• HBOT involves a fuel source (the patient, linen, equipment, dressing supplies, etc.) in an oxygen enriched environment in an HBO chamber
• The fire triad is made up of fuel, oxygen, and an ignition source. To complete the fire triad in the HBO environment, an ignition or heat source is necessary. This can occur from a spark in the chamber
• Follow fire prevention procedures per facility established policy and procedures for Class A and Class B chambers:
• Oxygen levels shall be continuously monitored in Class A chambers in accordance with NFPA guidelines; ensuring chamber oxygen concentration does not exceed 23.5%
• Prohibited items are not allowed in the chamber. The Safety Director, in collaboration with the Medical Director, will determine the medical necessity of normally prohibited items, complete a risk analysis and institute additional safety measures as indicated
• Facilities are encouraged to conduct fire drills monthly or at least quarterly.
• A timed worst-case scenario fire drill shall be completed at least annually, to ensure preparedness in accordance with NFPA and industry standards
• Splints and casts must be allowed to cure before going into an oxygen enriched atmosphere 

• HBOT teaching and consent of the patient will include the risks of fire in the HBO environment
• Provide the patient/family with written instructions that provides information concerning prohibited materials in the HBO environment to reduce the potential for fire
• Education should be documented in patient’s clinical record

• Ensure supplies for emergent needle decompression are available and ready
• Do NOT decompress chamber until preparations are made for emergency management of pneumothorax and authorized by attending physician OR
• Until chest needle decompression is performed in a multi-place chamber
• Follow facility emergency procedures

Provide education on:

• Potential for barotrauma: otic, sinus or tooth, gastrointestinal, pulmonary
• Methods to equalize pressure in middle ear during treatment: yawning, swallowing, jaw thrust, head tilt, Valsalva, Toynbee, Roydhouse maneuver, Frenzel etc.
• Notify chamber operator immediately when pressure or fullness is felt in the middle ear 
• Notify chamber operator immediately if develop sudden, sharp chest pain, difficulty or rapid breathing, or shortness of breath
• Educates patient to rub affected area for tooth squeeze

Assess patient prior to HBOT for increased risk factors such as:

• Elevated core temperature
• Neurologic: history of seizures, history of brain injury/surgery
• Acute carbon monoxide (CO) poisoning
• Use of medications that may lower the seizure threshold
• Metabolic changes: metabolic acidosis, dehydration, hypoglycemia
• History of inhaled cannabis

Assess patient for and document s/s of CNS oxygen toxicity including V-E-N-T-I-D-C-C or V-E-N-T-I-D-S-H-H

• Visual changes (acute): tunnel or blurred
• Ears: auditory hallucinations, ringing or roaring in the ears
• Nausea, numbness
• Twitching of muscles (usually facial), tingling of extremities
• Irritability: Restlessness or personality changes
• Neurological changes: Dizziness or vertigo, Convulsions/seizure activity, Change in affect
• Respiratory changes: Shortness of breath, Hiccups
• Heart rate increased

Assess for and document symptoms of oxygen toxicity during HBOT

• Respiratory changes: dry, hacking cough, air hunger/shortness of breath (SOB), difficulty inhaling a full breath, dyspnea on exertion
• Substernal irritation or burning
• History of high FiO2
• Tightness in the chest/substernal burning

• If any symptoms occur including seizure, follow the facility emergency guidelines
• Remove built in breathing system (BIBS) mask/hood
• Instruct patient to apply air break mask
• Follow seizure procedure
• Class B – Monoplace Chamber: Do NOT decompress patient during seizure, wait for spontaneous respirations to return and then decompress
• Class A – Multiplace Chamber: Collaborate with the practitioner to use established guidelines e.g., the U.S. Navy, for treating CNS oxygen toxicity or follow provider orders
• Notify physician if s/s of pulmonary oxygen toxicity appear
• Add humidity to oxygen as needed to reduce chest discomfort 

