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Questions pertaining to medical or patient care

What are the recommendations/contraindications for concurrent HBO and Chemotherapy/Radiation?
Published: 20 January 2016

What are the recommendations/contraindications for concurrent HBO and Chemotherapy/Radiation?

This answer is from the recognized physician expert in the field of hyperbaric medicine dealing with oncological disease – John Feldmeier, DO.

“There is no easy answer to this question. We still struggle to answer the question of whether patients with a remote history can have HBO2.

Although I believe that in almost all cases this would be safe. There is very little published data with concurrent therapy. The issue of concurrent chemo/ HBO2 has next to no published information and really has become a fairly recent issue because patients are now living longer with active malignancy. There are more and more options for systemic treatment and quality of life issues are pertinent for patients even when they have active disease. The scenario where this becomes an issue is when a patient has had prior radiation, has a complication, needs HBO2 but is receiving chemo probably because recurrent or residual cancer has been found.

Chemo comes in many varieties with traditional cytotoxic drugs in at least 8 categories and now with more options including immune therapies and anti-angiogenic therapies. It is impossible to make a universal recommendation applicable to all chemotherapies.

Some of these drugs mediate their anti-tumor response through free radicals which cause chemical bond breaks in the DNA leading to reproductive death. Some are antibiotics: some are spindle cell blockers etc., etc. Those that mediate cytotoxicity through free radicals are likely to have their effect enhanced in the tumor and normal tissues.

This was the basis of using HBO2 as a sensitizer to radiation done from late 50's to early 70's. Since the therapeutic goal is to enhance QOL, this would not be perceived as an appropriate effect.

As I am sure, most of you know Eric Kindwall's book declares there to be a contraindication to Adriamycin and Cisplatin. This precaution is based on pretty weak evidence. On the other hand Dick Clarke has done a preliminary study with colleagues at U of Chicago using HBO2 along with Cisplatin and radiation without signs of increased toxicity.

I am especially concerned about Bleomycin and Avastin. Jake Freiberger, MD of Duke U. has reviewed their experience in treating patients with a PAST not concurrent history of Bleomycin exposure without a demonstrable ill effect. I would not give Bleo concurrently with HBO2. Avastin and some of the other so called biologics (Erbitux) target growth factors including VEGF to exert their effect. Since we enhance VEGF with HBO2 are we diminishing the anti-cancer effects of Avastin? Will HBO2 be effective if VEGF is being suppressed by the Avastin? We don't know.

My operational recommendation is: 1)to avoid chemo and HBO concurrently whenever possible.2) If you do give concurrently wait a few half-lives perhaps 4 or 5 to see serum levels significantly lowered before resuming HBO2 after each chemo administration. Half-lives for all the drugs are published. Avastin is 60 days!! 3) I would avoid Avastin and some of the other biologics as well as Bleomycin as concurrent therapies.“

I wanted to ask whether you had any knowledge of clinical circumstances or literature regarding having a patient with a 20+ year old mechanical aortic valve undergo HBO2. The valve has not been pressure tested by the manufacturer?
Published: 05 February 2016

I wanted to ask whether you had any knowledge of clinical circumstances or literature regarding having a patient with a 20+ year old mechanical aortic valve undergo HBO2. The valve has not been pressure tested by the manufacturer?

There are no pressure-sensitive components in a mechanical valve, since it contains no gas pockets. There are no issues with respect to hyperbaric oxygen therapy regarding a prosthetic valve.

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?

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

The 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 patient may present with conditions that could possibly lead to a lower threshold limit for oxygen toxicity (i.e. fever, low blood sugars, medications).    

A review conducted in 2003 by Hampson & Atik demonstrated an overall seizure rate of 1 in 3,388 treatments or 0.03% (Hampson & Atik, 2003). In 2011 Banham examined the incidence of oxygen toxicity seizures over 41,273 treatments for 3,737 patients and found the overall rate was 0.06% or 6/10,000 exposures with a higher incident rate in patients treated at increased pressures (0.56% at Navy Treatment Table 6 for dysbarism) (Banham, 2011). 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 (Heyboer et al. 2014). Patients treated for CO poisoning or decompression illness have an incidence as high as 0.5-2%, presumably due to a combination of CNS injury and higher PO2 (2.8-3 ATA) used for treatment of those conditions (Hampson et. al. 1996; Banham, 2011). A 2016 retrospective chart review of 2334 patients treated at a hyperbaric center in Israel found a seizure incident rate of 0.3% (7 patients); however, they determined “only one patient (0.04%) had a true oxygen toxicity event” (Hadanny et al. 2016).

