BHA Statement on Provision of Mild HBOT

The British Hyperbaric Association (BHA) opposes the provision of “mild” hyperbaric oxygen therapy (HBOT) by facilities that are not registered specifically as providers of Hyperbaric Oxygen Services with the Care Quality Commission (CQC). Such CQC registration is regarded by the BHA as mandatory to ensure the safe and effective delivery of HBOT in a setting maintained to an independently regulated standard, and subject to regular inspection.

Providers of “mild” HBOT (generally held to be that delivered at a pressure of less than or equal to 2 ATA) who advertise their service to treat disease and disorder should be able to demonstrate CQC registration as a provider of Hyperbaric Oxygen Services.

Furthermore, in the considered opinion of the BHA, there are ethical issues with charging patients for HBOT that either uses sub-therapeutic regimes, or purports to treat conditions with no related supportive evidence base.

Diver safety up in the air by Gerard Laden Hull Hyperbaric Chamber

A simple Saturday evening took a turn when Mimir Marine the UK based global lead in hyperbaric and saturation diver rescue received a call following damage to an in county (BP Baku owned) Hyperbaric Reception Facility (HRF) rending it unserviceable, BP agreeing with their diving contractors a replacement was necessary to allow seamless safe diving operation to continue.

The Hyperbaric Reception Facility is a triple compartment 300metre depth rated chamber complex that forms a shore based safe-haven available for the controlled decompression of saturation diver if the diving vessel has to be abandon, for example following a fire or collisions.

The diver’s decompression can take many days, see Fig 1, the hyperbaric lifeboat with its small internal chamber whilst appropriate for evacuation and getting clear of the danger their cramped conditions mean they are not appropriate for the multiday decompression of between 9 to 24 divers.

HRF`s are positioned so if required, the hyperbaric lifeboat can be taken to an appropriate safe harbour and the dives transferred under pressure (TUP) into the HRF chamber with it comfortable seating, show & toilet section so called (wet pot) and a sleeping area. HRF`s have multiple redundancy of all their life support systems.

The Hull UK based company Mimir Marine own globally deployable HRF systems and brough one to immediate notice for mobilisation by air to Baku using an Antonov 124 heavy lift aircraft from East Midland airport. The system was confirmed ready withing two hours of the call and held on standby.

The 80-ton life support package was designed by Mimir for air transport, Gerard Laden Director at Mimir commented whist designed for air transport; for overseas operations pre-positioning by ship is the norm.

Vessel Manager Diving BP AGT Region commented accessing both a HRF and Antonov 124 at short notice is a logistics challenge, however we have policy and procedures to ensure the safety and security of our diving operations.  

BP Global Diving Technical Authority said, occasionally other than routine decision making is required to ensure there is no deviation from our very high standards of emergency properness planning. The equipment arrive in country within 12 hours of leaving the UK.

The Antonov 124 was design in the Ukraine in the 1980`s and is the world 2nd heaviest gross weigh production aeroplane. The 124 can carry150 ton of cargo with a 120-ton single package being winched onboard. The 24-wheel landing gear is design for landing on rough terrain.

Depth mswHoursDays
25271
50482
78723
1501315.5
2001737
2502159
30025612.5

Decompression of divers

Hyperbaric Oxygen Therapy (HBOT) in Head Injuries and Stroke – A Review By Dr Rosie Stokes, DDRC Healthcare

The role of HBO as a potential therapy option for brain injury has long been discussed. The theory being that by maximising oxygenation post–injury the area of healthy tissue loss due to ischaemia and oedema will be reduced and healthy brain function maintained, whilst optimising recovery. If effective, this could result in reduced morbidity and lessen the number of patients left with long-term residua such as physical, cognitive and communication difficulties.

Unfortunately, however, indications such as traumatic brain injuries and stroke have remained controversial due to limited numbers of randomised control trials and inconsistent outcomes.

Traumatic Brain Injuries (TBI):

There have been experimental animal studies involving HBOT in the treatment of TBI since the 1960s1. Clinical studies, however, have mostly provided case study or retrospective analysis with mixed outcomes. For example, Mao et al. 20102 found that HBOT improved outcome in severe injuries with improved EEG readings and Glasgow Coma Outcome scores, whereas conversely, Rockswold et al. 19923 found no improvement in recovery or disability.

Bennett et al. 20124 performed a meta-analysis of randomised trials with the conclusion that the addition of HBOT in the treatment of TBI may improve survival but not quality of life. Thus, current evidence has been unable to prove that the benefit of treatment outweighs the risks of exposure to hyperbaric oxygen. The European Committee on Hyperbaric Medicine (ECHM) therefore only recommended HBOT ‘in the context of an investigational study protocol’ and state that ‘it would be reasonable to consider HBOT in acute moderate-severe TBI’5.

