Manufacturer (OEM) for service and repair of hyperbaric chambers.

The SC can provide information only and the responsibility of maintaining compliance with the UHMS Accreditation Program and The Joint Commission is with the administration, the medical director and hyperbaric safety director of the facility.

We are not aware of a specific survey probe from a UHMS accreditation survey that requires you to use the manufacturer. There are several regarding record keeping, PM schedules, and maintenance of original design specifications.

The Joint Commission (TJC) does have standards for certain facilities that identify when OEM is required and when you can use AEM. Both CMS (December 2013) and The Joint Commission (July 2014) have specific guidelines for hospital preventive maintenance programs.  In the most recent revisions there were changes related to AEM Programs.  The CMS document has the best guideline on how to appropriately place a piece of equipment on an AEM program and should be read carefully.

Below is a summary of the CMS Hospital Equipment Maintenance Guidelines that was published in a memo on December, 2013 (see attachment below).

Memorandum Summary
S&C 12-07-Hospital Superseded: We are updating previously provided guidance to clarify:

  • Hospital facilities, supplies and equipment must be maintained to ensure an acceptable level of safety and quality.
  • A hospital may adjust its maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel, unless:
    • Other Federal or state law; or hospital Conditions of Participation (CoPs) require adherence to manufacturer’s recommendations and/or set specific requirements. For example, all imaging/radiologic equipment must be maintained per manufacturer’s recommendations; or
    • The equipment is a medical laser device; or
    • New equipment without a sufficient amount of maintenance history has been acquired.
    • Hospitals electing to adjust facility or medical equipment maintenance must develop policies and procedures and maintain documentation supporting their Alternate Equipment Management (AEM) program. They must adhere strictly to the AEM activities and/or frequencies they establish.

There may be good reasons to either use OEM, AEM or a combination of both. Alignment with TJC, CMS and the NFPA requirements, warranty issues as well as defining who is qualified to work on your equipment are important to consider. It is also possible that the manufacturer will refuse to sell OEM parts and require that their own technicians perform the work. Hyperbaric chambers are considered by the FDA as class 2 devices and as such the manufacturer recommendations should be followed. Documentation of the maintenance and compliance with the manufacturer specifications are required to be kept on all equipment for accreditation and for best practice.

Listed below are some things you may want to consider in addition to the above comments when choosing whether to use the manufacturer, your own staff or a 3rd party contractor for maintenance:

  1. This issue should be raised during the initial procurement and/or installation contract. Sometimes it is impossible to get an OEM to agree to another contractor performing maintenance, but it is worth the question before a contract is signed.
  2. A new facility usually has a warranty period and it is unwise to make changes or use other contractors until this period has expired.
  3. The OEM, where still available or in existence, may have proprietary software installed, making this difficult to circumvent.
  4. In some cases, the OEM does not offer services that are to the satisfaction of the chamber owner; as such, the owner should be allowed to employ a contracting company on the basis of: proven competence and track record; servicing equipment & expertise; and at least some degree of investigation as to these aspects. It is only the owner that can declare a service provider as competent as the owner takes responsibility for the safety of the services being offered.
  5. A hyperbaric facility may contain aspects not covered by the chamber OEM – examples are compressors, filtration systems, gas supplies, electrical supplies, computer (patient) monitoring systems, medical equipment and so on. It would be wiser to contact these OEM’s for servicing, unless the chamber OEM has modified the equipment and provided some form of warranty for these changes.
  6. With an older chamber, where the warranties and any guarantees have expired; it is a fair question and should be investigated.
  7. The main issue, though, is to determine that the external (AEM) contractor has a full and working knowledge of the chamber. This they need to demonstrate to the satisfaction of the chamber owner.
  8. It is about competence of the person(s) completing the work, safety and the documented maintenance (together with the needed testing after any maintenance work has been conducted).
  9. The contractor needs to warranty their work for a period after the work has been completed. This is not the same as an OEM warranty when the system is new.
  10. The contractor should show proof of liability insurance in the event that some mistake is made, jeopardizing the integrity of the chamber or causing harm to any personnel or occupants.

pdfCenter for Clinical Standards and Quality /Survey & Certification Group177.75 KB

pdfClinical Hyperbaric Facility Accreditation Manual 2005 Edition (Revision 1)616.26 KB

pdfAccepted: New Hospital Requirements to Maintain Alignment with CMS217.1 KB

pdfStandards Revisions and Clarifications Related to Medical Equipment and Utility System Maintenance117.95 KB

pdfComparison of CMS Preventive Maintenance Regulations67.75 KB

 
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.