• Educate patient and/or family about risks of oxygen toxicity
• Educate patient and/or family on the s/s of CNS oxygen toxicity
• Educate the patient on the importance of notifying the chamber operator if they feel different or funny in the chamber
• Educate regarding increased risk of pneumothorax and ground glass opacity with inhaled cannabis
• Educate patient and/or family on the risks and side effects of pulmonary oxygen toxicity

Medical history assessments to include history of CHF and exacerbations:

• HBO practitioner will evaluate individual risk, weigh the risk against potential benefits of HBOT and re-assess throughout treatment

Assess/Assess for:

• Dry cough that begins during treatment
• Jugular vein distention
• Adventitious heart sounds
• S/S of fluid accumulation in the lungs and lower extremities
• Fluid and electrolyte balance per provider order
• Vital signs as indicated
• Daily weights as indicated

Assess vision pretreatment using a standard vision measurement tool, e.g., the Snellen or Jaeger (handheld) eye charts. If the patient wears glasses or contacts, make sure they are wearing them during testing.

Note: Patients may state increased reading ability and that glasses are no longer needed.

Assess for pre-existing acute angle glaucoma, cataracts or optic neuritis as more frequent visual assessments may be necessary 

Note: Patients with diabetes, history of head/neck radiation or systemic steroids are at increased risk for developing cataracts. 

• If vision declines to threshold for state Department of Motor Vehicle (DMV) guidelines, consider referral for optometrist and arrange for alternative transportation
• Ophthalmic risks include glaucoma or ocular surgery
• High risk patients (history of optic neuritis, progressive cataracts, diabetic retinopathy) should undergo a fundoscopic exam and an ophthalmology consult.
• NOTE: Visual changes can be easily dismissed if the patient complains of decreased vision. If reading ability is compromised, hold HBOT and obtain ophthalmologic evaluation.

• Educate patient to:
• Wait 6-10 weeks post HBOT to obtain new prescription for corrective lenses and
• Communicate to provider that they have recently received HBOT
• Discuss the risk of transient myopia, presbyopia and existing lenticular cataracts

• All removable devices will be removed prior to HBOT treatments per chamber safety policy
• Consider “Even Up” or similar product to raise contralateral limb
• Assess competence of patient or caregiver with facilitating activities of daily living (ADLs) or instrumental activities of daily living (IADLs)
• Prosthetics, diabetic shoes, orthotic boots and total contact cast all impact range of motion and ability for population that may already have balance and gait issues
• If a new device, there may not be sufficient accommodation at home, in their car, or with their employment to maintain baseline ADLs
• Advise ordering physician of ineffective treatment, if indicated

• Provide education/re-education regarding safe use of assistive devices                                                                                                                            
  

• Comply with facility fall risk/prevention policy
• Assess patient’s potential risks for falls
• Discuss safety measures and apply precautions as appropriate
• Provide patient assistance with transfers according to patient needs and facility policy:
• 1-2 person assist, as necessary
• Use of gait belt, as necessary
• Use of footstool and/or lower stretcher to load patient
• Use of slide board, or other transfer equipment as necessary, ensuring all equipment is removed prior to HBOT
• Use of side rails on stretcher as appropriate
• Use facility approved mechanical lift equipment and transfer devices when indicated, assuring all materials used is removed prior to HBOT
• Follow Safety Time Out/Pause (STOP) procedure prior to beginning any HBOT
• Equipment located in the HBO room should only include items necessary to provide patient care and stored appropriately
• All patient care equipment in the facility should be always in good working order and inspected per facility policy
• It is the responsibility of all staff operating HBO equipment to be knowledgeable of any potential hazards

• Communicate plan with patient and staff involved prior to taking action.
• Provide patient education regarding safety precautions                                                                                                             

