HBOT in Burn Treatment

The Clinical Role of Hyperbaric Oxygen in Acute Thermal Injury, Smoke Exposure, Tissue Preservation, and Burn Reconstruction

Severe burns are dynamic injuries. Tissue damage can continue after the heat source has been removed because edema, microvascular thrombosis, inflammation, and impaired oxygen delivery may convert marginally viable tissue into deeper necrosis.

Hyperbaric oxygen therapy, commonly abbreviated as HBOT, may be considered as an adjunct for selected acute thermal burns. Its proposed role is to increase oxygen delivery to threatened tissue, reduce edema, support microvascular function, and potentially limit the progression of burn depth.

The Undersea and Hyperbaric Medical Society recognizes acute thermal burn injury as a clinical indication for adjunctive HBOT. The available evidence, however, does not support routine chamber treatment for every burn. HBOT should be delivered only when it can be integrated safely with burn-center care and without delaying airway management, fluid resuscitation, wound excision, grafting, or another essential intervention. (UHMS)

Burn Depth and Tissue Viability

Burn severity is determined by more than the percentage of skin involved. Clinicians must also consider depth, location, inhalation injury, associated trauma, age, comorbidities, and the patient’s physiologic response.

Burns are generally classified as:

• Superficial: Injury limited to the epidermis
• Superficial partial thickness: Injury extending into the upper dermis
• Deep partial thickness: More extensive dermal injury with reduced blanching and a greater risk of scarring or grafting
• Full thickness: Destruction of the entire dermis
• Deep tissue injury: Extension into fat, fascia, muscle, or bone

Superficial burns are not included in calculations of total body surface area. Partial-thickness and full-thickness burns are included. The American Burn Association recommends immediate burn-center consultation for full-thickness burns, partial-thickness burns involving at least 10 percent of total body surface area, and deep burns involving the face, hands, feet, genitalia, perineum, or major joints. (American Burn Association)

A thermal burn is often described as having three tissue zones. The central zone of coagulation contains irreversibly injured tissue. The surrounding zone of stasis has impaired circulation but may remain viable. The outer zone of hyperemia generally has better perfusion and a stronger likelihood of recovery.

The zone of stasis is the principal potential target of adjunctive HBOT. Treatment cannot restore tissue that has already undergone irreversible coagulative necrosis. Its proposed benefit is preservation of hypoxic but viable tissue surrounding the deepest portion of the burn.

Why Burn Wounds Can Become Deeper

A burn that initially appears partial thickness can progress into a deeper injury during the first several days. This process is commonly called burn wound conversion.

Factors contributing to conversion may include:

• Microvascular thrombosis
• Endothelial injury
• Capillary leakage
• Progressive edema
• Inflammatory cell activation
• Vasoconstriction
• Infection
• Hypotension or inadequate resuscitation
• Repeated pressure or trauma
• Drying or inappropriate wound management

The microcirculation may be particularly compromised during the first 12 to 24 hours, while the injury can remain biologically active for approximately 72 hours. This provides the rationale for beginning adjunctive HBOT early when it is selected. (NCBI)

Preventing burn conversion can have important clinical consequences. Preserving even a portion of the dermis may reduce the area requiring excision, improve epithelial regeneration, decrease grafting requirements, and limit long-term contracture or hypertrophic scarring.

HBOT should not be expected to prevent conversion when perfusion has been lost completely, shock remains uncontrolled, or tissue is already necrotic.

Standard Burn Care Remains the Foundation

Initial burn management follows established trauma and critical-care priorities. These should never be postponed for chamber treatment.

Depending on the injury, essential care may include:

• Airway evaluation and early intubation
• High-concentration oxygen
• Hemodynamic stabilization
• Intravenous fluid resuscitation
• Burn-depth and surface-area assessment
• Escharotomy or fasciotomy
• Wound cleansing and debridement
• Early excision of deep burns
• Skin grafting or flap reconstruction
• Temperature control
• Pain and anxiety management
• Nutritional support
• Infection surveillance
• Physical and occupational therapy

Suspected inhalation injury requires burn-center consultation. The American Burn Association recommends immediate consultation with consideration for transfer for all patients with suspected inhalation injury. (American Burn Association)

HBOT should be viewed as a supporting intervention within this system. A patient who needs airway control, escharotomy, hemorrhage management, or surgery should receive that intervention first.

How HBOT Changes Oxygen Delivery

During HBOT, the patient breathes oxygen while exposed to an ambient pressure higher than normal atmospheric pressure. The elevated pressure substantially increases arterial oxygen tension and the amount of oxygen dissolved directly in plasma.

