Skip to main content
search

Hyperbaric Medicine in Intensive Care: Treatment in a Pressure Chamber for Carbon Monoxide Poisoning and Necrotizing Fasciitis

The Anesthesia Guide » Topics » Hyperbaric Medicine in Intensive Care: Treatment in a Pressure Chamber for Carbon Monoxide Poisoning and Necrotizing Fasciitis

Author:
Kai Knudsen



Updated:
8 September, 2025

Hyperbaric oxygen therapy (HBO) is increasingly recognized as a valuable adjunct in intensive care, where critically ill patients often present with life-threatening hypoxic conditions. By delivering 100% oxygen under elevated atmospheric pressure, HBO enhances oxygen availability, modulates inflammation, and improves host defense mechanisms. This chapter highlights its role in two of the most clinically relevant indications: carbon monoxide poisoning, where HBO accelerates elimination of carboxyhemoglobin and prevents neurological damage, and necrotizing fasciitis, where it serves as an adjunct to surgery and antibiotics to reduce mortality and tissue loss.

Content:
  1. Introduction

Introduction

Hyperbaric oxygen therapy (HBO) is a medical intervention in which patients breathe 100% oxygen under pressures exceeding atmospheric levels inside a pressure chamber. By markedly increasing the amount of physically dissolved oxygen in plasma, HBO improves oxygen transport to hypoxic or underperfused tissues. In addition, HBO has been shown to modulate inflammatory processes, inhibit anaerobic bacterial growth, reduce edema, and promote tissue repair.

In the context of intensive care, HBO has particular relevance in the treatment of two acute and potentially life-threatening conditions: carbon monoxide (CO) poisoning and necrotizing fasciitis. In CO poisoning, HBO accelerates the elimination of carboxyhemoglobin and reduces the cellular effects of hypoxia and oxidative stress. In necrotizing fasciitis, HBO acts as an adjuvant to surgery and antibiotics, improving oxygenation in infected tissues, enhancing immune function, and limiting infection progression.

The purpose of this chapter is to provide a systematic review of the physiological mechanisms, clinical indications, and therapeutic strategies of HBO in intensive care, with a focus on the aforementioned conditions. The chapter also addresses risks, logistical challenges, and the need for multidisciplinary collaboration to optimize outcomes.

Physiological Background

Under normobaric conditions, oxygen is transported predominantly bound to hemoglobin. In hyperbaric environments, however, the amount of oxygen dissolved in plasma increases several-fold, allowing diffusion into poorly perfused tissues and circumventing the limitations imposed by hemoglobin saturation. HBO further influences cellular mechanisms by reducing leukocyte adhesion, modulating free radical activity, and enhancing neutrophil-mediated antibacterial function (2–4).

Carbon Monoxide Poisoning

Carbon monoxide binds to hemoglobin with an affinity 200–250 times greater than that of oxygen, forming carboxyhemoglobin. This reduces oxygen transport capacity and shifts the oxyhemoglobin dissociation curve to the left, further impairing tissue oxygen delivery. Additionally, CO binds to cytochrome oxidase and other heme proteins, leading to cellular hypoxia and oxidative stress (5).

Rationale for HBO

HBO significantly accelerates the dissociation of CO from hemoglobin, reducing the half-life of carboxyhemoglobin from approximately 320 minutes in room air to about 20 minutes at 3 ATA (6). Beyond this effect, HBO mitigates cellular toxicity by improving tissue oxygenation and reducing lipid peroxidation (7).

Clinical Aspects in Intensive Care

Indications for HBO in CO poisoning include impaired consciousness, neurological symptoms, pregnancy, and elevated carboxyhemoglobin levels (8). In the intensive care setting, patients are frequently intubated and mechanically ventilated, making transport to the pressure chamber logistically complex. Nevertheless, HBO constitutes an integral part of the therapeutic strategy, alongside airway management, hemodynamic stabilization, and neurological monitoring.

Necrotizing Fasciitis

Necrotizing fasciitis is a rapidly progressing soft-tissue infection, often polymicrobial, characterized by extensive tissue necrosis and systemic inflammatory response. Despite advances in intensive care and surgical techniques, mortality remains high (9,10).

Rationale for HBO

The pathophysiology of necrotizing fasciitis involves synergistic bacterial activity in a hypoxic tissue environment. HBO increases local oxygen tension, thereby inhibiting anaerobic bacterial growth, potentiating the effects of certain antibiotics, and enhancing leukocyte activity (11). HBO also reduces edema and stimulates angiogenesis, supporting tissue repair and surgical outcomes.

