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HBO Treatment Indication With Protocol

INTRODUCTION

The purpose of this topic is to provide practitioners of Hyperbaric Oxygen Therapy (HBO) an in-depth summary of HBO indications and common HBO treatment protocols.for an introduction to HBO, pls refer to hbo 101

Treatment Protocol Guidelines

The following hyperbaric medicine treatment protocols are based upon the recommendations of the Hyperbaric Oxygen Committee of the Undersea and Hyperbaric Medical Society.

These protocols are designed to standardize therapeutic regimens, whenever possible, in order to optimize clinical outcomes and cost-effectiveness, and provide the basis for prospective analysis of data.  Care plans may need to be individualized according to a particular patient’s general medical condition and relevant medical history. When the clinical decision is to deviate from the protocols, including the upper treatment threshold, a case audit should be initiated. 

Medical Necessity

The listing of treatment indications for hyperbaric oxygen therapy contained herein represent the commonly accepted uses. It is important to note, however, that there are minor “medically necessary” differences between the various providers of health insurance.  The approved uses and indications are standardized across the country and can be found National Coverage Determination (NCD) 20.29. [1] .  

Each health insurance company’s decision-making process for inclusion or exclusion of a particular indication for hyperbaric oxygen therapy is based upon several factors.   Literature-specific reviews by panels of experts, technology assessments, resourcing of evidence-based repositories and historical precedent are tools used for “medically necessary‟ determination. 

HBO INDICATIONS

By Indication

See all indications below in "Evidence-based indications accepted by the UHMS, approved by Medicare" and "Evidence-based indications accepted by the UHMS, NOT approved by Medicare"

By Treatment Protocol

Table 1: 2.0 ATA oxygen x 90 minutes

Indications:         

Need to link orders

Topics

Sample Physician Order

HBO request requirements checklist  
and sample EMR documentation

Acute Exceptional Blood Loss Anemia


Acute Peripheral Ischemia/Crush Injury (without associated ischemia-reperfusion component)

 / 


Chronic Refractory Osteomyelitis (without E.Coli or pseudomonas isolated)



Preparation and Preservation of Compromised  Skin Flaps & Grafts



Diabetic Wound of Lower Extremity



Preparation of Wounds for Grafting



Soft Tissue Radionecrosis (STRN)



Intracranial Abscess




Table 2: 2.0 ATA Oxygen x 90 Minutes with 10 min Air Break

(patients with high seizure risk)

Indications:

Topics

Sample Physician Order

HBO request requirements checklist and sample EMR documentation

Acute Exceptional Blood Loss Anemia


Acute Peripheral Ischemia / Crush Injury (with no associated ischemia-reperfusion component)

 / 


Chronic Refractory Osteomyelitis



Compromised Skin Flaps & Grafts


Diabetic Foot Ulcer - Hyperbaric Oxygen Therapy



Preparation of Wounds for Grafting



Soft Tissue Radionecrosis




Intracranial Abscess




Table 3: 2.5 ATA Oxygen x 90 Minutes

Indications:        

Topics

Sample Physician Order

HBO request requirements checklist and sample EMR documentation

Acute Peripheral Ischemia / Crush Injury (involving ischemia- reperfusion component)

 / 


Acute Retinal Artery Insufficiency (including central and partial retinal occlusion, arterial branch occlusion and central retinal vein occlusion)



Chronic Refractory Osteomyelitis



Compromised Skin Flaps & Grafts



Osteoradionecrosis - Mandibular



Late Radiation Tissue Injury – Prophylaxis (complications of radiation therapy)


Necrotizing Soft Tissue Infections


Replantation Limb / Digits


Selected Invasive Fungal Infection (aspergillosis; mucormycosis)



Intracranial Abscess



Idiopathic Sudden Sensorineural Hearing Loss




Table 4a: 3.0 ATA oxygen x 90 minutes

Indications:

Topics

Sample Physician Order

HBO request requirements checklist and sample EMR documentation

  Acute Carbon Monoxide Poisoning

 


  Clostridial Myonecrosis (Gas Gangrene)

 



Table 4b: Indication for Acute Carbon Monoxide Poisoning


Table V



Adapted from the U.S. Navy Diving Manual  [2]


  1. Descent Rate – 20 ft/min.
  2. Ascent Rate – Not to exceed 1 ft/min. Do not compensate for slower ascent rates. Compensate for faster rates by halting the ascent.
  3. Time on oxygen begins on arrival at 60 feet.
  4. If oxygen breathing must be interrupted because of CNS Oxygen Toxicity, allow 15 minutes after the reaction has entirely subsided and resume schedule at point of interruption
  5. Treatment Table may be extended two oxygen-breathing periods at the 30-foot stop. No air break required between oxygen-breathing periods or prior to ascent.
  6. Tender breathes 100% O2 during ascent from the 30-foot stop to the surface. If the tender had a previous hyperbaric exposure in the previous 12 hours, an additional 20 minutes of oxygen breathing is required prior to ascent.

Note: In a hyperbaric monoplace chamber operating on psi measurements, decompress at a rate of: 1 psi/2 min

  • 30 fsw = 13.3 psi (1.9 ATA)
  • 60 fsw = 26.7 psi (2.8 ATA)

Table VI


Adapted from the U.S. Navy Diving Manual [2]

  1. Descent Rate – 20 ft/min.
  2. Ascent Rate – Not to exceed 1 ft/min. Do not compensate for slower ascent rates. Compensate for faster rates by halting the ascent.
  3. Time on oxygen begins on arrival at 60 feet.
  4. If oxygen breathing must be interrupted because of CNS Oxygen Toxicity, allow 15 minutes after the reaction has entirely subsided and resume schedule at point of interruption
  5.  Table 6 can be lengthened up to 2 additional 25-minute periods at 60 feet (20 minutes on oxygen and 5 minutes on air), or up to 2 additional 75-minute periods at 30 feet (15 minutes on air and 60 minutes on oxygen), or both.
  6. Tender breathes 100% O2 during the last 30 minutes at 30 fsw and during ascent to the surface for an unmodified table or where there has been only a single extension at 30 or 60 feet. If there has been more than one extension, the O2 breathing at 30 feet is increased to 60 minutes. If the tender had a hyperbaric exposure within the past 12 hours, an additional 60-minute O2 period is taken at 30 feet.

Note:  In a hyperbaric monoplace chamber operating on psi measurements, decompress at a rate of: 1 psi/2 min

  • 30 fsw = 13.3 psi (1.9 ATA)
  • 60 fsw = 26.7 psi (2.8 ATA)

By Threshold Level

For a separate view of the table below, along with the treatment tables, see  HBO Threshold Levels

Indications

Threshold Levels

 

Lower Limit

Upper Limit / Utilization Review

Elective - Chronic

   

Chronic Refractory Osteomyelitis

20*

30-40‡

Diabetic Ulcer Lower Extremity

14

40

Intracranial Abscess

5

20‡

Late Radiation Tissue Injury Prophylaxis

20*

30‡

Mandibular Osteoradionecrosis

30*

60‡

Preparation of Wounds for Grafting

10

30‡

Problem Wound Support

14

30‡

Soft Tissue Radionecrosis

20*

60‡

Emergent – Acute

   

Acute Carbon Monoxide Poisoning

 

5‡

Acute Exceptional Blood Loss Anemia

Until satisfactory hematocrit or pt. stable, asymptomatic,

or transfusion becomes possible

Acute Peripheral Ischemia/Crush Injury

3*

14‡

Acute Retinal Artery Insufficiency

 

**‡

Acute Thermal Burns

5*

30‡

Cerebral Arterial Gas Embolism

 

10‡

Clostridial Myonecrosis (Gas Gangrene)

5*

10‡

Compromised Skin Grafts and Flaps

6*

20‡

Decompression Sickness

 

10‡

Necrotizing Soft Tissue Infections

5*

30‡

Reattachment Limb/Digits

5

30

Selected Invasive Fungal Infections

7

20

Idiopathic Sudden Sensorineural Hearing loss120

      *   If the patient receives less than the indicated lower treatment threshold, a case audit is to be undertaken. For these disorders, too few treatments may be unlikely to have sufficient therapeutic effect and potentially waste resources. Reasons for early termination of HBO therapy may include: death; misdiagnosis; non-compliance; deterioration, or failure to perceive improvement.