This may allow oxygen-rich plasma to move through functioning microvessels and diffuse farther into tissue surrounding the burn. Potentially relevant effects include:

• Increased oxygen delivery to hypoxic but viable tissue
• Reduced edema through hyperoxic vasoconstriction
• Preservation of marginal microcirculation
• Support for cellular energy production
• Reduced leukocyte adhesion during reperfusion injury
• Improved oxygen-dependent microbial killing
• Support for fibroblast and epithelial activity
• Promotion of vascular repair

The combination of increased plasma oxygen and controlled vasoconstriction is important. Vasoconstriction may reduce capillary pressure and fluid leakage while the elevated oxygen content helps maintain tissue oxygen delivery.

HBOT does not restore circulation through a completely thrombosed artery, correct inadequate fluid resuscitation, or remove devitalized tissue. Enough functioning circulation must remain for oxygenated plasma to reach the wound.

Edema Reduction in Acute Burns

Edema is a major component of burn pathophysiology. Thermal injury increases capillary permeability, allowing fluid and proteins to move into the interstitial space. Large burns can produce both local swelling and systemic intravascular volume depletion.

Within the wound, edema increases the distance oxygen must diffuse between capillaries and cells. Swelling may also compress small vessels and worsen microvascular perfusion.

HBOT may reduce edema by producing vasoconstriction in oxygenated tissue while preserving oxygen delivery through the increased plasma oxygen concentration. Experimental and clinical reports have suggested that this may help interrupt the cycle of edema, ischemia, and additional capillary injury. (UHMS)

This effect does not replace appropriate burn resuscitation. Large burns may require substantial fluid administration, and the patient’s urine output, hemodynamics, lactate, electrolytes, and organ function must continue to be monitored.

Attempts to reduce edema by withholding necessary resuscitation can worsen tissue ischemia and organ injury.

HBOT and Burn Wound Conversion

One proposed benefit of early HBOT is the preservation of the zone of stasis. Increased oxygen delivery may support cells that are metabolically stressed but not yet irreversibly injured.

The treatment may also influence secondary injury by reducing leukocyte-endothelial adhesion, inflammatory signaling, and ischemia-reperfusion effects. These mechanisms could help limit the progression of a deep partial-thickness wound into a full-thickness injury.

Clinically meaningful preservation would be reflected by:

• Less progression of burn depth
• More spontaneous epithelialization
• Smaller areas requiring excision
• Reduced grafting requirements
• Shorter time to wound closure
• Improved tissue quality

Temporary redness or improved color during chamber exposure does not establish tissue salvage. The benefit must persist outside the chamber and translate into durable wound healing.

Which Burn Patients May Be Considered for HBOT?

There is no universally accepted set of burn-specific selection criteria. Practice varies by burn center, hyperbaric facility, injury severity, and chamber availability.

A consultation may be considered for selected patients with:

• Extensive deep partial-thickness burns

• Burns at substantial risk of wound conversion

• Severe edema threatening tissue viability

• Circumferential burns after appropriate decompression

• Burns involving critical functional areas

• High-voltage electrical injuries with traumatic ischemia

• Compromised grafts or flaps after burn reconstruction

• Carbon monoxide poisoning associated with a fire

• Burn injury combined with another recognized hyperbaric indication

Factors making HBOT less appropriate may include:

• Superficial or uncomplicated burns

• Completely necrotic tissue requiring excision

• Uncontrolled shock

• An untreated pneumothorax

• An airway that cannot be managed safely in the chamber

• Immediate need for surgery

• Lack of chamber-compatible critical-care equipment

• Transport that would disrupt burn-center treatment

The most useful question is not simply whether the patient has a burn. It is whether HBOT can plausibly preserve viable tissue or treat a separate recognized complication without compromising standard care.

Treatment Timing

If HBOT is selected for an acute thermal burn, early initiation is generally favored because the zone of stasis is most salvageable before secondary microvascular failure becomes established.

Published protocols commonly describe beginning treatment during the first 24 hours when possible. Some regimens use several treatments during the initial day, followed by once- or twice-daily sessions during the early period of burn progression. Reported treatment pressures often range from approximately 2.0 to 2.4 atmospheres absolute, with oxygen exposure lasting around 90 minutes. (NCBI)

These values should not be interpreted as a universal prescription. The 2026 systematic review of current burn evidence found substantial variation in pressure, frequency, treatment duration, number of sessions, patient severity, and reported outcomes. (PubMed Central (PMC))

The hyperbaric physician and burn surgeon should determine:

• Whether the injury remains salvageable
• How urgently treatment should begin
• How chamber sessions will fit around operations
• Whether once- or twice-daily treatment is feasible
• Which clinical findings justify continuation
• When HBOT should be discontinued

A necessary operation always takes priority over a scheduled chamber session.