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 ATA for up to 19 hours (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). 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 ATA. The time or length of the air break can vary from five (5) to ten (10) minutes (up to 15 minutes for treatment protocols used for decompression illness), typically after 100% O2 breathing periods of 20-30 minutes.

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

Hadanny, A., Meir, O., Bechor, Y., Fishlev, G., Bergan, J., Efrati, Shai. (2016). The safety of hyperbaric oxygen treatment - retrospective analysis in 2,334 patients. Undersea and Hyperbaric Medicine, 43(2): 113-122

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

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

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

 

Do you have any information regarding HBOT and concurrent use of chemotheapeutic agents 1) ixabepilone and 2) faslodex?
Published: 12 July 2017

Do you have any information regarding HBOT and concurrent use of chemotheapeutic agents 1) ixabepilone and 2) faslodex?

None of the drugs have a published experience discoverable on a pub med search.

Based on mechanisms of action I doubt any of the drugs wiuld have their toxicities enhanced by HBO2. However, as you know, the decision to treat a patient with HBO2 who is receiving these drugs is the managing physicians decision and our input is meant only to provide guidance based on the information that is discoverable.

Please see the attachment.

docxChemotx_and_HBO_3_drugs.docx

Can you clarify? For dx of DFU 3 or higher, one of the qualifiers for HBO is that patient failed 30 days of wound care. If the patient''s wound was only a DFU 2 during those 30 days, does that count or does the wound need to be a DFU 3 during those 30 days?
Published: 04 December 2018

Can you clarify? For dx of DFU 3 or higher, one of the qualifiers for HBO is that patient failed 30 days of wound care. If the patient''s wound was only a DFU 2 during those 30 days, does that count or does the wound need to be a DFU 3 during those 30 days?

CMS clearly states must be Wagner Grade III or higher. See links below for the NCD and also for the UHMS CPG for Diabetic Foot Ulcer.

The question concerns a 49-year-old otherwise healthy woman who presented in 2017 with complaints of progressive noise magnification and severe headaches.
Published: 05 December 2018

The question concerns a 49-year-old otherwise healthy woman who presented in 2017 with complaints of progressive noise magnification and severe headaches.

There are several anecdotal reports of HBO2 for brain necrosis. In some radiosurgery series, the incidence of brain necrosis is as high as 25%.As with all CNS injuries early intervention is likely to have a higher rate of success. Determinants of outcome obviously include neurologic symptom response, but some series report decreases in steroid requirements and improvement on brain imaging mostly MRI. In my reading of the literature Avastin does not give consistent response.

I would recommend at least 40 treatments at 2.4 ATA. Many patients appear to require a good number of treatments for sustainable response, perhaps well over 60.To my knowledge no one has reported a higher likelihood of seizures during HBO with this group. If seizure activity is part of the picture adequate coverage with anti-convulsants is obviously needed.

See the below abstract and some pdf of slides from one of my presentations.

John Feldmeier

 

61 year old patient with bilateral optic neuropathy secondary to radiation. Has recently been started on prednisone 80mg daily, vitamin E 1000U daily, and pentoxifylline 400mg TID by neuro-ophthalmology. I know the steroids can increase oxygen toxicity, but that the Vitamin E also decreases this risk. Not sure if they offset each other. No seizure history, no pulmonary history, no history of tobacco use. Plan would be 90 minutes at 2.0 ATA with one 5 minute air break? Should number of air breaks be
Published: 25 March 2019

61 year old patient with bilateral optic neuropathy secondary to radiation. Has recently been started on prednisone 80mg daily, vitamin E 1000U daily, and pentoxifylline 400mg TID by neuro-ophthalmology. I know the steroids can increase oxygen toxicity, but that the Vitamin E also decreases this risk. Not sure if they offset each other. No seizure history, no pulmonary history, no history of tobacco use. Plan would be 90 minutes at 2.0 ATA with one 5 minute air break? Should number of air breaks be

Other history: Previously healthy male diagnosed with grade 4 glioblastoma 10/2017 s/p resection and chemoradiation (completed 1/2018).  Loss of visual acuity bilaterally x 4 weeks, with nearly complete loss of vision on the right.  MRI consistent with radiation optic neuropathy.  Patient hoping to preserve what vision he has left.  Understands data is limited.  Also noteworthy, patient has a known atrial septum defect with bidirectional shunting.