Clinical Aspects in Intensive Care

The cornerstone of treatment for necrotizing fasciitis is urgent surgical debridement combined with broad-spectrum antibiotics and advanced intensive care support. HBO is employed as an adjuvant therapy, often in repeated sessions, to limit infection spread and improve survival (12). Patients are frequently critically ill, requiring ventilatory support, circulatory stabilization, and close monitoring for multiorgan dysfunction. Successful implementation of HBO requires careful coordination between intensive care, surgery, infectious diseases, and hyperbaric medicine teams.

Risks and Limitations

Despite its therapeutic benefits, HBO is not without risks. Potential adverse events include barotrauma, oxygen-induced seizures, and logistic complications associated with the transfer of critically ill patients (13). Furthermore, access to hyperbaric facilities remains limited in many healthcare systems, which may delay treatment initiation.

Conclusions

Hyperbaric oxygen therapy is a valuable adjunct in intensive care, particularly in the management of carbon monoxide poisoning and necrotizing fasciitis. By improving oxygen delivery, reducing infection progression, and mitigating cellular damage, HBO contributes to improved patient outcomes. Optimal benefit is achieved through early intervention, careful patient selection, and close collaboration between multiple medical specialties.

Key Points

  • Hyperbaric oxygen therapy (HBO) increases dissolved oxygen in plasma, enhancing delivery to hypoxic or underperfused tissues.
  • HBO exerts anti-inflammatory and antibacterial effects, including inhibition of anaerobic bacteria and improved neutrophil function.
  • In carbon monoxide poisoning, HBO reduces the half-life of carboxyhemoglobin and mitigates neurological sequelae.
  • In necrotizing fasciitis, HBO serves as an adjuvant to surgery and antibiotics, improving survival and tissue preservation.
  • HBO is particularly relevant in intensive care, where patients often require ventilatory and circulatory support.
  • Risks include barotrauma, oxygen-induced seizures, and logistical challenges in transporting critically ill patients.
  • Effective use of HBO requires multidisciplinary collaboration between intensive care, surgery, infectious diseases, and hyperbaric medicine teams.

References

  1. Moon RE. Hyperbaric oxygen therapy indications. 14th ed. Durham: Undersea and Hyperbaric Medical Society; 2019. (Book, no DOI)
  2. Mathieu D, Marroni A, Kot J. Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving Hyperb Med. 2017;47(1):24–32. https://doi.org/10.28920/dhm47.1.24-32
  3. Jain KK. Textbook of Hyperbaric Medicine. 6th ed. Cham: Springer; 2017. https://doi.org/10.1007/978-3-319-47140-2
  4. Thom SR. Oxidative stress is fundamental to hyperbaric oxygen therapy. J Appl Physiol. 2009;106(3):988–995. https://doi.org/10.1152/japplphysiol.91004.2008
  5. Weaver LK. Clinical practice. Carbon monoxide poisoning. N Engl J Med. 2009;360(12):1217–1225. https://doi.org/10.1056/NEJMcp0808891
  6. Weaver LK, Hopkins RO, Chan KJ, et al. Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med. 2002;347(14):1057–1067. https://doi.org/10.1056/NEJMoa013121
  7. Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011;(4):CD002041. https://doi.org/10.1002/14651858.CD002041.pub3
  8. European Committee for Hyperbaric Medicine. Guidelines for Hyperbaric Oxygen Therapy. Brussels: ECHM; 2016. (Report, no DOI)
  9. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis. 2007;44(5):705–710. https://doi.org/10.1086/511638
  10. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2017;377(23):2253–2265. https://doi.org/10.1056/NEJMra1600673
  11. Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. Am J Surg. 2005;189(4):462–466. https://doi.org/10.1016/j.amjsurg.2005.01.021
  12. Wilkinson D, Doolette D. Hyperbaric oxygen treatment and survival from necrotizing soft tissue infection. Arch Surg. 2004;139(12):1339–1345. https://doi.org/10.1001/archsurg.139.12.1339
  13. Kindwall EP, Whelan HT, editors. Hyperbaric Medicine Practice. 3rd ed. Flagstaff: Best Publishing Company; 2008. (Book, no DOI)

 

Disclaimer:

The content on AnesthGuide.com is intended for use by medical professionals and is based on practices and guidelines within the Swedish healthcare context.

While all articles are reviewed by experienced professionals, the information provided may not be error-free or universally applicable.

Users are advised to always apply their professional judgment and consult relevant local guidelines.

By using this site, you agree to our Terms of Use.




Close Menu