Hyperbaric Oxygen Therapy for Mechanically Ventilated Decompression Sickness Patients
Yes, patients with decompression sickness requiring mechanical ventilation can and should undergo hyperbaric oxygen therapy (HBOT), as this is the definitive treatment for decompression sickness regardless of ventilatory status, though it requires specialized equipment, intensive care-level staffing, and careful risk-benefit assessment. 1
Primary Treatment Mandate
- Recompression therapy combined with hyperbaric oxygen breathing is the essential primary treatment for all decompression illnesses, including arterial gas embolism and all types of decompression sickness 2
- The American Heart Association guidelines support the use of supplementary oxygen by trained providers for decompression sickness cases 3
- Treatment should be initiated as soon as symptoms arise, with urgent HBOT mandatory for all severe decompression disorders 2
Feasibility in Critically Ill Patients
Mechanical ventilation is not a contraindication to HBOT. The evidence demonstrates:
- HBOT can be delivered safely to critically ill patients, including those requiring mechanical ventilation, when performed in appropriately equipped facilities 1
- Successful treatment has been documented in severely ill decompression sickness patients requiring both mechanical ventilation and advanced life support, including cases requiring veno-venous extracorporeal oxygenation (VV-ECMO) alongside HBOT 4
- Hyperbaric chambers suitable for intensive care under pressure exist and can accommodate ventilated patients 2
Critical Requirements for Safe Treatment
Specialized infrastructure is essential:
- Only hyperbaric medicine centers with ICU-level staffing, specialized equipment, 24/7 availability, and experience treating critically ill patients should attempt this 1
- Not all ICU equipment can withstand hyperbaric pressurization, and some equipment increases fire risk inside the chamber 1
- Multiplace chambers are generally preferred over monoplace chambers for critically ill patients requiring continuous monitoring and interventions 1
Risk-Benefit Considerations
The British Thoracic Society warns that HBOT causes physiological changes potentially compromising critically ill patients, including barotrauma, seizures, hypotension, cardiac arrhythmias, and pneumonia 5. However:
- For decompression sickness specifically, the risk of withholding definitive treatment (HBOT) typically outweighs the procedural risks 2, 1
- Latency of symptom onset serves as a prognostic indicator, but urgent HBOT remains mandatory even with delayed presentation 2
- The transport risks of moving critically ill patients to hyperbaric facilities must be weighed against potential benefits on a case-by-case basis 5
Pre-Treatment Stabilization
Prior to HBOT, particularly with any treatment delay, specific supportive therapy is mandatory 2:
- 100% normobaric oxygen breathing
- Intravenous crystalloids or dextrose saline for fluid resuscitation
- Flat supine positioning
- Arrangement of appropriate transportation to the nearest hyperbaric center equipped for critical care 2
Ventilator Management During HBOT
- Mechanical ventilation goals during stroke management (which provides relevant guidance for critically ill patients) emphasize maintaining adequate mean arterial pressure, though evidence-based targets are not firmly established 3
- Normocapnia is generally advocated, with no evidence supporting prophylactic hyperventilation 3
- Short-acting sedatives like propofol or dexmedetomidine can be used for patient comfort and ventilator synchrony 3
Common Pitfalls to Avoid
- Do not delay HBOT waiting for the patient to be extubated—mechanical ventilation is not a contraindication 2, 1
- Do not transfer to facilities lacking ICU-capable hyperbaric chambers—ensure the receiving center has appropriate critical care capabilities under pressure 1
- Do not assume all hyperbaric facilities can manage ventilated patients—most chambers in the United States treat outpatients and lack ICU-level capabilities 1