 

A: Treatment for this disorder is recommended. I am always in favor of 2.4 ATA for treatment of radiation injuries especially of the CNS. Many if not most of these patients  are on steroids. In the fairly large series from Laurie Gesell while at U of Cincinnati, these folks were not prone to O2 related seizure though certainly this can happen. The known septal defect is not an issue because we are not talking about an air dive. Treatment with Vitamin E might offer some slight protection. If I were to treat this patient, I would treat 3 30 min periods with 5 minute airbreaks at 2.4 ATA and only depart from this if there was a seizure. Informed consent of course is important. This profile chosen because of the severity of the condition and the track record in treating radiation injuries at 2.4 ATA-also the animal study by Marx et al. The profile you suggest is certainly safe but may not be as effective.

John Feldmeier, DO

Anybody have any experience treating pneumocephaly (complication of epidural injection) with HBOT?
Published: 18 March 2019

Anybody have any experience treating pneumocephaly (complication of epidural injection) with HBOT?

Unless there is a clinical problem besides the presence of air (while will resolve on its own), I see no reason to treat. If there is a desire to accelerate resolution, 100% O2 administration at 1 ATA will do that.

Is there any salutary effects for the use of HBO in aggressive glioblastoma ?
Published: 17 April 2019

Is there any salutary effects for the use of HBO in aggressive glioblastoma ?

As yet, there are no approved or reimbursed indications for HBO2 and the treatment of GBM or the complications of its treatment except for the treatment of radiation necrosis. Please see the attached. It comes from a draft of the about to be published update of the Indications BOOK (HBO2 Committee Report). As such it is unpublished data,.and as such its reproduction is prohibited.

John Feldmeier

Has there been any research to see if there are contraindications to a female patient being dove to 2.4 ATA with a Mirena IUD in place? Will the change in ATA cause an increase or decrease in hormone delivery? (Currently 20mg/24 hrs over 5 years) and 2nd, will the change in ATA increase the risk that the IUD will migrate to perferate the uterus?
Published: 10 February 2020

Has there been any research to see if there are contraindications to a female patient being dove to 2.4 ATA with a Mirena IUD in place? Will the change in ATA cause an increase or decrease in hormone delivery? (Currently 20mg/24 hrs over 5 years) and 2nd, will the change in ATA increase the risk that the IUD will migrate to perferate the uterus?

Date Posted:       3/11/2020


MEDFAQ Question: Has there been any research to see if there are contraindications to a female patient being dove to 2.4 ATA with a Mirena IUD in place? Will the change in ATA cause an increase or decrease in hormone delivery? (Currently 20mg/24 hrs over 5 years) and 2nd, will the change in ATA increase the risk that the IUD will migrate to perferate the uterus?

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

Generally speaking, intrauterine devices are an effective and popular form of birth control. Based upon the frequency of their use, hyperbaric professionals should be prepared to field questions related to the safety of these devices within the unique environment of the hyperbaric chamber.

For the sake of clarity, there are two types of IUDs:

Non-hormonal IUD: These devices are made of copper and may last up to twelve years.

Hormonal IUD: These devices are designed to release small amounts of hormone (typically levonorgestrel) locally into the uterus.  Levonorgestrel causes thickening of the cervical mucus and thins the lining of uterus.

In particular, the Mirena IUD is a hormonal IUD that is made of soft, flexible plastic and does not appear to contain gas spaces that could be affected by changes in atmospheric pressure. As such, the rate of hormone release would theoretically remain unchanged. Furthermore, increased atmospheric pressure at standard hyperbaric oxygen therapy pressures between 2.0 and 3.0 ATA is not expected to increase the risk of uterine wall perforation. Unfortunately, there are no confirmed studies, reports or testing of this product by the manufacturer under hyperbaric conditions that would validate these suppositions.

The UHMS Hyperbaric Oxygen Safety Committee therefore suggests that a risk assessment be conducted by the Safety Director and Medical Director of the Hyperbaric Facility for your particular patient. There are several related references that may assist you in completing the risk assessment and determining the proper course of action. Of note, the Divers Alert Network has responded to several inquiries related to these devices from a commercial or scuba diving perspective. Their position pertaining to intrauterine devices and diving is that an increase in absolute barometric pressure should have no mechanical effect on the IUD, and there is probably no reason to suspect their hormonal bioavailability or metabolism should be affected. The proportion of female divers diving with a IUD should be no different than that of general population, and DAN has never been made aware of any issues with IUD devices, medicated or not.