  **   For patients treated more than three days after clinical plateau.

  ‡   Recommendations of the Undersea and Hyperbaric Medical Society, Hyperbaric Oxygen therapy Indications 13th Edition, 2014.

HYPERBARIC CPT CODES

  • 99183 Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session (PROFESSIONAL CHARGE)
  • G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute intervaL (FACILITY CHARGE)

TRANSCUTANEOUS ALGORITHMS-NARRATIVE

By Algorithm

Hyperbaric wound healing referrals undergo a comprehensive work-up, including a detailed medical history, physical examination, and selected diagnostic testing. Baseline transcutaneous oxygen screening is followed up in an algorithmic manner in those patients whose risk-benefit ratio is in favor of a trial of hyperbaric oxygen therapy. Algorithm 2 addresses four essential questions:

  1. Is wound healing complicated by hypoxia?
  2. When present, is hypoxia reversible?
  3. Is the patient responding to hyperbaric oxygen therapy?
  4. Has the patient reached a therapeutic endpoint?

1).  Is wound healing complicated by hypoxia?

  1. Normal lower extremity transcutaneous oxygen values exceed 50 mmHg*  [3] [4] 
  2. Values ranging from 35-40 mmHg, and higher, are considered sufficient to support oxygen-dependent wound healing. [5] [6] [7] 
  1. Values below this range represent a risk of healing compromise, the degree of which increases as value decreases.  [8] [9]

* when recorded at sea level pressure (760 mmHg)

2)  When present, is hypoxia reversible?

For hyperbaric oxygen, a systemic method of dose delivery, to be effective, a certain degree of regional perfusion must be present.

  1. Breathing 100% oxygen at normobaric pressure, following the recording of a steady-state ambient air breathing value, evaluates regional arterial inflow capacity.
  2. Oxygen challenge values in excess of 300 mmHg represent essentially uncompromised regional perfusion.
  3. Screening values in excess of approximately 100 mmHg are suggestive of sufficient regional perfusion for limb viability, and reflect a suitable candidate for in-chamber follow-up transcutaneous oxygen testing.
  4. Screening values that fail to reach 100 mmHg are consistent with a significant inflow abnormality, and warrant further arterial work-up. The decision to incorporate hyperbaric oxygen therapy into the treatment plan would be made on a case by case basis, in these circumstances and following decisions regarding any flow augmentation options, and as identified in Algorithm 1.

3) Is patient responding to hyperbaric oxygen therapy?

The above patient selection process does not predict outcome. It identifies those patients who have the physiologic capacity to deliver high oxygen tensions to the wound bed. There has been an unsuccessful effort to incorporate transcutaneous oximetry as an outcome predictor.  [10] [11] [12] [13] [14] This should not be to surprising, given the complexity of such lesions, particularly in the diabetic patient. Improvement in ambient (21% O2) transcutaneous oximetry over time probably remains the best indicator of therapeutic response. [11]Absence of increasing tissue oximetry values alerts the clinician to a potential non-responder. This should prompt evaluation of other possible impediments to wound repair, thereby avoiding an otherwise lengthy, unsuccessful and expensive course of therapy.

