Clinical Indications for Hyperbaric Oxygen Therapy

Early hyperbaric consultation may be appropriate when a patient has a confirmed or strongly suspected necrotizing soft tissue infection and HBOT can be delivered without delaying surgery or critical care.

Situations may include:

• Necrotizing fasciitis
• Fournier gangrene
• Rapidly progressive tissue necrosis
• Extensive infection with significant tissue hypoxia
• Severe systemic toxicity
• Persistent progression despite surgical debridement and antimicrobial therapy
• Infection threatening limb or major tissue loss

The patient’s stability, need for additional surgery, transport requirements, and availability of a chamber capable of managing critically ill patients must all be considered.

HBOT as Part of Multidisciplinary Care

The foundation of NSTI treatment remains rapid diagnosis and aggressive source control.

Management may include:

• Immediate surgical exploration
• Repeated surgical debridement
• Broad-spectrum intravenous antibiotics
• Hemodynamic resuscitation
• Critical care support
• Treatment of organ dysfunction
• Glycemic management
• Nutritional support
• Reconstruction after infection control

Care commonly involves surgery, infectious disease, emergency medicine, critical care, wound care, reconstructive surgery, and hyperbaric medicine.

HBOT must never delay necessary surgical debridement or resuscitation.

Clinical Evidence and Guidelines

Necrotizing soft tissue infections are recognized by the Undersea & Hyperbaric Medical Society as an accepted indication for adjunctive HBOT.

The physiologic rationale includes improved oxygen delivery to hypoxic tissue, enhanced leukocyte function, antimicrobial effects, and reduction of edema.

High-quality randomized clinical trials are lacking because NSTIs are uncommon, rapidly progressive, and require immediate treatment.

A 2023 systematic review and meta-analysis evaluating more than 49,000 patients found an association between adjunctive HBOT and lower mortality compared with standard treatment alone. However, the studies were retrospective and observational, so the certainty of evidence remains limited.

There was no significant reduction in amputation rates in that analysis.

Accordingly, HBOT should be viewed as an adjunct for appropriately selected patients rather than a replacement for established surgical and antimicrobial management.

Medicare Coverage

Progressive necrotizing infections, including necrotizing fasciitis, are specifically listed as covered conditions under the Centers for Medicare & Medicaid Services National Coverage Determination for Hyperbaric Oxygen Therapy (NCD 20.29).

Coverage recognition does not guarantee payment for every individual treatment.

Applicable documentation, coding, medical necessity, facility, and payer requirements should be reviewed.

When to Refer

Consider hyperbaric medicine consultation when a patient has:

• Confirmed or strongly suspected necrotizing fasciitis
• Fournier gangrene
• Rapidly progressive tissue destruction
• Persistent infection despite debridement and antibiotics
• Severe tissue hypoxia
• Significant risk of limb or tissue loss

Do not delay surgical exploration, debridement, antimicrobial therapy, or resuscitation while arranging HBOT.

Early coordination between the surgical and hyperbaric teams can help determine whether treatment can be safely incorporated into the patient’s overall care plan.