Since this meta-analysis and the last ECHM conference there have been further randomised trials. Zhong et el. 20206 studied patients with severe head injuries with routine HBO therapy started 1 week after admission. At the end of the treatment period the group receiving the HBOT showed improved GCS and lower NIHSS scores.

Strokes:

Systematic reviews have shown that there is no decrease in mortality in stroke patients treated with HBOT within 6 months after presentation therefore, the ECHM ‘do not recommend HBOT use in the acute phase of stroke’5. Evidence is based on a limited number of randomised controlled trials that have shown variable results for improvement in disability with HBOT7. Further research is required to establish clear guidelines for practice.

Whilst there is insufficient evidence to support the use of HBO in acute stroke, ECHM highlighted potential use in chronic stroke, given select criteria. ‘It would be reasonable to consider HBOT in the frame of an investigational clinical study in a highly selected group of patients with chronic stroke who have clear evidence of metabolically dysfunctioning brain regions that are mismatching with the necrotic brain regions. Patients who are candidates for HBOT should be properly evaluated prior to therapy by standardized cognitive tests and by a functional imaging of the brain’5.

This recommendation is based on evidence from selected randomized controlled trials which have shown that HBO has the potential to activate neuroplasticity long after stroke onset. Namely, Efrati et al. 20138; who used SPECT/CT on 74 patients with a history of a stroke 6-36 months prior, with at least 1 motor dysfunction. Results showed an increase in neurological function and quality of life with increased benefit seen in those with a SPECT/CT area mismatch. Schiavo et al. 20209 also showed that HBOT may have a role to play in a combined approach to aid neuroplasticity and recovery after stroke.

For some time, there has been clinical observation that HBO may be of benefit in chronic stroke patients. Neubauer & End 198010 suggested a minimum of 20 treatments on review of their cohort of 122 patients with ischaemic strokes. Further studies with varying numbers of participants have shown clinical improvement in language fluency and motor paresis11. Hadanny et al. 202012 recognised that HBOT produced significant improvements in cognition with prognosis determined by functional analysis and baseline cognitive score rather than the nature of the type or location of the stroke. This is supported by other studies which show a significant improvement in memory measures, cognition, and physical abilities even years after the stroke event13,14.

Studies have utilised SPECT/CT and retrospective analysis of this imaging has shown good correlation as a predictor for positive clinical outcome following HBOT in post-stroke patients15.

Overall, there is much potential for further research in these areas with current evidence suggesting that HBOT may provide a benefit as an adjunct therapy in specific groups of head injury/stroke patients. The possibility of reducing the number of residual symptoms that patients are left with could have a significant impact on individual quality of life, as well as reducing the financial burden of lifelong care and continued healthcare input.

Letter to the Editor

Gerard Laden, director of the hyperbaric chamber in

Hull and East Riding Hospital, wrote a the “Letter to

the Editor” below with regards to the HOPON trial

for osteoradionecrosis.

OBITUARY: DR. VINCENT HONG MB. BCH. BAO., FRCA, FFICM, MBA

The premature death of Vincent has been a shock for the British Hyperbaric Medicine Community, all his colleagues and friends, as well as numerous patients for whom he cared passionately, and most sadly for his beloved family. From the BHA we extend our condolences to Lily, daughter Ellie and the rest of his family. His place will never be filled, but the only consolation for us is the fact that he lived life to the fullest commitment and achieved so much in his shortened life.

He had a successful career as a Consultant Cardio-thoracic Anaesthetist and Intensivist at Hull & East Yorkshire Hospitals NHS Trust as well as Spire Hull & East Riding Hospital and as Hyperbaric Physician at North England Hyperbaric and Medical Services. This gave him a an excellent background in physiology and physics to understand the intricacies of rebreather diving and a focus on safety.

Vincent was a very keen diver who preferred to spend as much time underwater as possible. He also was a passionate underwater photographer and marine conservationist. In his spare time, he loved to organise frequent dive trips to various UK and overseas dive locations.

In addition to the BHA he was also a Member of United Kingdom Diving Medical Committee, a Recreational and Technical (CCR) Diving Instructor, and PADI, BSAC, ITDA & PSAI member.

The void he leaves will never be filled. We can only be grateful that his path crossed and lit up ours- rest peacefully dear friend.

Pieter Bothma

BHA Chairman

BHA response to NHSE consultation

Please find below our response to the recent NHSE consultation, or click to download the full response as a pdf.

Important Notice About Public Consultation

At https://www.england.nhs.uk/2016/04/consultations-specialised-services/ you will find details of a proposal from NHS England that hyperbaric oxygen therapy is routinely funded for decompression illness and gas embolism but nothing else in England.
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