Lack of Oxygen: The Commonplace Practice of Cutting Hyperbaric Oxygen Therapy Dosages Protection Status
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by Thomas E. Serena MD, FACS, FACHM, FAPWCA

From the third floor patio of the Foreign Correspondent’s Club (FCC), the evening breeze is a welcome respite from the sweltering heat of Phnom Penh’s hospital wards. An assortment of barges and boats strung with neon lights drifts along the Mekong Delta. This location, made famous by the movie the Killing Fields, has become the meeting place for NGOs (non-governmental organizations) and volunteers of all sorts. Nightly, we would share our tales of life and death in Cambodia’s capital city. A recurring theme was the lack of active ingredients in medicines purchased at local pharmacies. A trio of Brits complained that it was far worse in other resource poor nations. I was appalled that someone would reduce the dose of a medicine for economic gain.

This practice of dosage reduction, however, is not just limited to poor countries and internet purchases. In fact, it is commonplace in the wound and hyperbaric centers across the United States. The standard prescribed dose of hyperbaric oxygen is 2.4 ATA (atmospheres absolute) for 90 minutes of treatment. There are times when we adjust the depth to 2.0 ATA for medical reasons, such as patients on dialysis for end stage renal disease, or patients with moderately severe congestive heart failure. This is the exception, not the rule.

The preponderance of evidence for hyperbaric oxygen has been demonstrated at 2.4 ATA. Advocates for the lesser depth point to a reduction in oxygen toxicity. However, the difference in risk for patients at 2.4 ATA and 2.0 ATA is exceedingly small. Why has the practice of treating all patients at 2.0 become so popular if there is little clinical evidence to support it? The reason is simple: money. Treating all patients at 2.0 ATA means that more patients can be treated in a day, and the cost of air break equipment and medical air tanks can be avoided.

My Cambodian colleagues would be appalled!

About The Author
Dr. Thomas Serena has published more than 75 peer-reviewed papers and has made in excess of 200 presentations worldwide. He has been elected to the Board of Directors of both The Wound Healing Society and the American College of Hyperbaric Medicine (ACHM), the leading academic society in the field of Hyperbaric Medicine. In 2013 Dr. Serena was elected vice president of the American Professional Wound Care Association (APWCA). Dr. Serena has opened and operates Wound Care and hyperbaric oxygen treatment clinics across the United States.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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I am a Hyperbaric Tech and I don't agree completely. Air break equipment goes in with all patients anyway, whether you use it or not is another matter. Regardless of the depth, it's a precaution measure.

It's not all about the money. There are other factors that go into whether the treatment is 2.0 or 2.4. Patient health is a big one. Heart and lung conditions that are monitered can not handle the extra pressure. Can the patient handle doing an air break, do they understand the process and why they are doing it? Even though the Technician did his best to explain the hows and whys, the patient may not be able to do an air break.
Not all protocols are written for 2.4 ATA's. Again, this depends on the conditions and the patient.

Some of our patients can only go to 2.0, so we just run them longer at the 2.0 instead of pushing them to 2.4.

Anonymous Tech,

You are correct that sometimes the patient's condition necessitates
lowering ht depth to 2.0. The focus of this blog was to draw attention to
the practice of routinely using 2.0 for ALL patients regardless of their
clinical condition. The primary reason for this is monetary.

If it's the money that they are concerned about, they could compress to 2.5 ATA and decompress at 1.5 psig per min. This comes out to 15 minutes down and 15 minutes up.
Add to this three 30 minute O2 breathing periods with two 10 minute air breaks and you end up with a 140 minute treatment that is billed as 5 units. This is much less stressful for the patient and allows for a much longer air break, ensuring the patients with shallow breathing/tidal volumes still achive the intended design of the air break.
The patient and the hospital both benifit from this dive profile.

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