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BMJ 2022; 377 doi: (Published 03 May 2022) Cite this as: BMJ 2022;377:o1078

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Hyperbaric Oxygen Therapy for War Wounds, related diseases and heavy sequelae. Conflicts produce serious injuries: the injured people could arrive in hospitals in non-war countries to be treated.

Dear Editor,

With the purpose of being useful from a distance, I link to this excellent article exposed here, to be able to talk about helping for the patients recovery.

Many people are injured by the war explosions and the resulting shrapnel, which cause infinite pictures of urgent gravity.

It could happen that wounded people come to hospitals, in non-war countries, to be treated. There is a risk of wounds complicated by septic phenomena and gangrenosis (in limbs, in head, e.g. Orbital Necrotizing Fasciitis, or in other parts of the body).

In these dramatic situations, surgical and antibiotic therapies could be advantageously supported by the administration of hyperbaric oxygen therapy (HBOT), that could be considered a valid help for the recovery, as highlighted by the study of Split University Hospital between 1991 and 1995, when HBOT was administered to the wounded in the Balkan war (1).

Several studies contemplate the basis of the therapeutic action of HBOT, in clinical and acute surgical conditions:
• Gas Gangrene • Crush Injuries, Compartment Syndromes & Acute Traumatic Ischaemias • Enhancement of Healing in Selected Problem Wounds • Exceptional Bloodloss Anaemia • Necrotising Soft Tissue Infections • Compromised Skin Grafts & Flaps • Thermal Burns. (1-10,13); Gas embolism (gas bubbles enter arteries or veins) (13,15).

Therapeutic effect has also been found for Covid19, so if the injured were simultaneously affected by this infection, there would be additional benefits (10-12).

Some articles (1-10, 13) report:

- Hypoxia present in hypoperfused necrotic tissue often complicates wound healing. HBOT can double or triple oxygen delivery to necrotic tissue, improves wound healing, can also be helpful in directly fighting active bacterial infections.

- HBOT must not replace the combination of early aggressive debridement and wide-spectrum antibiotic therapy, but rather must be considered as an important adjuvant treatment.
Like all medical treatments, have side effects and potential risks (2,9,13):
(a) barotrauma of the middle ear
(b) seizures and pulmonary oxygen toxicity. An article shows that there was no demonstrable pulmonary epithelial permeability change under current clinical HBOT protocol (14). Careful history is taken and prophylactic treatment is given in those with specific risk factors; e.g. those with history of seizures, fever, acidosis, or low blood sugar. Claustrophobia may be a problem with some patients, and it is reduced by having an attendant inside the chamber (multiplace) or beside it (monoplace). Fire risk precautions are mandatory, with unsafe objects not being admitted.

The contra-indications are indicated as:
A) Absolute: an untreated pneumothorax, bullae or blebs (2,9).
B) Relative: bullous pulmonary disease, emphysema, COPD (2,9), acute viral URTI’s, sinusitis, history of pneumothorax and spherocytosis. Certain anticancer drugs, as HBOT increases their cytotoxicity.

Consultation with a physician trained in hyperbaric medicine is important, both for evaluating the indication for HBOT and for addressing any possible contraindication (2). During a HBOT, typically a patient’s blood sugar is lowered, wich is also synergistic to lower an individual’s seizure threshold while breathing oxygen at pressure (9).

Problems related to HBOT are also: to access in useful time and to calculate the discomfort for the patient caused by transport, with all the economic costs.

Some authors propose that surgeons are urged to identify HBOT facilities, both fixed and portable, and to establish communication with hyperbaric therapy colleagues (2).

The purpose of my communication is to remember this important therapeutic aid so that the emergency hospitals are coordinated in advance to have HBOT available.