Related Articles:

http://www.alertdiver.com/womens_health_and_diving

https://www.diversalertnetwork.org/medical/articles/DAN_Explores_Fitness_and_Diving_Issues_for_Women

http://midlandsdivingchamber.co.uk/index.php?id=advice&page=6&cat=10&sub_cat=11

Respectfully,

The UHMS Safety Committee


 DISCLAIMER

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

What are the current guidlines for a non insulin dependent patient in a monoplace chamber?
Published: 21 April 2020

What are the current guidlines for a non insulin dependent patient in a monoplace chamber?

Posted: 4/22/2020


We do not have guidelines for the management of diabetics in the chamber however there are a number of resources available to you, including the attached BNA Nursing Guidelines, Best Publishing’s Policy and Procedural Guidelines for Hyperbaric Facilities (2017) published a recommended scale in policy #304 on page 51 and Best Publishing Company’s Hyperbaric Medicine Practice, 4th Edition (2017) on page 126 in the Hyperbaric Nursing chapter and on page 144 in The Use of Drugs Under Pressure chapter, the topic is covered.

Baromedical Nurses Association (BNA): Guidelines of Nursing Care for the Patient Receiving Hyperbaric Oxygen Therapy (HBO2)

I had COVID-19. Will I be able to return to diving?
Published: 22 April 2020

I had COVID-19. Will I be able to return to diving?

Posted: 4/23/2020


QUESTION: 

I had COVID-19. Will I be able to return to diving? 

ANSWER: 

At the present time, we simply do not have sufficient data to support or refute the definitive proclamations made by this case series. Any attempt to generalize the effects of COVID-19 based upon a single case series (6-cases) published in the lay-press1,2, should be met with appropriate scrutiny.

Covid-19 symptoms range from mild to severe. Some people have no symptoms at all while others require complicated stays in an intensive care setting and require ventilatory support. The recent report published in the lay-press1,2 has resulted in considerable concern related to the finding of pulmonary inflammation in mild cases of COVID-19. This case series reports findings that may provide some insight into post-infection recovery, with a potential knock-on effect on fitness to dive evaluations, and recommendations related to medical follow up studies, and convalescence period prior to a return to diving. However, we must interpret this small case series (6-cases) with caution, as there is not enough known about the natural history of this disease to confidently extrapolate prognostic guidance from this one report, nor generalize these findings to every case of COVID-19. Likewise, calls for a particular medical examination or screening test(s) following infection to determine fitness to dive, based on this work alone, are currently unsubstantiated and premature.

The list of potential variables related to how this disease manifests, its clinical course, and longterm prognosis is lengthy and may include factors such as underlying medical conditions, age, disease severity, and secondary complications. Case reports suffer from multiple design weaknesses to include a lack of controls and randomization, which makes any conclusions that we may want to generalize to a larger population suspect. While these findings are indeed disquieting, it will take time before the potential impact on individual health, and any lasting effects on lung or heart function, are captured in the peer-reviewed literature.

COVID-19 shares many of the same features as other serious viral pneumonias that require a period of convalesce before returning to full activities – a process that can take weeks or months depending on symptom severity. The long-term effects of COVID-19 on pulmonary function and recovery time will vary, and there is insufficient experience and sound clinical research to make accurate prognostic determinations.

As the diving medical community gains more experience, and has the opportunity to study this illness and follow patients through their recovery, we will develop a thoughtful approach to making fitness to dive determinations. A single small case series is insufficiently powered to support definitive statements related to permanent lung function changes or air trapping risk – but these are unquestionably areas of keen interest within the diving medical community and will be closely monitored.

Over the next several months, the global medical community will gain a better understanding of the natural history of this disease. In addition, multiple studies are underway looking at treatment modalities and how we may reduce morbidity and mortality. COVID-19 has gripped the world and there is no other time in our history where we have as many people searching for answers about a single disease. We will continue to track research on this topic and update this position as new information becomes available.

_________________________________

A recent article, “Tauchen nach Covid-19-Erkrankung?” concludes that divers who have had COVID-19 will be permanently unfit to dive. Is this opinion shared by diving medical professionals? What is the evidence?
Published: 24 April 2020

A recent article, “Tauchen nach Covid-19-Erkrankung?” concludes that divers who have had COVID-19 will be permanently unfit to dive. Is this opinion shared by diving medical professionals? What is the evidence?

Posted: 4/24/2020


QUESTION:  
A recent article, “Tauchen nach Covid-19-Erkrankung?” concludes that divers who have had COVID-19 will be permanently unfit to dive. Is this opinion shared by diving medical professionals? What is the evidence?  

ANSWER: 
At the present time, we simply do not have sufficient data to support or refute the definitive proclamations made by this case series. Any attempt to generalize the effects of COVID-19 based upon a single case series (6-cases) published in the lay-press1,2, should be met with appropriate scrutiny.