NFPA99 14.2.9.1.1 states all communication equipment inside a hyperbaric chamber shall meet the requirements set forth in 14.2.8.3.16 This states that the electrical "rating" of chamber speakers shall not exceed 28V rms and 25W. are we to assume that a higher rated speaker can be used inside the class B chamber? Just looking for little more clarification on this statement.
Published: 06 August 2016

NFPA99 14.2.9.1.1 states all communication equipment inside a hyperbaric chamber shall meet the requirements set forth in 14.2.8.3.16 This states that the electrical "rating" of chamber speakers shall not exceed 28V rms and 25W. are we to assume that a higher rated speaker can be used inside the class B chamber? Just looking for little more clarification on this statement.

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.

Regarding: NFPA 99 14.2.9.1.1

The UHMS SC is not able to provide a formal interpretation of NFPA code. Jonathan Hart NFPA Staff Liaison, gave an informal response to this question in the NFPA XChange, members only section of the NFPA website. Mr. Hart has given us permission to duplicate his reply and disclaimer (below). In addition to Mr. Hart’s reply, the UHMS SC response can be found below.

Response from Jonathan Hart (NFPA):

“The answer from the language in the code is clear that there is no leeway provided. It applies to the maximum rating of the speaker and therefore any speaker with a rating higher would not be in compliance. An alternative approach could be argued under the Equivalency clause of Chapter 1 provided it were acceptable to the AHJ involved in the decision. My discussions with committee members on this topic indicate that there needs to be a bigger discussion within the committee next code cycle to determine the purpose of this clause and clarify if it is truly the rating we are worried about or the output of a system to the speaker itself. Because it is not clear as of now, the code has to stand on its own as written.

Important Notice: Any opinion expressed in this correspondence is the personal opinion of the author and does not necessarily represent the official position of the NFPA or its Technical Committees. In addition, this correspondence is neither intended, nor should it be relied upon, to provide professional consultation or services.”

Response from UHMS SC:

Throughout the Hyperbaric Facilities chapter of NFPA 99 (2015 edition), one consistent protection strategy is to limit power levels in Class B (monoplace) chambers more so than in Class A chambers. To this end, communication systems for Class A and Class B chambers are addressed differently in different sections of the code. Section 14.2.8.3* Wiring and Equipment Inside Class A chambers, and all the subsections of 14.2.8.3 were intended for multiplace chambers. Section 14.2.8.6 Additional Wiring and Equipment Requirements inside Class B chambers, was intended for monoplace chambers.

The wording of paragraph 14.2.9.1.1 implies that all communications equipment located inside a chamber (monoplace or multiplace) should comply with the requirements of the section intended for multiplace chambers. Because of the difference in power limits, it would be inappropriate for monoplace chambers to use electrical design rules from a section intended for multiplace chambers. A Tentative Interim Amendment (TIA) to NFPA 99 has been proposed to alter the wording of paragraph 14.2.9.1.1 in order to avoid future confusion about this issue.

We would encourage you to get involved with the NFPA code process. The 2018 edition of NFPA 99 is in its second draft and there is no mechanism to add new business at this point. If you have specific changes you would like to see, please consider making a public input for the 2021 edition of NFPA 99 when that cycle is open.

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 currently have a new HBO patient that is requesting to have water in the chamber with "Thick-It" added as he has swallowing issues. Does anyone have experience with this or have any reason to not have this in the chamber. The only ingredients are modified food starch and maltodextrin.
Published: 03 October 2016

We currently have a new HBO patient that is requesting to have water in the chamber with "Thick-It" added as he has swallowing issues. Does anyone have experience with this or have any reason to not have this in the chamber. The only ingredients are modified food starch and maltodextrin.

There are no issues with patients consuming “Thick-It” in the hyperbaric chamber regardless of monoplace or multiplace.

If a CHT is ivolved with off-label treatment is there any threat to their certification?
Published: 18 May 2016

If a CHT is ivolved with off-label treatment is there any threat to their certification?

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.

Regarding: CHT involvement with off label hyperbaric oxygen therapy.