1) Roje Z, Roje Z, Eterović D, Druzijanić N, Petrićević A, Roje T, Capkun V. Influence of adjuvant hyperbaric oxygen therapy on short-term complications during surgical reconstruction of upper and lower extremity war injuries: retrospective cohort study. Croat Med J. 2008 Apr;49(2):224-32. doi: 10.3325/cmj.2008.2.224. PMID: 18461678; PMCID: PMC2359875.
2) MacFarlane C, Cronjé FJ, Benn C. Hyperbaric Oxygen in Trauma and Surgical Emergencies. BMJ Military Health 2000;146:185-190.
3) Fife, Caroline E. MD; Eckert, Kristen A. MPhil; Carter, Marissa J. PhD, MA An Update on the Appropriate Role for Hyperbaric Oxygen: Indications and Evidence, Plastic and Reconstructive Surgery: September 2016 - Volume 138 - Issue 3S - p 107S-116S doi: 10.1097/PRS.0000000000002714
4) Kruse M, Nielsen S, Berg A, et al. Use of adjuvant hyperbaric oxygen therapy in a patient with traumatic inoculation of mucormycosis resulting in extremity amputation. Trauma Surgery & Acute Care Open 2020;5:e000434. doi: 10.1136/tsaco-2019-000434
5) Quandahl R, Jan AH, Cooper JS. Hyperbaric Zygomycotic Infections. [Updated 2022 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
6) Buettner MF, Wolkenhauer D. Hyperbaric oxygen therapy in the treatment of open fractures and crush injuries. Emerg Med Clin North Am. 2007 Feb;25(1):177-88. doi: 10.1016/j.emc.2007.01.008. PMID: 17400080.
7) Singam NV, Rusia D, Prakash R. An Eye Popping Case of Orbital Necrotizing Fasciitis Treated with Antibiotics, Surgery, and Hyperbaric Oxygen Therapy. Am J Case Rep. 2017 Apr 1;18:329-333. doi: 10.12659/ajcr.902535. PMID: 28364115; PMCID: PMC5384621.
8) Bağli BS, Durgut O. Hyperbaric oxygen therapy as adjuvant therapy in necrotizing fasciitis of the face: case report. Undersea Hyperb Med. 2018 Nov-Dec;45(6):695-699. PMID: 31158939.
9) Kirby JP, Snyder J, Schuerer DJE, Peters JS, Bochicchio GV. Essentials of Hyperbaric Oxygen Therapy: 2019 Review. Mo Med. 2019 May-Jun;116(3):176-179. PMID: 31527935; PMCID: PMC6690283.
10) Ortega MA, Fraile-Martinez O, García-Montero C, Callejón-Peláez E, Sáez MA, Álvarez-Mon MA, García-Honduvilla N, Monserrat J, Álvarez-Mon M, Bujan J, Canals ML. A General Overview on the Hyperbaric Oxygen Therapy: Applications, Mechanisms and Translational Opportunities. Medicina (Kaunas). 2021 Aug 24;57(9):864. doi: 10.3390/medicina57090864. PMID: 34577787; PMCID: PMC8465921.
11) Cannellotto, M., Duarte, M., Keller, G., Larrea, R., Cunto, E., Chediack, V., ... & Estrada, E. (2022). Hyperbaric oxygen as an adjuvant treatment for patients with COVID-19 severe hypoxaemia: a randomised controlled trial. Emergency Medicine Journal, 39(2), 88-93.
12) Kirby J. Hyperbaric oxygen therapy for patients with COVID-19. Emerg Med J. 2022 Feb;39(2):86-87. doi: 10.1136/emermed-2021-212015. Epub 2021 Dec 14. PMID: 34907002.
13) Indications for Hyperbaric Oxygen Therapy
14) Chang YC, Kao PF, Lee MS, Lin MC, Tzen KY. Investigation of pulmonary epithelial permeability in patients after hyperbaric oxygen therapy by 99mTc diethylenetriaminepentaacetic acid aerosol inhalation lung scintigraphy. Nucl Med Commun. 2002 Jun;23(6):569-72. doi: 10.1097/00006231-200206000-00010. PMID: 12029213.
15) Ho AM, Ling E. Systemic air embolism after lung trauma. Anesthesiology. 1999 Feb;90(2):564-75. doi: 10.1097/00000542-199902000-00033. PMID: 9952165.

Competing interests: No competing interests

06 May 2022
Gianni Zuccheri
Collegno TO ITALY