Covid-19 symptoms range from mild to severe. Some people have no symptoms at all while others require complicated stays in an intensive care setting and require ventilatory support. The recent report published in the lay-press1,2 has resulted in considerable concern related to the finding of pulmonary inflammation in mild cases of COVID-19. This case series reports findings that may provide some insight into post-infection recovery, with a potential knock-on effect on fitness to dive evaluations, and recommendations related to medical follow up studies, and convalescence period prior to a return to diving. However, we must interpret this small case series (6-cases) with caution, as there is not enough known about the natural history of this disease to confidently extrapolate prognostic guidance from this one report, nor generalize these findings to every case of COVID-19. Likewise, calls for a particular medical examination or screening test(s) following infection to determine fitness to dive, based on this work alone, are currently unsubstantiated and premature.

The list of potential variables related to how this disease manifests, its clinical course, and longterm prognosis is lengthy and may include factors such as underlying medical conditions, age, disease severity, and secondary complications. Case reports suffer from multiple design weaknesses to include a lack of controls and randomization, which makes any conclusions that we may want to generalize to a larger population suspect. While these findings are indeed disquieting, it will take time before the potential impact on individual health, and any lasting effects on lung or heart function, are captured in the peer-reviewed literature.

COVID-19 shares many of the same features as other serious viral pneumonias that require a period of convalesce before returning to full activities – a process that can take weeks or months depending on symptom severity. The long-term effects of COVID-19 on pulmonary function and recovery time will vary, and there is insufficient experience and sound clinical research to make accurate prognostic determinations.

As the diving medical community gains more experience, and has the opportunity to study this illness and follow patients through their recovery, we will develop a thoughtful approach to making fitness to dive determinations. A single small case series is insufficiently powered to support definitive statements related to permanent lung function changes or air trapping risk – but these are unquestionably areas of keen interest within the diving medical community and will be closely monitored.

Over the next several months, the global medical community will gain a better understanding of the natural history of this disease. In addition, multiple studies are underway looking at treatment modalities and how we may reduce morbidity and mortality. COVID-19 has gripped the world and there is no other time in our history where we have as many people searching for answers about a single disease. We will continue to track research on this topic and update this position as new information becomes available.

_________________________________

I have a patient that I am trying to get approved for HBO. His radiation dose was 5040 over 28 treatments to his pelvis for colorectal CA. Is he a good candidate based on his dose? It seems that it may be a bit low (thinking 6000 cut off).
Published: 24 June 2020

I have a patient that I am trying to get approved for HBO. His radiation dose was 5040 over 28 treatments to his pelvis for colorectal CA. Is he a good candidate based on his dose? It seems that it may be a bit low (thinking 6000 cut off).

Posted: 6/24/2020


Q: I have a patient that I am trying to get approved for HBO2. His radiation dose was 5040 over 28 treatments to his pelvis for colorectal CA and is having continuous perianal skin breakdown for one year. Is he a good candidate based on his dose? It seems that it may be a bit low (thinking 6000 cut off).

A: The perineal area when included in the treatment volume is a tough area to heal. I think the dose is adequate to cause these problems and the material fact is that there are non-healing tissues and that they are persistent at a year.

John F

 

A patient that is likely going to start HBO2 soon,  presented a model number of his intraocular lens implant (MI60L). While I think this is okay, I would like to check since he has the model number from Bausch & Lomb. How can I determine if this posterior chamber implant is compatible with HBO2 Therapy?
Published: 01 July 2020

A patient that is likely going to start HBO2 soon,  presented a model number of his intraocular lens implant (MI60L). While I think this is okay, I would like to check since he has the model number from Bausch & Lomb. How can I determine if this posterior chamber implant is compatible with HBO2 Therapy?

Posted: 7/1/2020


Q:
A patient that is likely going to start HBO2 soon,  presented a model number of his intraocular lens implant (MI60L). While I think this is okay, I would like to check since he has the model number from Bausch & Lomb. How can I determine if this posterior chamber implant is compatible with HBO2 Therapy?

A:  
Most of the issues of eye surgery and immersed diving are largely irrelevant in the dry hyperbaric environment unless there are intraocular gas bubbles as mentioned below.

Air bubbles are sometimes present in the eye for a few days after cataract surgery and their absence should be specifically documented by the ophthalmologist prior to HBO2 if the HBO2 takes place shortly after cataract surgery.

There is no physiological reason that I am aware of that would mandate a waiting period for an HBO2 treatment after cataract surgery in the absence of an intraocular gas bubble.