MULTIPLACE CHAMBER: Oxygen Treatment Hood

• Assist patient with application and removal of neck seal and hood
• Ensure the oxygen flow is sufficient to ventilate the treatment hood and maximize FiO2
• After assembly, check for leaks
• Observe patients for signs of inadequate treatment hood ventilation such as CO2 buildup, fogging, restlessness, anxiety and overt symptoms of oxygen toxicity 

MONOPLACE CHAMBER: face mask / mouthpiece

• Coaching patient with mask application and removal, and reposition mask/mouthpiece as needed
• Check for leaks, continuity of seal against patient’s face, keep tight fit around mouthpiece
• If using a Built-In-Breathing System (BIBS) mask, ensure that the straps are adjusted for patient comfort and a tight seal 

• Involve interpreter, if indicated
• Apply age-specific teaching
• Consider cultural/religious factors
• Readiness to learn
• Patient’s expectations of treatment

Educate on:

• Disease process for which referred to HBOT in language and manner which patient learns best
• Purpose and goals of HBOT
• Procedures involved
• Potential hazards of HBOT
• Sequence of treatment procedures and what to expect e.g., pressure, temperature, noises, and wound care
• The HBO environment including:
• chamber orientation
• middle ear pressure equalization
• fire hazards
• safety policy and procedures
• risk and benefits of HBOT
• provide patient and/or family with written education on HBOT
• provide written discharge instructions per facility guidelines 

• Risk assessment of environment should be completed/reviewed at least annually and a plan to mitigate risks established.
• Depression screening should be completed on all patients receiving HBOT upon initial consult and as needed or per facility guidelines.                                                  

• Educate on potential for PTSD, repressed memories etc. to resurface at approximately 15-20 treatments, but generally improves in approximately 5 treatments.
  

• Patient verbal admission of anxiety
• Clenching fists
• Flushed face
• Complaint of nausea or diarrhea
• Sudden complaint of pain or discomfort
• Feelings of being smothered or suffocated
• Urgency to empty bladder
• Defensive attitude
• Hyperventilation
• Profuse diaphoresis
• Flat affect
• Tachycardia/reports of heart palpitations (Note: this may also be a sign of oxygen toxicity)
• Restlessness
• Sudden complaint of feeling warm/hot during treatment 

• Rings, jewelry (remove)
• Ligature risk assessment – remove items as able/plan
• De-escalation strategies
• Communicate in language patient uses

• Educate patient on what expect from the treatment
• Confinement anxiety vs claustrophobia
• Procedures
• How to communicate with staff
• How long it will take to get patient out of chamber
• Right to refuse care

Provide non-pharmacological pain interventions:

• Relaxation techniques
• Distraction
• Repositioning / Positioning
• Family present at chamber side as appropriate

• Avoid intramuscular (IM) medications immediately prior to treatment due to vasoconstriction affect from HBOT
• Assess for topical patches. Safety Director and Medical Director to perform risk assessment and review facility policy to determine if needs to be removed for HBOT. (Add to Go/No Go list as appropriate)
• Over-sedation
• Avoid overuse of linens/pillows etc

• Educate on non-pharmacological pain reducing interventions
• Pharmacological pain reducing interventions                                                                                                                                                                            

• Monitor room temperatures within the HBO suite according to NFPA 99 guidelines
• Avoid overuse of linens as this could add to a fire risk

• Educate on temperature changes anticipated during HBOT                     
  

• Educate patient/family related to nutritional needs and dietary preferences
  

• Follow the recommended interactions to reduce anxiety during HBOT:
• Stay in patient’s visual field
• Address patient calmly
• Establish eye contact
• Reassure patient that he/she is safe
• Encourage relaxation techniques and offer diversional activities: TV, music, books on tape, family member at chamber side (as appropriate per HIPAA standards)
• Assure patient of HBO trained nurse presence throughout treatment

• Provide a safe and calm environment for individuals that may be anxious                                                                                                                                                                                                  
  

• Comprehensive informational visit explaining the purpose, risk factors, expected outcome, and procedure for HBOT allowing for time to ask and answer questions prior to initiating HBOT.
• Educating individuals on their rights and responsibilities as a patient, including the right to refuse treatment.
• Educate on the necessary length of time to safely bring someone out of the HBO chamber – PRIOR to HBO treatment, so they are aware that staff cannot open the door immediately. 

