Hi,
I'm looking to provide further education to staff regarding CXR prior to HBOT. I could not find chest imaging recommendation directly addressed within Wound Reference. What data does Wound Reference use to support CXR, or not, for a screening tool for even low risk patients prior to HBOT?
I have found an article stating routinely using chest X-ray or computed tomography scans as screening tools prior to HBOT for low-risk patients without a pertinent medical history or lack of clinical symptoms of cardiorespiratory disease is of low value. (Diving Hyperb Med 2022 Sep 30;52(3):197-207. doi: 10.28920/dhm52.3.197-207.
The role of routine pulmonary imaging before hyperbaric oxygen treatment
Connor Ta Brenna 1 2, Shawn Khan 2, George Djaiani 3, Jay C Buckey Jr 4, Rita Katznelson 1 3)
Another study concluded: Some centers reported that they didn't treat the patients if they had bullea or bleb. But they also stated that they do routine screening by chest X-ray. We know now plain chest X-ray doesn't show such lesions efficiently. Our survey demonstrated that a significant portion of the HBO centers accept patients with pulmonary bleb or bullae, although insufficient, X-ray is the mostly used screening tool for patients with a history of pulmonary disease and the prevalence of pulmonary barotrauma during HBOT is very low. For the selected indications, HBOT may be administered without screening for air trapping lesions, if there is no clinical evidence of a current lung disease. (Are pulmonary bleb and bullae a contraindication for hyperbaric oxygen treatment? Respiratory MedicineVolume 102, Issue 8, August 2008, Pages 1145-1147 Akin Savas Toklu a, Sefika Korpinar a, Mustafa Erelel b, Gunalp Uzun c, Senol Yildiz c)
Others articles state the importance of CXR screening:
-It is important to obtain screening chest x-ray prior to HBOT to rule out any anatomic abnormalities (i.e. bullous lung disease) and avoid treatment if there is active bronchospasm or mucous plugging. (J Am Coll Clin Wound Spec. 2016; 8(1-3): 2–3.Published online 2018 Feb 5. doi: 10.1016/j.jccw.2018.01.005 PMCID: PMC6161636 PMID: 30276115
Hyperbaric Oxygen Therapy Side Effects – Where Do We Stand? Marvin Heyboer, III, MD, FACEP, FACCWS, FUHM)
-Asymptomatic pulmonary lesions on chest x-ray should be evaluated before proceeding to determine the underlying etiology (Hyperbaric Contraindications, Rohin Gawdi; Jeffrey S. Cooper. StatPearls [Internet].Treasure Island (FL): StatPearls Publishing; 2023 Jan-.) --> This would lead me to conclude, we should screen even low risk patients, to further evaluate a potential relative contraindication.
-ARDS is life-threatening, so clinicians must screen candidates receiving HBOT for pre-existent
pulmonary disease with a thorough history, checking for past pneumothorax or chest surgery, and at minimum screening CXR. (ARDS AS A VERY RARE COMPLICATION OF HYPERBARIC OXYGEN THERAPY: A CASE REPORT S. De Silva, R. Loftus, J. Dabu, DOI:
https://doi.org/10.1016/j.chest.2019.02.369). Hoping you can shed light on best practice. Thank you!
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Millman M. Hyperbaric oxygen therapy in a patient who has pulmonary blebs. Abstract E85, UHMS ASM. 2013.
Germonpré P, Balestra C, Pieters T. Influence of SCUBA diving on asymptomatic isolated pulmonary bullae. Diving and Hyperbaric Medicine.2009;38(4):206-211.
Bang DH, Lim D, Jeong OM, Hwang WS, Jung JY, Lim J. Low-dose chest computed tomography as a screening tool: findings in 536 aircrews. Aviat. Space Environ Med. 2012;83(9):896-898.
Hi, Sarah! Want to be more confused? Just read these articles to add to your excellent collection.
Some philosophical points to consider. Why do we get a chest x-ray in the first place? I think it's safe to say that we've all been scared to death of pulmonary barotrauma and the risk of fatal tension pneumothorax. I've given lectures at diving medicine conferences about pulmonary complications in scuba diving, not so different than HBOT exposure. I frequently present 3 cases that I know about where pulmonary barotrauma did occur but without evidence of tension pneumothorax --- even with repeated HBOT exposures for days after the HBOT related pneumothorax. One pneumothorax was discovered by accident in CXR for central PICC line insertion.