This question is best answered by the National Board of Diving and Medical Technology. Please contact them at http://www.nbdhmt.org/index.asp and consider the Code of Conduct and CHT Resource manual attached.

pdfCode of Conduct - 2012353.83 KB

pdfCertified Hyperbaric Technologist® Recertification Form732 KB

 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 an oxygen filled monoplace chamber are the same policies used as an air filled multi-place setting in regards to flying after treatment. I have been telling patients not to fly but wanted to double check anyways.
Published: 20 April 2016

In an oxygen filled monoplace chamber are the same policies used as an air filled multi-place setting in regards to flying after treatment. I have been telling patients not to fly but wanted to double check anyways.

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.

Regarding: Flying after hyperbaric oxygen therapy

The UHMS defines hyperbaric oxygen therapy (HBO2) as an intervention where an individual breaths near 100% oxygen intermittently while inside a hyperbaric chamber that is pressurized to greater than sea level pressure. For clinical purposes this pressure meet or exceed 1.4 atmospheres absolute of pressure while breathing near 100% oxygen.

If your patient is breathing near 100% oxygen as in the definition then there would be no restriction from flying we are aware of because of the HBO2. There may be some other reason for not flying but the patient will not absorb enough nitrogen during HBO2 in an oxygen filled monoplace to be at risk for decompression illness.

The inside attendant in a multiplace would have restrictions on flying as they are breathing air for much of the time at pressure and therefore will need to follow the rules for diving such as the USN diving manual or other.

For reference:
In chemistry, Henry's law is one of the gas laws formulated by William Henry in 1803. It states: "At a constant temperature, the amount of a given gas that dissolves in a given type and volume of liquid is directly proportional to the partial pressure of that gas in equilibrium with that liquid."

UHMS Hyperbaric Oxygen Therapy Indications, 13th Edition

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 HBO centers required to have EKG/ECG monitoring equipment readily available?
Published: 03 May 2016

Are HBO centers required to have EKG/ECG monitoring equipment readily available?

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.

Regarding: Requirement for HBO2 centers to have EKG/ ECG monitoring.

This depends on the acuity of the patients you are treating and the qualifications of the medical staff: this should be congruous with your stated scope of services. We are not allowed to lower the level of care. For facilities in a Health Care Occupancy that would mean, yes, you would need to be able to monitor EKG/ECG as there will most likely be inpatients or emergencies where monitoring would already be in place and to discontinue it would be incorrect.

For a facility with outpatients only, this might mean that you would not be required to monitor patients with EKG/ECG during hyperbaric oxygen therapy. We would caution you to be aware of the patient population you serve and especially the stated scope of such services.

If you do monitor this also implies that you have qualified personnel available that can interpret what they are seeing on the monitor and provide ACLS / BLS support as necessary. It also stands to reason that any equipment used to monitor patients must be integrated safely into the chamber system.

For reference please see:
UHM 2016, Vol.43, No1 – Hyperbaric programs across the United States. Walter Chin, Laura Jacoby, Olivia Simon, Nisha Talati, Gracelene Wegrzyn, Rachelle Jacoby, Jacob Proano, Susan E. Sprau, Gerald Markovitz, Rita Hsu, Ellie Joo

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.

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

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.

Regarding: Treating a patient with a peritoneal dialysis catheter.

This is a question for your medical director, there may be medical reasons why this patient should or should not be treated in the chamber. The catheter in and of itself does not present a safety hazard in the chamber.

 
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 evidence for limiting linens in a monoplace chamber to a minimum of 50% cotton/polyester blend? I understand the fire risks of synthetic fibers, but why is the cutoff 50%?
Published: 24 November 2016

What is the evidence for limiting linens in a monoplace chamber to a minimum of 50% cotton/polyester blend? I understand the fire risks of synthetic fibers, but why is the cutoff 50%?

Thank you for your question. The UHMS Hyperbaric Oxygen Safety Committee (SC) can provide information, but ultimately the responsibility the lies with the Medical Director and Hyperbaric Safety Director of your facility.

Regarding: Concerning evidence for limiting linens in the monoplace to 100% cotton or minimum 50% cotton/poly blend.

The SC recommends submission of the question to the National Fire Protection Association, NFPA, 99 Health Care Facilities Code (http://www.nfpa.org). The NFPA has a process for the formal interpretation of these types of questions. There are several members of the SC that are also committee members of NFPA 99. Therefore, we need to add the disclaimer that this is our opinion and not a formal interpretation of the NFPA code. Testing has been completed on 55/45 cotton/poly blend fabric by the UHMS Ad Hoc Materials Testing Advisory Committee (MTAC) with more testing scheduled for January 2017. MTAC is expected to publish results is mid-2017.

