Equipment Exam: Accessories and Options For Hyperbaric Chambers

  When you establish a hyperbaric program, it’s not as simple as buying a chamber or three and starting to treat patients. You also have to consider what ancillary equipment or accessories will be necessary to provide safe and effective treatment. The type of ancillary equipment chosen will impact departmental operations, staffing, and training.

  So, what additional equipment will you need? We will group our list by:
    • Things every program must have (reference, safety, and patient care).
    • Entertainment and comfort.
    • Monitoring and critical care.

  But before considering the hardware (or for that matter—chambers), you should decide what type of hyperbaric cases your facility is going to treat.

  In the quarter century that this author has been involved in hyperbaric medicine, program structures have evolved from traditional “hyperbaric” programs that were established with a mission to treat all of the “approved” indications, to “wound care and hyperbaric” programs that primarily use HBO as an adjunct to problem wound management, and rarely treat other HBO indications.

  It seems that more facilities are located in outpatient-only clinics, limit their operating hours to 8–5, Monday–Friday, and are staffed by personnel without training or experience in management of high-acuity patients. The result of this trend is that a community may have multiple hyperbaric facilities, but only one (or in some cases, none) that is equipped to manage acute indications. This article is not the forum to debate this trend, but it must be considered, given the continued research into the use of HBO in treatment of acute injuries.

So, What Do You Need?

  • Some items are required by NFPA code:
    ˚ “No Smoking” signs.
    ˚ Fire extinguisher(s).
    ˚ Smoke hood, SCBA, or similar device (per NFPA 99, 20.2.4.5.3 and Appendix).
    ˚ Telephone or other signaling device (fire alarm) at chamber side for tech to call for help.
    ˚ Patient grounding system.

Grounding Systems:

  • Reusable wrist straps are provided by chamber manufacturers, but spare cables and single-patient use straps or ECG pads should be stocked.

  • Ground check system.

  • Though not strictly required by code, there should be a mechanism in place to verify the operational integrity of the patient/chamber ground system. Depending upon facility policy, continuity and resistance of the chamber ground system may be checked regularly using an ohmmeter and cable set.

Additional Items for Multiplace Chambers

  If you operate a multiplace chamber, there are additional items that may be mandated by NFPA code and integrated into the chamber, though some may only be required under certain operating conditions:

  • Fire suppression system.
  • Oxygen analyzer.
  • CO2 analyzer.
  • Other gas detectors.
  • Fire detectors.
  • Reference material – the bare bones:
    ˚ At least one general HBO book (Kindwall or Jain).
    ˚ Hyperbaric Facility Safety. – A Practical Approach (Workman).
    ˚ Hyperbaric Nursing (Larson-Lohr).
    ˚ UHMS Committee Report.
    ˚ NFPA 99, Chapter 20.

  • Operations manuals for each chamber model and ancillary equipment.
  • Policy and Procedure manuals, up to date and in compliance with the hospital’s P&P (if a hospital-affiliated program) in both form and content.
  • Additional Safety Equipment:
    ˚ Patient education poster (What Not to Bring Into the Chamber).
    ˚ Quick reference to emergency procedures at chamber side.

  • Tools to perform minor repairs or adjustments (if trained).
    ˚ A system to document any repairs or maintenance conducted on the chamber.

  • Spare/replacement parts:
    ˚ Door gasket.
    ˚ Filter elements.
    ˚ O-rings and blank plug for IV ports (if IVs administered).

  • Air break system (if any treatments are administered at pressures > 2.0 ATA).
    ˚ Demand valve systems are typical with most monoplace chambers, but I’m not a fan of them—many patients have problems with obtaining a good mask seal, the valve can be an infection vector (particularly when the valve is left in the chamber continuously), and the valve could damage the chamber acrylic if trapped between the gurney and window.

Entertainment and Patient Comfort
  Unlike the safety items listed above, which are mandated by codes or regulatory agencies, entertainment and comfort items are not mandatory, but it is hard to run a program without them. The following items are advisable:

  • A television with more than three channels and a good audio feed into the chamber.
    ˚ Most manufacturers now offer bracket systems to mount flat screen televisions directly to the exterior of the chamber.

  • DVD player and small library of movies.
  • CD player/radio for patients with visual impairment.
  • Hydraulically-adjustable gurney to ease patient transfer and save technicians’ backs.
  • Pressure-relieving mattress.
  • Wedge and roll pillows to enhance patient positioning.

Monitoring and Critical Care.

  Hyperbaric medicine is at a crossroads with respect to critical care. Fewer facilities have the interest nor capability to manage even the moderately acute case, which leads to less demand for critical care support equipment. Manufacturers are reluctant to produce innovative products for such a small market, resulting in hyperbaric facilities being forced to use near-obsolete technology. Ventilators are a prime example—the only ventilator available for monoplace chambers was introduced in the late 1970’s and has remained essentially unchanged since that time. It has no alarm functions and only an airway pressure gauge. In the early 1990’s a company introduced an airway monitor/alarm system, but dropped it within a few years due to low sales.

  The decision to treat acutely-ill patients should not be taken lightly, nor without careful pre-planning, staff training, and ongoing competency assessments. The treatment of high-acuity patients is a rarity for most facilities, so the challenge is not just having the right equipment, but having the right people to properly utilize that equipment. The facility should have a policy in place that defines what level of acuity the facility will accept, before the facility opens and to communicate that policy to the potential referral base.

  For each device utilized, the facility should have operational policies and procedures for the use of the device in place, a standardized initial and recurrent training program, and regular competency assessments for all personnel. A program can be equipped with the hardware to support the sickest patient, but if the staff is not competent to utilize that equipment, all parties can be at risk, both medically and legally.