Hyperoxic-induced angiogenic responses have been monitored transcutaneously in tissues rendered ischemic secondary to therapeutic radiation. [6]. A distinct “rapid rise phase” in transcutaneous oximetry occurs following 8-10 treatments. This rise tends to plateau at 20-22 treatments. We have selected 14 treatments, essentially midway through this period of rapid change in tissue oximetry, as a point of re-evaluation. If neovascularization is being produced it should be evident by improved baseline (21% O2) peri-wound values.

  1. If values are increasing, the patient is considered a responder, and hyperbaric treatments are continued to Step 4.
  2. If there has been no change, or if deterioration is evident, the patient undergoes further work-up for etiologies other than hypoxia. Hyperbaric oxygen therapy may be held at this point.

The goal of Step 3 is to reduce the likelihood of lengthy and ultimately unsuccessful courses of hyperbaric oxygen therapy.

4).  Has the patient reached the endpoint?

In this era of evidence-based medicine and cost containment, greater scrutiny is being directed at the health care delivery system in general. It is important, therefore, that the decision to utilize hyperbaric oxygen therapy be mediated, in part, by its financial impact. In carefully selected patients, managed along algorithmic and evidence-based lines, hyperbaric oxygen therapy provides generally encouraging and clinically enduring outcomes, while reducing the patient’s total health care cost. When used in a largely indiscriminate manner, it can be expensive and of questionable clinical value.

In terms of the wound referral, transcutaneous oxygen monitoring holds great promise as an algorithmic management and cost containment tool. Well oxygenated chronic wounds are directed to management strategies other than hyperbaric oxygenation. Hypoxic wounds that are the consequence of high-grade regional ischemia are likewise referred from the hyperbaricist for flow augmentation. In those patients entered into a hyperbaric treatment protocol, non- responders are identified early, rather than following many weeks, or even months, of treatment.  The final step is to identify when a course of hyperbaric oxygen therapy has produced sufficient angiogenesis to support further and spontaneous healing. It is not necessary, nor is it cost effective, to treat such wounds to complete resolution. Once the environment around the wound has been “normalized”, and the patient converted to a locally host-competent state, hyperbaric oxygen can be stopped. Peri-wound transcutaneous oxygen values that reach or exceed 40 mmHg suggest adequate neovascularization has been formed. Typically, clinical evidence of healing responses will be apparent at this time. The wound may not be completely healed, however. At this point, hyperbaric oxygen therapy can be stopped. Standard wound care measures remain in force, and the patient is followed for continued healing responses. If the wound plateaus, or regresses, hyperbaric oxygen therapy is reinstituted. This is uncommon. In the setting for which this protocol is designed, the chronic and refractory skin ulceration, withholding hyperbaric therapy for one or two weeks is unlikely to represent a limb-threatening event. Should there be very significant improvement in wound quality, yet not all peri-wound values have reached the 40 mmHg threshold, a one week treatment hold, with the above evaluation schedule, would be appropriate.


Algorithm 1. Normobaric Transcutaneous Algorithm

Algorithm 2. In-Chamber & Follow-Up Transcutaneous Algorithm

CPT CODES

93922-52- TCOM, 1-2 levels, unilateral no provocative maneuvers

93922 – TCOM, 1-2 levels, unilateral with provocative maneuvers or 3 or > levels unilateral

93923 – TCOM, bilateral, 3 or more levels, with provocative maneuvers

TREATMENT

Evidence-based indications accepted by the UHMS, approved by Medicare

Elective – Chronic Indications

Emergent/Urgent – Acute Indications

Evidence-based indications accepted by the UHMS, NOT approved by Medicare

Elective – Chronic Indications

Emergent/Urgent – Acute Indications


Official reprint from WoundReference® woundreference.com ©2018 Wound Reference, Inc. All Rights Reserved