Please see an excerpt below copied from the 2015 NFPA 99, Health Care Facilities Handbook:

14.3.1.5.4.1 Except where permitted in 14.3.1.5.4.3, silk, wool, or synthetic textile materials, or any combination thereof, shall be prohibited in Class A or Class B chambers.

14.3.1.5.2.2 Garments permitted inside of chambers shall be as follows:

(1) Garments fabricated of 100 percent cotton or a blend of cotton and polyester fabric shall be permitted in Class A chambers.
(2) Garments fabricated of 100 percent cotton, or a blend of cotton and polyester fabric containing no more than 50 percent polyester, shall be permitted in Class B chambers.

Why is this important?

The intent of this paragraph is to make common textiles an option in hyperbaric chambers.  The amount of polyester is limited in Class B chambers to reduce the amount of static electricity.  In general, cotton generates less static charge than synthetic material.  However, pure cotton tends to produce lint, and accumulated lint or dust in a hyperbaric chamber is an easily ignitable fuel. Selection of textiles for the hyperbaric chamber should be based on a variety of factors, including comfort, lint production, ignition temperature, static-producing properties, and fuel load of the material.  The percentage of polyester in a cotton/polyester blend can have an effect on all of these factors.

Historically, all synthetic fabrics were prohibited in the chamber.  However, previous editions of NFPA 99 allowed an “antistatic blend of cotton and polyester” because of one specific fabric – a blend of cotton and polyester with steel fibers, originally intended for surgical scrubs – whose conductive properties made it a good choice for hyperbaric garments.  The polyester in the fabric was deemed acceptable because the conductive properties of the fabric actually afforded some protection from static production that cotton fabric did not.  Unfortunately, this particular fabric is no longer made.  Selection of textiles has always been about balancing various safety concerns.  Further guidance on selecting appropriate textiles can be found in A.14.3.1.5.4.3.

For the 2015 edition of the code, a differentiation was made between the garments permitted inside of Class A and those permitted in Class B chambers.  There is now a maximum limit on the percentage of polyester permitted in blends that are allowed in Class B chambers.  This is based on the different risks for each type of chamber.  Class A chambers typically maintain an oxygen concentration below 23.5 percent and have fire suppression capability; the opposite can be said for Class B chambers.

A.14.3.1.5.4.2 Selection of textiles for the hyperbaric chamber should be based on a variety of factors, including comfort, lint production, ignition temperature, static-producing properties, and fuel load of the material.  The amount of polyester in a cotton/polyester blend will likely have an effect on all of the factors.

Historically, all synthetic fabrics were prohibited from the chamber.  Previous editions of this code allowed an “antistatic blend of cotton and polyester” because of one specific fabric – a blend of cotton and polyester with steel fibers to make it conductive.  This blended fabric was intended for surgical scrubs, but its conductive properties made it a good choice for hyperbaric garments.  The polyester in the fabric was acceptable because the conductive properties of the fabric actually afforded some protection from static production that cotton fabric did not.  This particular fabric is no longer made.  Selection of textiles has always been about balancing various safety concerns; primarily fire-resistance and static production.  For further guidance on selecting appropriate textiles, see A.14.3.5.4.3.

14.3.5.6  All other fabrics used in the chamber, such as sheets, pillow cases, and blankets, shall conform to 14.3.1.5.4.1 and 14.3.1.5.4.2”


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 with HBO2 in a monoplace chamber if the individual is having a BSN fiberglass cast put on biweekly?
Published: 25 November 2016

Is it safe to treat a patient with HBO2 in a monoplace chamber if the individual is having a BSN fiberglass cast put on biweekly?

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.

Regarding: BSN Fiberglass cast in a monoplace chamber..

The manufacturer of the cast states that the curing levels reach a high point after approximately 1.5 hours and suggests that hyperbaric therapy could commence soon after the cast was applied. There is also an abstract on http://archive.rubicon-foundation.org/10534 regarding a plaster surgical cast during hyperbaric oxygen therapy.

We see no reason that a patient could not be treated in a monoplace chamber when the BSN fiberglass cast is applied bi-weekly. You are encouraged to follow the manufacturer’s recommendation of 1.5 hours as a minimum prior to hyperbaric therapy. The cast should be wrapped with a soft cotton or minimum 50% cotton / poly blend blanket or towel to protect the chamber acrylic from damage in case of a seizure.