• Inflate the endotracheal tube (ET) or tracheostomy cuff with normal saline (NS) or sterile water prior to pressurization and replace the saline or sterile water with air after treatment, or per facility guidelines
• Keep suction equipment nearby and ready to use
• All HBO staff and RT staff that will utilize the HBO ventilator will receive training on the use of the HBO ventilator
• Ensure immediate access to an advanced cardiac cart/crash cart and staff appropriately trained on advanced cardiac life support.

• Educate family on the potential need to increase analgesia/sedation during HBOT.                                                                                                                
  

• Hemolytic anemia patients (i.e., sickle cell) and smokers may run a 10% or greater carboxyhemoglobin levels as their normal baseline
• Pulse oximetry cannot be used to establish adequate oxygenation in CO victims
• Fetal carboxyhemoglobin levels rise more slowly than maternal levels but usually peak higher due to the delayed off-gassing
• If possible, determine the source of the CO and provide resources to assist with the mitigation of the poisoning

DCS

• Arises from the formation of gas bubbles in tissue or blood in volumes sufficient to interfere with function of an organ or to cause alteration in sensation
• Type I – musculoskeletal pain
• Type II – aching pain in a limb after diving
• Can occur alone or in combination with musculoskeletal pain
• Primary targets
• Pulmonary
• Vestibular
• Nervous systems
• Cerebral AGE
• The possibility of AGE during decompression is high if the patient has suspected
• Pneumothorax
• Subcutaneous emphysema
• Arterial gas                                                                                                                                                                                                                                                                                                       

• Provide written post HBOT instructions including s/s to watch for, and report, follow up and resources (for all of these conditions)
• Educate patient/family on potential for delayed neurologic sequelae following carbon monoxide poisoning
• Educate patient/family on potential s/s of delayed sequelae including headache, irritability, personality changes, loss of memory cognitive changes, psychomotor changes, and parkinsonian appearance
• Educate patient/family to not return to the source of the poisoning until the source has been mitigated
• Instruct patient to rest, avoid caffeine and alcohol, encourage fluids and adequate diet, avoid strenuous activity, and avoid hot bath or shower for 24 hours after completion of HBOT
• Contact the HBO department or Diver’s Alert Network (DAN) if any symptoms return
• Avoid altitude exposure for 72 hours or underwater diving per physician recommendations
• Reinforce the importance of follow-up after discharge

• Educate patient/family related to nutritional needs and dietary preferences
  

• Recommend patient eat one hour prior to HBOT with protein and/or complex carbohydrates e.g., vegetables, whole grains, meat, cheese, dairy
• Consider sending simple carbohydrate source, fruit juice, glucose tabs or tube of glucose gel into chamber with patient in the event of symptomatic hypoglycemia during treatment, depending on type of chamber used
• Assist patient to use glucose gel/tabs or juice prior to HBOT
• Provide complex carbohydrate e.g., high protein diabetic beverage if needed 

• Educate that HBOT carries its own mechanism for increased glucose usage through oxygen mediated transport of glucose into muscle cells and may increase insulin sensitivity resulting in hypoglycemia
• Educate that adequate glucose control (less than 200mg/dL) is vital for wound healing

• Rights and responsibilities related to communication.
• Available communication aids

• Appropriate footwear (e.g., diabetic shoes, inserts, offloading boots, etc.) is necessary for adequate healing of wounds on the feet
• Monitor compliance with wound cares to promote healing

• Educate on potential lifestyle changes that could improve tissue perfusion
• Avoid crossing legs
• Change positions frequently
• Reduce risk/impact of atherosclerosis
• Smoking cessation
• Appropriate footwear
• S/S of infection
• Wound care