  In some cases, equipment may require modification to allow its use with a chamber, and some risk managers and biomedical engineers are reluctant to perform the modification or clear a modified device for use, typically citing concerns with getting in trouble with the FDA over modifying a device.

  In the following list, we will consider equipment from the most common to the more exotic.

Monitoring/Assessment

  • Hand-held Doppler.
  • TcpO2 monitor.
    ˚ TcpO2 still remains a valuable device for assessing oxygenation, particularly when used in conjunction with HBO. Some chamber manufacturers provide custom cable sets that allow in-chamber studies, or you can purchase a hull penetrator fitting that will fit through a standard door port and allow direct connection of the TcpO2 cable, without the need for adapters.

  • Laser Doppler.
    ˚ Growing in popularity for evaluation of microvascular flow – not to be used in the chamber.

  • ECG monitor.
    ˚ Useful to monitor for arrhythmias, assuming staff is trained in ECG interpretation. Some training programs recommend that all patients undergo ECG monitoring as a means to determine oxygen toxicity based on heart rate changes, but there is little evidence to show the utility of this technique. Requires modification/adaptation of cables to fit electrical pass-thru ports.

  • Arterial/Central Venous Pressure monitor.
    ˚ Typically combined with ECG monitor in a modular format. Will require some type of flush system to prevent clots – the Ethox pressure infuser, with lubricant changed to an oxygen compatible lube is the common adjunct for flush systems. Also will require cable modification for use.

  • Non-Invasive Blood Pressure monitor
    ˚ CAS Medical Systems manufactured their OscilloMate 1630 non-invasive pressure monitor through 2009, and still provides support. This monitor was designed for use with monoplace chambers and consists of an external pump/monitor, specialized hull penetrator/hose set, and various sizes of cuffs.

  • Tympanometer.
    ˚ Used to assess flexibility of the tympanic membrane, a tympanometer can be helpful to screen patients for Eustachian tube dysfunction or ability to successfully autoinflate/clear ears. The typmanometer probe is placed in the external ear canal and the device applies a positive/negative pressure pulse and produces a graph (tympanogram) that indicates the movement of the eardrum. If the test is repeated while the patient performs an autoinflation maneuver, flattening of the tympanogram indicates that the patient is likely to be able to handle pressurization without barotrauma. Exactly how reliable this device is at determining whether patients can “clear” their ears is not known, but it may be a useful adjunct to patient education and evaluation.

Therapeutic/Clinical Support

  • IV Pump.
    ˚ Currently there is only one pump designed for use with monoplace chambers, the Hospira Plum A+, which replaced the venerable Abbott 3HB. Accessories for the 3HB pump are no longer manufactured and support is limited.

  • Ventilator.
    ˚ The Sechrist 500A is the only ventilator currently available for use with monoplace chambers. It is designed for use with Sechrist chambers, but has been used with other chambers. Though functional, this ventilator is very limited in its features: no monitors or alarms, no air break capability without modification, and is limited to controlled ventilation only. Management of a patient with substantial lung dysfunction may be extremely difficult if not impossible with this ventilator. Only personnel who are properly trained and well experienced in providing ventilatory support should use it. In some facilities, the respiratory therapy staff handles ventilator management. If this is the case, there should be an ongoing training and competency assessment program for the RT staff to assure that properly trained personnel are available when needed.

What about a Crash Cart?

  Crash carts are typically equipped with monitor/defibrillator units, airway support equipment (laryngoscopes/endotracheal tubes/manual ventilators/suction), and emergency drugs and fluids. A method for emergently managing pneumothorax (chest tube, McSwain Dart, or large bore needle/hemostat) is a common addition to crash carts in hyperbaric facilities. The decision to equip (or not to equip) a program with a crash cart raises a number of questions to consider, including:

  • Do you intend to treat high-acuity patients in your facility?
  • Is your staff, including physicians, trained and verified competent in ACLS?
  • Are trained staff on duty at all times patients are in the facility?
  • Is your unit located within a facility that has a “code team” or formalized emergency response plan?
    ˚ If so, is your facility included in that plan – do code team members know how to get to your facility and where the nearest crash cart is located? Do you have pneumothorax management supplies immediately available within the facility if that equipment is not kept on the crash cart?

  • Do you treat high-acuity patients in a unit located in a non-hospital setting (out-patient clinic, surgicenter, free-standing facility, etc)?
    ˚ If so, how do you maintain continuity of care for those patients who must be transferred from the referring hospital?

  • How will you manage acute medical emergencies that occur within your facility?
  • If your staff trained in BLS? Are they trained to use airway support equipment such as oral or nasal airways, bag ventilators, and suction systems?
    ˚ If so, do you maintain a “BLS” kit that is equipped with airway support equipment?

Summary

  As you can see, a hyperbaric facility is not just a chamber. There is a core set of accessories that are necessary for any program to operate in a safe manner. The type and acuity of the patient population treated and the location of the facility largely drive the type of ancillary equipment needed for a facility.

  The time to decide how ill a patient your facility will treat is before you treat your first patient, then obtain the necessary equipment and train in its use. Failure to do so can put your patients, and your facility at risk.

Steve Wood’s 25-year career in hyperbaric medicine has ranged from working as a clinician to building hyperbaric chambers to managing hyperbaric and wound care contract service providers. He is President of Hyperbaric Safety Systems, Inc. a firm specializing in hyperbaric technical consulting and development of innovative safety accessories for hyperbaric chambers.