References:
BSN Medical manufacturer notice regarding the fiberglass cast and HBO2
UHMS 2012 ASM, abstract Safety of Plaster Cast Material During Hyperbaric oxygen Therapy.

PDFoff-loader_HOT.PDF


 
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 multiplace setting, what treatment table is used for Acute CO poisoning? When does tender go on O2? I was presented a Weaver Protocol that appears to have been developed for monoplace chambers as it has patients on O2 during descent and ascent and does not take into account a tender in a multiplace setting. Can anyone send me their Multiplace CO Treatment table?
Published: 22 December 2016

In the multiplace setting, what treatment table is used for Acute CO poisoning? When does tender go on O2? I was presented a Weaver Protocol that appears to have been developed for monoplace chambers as it has patients on O2 during descent and ascent and does not take into account a tender in a multiplace setting. Can anyone send me their Multiplace CO Treatment table?

Weaver, Bell, et al published a paper in 2002 in NEJM on how they operate in a multiplace environment for CO and they are at altitude. Also attached is their paper from UHM – see Figure 3.

Hampson, et al published two papers on the subject, including the 2012 paper addressing treatment pressure and the 2005 paper addresses treatment number.

pdfHyperbaric treatment of patients with carbon monoxide poisoning in the United States

pdfThe UHMS/CDC Carbon Monoxide Poisoning Surveillance Program Three-year data

pdfDecompression tables for inside chamber attendants working at altitude

We treat patients on a treatment table in a multiplace chamber where we pressurize to 14 m or 46 FSW pressure equivalent (1 meter sea water = 3.29 foot sea water) for 100 minutes. USP O2/air break periods are 30 min`s USP O2, 5 min air and decompress in 7 min to the surface...
Published: 03 February 2017

We treat patients on a treatment table in a multiplace chamber where we pressurize to 14 m or 46 FSW pressure equivalent (1 meter sea water = 3.29 foot sea water) for 100 minutes. USP O2/air break periods are 30 min`s USP O2, 5 min air and decompress in 7 min to the surface...

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: We treat patients on a treatment table in a multiplace chamber where we pressurize to 14 m or 46 FSW pressure equivalent (1 meter sea water = 3.29 foot sea water) for 100 minutes. USP O2/air break periods are 30 min`s USP O2, 5 min air and decompress in 7 min to the surface.

We want to know, can/should the inside staff member breathe USP O2 during the first, second or third 30 minutes of the table to potentially avoid missing decompression if the treatment needs to be aborted.

The reason being, a few times we have had to abort the treatment because the patient is too unstable and if we start breathing USP O2in the first or second 30 min`s period and need to abort the treatment and start decompression (slowly, no stops) after for instance 60 min`s, it will certainly not be a problem to go straight to the surface. It would most likely not be a problem if we go straight to the surface after 60 min`s breathing air at 14 m either, but we there is a concern of increased risk for the inside staff member.

So the questions:

Is there a better treatment table to use? When do the inside staff members breathe USP O2 and for how long?

Have you heard of anyone else using a table where the staff are breathing oxygen routinely in the beginning of a treatment table?


There are several questions in this query and many possible ways of looking at this. This reply is assuming the chamber is at sea level (or at least below 1000 feet altitude).

The SC is not aware of facilities routinely pre breathing oxygen to affect the inside tenders decompression obligation.

The SC would recommend using the USN dive tables rev 7 Dec, 2016, as a gold standard for planning purposes. The USN alternative shallow water tables (2A-1 ) has an option for 46 fsw which has a no decompression limit of 116 minutes which would work well for an inside attendant on a 46 fsw for 100 minute treatment profile. The standard air decompression table, entered at the exact or next greater pressure of 46 fsw would be the 50 foot profile which has a no decompression limit of 92 minutes. The treatment you describe would therefore require decompression for the inside attendant. The USN 50 / 100 requires one of three choices; a 4 minute stop at 20 fsw pressure for 4 minutes breathing air, a 2 minute stop at 20 fsw breathing O2 or a direct decompression to ambient and back in the chamber and at 50 fsw pressure for 15 minutes of oxygen breathing using surface decompression with oxygen. Surface decompression using oxygen should not be used unless practiced and understood by all members of the team. (1)

Oxygen is certainly being used as a safety measure for inside attendants in multiplace chambers. This is done most often at the end of the treatment and during decompression. This practice has been called “zero time” as the nitrogen clock essentially stops when breathing oxygen at pressure. Since this practice is not scientifically validated, the use oxygen is an adjunct and not a mechanism to stop the bottom time. The USN air tables should be used as written and as if the inside attendant was breathing air for the entire time, regardless of oxygen use or not. The use of oxygen breathing by the IA has shown to be an effective tool in lowering the risk of decompression sickness.

