82yo male patient with STRN and ORN of the mandible (diagnosis SCC of lip 2016 w/radiation from 2016-2017) - the workup on this patient indicated a small right basilar pleural effusion on 3/21/2023 (known history of COPD). Small to moderate chronic bilateral pleural effusions were noted on CT w/o contrast on 11/14/2022. Again, these were documented as "stable effusions" on 9/10/2022. Repeat CT soft tissue of neck on 5/1/2023 visualized the same, but documented only as "small" and only on the right. A few mediastinal lymph nodes were also noted and measured at 9mm - these were decreased from 11mm in 11/14/2022. The reason for the updated question is that this most recent CT has now shown right parasymphyseal fracture with adjacent permeated appearance of the right parasymphyseal mandible likely secondary to underlying osteonecrosis of the jaw - this was not present on CT in November. Of additional note, this patient is currently on HBOT #27 of 30 for STRN before follow-up with his oral surgeon on 5/8/2023. We have been diving at rate of 1.5psi/min to 2.0ATA for 90min w/no air breaks. Additionally, we have noted improvement in the ulcerated area in the mouth as documented by oral surgery at 4/24/2023 visit with no bone no longer visible. I previously corresponded with Dr. Mike White, MD regarding this patient. Taking this new information into consideration, I have a few questions:

1) Based on the information on wound reference re:HBOT protocol for ORN, it recommends staging - based on this history, he would meet Stage III criteria d/t pathologic fracture, but, at this point, no complete resection or reconstruction has been completed. Prior to this fracture, only Stage I criteria.

2) Given the lung findings on CT, would it be appropriate for me to increase to 2.5ATA with changes to ORN w/two 5 min air breaks and maintain the 1.5psi/min rate of descent/assent?

Other PMHx: Diastolic heart failure (EF 50-55% on recent echo), CAD, RAS, stage 4 chronic kidney disease (most recent CrCl 18mL/min, Na 141, K 3.6). I have received cardiac clearance from the patient's cardiologist prior to dive #1 on 3/23/2023, but he does not see an actual pulmonologist. Barotrauma on 4/13/2023 of left ear - myringotomy tube placed. Also being treated for stage 4 pressure ulcer of the right ankle w/osteomyelitis and stage 4 pressure ulcer of sacrum that recently underwent surgical debridement and has a wound VAC in place.