Clinical Indications for Hyperbaric Oxygen Therapy

Hyperbaric consultation may be considered for selected patients with significant acute thermal injury when HBOT can be provided without interfering with definitive burn care.

Potential situations include:

• Deep partial-thickness burns
• Full-thickness burns
• Extensive burns with significant tissue edema
• Burns at risk for progressive tissue loss
• Complex burns involving marginally viable tissue
• Burns associated with significant ischemic injury
• Patients already requiring HBOT for associated carbon monoxide poisoning

The decision should consider burn severity, total body surface area, associated injuries, clinical stability, transport requirements, and access to an appropriate hyperbaric facility.

HBOT as Part of Comprehensive Burn Care

The foundation of severe burn treatment remains specialized burn care.

Management may include:

• Airway and respiratory support
• Fluid resuscitation
• Pain management
• Burn wound cleansing
• Appropriate dressings
• Escharotomy or fasciotomy when indicated
• Surgical excision
• Skin grafting
• Infection management
• Nutritional support
• Temperature management
• Rehabilitation and scar management

HBOT should be coordinated with these interventions rather than interrupting or delaying them.

Patients with suspected smoke inhalation should also be evaluated for carbon monoxide and cyanide toxicity when appropriate.

Clinical Evidence and Guidelines

Acute thermal burn injury is recognized by the Undersea & Hyperbaric Medical Society as an accepted indication for adjunctive HBOT.

The proposed benefits include improved tissue oxygenation, reduced edema, preservation of marginally viable tissue, modulation of inflammation, and support of wound healing.

Clinical evidence remains limited.

Systematic reviews have identified only a small number of randomized controlled trials, with concerns regarding study size and methodological quality. Other studies and clinical experience have reported potential reductions in wound progression, healing time, grafting requirements, or length of hospitalization.

Overall, the available evidence is not strong enough to support routine HBOT for every burn patient.

HBOT is therefore best considered an adjunct for carefully selected patients within an experienced burn and hyperbaric medicine program.

Medicare Coverage

Although acute thermal burn injury is recognized by UHMS as an indication for HBOT, Medicare National Coverage Determination 20.29 specifically lists thermal skin burns as a noncovered condition.

Medicare also lists acute thermal and chemical pulmonary damage, including smoke inhalation with pulmonary insufficiency, as noncovered under this HBOT benefit.

This does not affect Medicare coverage for a separate covered diagnosis that may occur in a burn patient, such as qualifying carbon monoxide poisoning.

Commercial payer policies may differ and should be reviewed individually.

When to Refer

Consider hyperbaric medicine consultation for selected patients with:

• Deep partial-thickness or full-thickness thermal burns
• Progressive burn-wound conversion
• Extensive tissue edema and hypoxia
• Threatened but potentially viable tissue
• Complex burns where preservation of tissue may reduce reconstruction requirements
• Concurrent carbon monoxide poisoning requiring hyperbaric evaluation

HBOT should never delay airway management, resuscitation, surgical intervention, transfer to a burn center, or other established burn treatment.