The USN tables are written for the Navy diver in water exposures and have a relatively high rate of DCS. They are not written for the IA in an air environment, and the IA may not be as physically fit as a navy diver. We do not recommend “pushing” the tables to their limits and suggest always staying well below the limits set in the tables. At 46 fsw (2.4 ata) we would encourage the inside attendant to be seated and at rest during oxygen breathing. Unless there is another inside attendant in the chamber the mask(s) should be held in place and not strapped on. (1)(2)

The use of multiplace chambers for long critical care treatment profiles requires the chamber to have double or multiple locks in order to transfer multiplace personnel in and out of the treatment without affecting the treatment pressure for the patient. Rotating staff in and out of the chamber while well within the no-decompression limits protects the IA from decompression obligation without involving SUR-D or omitted decompression procedures.

There are computer models that can be used to supplement the USN diving tables in order to calculate the benefit of oxygen. These models should be taken as secondary sources in your planning. (3) Your physician may also want to look at treating at 45 fsw (2.36 ata) or other pressures for the safety of your IA.(4)

If you have not already done so we would encourage you to build Early Treatment Abort Procedures for all of your treatment profiles and practice them. These abort profiles should enable you to manage medical, mechanical and other changes quickly without putting your IA at an unreasonable risk for decompression sickness.

References:

  1. USN Dive tables rev 7, Dec 2016 (http://www.navsea.navy.mil/Home/SUPSALV/00C3-Diving/Diving-Publications/ accessed 1-16-2017
  2. Hyperbaric Facility Safety: A Practical Guide, Wilber T. Workman, Best Publishing, https://www.bestpub.com/books/product/cid-124.html accessed 1-16-2017
  3. Davis Laboratory- Down loads page http://tanktigers.net/Tech.htm accessed 1-16-2017
  4. How the Davis 2.36 ATA wound healing enhancement table was established, UHM 2004, Vol. 31, No.2 Mini forum on oxygen toxicity and air breaks in HBO2 therapy (https://www.uhms.org/resources/archived-publications.html# accessed 1-16-2017

pdfHow the Davis 2.36 ATA wound healing enhancement treatment table was established

pdfUS_DIVING_MANUALREV7_TT2A.pdf


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.

For a patient with real hair extensions glued together with a keratin glue, is it safe to treat them in a monoplace or multiplace chamber?
Published: 07 March 2017

For a patient with real hair extensions glued together with a keratin glue, is it safe to treat them in a monoplace or multiplace chamber?

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.

The SC reply to a similar question in 2015 and our answered has not really changed. The earlier reply is copied below for your convenience. We were able to locate a Safety Data Sheet for Meta-Keratin III. The fire data on this product in section 5 of the SDS would suggest that it is safe in an un-pressurized air environment. We are not aware of any studies completed at pressure in an oxygen filled monoplace or an air filled multiplace.

(Copied from 2015, no changes)

Regarding information concerning patients wearing hair extensions during hyperbaric therapy.

  • We are not aware of any specific information regarding hair extensions in the chamber monoplace or multiplace.
  • NFPA 99, 2015 edition chapter 14 , 14.3.1.5.4.3 and the annex material relate to textiles and wound dressing not specifically for hair extensions. The risk assessment process may be useful to you.
  • While the UHMS SC would not be in a position to recommend practice in this specific case our general consensus is that if the wig or extension is easily removed then we recommend removing the item. If it is not easily removed consider a tight fitting cap to cover the extension or wrapping with a damp cloth to mitigate any static concerns. Our concern is primarily regarding hair products that are applied soon before a hyperbaric treatment and not enough time was allowed for off gassing of any flammable fumes. Not all hair extensions are glued in and not all are synthetic. This is a local decision to make.
  • Multiplace:  see if patient can tolerate a mask.
  • Monoplace or hood:  Research the details; they will lead you to an answer.
    1. Volume of weave/hair extensions (understand there is a difference between the two!  Although some people use the two synonymously)
    2. Volume of real hair.
    3. List of Material(s) involved: real hair, synthetic hair, metal(s), glues, cure time of adhesive(s), etc.
    4. Washing history, chemical(s) used on it, etc.
    5. Does the facility have the ability to humidify a hood circuit?  If so, and research data doesn’t bring up any major RED flags, consider humidifying the hood.  As always, the facility needs to determine the definition of RED flags.
    6. For some types of weaves/hair extensions there is a service life (recommended to be changed out every “X” amount of time).  If non-emergent, when does the patient plan on getting them removed/changed out anyway?
    7. Last but not least, encourage the patient to have it removed.  However, sometimes that can be a financial and/or vanity deal breaker.

