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Top Ten Things You Need to Know About HBOT #3: Side Effects Are Rare
In the eighth article in a series, this review article will discuss and give updates on top ten things we need to know about hyperbaric oxygen therapy (HBOT).
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Did you know that HBOT is an extremely safe treatment but there could be some side effects?
HBO therapy is extremely safe but like all treatments, it can come with some unwanted side effects. We will discuss some of them below. Before we move forward, we would like to point out the age-old medical maxim that we hope all wound care clinicians will adhere to when providing HBOT: “If it hurts, don’t do it!”
One of the most common side effects of HBOT is middle ear barotrauma (MEB). The incidence of barotrauma is not well defined, but sources report values ranging from 0.0029% to 0.04% of HBOT sessions.1,2 Though usually temporary and not severe, MEB can be uncomfortable and lead to the cessation of therapy for some patients. MEB can present simply as pressure and/or pain in the affected ear. It can also have more severe clinical presentations such as serous otitis media, hemotympanum and even tympanic membrane perforations.3 Often MEB is self-limited; however, severe cases of MEB can often be managed by the surgical placement of myringotomy tubes, which can prevent the previously mentioned complication of rupture of the tympanic membrane and further conductive hearing loss.4 Some MEB prophylactic methods include the use several maneuvers during HBOT such as the following: the Valsalva and Toynbee maneuvers, and the Edmonds and Lowry techniques.
Additionally, we try to avoid exposing patients with upper respiratory infections to HBOT. The use of decongestants and antihistamines has also been known to play a role in the prophylaxis of MEB associated with HBOT. A clinical trial is currently underway in Baltimore to examine the use of pseudoephedrine as a prophylactic agent for MEB as a result of HBOT. Another clinical trial is currently analyzing the effect of self acupressure on MEB related to HBOT.5 We look forward to their findings.
Other types of side effects can also be associated with HBOT. Oxygen toxicity is one of them. Essentially, oxygen toxicity is caused by increased levels of oxygen exposure, like those seen in HBOT. The symptoms related to oxygen toxicity can be insidious and include chest tightness, dyspnea, pleuritic chest pain, cough, and even tonic-clonic seizures.6 Oxygen toxicity can be prevented by alternating between short intervals of air and longer intervals of 100% oxygen, which then limits free radical formation.7 Some drugs have been associated with a reduction in the incidence of oxygen toxicity and include allopurinol, vitamin C and vitamin E.8
Additionally, hypoglycemia is another side effect of which we must be aware of, as many patients undergoing HBOT have diabetes and are more prone to hypoglycemic episodes. The symptoms of hypoglycemia can be vague and include but are not limited to palpitations, dizziness, light headedness, agitation, changes in mental status, nausea, vomiting and sweating. This side effect is unpredictable but has been linked mostly with patients with Type 1 diabetes mellitus, as well as those with poor appetite and weight loss. The incidence of HBOT related hypoglycemia is that of 1.5%, defining hypolglycemia as a blood glucose reading of less than 70 mg/dL during or immediately after HBOT.9 This has led to the development of protocols for pre-treatment glucose monitoring in many HBOT centers.
More uncommon side effects include sinus barotrauma, increase in blood pressures, reversible myopia, pulmonary barotrauma, and flash pulmonary edema.10 We would like to remind our readers that HBOT is a very safe and has been around for more than 150 years. It is a valuable therapeutic option for our patients with hard to heal wounds.
Denise Nemeth is a second-year medical student at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio, TX. Formerly a general and vascular surgery PA in a rural community, Ms. Nemeth aspires to become a general surgeon. She is certified wound specialist with the American Board of Wound Management. Her interests include rural health, wound healing, colorectal surgery, and minimally invasive surgery.
Jayesh B. Shah is Immediate Past president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. In addition, he is president of South Texas Wound Associates, San Antonio. He is also the past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society and Current of Board of Trustees of Texas Medical Association.
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References
1. Nasole E, Zanon V, Marcolin P, Bosco G. Middle ear barotrauma during hyperbaric oxygen therapy; a review of occurrences in 5,962 patients. Undersea Hyperb Med. 2019;46(2):101-106.
2. Jokinen-Gordon H, Barry RC, Watson B, Covington DS. A retrospective analysis of adverse events in hyperbaric oxygen therapy (2012-2015): Lessons learned from 1.5 million treatments. Adv Skin Wound Care. 2017;30(3):125-129. doi: 10.1097/01.ASW.0000508712.86959.c9 [doi].
3. Karahatay S, Yilmaz YF, Birkent H, Ay H, Satar B. Middle ear barotrauma with hyperbaric oxygen therapy: Incidence and the predictive value of the nine-step inflation/deflation test and otoscopy. Ear Nose Throat J. 2008;87(12):684-688.
4. Heyboer M,3rd, Sharma D, Santiago W, McCulloch N. Hyperbaric oxygen therapy: Side effects defined and quantified. Adv Wound Care. 2017;6(6):210-224. https://pubmed.ncbi.nlm.nih.gov/28616361 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467109/. doi: 10.1089/wound.2016.0718.
5. Chen JM, Lu ZN, Wu RW, Bi KW, Liu CT. Effect of self-acupressure on middle ear barotrauma associated with hyperbaric oxygen therapy: A nonrandomized clinical trial. Medicine (Baltimore). 2021;100(17):e25674. doi: 10.1097/MD.0000000000025674 [doi].
6. Neuman T. Physiology and Medicine of Hyperbaric Oxygen Therapy. Elsevier; 2008.
7. Leach RM, Rees PJ, Wilmshurst P. Hyperbaric oxygen therapy. BMJ. 1998;317(7166):1140-1143. http://www.bmj.com/content/317/7166/1140.abstract. doi: 10.1136/bmj.317.7166.1140.
8. Jain KK. Textbook of Hyperbaric Medicine. 3rd ed. Hogrefe & Huber, 1999.
9. Stevens SL, Narr AJ, Claus PL, et al. The incidence of hypoglycemia during HBO2 therapy: A retrospective review. Undersea Hyperb Med. 2015;42(3):191-196.
10. Weaver LK, Churchill S. Pulmonary edema associated with hyperbaric oxygen therapy. Chest. 2001;120(4):1407-1409. doi: S0012-3692(16)35555-6 [pii].