Smoke Inhalation and Airway Injury

Smoke inhalation can produce several distinct problems:

• Upper-airway thermal injury
• Chemical irritation of the tracheobronchial tree
• Pulmonary inflammation and edema
• Carbon monoxide poisoning
• Cyanide poisoning
• Acute respiratory failure

HBOT does not directly remove airway casts, reverse upper-airway edema, or replace mechanical ventilation. Patients may require early intubation, bronchoscopy, pulmonary hygiene, ventilator support, and burn-intensive-care management. (PubMed)

The role of HBOT is clearer when the fire exposure has caused clinically significant carbon monoxide poisoning. Carbon monoxide reduces oxygen transport and can produce neurologic and cardiac injury. HBOT may be considered according to the patient’s neurologic findings, loss of consciousness, cardiac involvement, acidosis, pregnancy status, exposure severity, and transport logistics.

Suspected cyanide poisoning should be treated promptly with appropriate antidotal and critical care, commonly including hydroxocobalamin when clinically indicated. Chamber treatment must not delay antidote administration or airway stabilization. (PubMed)

Smoke inhalation should therefore not be treated as one uniform hyperbaric diagnosis. The clinician must distinguish airway injury, pulmonary damage, carbon monoxide toxicity, cyanide toxicity, and the cutaneous burn itself.

Burn Surgery, Grafting, and Reconstruction

Deep partial-thickness and full-thickness burns frequently require excision and grafting. HBOT should not delay removal of nonviable eschar or definitive wound coverage.

It may become relevant when:

• The recipient bed is poorly oxygenated
• A graft is failing to establish adequate uptake
• A flap develops ischemia or venous congestion
• Radiation, trauma, or infection has compromised the wound bed
• Marginal tissue around a reconstruction remains salvageable

The role in a compromised graft or flap is clinically distinct from routine treatment of an acute burn. Medicare recognizes preparation and preservation of compromised skin grafts as a covered indication, although it does not cover HBOT for the primary management of ordinary wounds. (Centers for Medicare & Medicaid Services)

A threatened graft or flap first requires surgical evaluation. Hematoma, seroma, pressure, infection, pedicle kinking, thrombosis, and other correctable causes must be addressed. HBOT may then support viable hypoxic tissue while vascular connections recover or mature.

Infection and Immune Function

Loss of the skin barrier, devitalized tissue, invasive devices, prolonged hospitalization, and immune dysfunction all contribute to infection risk after major burns.

HBOT can increase oxygen-dependent microbial killing by neutrophils and may improve oxygen delivery to tissue receiving antimicrobial therapy. It may also support granulation and wound defense in selected hypoxic regions.

It cannot replace:

• Surgical excision of infected or necrotic tissue
• Drainage of abscesses
• Culture-directed antimicrobial therapy
• Sepsis management
• Removal of infected devices
• Definitive wound closure

The 2026 systematic review identified signals suggesting improved infection control in some studies, but variability in study design and outcomes prevented definitive conclusions. (PubMed Central (PMC))

HBOT should not be continued simply because a burn is infected. The team must identify whether a recognized oxygen-responsive problem remains after source control has been addressed.

What Current Evidence Shows

The clinical evidence for HBOT in burn treatment is mixed.

A 2026 systematic review included 13 studies, consisting of five randomized controlled trials, seven cohort studies, and one case-control study. The studies evaluated 566 burn patients treated with HBOT and varied considerably in burn severity, treatment protocols, and outcome measures. The review found promising signals related to healing, infection, progression of burn depth, surgery, and hospital stay, but it could not establish definitive effects on mortality or long-term outcomes. (PubMed Central (PMC))

Earlier controlled research produced inconsistent results. A randomized prospective study in a referral burn-center population did not demonstrate a significant overall benefit from HBOT. (PubMed)

A Cochrane review concluded that there was insufficient evidence to support or refute routine HBOT for thermal burns. The small trials were clinically heterogeneous and had substantial methodologic limitations. A separate trial involving burn wounds treated with split-thickness grafting reported greater graft survival, but the result was not enough to justify routine treatment of all acute burns. (PubMed)

The evidence can therefore be summarized cautiously:

• HBOT has a credible physiologic rationale.
• Some studies report improved wound healing and reduced complications.
• Other controlled research has found little or no benefit.
• Patient selection and treatment protocols are not standardized.
• High-quality evidence for mortality reduction is lacking.
• Routine treatment of every burn is not supported.

This uncertainty makes multidisciplinary selection more important, not less.

Measuring Whether HBOT Is Helping

The treatment team should define objective goals before beginning HBOT.

Potential measures include:

• Change in burn depth
• Area of preserved dermis
• Reduction in edema
• Rate of epithelialization
• Area requiring excision
• Graft or flap viability
• Number of operative procedures
• Time to wound closure
• Infection status
• Functional tissue preservation
• Length of hospitalization

Serial photography, standardized wound assessment, operative findings, perfusion testing, and graft-survival measurements may help document response.