pdfkeratin3_MSDS.pdf


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 appropriate for treating patient after seizure in chamber? Should every patient who has had seizure be treated with valium? Is it needed if they are alert/talking after treatments and vitals/glucose is normal?
Published: 22 February 2017

What is appropriate for treating patient after seizure in chamber? Should every patient who has had seizure be treated with valium? Is it needed if they are alert/talking after treatments and vitals/glucose is normal?

Our patient was a 91 yr old male being treated for osteoradionecrosis. He had a seizure we believe from possible O2 toxicity. He was being treated at 2.5 ATA for 90 min with one 10 minute air break and pressurization rate of 2psi. Seizure happened minutes after his 10 minute air break. Patient did well with air break (given with mask and air tank gauge showed good respiratory effort).

His seizure lasted for ~30 seconds. He never lost consciousness and was alert and talking during decompression and after removal from chamber. He is not diabetic but did check vitals and glucose post tx and all was normal. Patient also had normal vitals, including normal temp prior to tx.

Our NP examined patient pre and post tx. Patient was outpatient so he went home after tx. We do have standing order that we can give 5mg valium for seizures however NP and myself didn’t think it was indicated.

We would like our policy for possible O2 toxicity to be appropriate so your recommendations would be greatly appreciated. What is appropriate for treating patient after seizure in chamber? Should every patient who has had seizure be treated with valium? Is it needed if they are alert/talking after treatments and vitals/glucose is normal?


The responses to the question varied and therefore rather than consolidating them, we are listing them in order of response. Editor

  1. I have a number of comments.  Can you describe this seizure?  Was this a focal seizure without LOC?  I have never seen that during HBO2, but I guess it can happen.  The only ones I have seen were grand mal.  This dose of HBO2 seems a little high for this indication.  Many years ago we went to 2.0 x 90 minutes (at pressure time) for almost all of wound care and radiation injury and still get good clinical outcomes.  Neal authored a letter to the editor in UHM that was convincing that seizures due to HBO2 do not occur at 2.0.  Next, HBO2 may have unmasked an occult seizure disorder. I have seen this several times, in which a patient has underlying brain pathology, including occult seizures (“black out spells” the patient later recalled), so this patient needs to be evaluated for this.  That evaluation typically includes neurology consult with provocative EEG, exam and MRI.  Regarding Valium….If you want seizure prophylaxis for 30 minutes use Valium. If you want it for 2 hours use Ativan.  But before using prophylaxis, it would be prudent to work up the patient first.  I leave the dosing of HBO2 up to that department, but to my knowledge there is no convincing information about 2.5 ATA being superior to 2.0 ATA. LW

  2. Dr. LW "said it all" including questioning the type of seizure, obtaining a neurology consultation, treating at 2 ATA pressures, deferring retreatments until cleared by neurology consultant and use of Ativan rather than Valium. MS

  3. This is a more complicated question than it appears at first glance.  First, I agree that the incidence of oxygen toxic seizures during routine hyperbaric treatment performed at a maximum pressure of 2.0 ATA is vanishingly rare.  There may have been a couple in the history of the world.  This compares to approximately 3-4 in 10,000  routine treatments performed at 2.36 ATA (Welslau 1998, Pflaki 2000, Hampson 2003).

    However, the data are not from a population of nonagenarians.  I'm not sure if we know whether the extreme elderly are more (or less) susceptible to CNS oxygen toxicity.  For that matter, I don't think that we know the response rate to HBO2 with regard to angiogenesis in irradiated tissue in patients of this age.

    Secondly, to my knowledge, no hard data have ever been published either in human or animal models demonstrating that benzodiazepines are effective in either preventing or aborting oxygen toxic seizures.  When administered prophylactically, it may be a self-fulfilling prophecy because oxygen toxic seizures are so rare, including among patients who have had one previously.  The same goes when administering the drugs to abort an oxygen toxic seizure because the seizure will stop whether you administer drugs or not.