I am unaware of any reports of negative effects of HBO2 on intraocular lens implants. I have also never heard of patients who have intraocular lens implants experiencing a myopic shift as a result of HBO2 treatments, as many patients with their natural lens still in place do.

As always, I would suggest that the patient discuss this information with the ophthalmologist responsible for their care.

Dr. Frank Butler

I would like to start my 57-year-old patient on HBO therapy for soft tissue radiation injury. He completed chemotherapy and radiation for treatment of rectal cancer about 21 months ago. Since that time, he struggled with perianal cutaneous ulcers. I think HBO will help.  I want to make sure the FOLFOX and 5-FU chemotherapy he completed 21 months ago does not complicate his case. I do not think they do, I am sure they have cleared his system.
Published: 06 July 2020

I would like to start my 57-year-old patient on HBO therapy for soft tissue radiation injury. He completed chemotherapy and radiation for treatment of rectal cancer about 21 months ago. Since that time, he struggled with perianal cutaneous ulcers. I think HBO will help.  I want to make sure the FOLFOX and 5-FU chemotherapy he completed 21 months ago does not complicate his case. I do not think they do, I am sure they have cleared his system.

Posted: 7/6/2020


Q: 
I would like to start my 57-year-old patient on HBO therapy for soft tissue radiation injury. He completed chemotherapy and radiation for treatment of rectal cancer about 21 months ago. Since that time, he struggled with perianal cutaneous ulcers. I think HBO will help.  I want to make sure the FOLFOX and 5-FU chemotherapy he completed 21 months ago does not complicate his case. I do not think they do, I am sure they have cleared his system.

A: 
None of the drugs in the FOLFOX multi-drug protocol given nearly 2 years ago should complicate your intent to give HBO2
for perianal ulcers, presumably caused by radiation.

Please, remember that the cancer itself can cause fistulas to the skin of the perineum. Just cautioning that you make sure that he has no active cancer because the cancerous wounds will not heal using HBO2.

John Feldmeier, DO

 

I am currently treating a patient with breast cancer for a lower extremity wound due to late effects of radiation. Ibrance has been held due to known effects on wound healing. She has completed #20 HBOT. Wound has shown some improvement, but not yet resolved. Patient's oncologist would like to resume Ibrance. Are there any relative or absolute contraindications to continuing HBOT once Ibrance is resumed?
Published: 13 July 2020

I am currently treating a patient with breast cancer for a lower extremity wound due to late effects of radiation. Ibrance has been held due to known effects on wound healing. She has completed #20 HBOT. Wound has shown some improvement, but not yet resolved. Patient's oncologist would like to resume Ibrance. Are there any relative or absolute contraindications to continuing HBOT once Ibrance is resumed?

Posted: 7/14/2020


Q:
I am currently treating a patient with breast cancer for a lower extremity wound due to late effects of radiation. Ibrance has been held due to known effects on wound healing. She has completed #20 HBOT. Wound has shown some improvement, but not yet resolved. Patient's oncologist would like to resume Ibrance. Are there any relative or absolute contraindications to continuing HBOT once Ibrance is resumed?

A:
Please see the following paper: Ibrance (Palbociclib) and Hyperbaric Oxygen

It does look like this drug might interfere with wound healing although probably no more so than many other chem drugs. There is nothing found on a literature search of the two together.

I would predict no enhancement of toxicity with the caution that without any published experience that prediction is no more than an educated guess based on a review of the drug's characteristics. As I always try to do, I also add the caution that the treating physician must take responsibility for any unexpected enhanced toxicities when HBO2 is given to a patient on this drug.

Best Regards,

John Feldmeier, DO

How long do the effects of HBO for osteoradionecrosis last? E.g. a patient was treated for ORN (40 sessions) four years ago, needs repeat oral surgery, would warrant re-treatment with Marx protocol 20+10? What about if it was only 2 years ago?
Published: 30 July 2020

How long do the effects of HBO for osteoradionecrosis last? E.g. a patient was treated for ORN (40 sessions) four years ago, needs repeat oral surgery, would warrant re-treatment with Marx protocol 20+10? What about if it was only 2 years ago?

Posted: 7/31/2020


Q: 
Title: How long do the effects of HBO for osteoradionecrosis last? E.g. a patient was treated for ORN (40 sessions) four years ago, needs repeat oral surgery, would warrant re-treatment with Marx protocol 20+10? What about if it was only 2 years ago?