REFERENCES

  1. . National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29) . Date of publication 2017 Oct 7;volume ():.
  2. U.S. Navy. Chapter 17. Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism in U.S. Navy Diving Manual , 7th ed. . Date of publication 2017 Oct 7;volume ():.
  3. Dowd, G S; Linge, K; Bentley, G et al. Measurement of transcutaneous oxygen pressure in normal and ischaemic skin. The Journal of Bone and Joint Surgery. Britis.... Date of publication 1983 Jan 1;volume 65(1):79-83.
  4. Dowd GS, Linge K, Bentley G et al. The effect of age and sex of normal volunteers upon the transcutaneous oxygen tension in the lower limb. Clinical physics and physiological measurement : an official journal of the Hospital Physicists.... Date of publication 1983 Feb 1;volume 4(1):65-8.
  5. Hunt TK, Winkle WV et al. Wound Healing Normal Repair. In: Dunphy JE, editor. Fundamentals of Wound Management in Surgery: Wound Healing, Normal Repair. South Plainfield, NJ: Cirurgecom; p. 1–68. . Date of publication 2017 Oct 7;volume ():.
  6. Pai, M P; Hunt, T K et al. Effect of varying oxygen tensions on healing of open wounds. Surgery, gynecology & obstetrics. Date of publication 1972 Nov 1;volume 135(5):756-758.
  7. Davis JC, Hunt TK. et al. Problem wounds in oral and maxillofacial surgery: The role of hyperbaric oxygen: In: Davis JC, Hunt TK, editors. Problem wounds: the role of oxygen. illustrated. Elsevier; . Date of publication 2017 Oct 7;volume ():.
  8. Padberg, F T; Back, T L; Thompson, P N; Hobson, R W et al. Transcutaneous oxygen (TcPO2) estimates probability of healing in the ischemic extremity. The Journal of Surgical Research. Date of publication 2017 Oct 7;volume 60(2):365-369.
  9. Reiber, G E; Pecoraro, R E; Koepsell, T D et al. Risk factors for amputation in patients with diabetes mellitus. A case-control study. Annals of Internal Medicine. Date of publication 2017 Oct 7;volume 117(2):97-105.
  10. Wattel F, Mathieu D, Cogel JM. et al. Prediction of final outcome with transcutaneous oxygen measurements of problem wounds treated with hyperbaric oxygen. In: 2nd European Conference on Hyperbaric Medicine, editor. 2nd European Conference on Hyperbaric Medicine. Basel: European committee for Hyperbaric Medicine;. . Date of publication 2017 Oct 7;volume ():.
  11. Fife, Caroline E; Buyukcakir, Cem; Otto, Gordon H; Sheffield, Paul J; Warriner, Robert A; Love, Tommy L; Mader, Jon et al. The predictive value of transcutaneous oxygen tension measurement in diabetic lower extremity ulcers treated with hyperbaric oxygen therapy: a retrospective analysis of 1,144 patients. Wound Repair and Regeneration. Date of publication 2002 Aug 1;volume 10(4):198-207.
  12. Dooley, J; Schirmer, J; Slade, B; Folden, B et al. Use of transcutaneous pressure of oxygen in the evaluation of edematous wounds. Undersea & hyperbaric medicine : journal of t.... Date of publication 1996 Sep 1;volume 23(3):167-174.
  13. Strauss, Michael B; Bryant, Brandon J; Hart, George B et al. Transcutaneous oxygen measurements under hyperbaric oxygen conditions as a predictor for healing of problem wounds. Foot & Ankle International. Date of publication 2002 Oct 1;volume 23(10):933-937.
  14. Sheffield PJ, Dunn JM. et al. Continuous monitoring of tissue oxygen tension during hyperbaric oxygen therapy. In: 6th International Congress on Hyperbaric Medicine, editor. 6th International Congress on Hyperbaric Medicine. Scottland: European Committee on Hyperbaric Medicine;. p. 125–9. . Date of publication 2017 Oct 7;volume ():.
  15. Midwest Hyperbaric LLC. Midwest Hyperbaric Safety Discussion . Date of publication ;volume ():.
  16. Midwest Hyperbaric LLC. Midwest Hyperbaric Safety Discussion . Date of publication ;volume ():.

SUBTOPICS