    Finally, most oxygen toxic seizures are tonic-clonic, but at least one focal seizure has been reported.  The article is attached. NH

  4. A few points:

    (1). Characterization of the seizure is important. If it was a focal seizure at onset, or as evidenced by Todd’s paralysis afterward, then the patient probably has underlying pathology. Seizures due to O2 exposure alone are generalized at onset, not focal.

    (2). In our facility we observe O2 seizures even at 2 ATA, although uncommonly. Around 50% of these are due to concomitant hypoglycemia.

    (3). Re-institution of O2 after recovery from the seizure rarely causes a recurrent seizure. Nevertheless, many practitioners administer some sort of anticonvulsant, usually a benzodiazepine. When a seizure occurs in a multiplace facility, the optics of restarting the O2 may appear uncaring to other patients. Thus, locking the patient out of the chamber after the seizure has stopped is a common practice, which also allows for closer assessment and appropriate referral. RM

  5. I agree the story is suspicious of something more than a hyperoxic seizure and needs investigation if it was anything but a generalized seizure.

    I was interested to hear the other responses and have a couple of comments:

    1. We also see very occasional seizures but these are (for the last 10 years or so) never associated with hypoglycaemia. That problem seems to have been eliminated with the introduction of an active sugar management program with the diabetic patients.

    2. We treat as a routine at 2.4 ATA in the multiplace, but after the elimination of a rebreathing phenomenon many years ago, we have come down to a low rate of seizures that we have accepted (right or wrong!). It is about 1:8.000 compressions. I noted Lin's post about treating routinely at 2.0 ATA - we have considered the same but rejected it to date based on the fear we cannot be sure about treatment efficacy given the lower inspired oxygen likely in a multiplace compared to the oxygen-filled monoplace at 2.0 ATA. Perhaps this is illogical and I would welcome more from Lin about how that decision was made. 

    3. I am very interested to hear that many would prescribe benzodiazepines for someone who has suffered a hyperoxic seizure. This is not our practice and has not been a problem to date - touch wood. In our counselling, we are very keen to distance these seizures from any notion of epilepsy and this includes the benefit of benzos or other anticonvulsants.

    4. Agree with Richard that it is not a good look to try and put the patient back in the same run. In general, the average hyperbaric patient who suffers a hyperoxic siezure takes some time to recover - rather longer than the classic teaching which is presumably based more on fit young male divers in the Navy than octogenerians with multiple pathologies.... MB

 

Is there any regulations concerning the entry door(s) to a chamber room being secured with a punch code system?
Published: 08 February 2017

Is there any regulations concerning the entry door(s) to a chamber room being secured with a punch code system?

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 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.

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, 2012 edition, 7.2.1.5 Locks, Latches and Alarm Devices and NFPA 99, 2012 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, 2015 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 insure 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?

 
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 am curious what your thoughts are on the use of aerosolized anti-fungal spray directly prior to treatment in a monoplace chamber. The spray in question is generic miconazole nitrate, and the main propellants are isobutane and alcohol.
Published: 11 January 2017

I am curious what your thoughts are on the use of aerosolized anti-fungal spray directly prior to treatment in a monoplace chamber. The spray in question is generic miconazole nitrate, and the main propellants are isobutane and alcohol.

I am curious what your thoughts are on the use of aerosolized anti-fungal spray directly prior to treatment in a monoplace chamber. The spray in question is generic miconazole nitrate, and the main propellants are isobutane and alcohol. Is there any documentation to identify how long after being applied the combustible propellants would be dissipated? I\'m inclined to err on the side of caution and say that it should be applied post treatment, but am having some push back from the physicians. Am I being overly cautious? Or is there any documentation to support my position?


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.

Regarding: The use of aerosolized anti-fungal spray (generic miconazole nitrate) prior to hyperbaric oxygen therapy

The SC would not encourage the use of this product prior to hyperbaric oxygen therapy. The Directions for Use found on-line, list this product as flammable and to avoid inhaling the vapors. We would be concerned about both the flammability of the fumes as well as inhalation of the product. The flammability of the propellants used is concerning, especially in the high concentration of oxygen in the monoplace chamber. There are no studies we are aware of specifically for this product and its use in hyperbaric conditions. Using the Risk Assessment Guide found in the NFPA 99, 2015 Edition, Annex A: A.14.3.1.5.4.3, we would recommend waiting until after the hyperbaric treatment is over to apply this product.

 

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.