A:
Bob Marx is of the opinion that once a patient completes a full course of HBO2 he or she does not need to repeat again EXCEPT if there is actual radionecrosis. If it is to support a dental extraction or implant, there would be no need for more HBO2. Bob Johnson who has been Bob Marx's collaborator on much of their joint efforts would say that if at the time of the oral surgery the tissues did not appear well-vascularized, it would be appropriate to give 10 post procedure treatments but with out the pre-op sessions. BUT, if there is bony necrosis present a second full 30 and 10 would be the best course.

John Feldmeier, DO

In a person with heavy alcohol dependence, is there a concern of alcohol withdrawal seizures during HBO therapy for a different condition (i.e. STRN, etc)? If so, has this risk been described or quantified, and would expert consensus recommend using a specific chamber class (multiplace vs monoplace) to treat an approved indication, given this comorbidity? Thank you.
Published: 23 June 2020

In a person with heavy alcohol dependence, is there a concern of alcohol withdrawal seizures during HBO therapy for a different condition (i.e. STRN, etc)? If so, has this risk been described or quantified, and would expert consensus recommend using a specific chamber class (multiplace vs monoplace) to treat an approved indication, given this comorbidity? Thank you.

Posted: 8/11/2020


Q: 
In a person with heavy alcohol dependence, is there a concern of alcohol withdrawal seizures during HBO therapy for a different condition (i.e. STRN, etc)? If so, has this risk been described or quantified, and would expert consensus recommend using a specific chamber class (multiplace vs monoplace) to treat an approved indication, given this comorbidity?A:

A:
In regard to dealing with alcohol withdrawal and hyperbaric treatment for non-emergent indications, it seems to me that the most prudent course of action is to delay treatment until the patient has gone through the process of withdrawal with all its attendant physiologic and neuropsychiatric problems. I personally would not want to deal with a patient in the chamber in this state. After the process of withdrawal has been completed the patient should be fine for treatment. Just as in other patients, if he or she is agitated or claustrophobic, a benzodiazepine anxiolytic would be in order.

Many alcoholic patients have been treated with HBO2 over the years. Although alcohol abuse may theoretically reduce threshold for seizure activity, it has not been a common problem.

Below is an abstract that suggests based on very limited anecdotal experience that alcohol withdrawal may lower the threshold for O2 induced seizure.

John Feldmeier, DO

 

Risk Factors for Oxygen Toxicity Seizures in Hyperbaric Oxygen Therapy: Case Reports From Multiple Institutions
Ruthanna Seidel 1Christopher Carroll 2Debra Thompson 2Rena G Diem 2Kwabena Yeboah 2A J Hayes 2Brett Hall 2Harry T Whelan 2

Affiliations

·        1University of Arizona College of Medicine, Phoenix, Phoenix, Arizona, USA.
·        2Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
·        PMID: 24377194

Abstract

Oxygen toxicity seizures are a rare but recognized complication of hyperbaric oxygen (HBO2) therapy. Many patients undergoing HBO2 therapy have medical conditions or are taking medications that could contribute to seizures. Previous literature has not extensively reported on these factors in patients experiencing oxygen toxicity seizures. We conducted a chart review at several hyperbaric oxygen centers in the Milwaukee, Wisc., area to explore whether the patients who experienced seizures in the hyperbaric chamber had other medical comorbidities or were on medications which lowered their seizure threshold, thereby contributing to oxygen toxicity seizures. There were a total of seven cases of seizures in five patients. Each patient had risk factors for seizures, including hypercapnia secondary to chronic obstructive pulmonary disease, narcotic withdrawal, alcohol dependence, and antidepressant, tramadol or cephalosporin/ceftriaxone use. We hypothesize that patients who experience oxygen toxicity seizures may have other factors which contribute to the development of these seizures.

My partner and I are working on an HBO safety profile for a patient that may benefit from HBO. The patient is currently treated with cabazitaxel. Please see details below and if you have time, please weigh in as to the safety of this chemo and HBO combination.
Published: 28 August 2020

My partner and I are working on an HBO safety profile for a patient that may benefit from HBO. The patient is currently treated with cabazitaxel. Please see details below and if you have time, please weigh in as to the safety of this chemo and HBO combination.

Posted: 8/27/2020


Q:

My partner and I are working on an HBO safety profile for a patient that may benefit from HBO. The patient is currently treated with cabazitaxel. Please see details below and if you have time, please weigh in as to the safety of this chemo and HBO combination.

He is a 68 year old seeking HBOT for radiation proctitis and radiation cystitis with hematuria in the setting of chronic anticoagulation (Eliquis) for history of PE. Metastatic disease to lymph nodes currently treated with cabazitaxel every three weeks. Has been tolerating this well (has undergone 11 cycles to date) and associates treatment symptoms with Neulasta.