To a person, the patients (2 of whom are hyperbaric nurses) did not link their 'funny' chest pain to the hyperbaric exposure the day before. OK ... that's an aside.
Is it worth the money and risk to get a spiral chest CT? Nope. The Bang article linked below comes to that conclusion.
I have great respect for Dr. Heyboer and Dr. Weaver, both of whom get CXR and pulmonary function tests on all HBOT patients. I do not recommend it. I would further evaluate any patient who has chest pathology ... but I do not spend the money for every single HBOT patient. The, what do you do for emergencies after hours when the decision to treat is made in minutes ... not days or weeks ahead of time????
So, the science is exactly what you have stated ... and, it's none too clear. The bottom line is what your medical director is comfortable with. Once he/she is apprised of the conflicting data, it's time to make a decision that might change in the future.
I laughed at the reference above in "StatPearls" about evaluating pulmonary blebs found on routine chest films. The CXR is pitiful about finding pulmonary blebs unless the bleb is already huge. CXR is a crude evaluation tool.
While we pay attention to case reports, in statistical decision-making tasks, the case report does not enter into the process. We really need clinical trials and/or randomized controlled studies. In this indication, the reports are so rare and do not lend themselves to interpretation. They are simply "background noise" and they only lead to 'expert opinion.' For this, you are better off taking a dart and throwing it at the cork board on the wall ... wherever it lands is the decision of the day!!
All the best!
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Mar 25, 2023
![]()
Millman M. Hyperbaric oxygen therapy in a patient who has pulmonary blebs. Abstract E85, UHMS ASM. 2013.
Germonpré P, Balestra C, Pieters T. Influence of SCUBA diving on asymptomatic isolated pulmonary bullae. Diving and Hyperbaric Medicine.2009;38(4):206-211.
Bang DH, Lim D, Jeong OM, Hwang WS, Jung JY, Lim J. Low-dose chest computed tomography as a screening tool: findings in 536 aircrews. Aviat. Space Environ Med. 2012;83(9):896-898.
Hi, Sarah! Want to be more confused? Just read these articles to add to your excellent collection.
Some philosophical points to consider. Why do we get a chest x-ray in the first place? I think it's safe to say that we've all been scared to death of pulmonary barotrauma and the risk of fatal tension pneumothorax. I've given lectures at diving medicine conferences about pulmonary complications in scuba diving, not so different than HBOT exposure. I frequently present 3 cases that I know about where pulmonary barotrauma did occur but without evidence of pneumothorax --- even with repeated HBOT exposures for days after the pneumothorax. One pneumothorax was discovered by accident in CXR for central PICC line insertion.
To a person, the patients (2 of whom are hyperbaric nurses) did not link their 'funny' chest pain to the hyperbaric exposure the day before. OK ... that's an aside.
Is it worth the money and risk to get a spiral chest CT? Nope. The Bang article linked below comes to that conclusion.
I have great respect for Dr. Heyboer and Dr. Weaver, both of whom get CXR and pulmonary function tests on all HBOT patients. I do not recommend it. I would further evaluate any patient who has chest pathology ... but I do not spend the money for every single HBOT patient. The, what do you do for emergencies after hours when the decision to treat is made in minutes ... not days or weeks ahead of time????
So, the science is exactly what you have stated ... and, it's none too clear. The bottom line is what your medical director is comfortable with. Once he/she is apprised of the conflicting data, it's time to make a decision that might change in the future.
I laughed at the reference above in "StatPearls" about evaluating pulmonary blebs found on routine chest films. The CXR is pitiful about finding pulmonary blebs unless the bleb is already huge. CXR is a crude evaluation tool.
While we pay attention to case reports, in statistical decision-making tasks, the case report does not enter into the process. We really need clinical trials and/or randomized controlled studies. In this indication, the reports are so rare and do not lend themselves to interpretation. They are simply "background noise" and they only lead to 'expert opinion.' For this, you are better off taking a dart and throwing it at the cork board on the wall ... wherever it lands is the decision of the day!!
All the best!
![]()
Mar 25, 2023
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