Treatment should be reconsidered when:

• Necrosis continues to progress
• A surgical problem remains uncorrected
• The patient becomes unstable
• Treatment repeatedly disrupts burn care
• No measurable clinical benefit is developing
• The original treatment objective has been achieved

A predetermined number of sessions should not replace ongoing clinical judgment.

Treating Critically Ill Burn Patients Under Pressure

Major burn patients may require mechanical ventilation, continuous infusions, invasive monitoring, large-volume resuscitation, temperature control, and frequent surgical intervention.

HBOT should be provided only in a facility capable of preserving that level of care under pressure. Operational requirements may include:

• Chamber-compatible ventilators
• Infusion pumps able to function under pressure
• Secure airway and vascular access
• Continuous physiologic monitoring
• Management of chest tubes and drains
• Temperature maintenance
• Safe wound dressings
• Staff experienced in hyperbaric critical care
• Rapid access to emergency decompression

Transporting the patient from the burn intensive care unit to the chamber can itself create risk. Lines may become displaced, temperature may fall, infusions may be interrupted, and access to the patient may be limited during treatment.

The potential tissue benefit must be substantial enough to justify these operational burdens.

Fire Safety and Burn Dressings

The hyperbaric environment requires strict control of combustible materials, ignition sources, electrical equipment, clothing, linens, and wound products.

Burn patients may arrive with topical preparations, antimicrobial creams, petroleum-containing products, synthetic dressings, warming equipment, or electronic devices that have not been approved for chamber use. Every item must undergo a documented hyperbaric safety review.

The FDA advises facilities to follow the chamber manufacturer’s instructions, maintain continuous patient monitoring, use appropriate grounding, perform scheduled maintenance, and enforce fire-prevention procedures. (U.S. Food and Drug Administration)

A dressing that is appropriate in the burn unit is not automatically appropriate inside a pressurized oxygen environment. The burn, hyperbaric, pharmacy, and safety teams should agree on compatible alternatives before treatment begins.

Risks of HBOT in Burn Patients

Potential complications include:

• Middle-ear or sinus barotrauma
• Pulmonary barotrauma
• Oxygen-induced seizure
• Temporary vision changes
• Claustrophobia or agitation
• Glucose instability
• Interruption of critical-care therapies
• Hypothermia during transport
• Fire-safety hazards
• Delayed access during sudden deterioration

An untreated pneumothorax must be addressed before pressurization. This is especially important after blast injury, inhalation injury, chest trauma, or mechanical ventilation.

Patients with facial burns, airway edema, sedation, or altered mental status may be unable to report ear pain or neurologic symptoms. The chamber team must anticipate complications rather than depending solely on patient communication.

Reimbursement and Coverage Considerations

Professional recognition and insurance coverage are not the same.

Although UHMS recognizes acute thermal burns as a hyperbaric indication, the current Medicare National Coverage Determination lists thermal skin burns as nationally noncovered. Medicare also excludes acute thermal or chemical pulmonary damage described as smoke inhalation with pulmonary insufficiency. (Centers for Medicare & Medicaid Services)

Separate complications may qualify under another covered indication. Medicare covers conditions including acute carbon monoxide intoxication, cyanide poisoning, acute traumatic peripheral ischemia, crush injury, and preparation or preservation of compromised skin grafts. (Centers for Medicare & Medicaid Services)

Commercial payer policies vary. Before nonemergency treatment, the hospital should verify:

• The diagnosis being submitted
• Whether the indication is covered
• Prior-authorization requirements
• Required clinical documentation
• Treatment limits
• Facility and professional billing requirements

Coverage should not determine emergency stabilization, but it affects program planning and informed discussions about treatment burden.

Integrating HBOT Into Burn-Center Care

An effective hospital pathway should define:

1. Which burn injuries prompt urgent hyperbaric consultation.
2. Which burn surgeon remains responsible for definitive wound management.
3. How airway, resuscitation, and operative priorities are protected.
4. Which patients can be monitored safely inside the available chamber.
5. How HBOT is coordinated with excision, grafting, and dressing changes.
6. Which objective findings justify continued treatment.
7. How adverse events and outcomes are reviewed.

The decision should be made jointly by burn surgery, critical care, hyperbaric medicine, respiratory therapy, nursing, pharmacy, and hyperbaric safety personnel.

HBOT in burn treatment is best understood as an early tissue-preservation strategy for carefully selected patients. It may increase oxygen delivery, reduce edema, protect marginal microcirculation, and support graft or flap survival. It does not replace resuscitation, airway management, surgery, infection control, nutrition, or rehabilitation.

Current evidence is promising but inconsistent. The most responsible use is selective, protocol driven, and tied to measurable clinical goals within a specialized burn-care system.