A:
This particular drug was not used commonly in my experience but it may have become more popular since I have retired. On of its indications is for prostate cancer. Prostate cancers do not respond to chemotherapies well in general and this drug is second line even for that tumor. It interferes with the mitosis of cancer cells by interfering with the disassembly of the microtubules which is necessary for the movement of the chromosomes during mitosis to 2 poles to allow for cellular division. My reference textbook says that 80% of the drug has been eliminated from the body within 2 weeks of an IV infusion. Its main side effects are blood count suppression, mausea and vomiting, fatigue, peripheral nerve toxicity, myalgias and arthralgias, cardiac toxicities, hematuria and dysuria. This drug itself can cause hematuria. I am assuming your patient has had radiation? If so the hematuria is complex with the drug, radiation and anti-coagulants all contributing to the hematuria and making it more likely to be refractory to treatment.

See link below for one abstract where Taxol (the original Taxane) was used in a clinical protocol with HBO. It would appear to me that your patient is not receiving concurrent chemotherapy but has had the drug before.

I don't think that there is a high likeihood of worsened side effects with HBO.John Feldmeier, DO


Systemic chemotherapy using paclitaxel and carboplatin plus regional hyperthermia and hyperbaric oxygen treatment for non-small cell lung cancer with multiple pulmonary metastases: preliminary results
Takayuki Ohguri 1, Hajime Imada, Hiroyuki Narisada, Katsuya Yahara, Tomoaki Morioka, Keita Nakano, Yasuhiro Miyaguni, Yukunori Korogi
 

 

 

Is vitamin E is a reasonable approach to preventing oxygen toxicity seizures in a patient on chronic prednisone?
Published: 03 September 2020

Is vitamin E is a reasonable approach to preventing oxygen toxicity seizures in a patient on chronic prednisone?

Posted: 9/3/2020


Q:
Is vitamin E is a reasonable approach to preventing oxygen toxicity seizures in a patient on chronic prednisone?

A:
There is no current evidence that Vitamin E is an appropriate prophylactic in mitigating CNS oxygen toxicity during HBO2, and there is also no reported evidence that steroids increase CNS oxygen toxicity risk during HBO2.

We treated a patient recently with hemorrhagic cystitis secondary to BK virus.(40 treatments, 6/11/20-8/11/20) He has a history of CML. In the last 2-3 weeks the patient has had a recurrence of hematuria "dependent on hydration" and the team has reached out to us for more treatments. Do you think more treatments would be efficacious?
Published: 14 October 2020

We treated a patient recently with hemorrhagic cystitis secondary to BK virus.(40 treatments, 6/11/20-8/11/20) He has a history of CML. In the last 2-3 weeks the patient has had a recurrence of hematuria "dependent on hydration" and the team has reached out to us for more treatments. Do you think more treatments would be efficacious?

Posted: 10/16/2020


Q:
We treated a patient recently with hemorrhagic cystitis secondary to BK virus.(40 treatments, 6/11/20-8/11/20) He has a history of CML. In the last 2-3 weeks the patient has had a recurrence of hematuria "dependent on hydration" and the team has reached out to us for more treatments. Do you think more treatments would be efficacious?


A:
I did a search and have seen Dr. Moon's reply. As he said there may be a role for hyperbaric oxygen in hemorrhagic cystitis  in leukemic patients who have stem cell transplants for their leukemia. In my reading up to 50% of such patients sustain cystitis and there appears to be no other effective therapies. The cystitis is viral in etiology (polyoma virus). I attach 3 abstracts of small series of cases treated with HBO2. with a good reported response. I note that they typically report response after about 10 treatments. I did not see that patients have received more than 40 treatments.  

I have 2 observations:
1. There appears to be no other effective therapy. (see the last attached abstract)
2. HBO2 has had reported good effect but 40 treatments would be well outside the previously reported courses in case reports .
 
Does this patient have any other risk factors? Is he on anticoagulants for cardiac disease or prior DVT, PE. etc. Patients with leukemia often have decreased platelet counts (and red cell counts). Does he have thrombocytopenia?
 
I would also ask what his response to the previous HBO2 has been. I agree with Dr. Moon.  Additional HBO2 is probably justified due to the absence of other effective therapies BUT I think that a durable response in this patient is unlikely since already the number of treatments far exceeds prior reported experience. I would not give more than another 20 treatments. Although not the same thing, my experience is that radiation induced hemorrhagic cystitis often requires more that 40 treatments
 
John Feldmeier, DO