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Diving and Hyperbaric Medicine Volume 47 No. 1 March 2017

Consensus Conference

Tenth European Consensus Conference on Hyperbaric Medicine:
recommendations for accepted and non-accepted clinical indications
and practice of hyperbaric oxygen treatment
Daniel Mathieu, Alessandro Marroni and Jacek Kot
Abstract(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 and Hyperbaric
Medicine. 2017 March;47(1):24-32.)
The tenth European Consensus Conference on Hyperbaric Medicine took place in April 2016, attended by a large delegationof experts from Europe and elsewhere. The focus of the meeting was the revision of the European Committee on Hyperbaric
Medicine (ECHM) list of accepted indications for hyperbaric oxygen treatment (HBOT), based on a thorough review ofthe best available research and evidence-based medicine (EBM). For this scope, the modified GRADE system for evidence
analysis, together with the DELPHI system for consensus evaluation, were adopted. The indications for HBOT, including
those promulgated by the ECHM previously, were analysed by selected experts, based on an extensive review of the literatureand of the available EBM studies. The indications were divided as follows: Type 1, where HBOT is strongly indicated asa primary treatment method, as it is supported by sufficiently strong evidence; Type 2, where HBOT is suggested as it is
supported by acceptable levels of evidence; Type 3, where HBOT can be considered as a possible/optional measure, but
it is not yet supported by sufficiently strong evidence. For each type, three levels of evidence were considered: A, when
the number of randomised controlled trials (RCTs) is considered sufficient; B, when there are some RCTs in favour of theindication and there is ample expert consensus; C, when the conditions do not allow for proper RCTs but there is ample andinternational expert consensus. For the first time, the conference also issued ‘negative’ recommendations for those conditions
where there is Type 1 evidence that HBOT is not indicated. The conference also gave consensus-agreed recommendations
for the standard of practice of HBOT.
Key words
Medical conditions and problems; Evidence; Systematic review; Symposium; European Committee for Hyperbaric Medicine
Introduction
The European Committee for Hyperbaric Medicine (ECHM)
has in its objectives the continuous improvement in thequality of care and the safety of hyperbaric medicine.1 Oneof the tools used to reach this target is the organization ofconsensus conferences to issue guidelines which could berecognized and accepted as widely as possible. Two suchconsensus conferences have been organized previously in1994 and 2004. In 1994, the guidelines were elaborated by ajury from expert reports and discussion with the conference
audience.2 In 2004, the guidelines report was improved in
grading the recommendations both by the level of evidence
supporting the recommendation and their importance forclinical practice.3 Twelve years on, it was time to review andupdate these guidelines based on the advances in medical
knowledge and the experience gained in clinical practiceduring that period. For the 2016 guidelines, ECHM wished
to go a step further in reporting not only recommendations
with their clinical importance and evidence level, butalso how confident the conference audience was in thoserecommendations. A preliminary report with the short listof indications for hyperbaric oxygen treatment (HBOT)

was published recently.4 Here, we present the full report,
including methodology and detailed recommendations given
at the conference. Additional files with literature queries andanalysis of published evidence using the GRADE system
can be found on the ECHM website (www.ECHM.org).
Methodology
Evidence based medicine (EBM) methodology has gained
a widespread acceptance and is presently an integral part ofmodern medical practice. The approach and tools used in
EBM involve using scientific evidence to provide answers
to specific questions. However in the real world, there aredifferent levels of evidence depending on the source of
information and the design of the study (e.g., from casereports to randomised controlled trials RCTs). This resultsin the concept of a pyramid of evidence with a decreasing
chance of bias as the methodological rigour improves
moving up the pyramid. For interested readers, we provide
a useful reference on EBM.5
The process of issuing new recommendations for clinicalpractice is typically based on three components: 1) theDiving and Hyperbaric Medicine Volume 47 No. 1 March 2017

level of evidence (i.e., the quality of available data;) 2) theinterpretation of the evidence (i.e., what the data suggest
and how concordant these data are regarding a particular
problem) and 3) the type or strength of the recommended
practice (i.e., the extent to which a physician is able torecommend a particular intervention on the basis of the firsttwo considerations). This method may be used either by anindividual physician or by a group of experts who could be
expected to arrive at the same conclusion.
For clinical research, the various levels of evidence are thefollowing:
Level A: At least two concordant, large, double-blind
RCTs with no or little methodological bias;
Level B: Double-blind RCTs but with methodologicalflaws, studies with only small samples or one study only;
Level C: Consensus opinion of experts;
Level D: Only uncontrolled studies with no consensus
opinion of experts;
Level E: No evidence of beneficial action, or
methodological or interpretation bias precluding any
conclusion;Level F: Procedure not indicated by existing evidence.
Even though the hyperbaric medicine community has madeconsiderable effort to achieve high quality clinical studies, wemust recognize that many questions remain with insufficientevidence to give a definite answer. Therefore, it is hardly
surprising that, from the current list of clinical indicationsfor HBOT, only a small number of clinical entities in which
HBOT is conventionally used is supported by the highest
level of evidence. Physicians should remember that clinicaldecisions are usually based on some level of evidence thatis less than absolute proof and that no evidence of a benefit
is not the same as evidence of no benefit. In the view of
the ECHM, there are some clinical situations in which it isextremely difficult or even virtually impossible to undertakehigh quality, controlled trials, for example:•••

Using HBOT in a particular condition, unsupported bya high level of evidence, is so logical that it has become
universally accepted to such an extent that it would begrossly inappropriate to consider omitting it to establish
proof of efficacy or even that it would be considered aviolation of accepted standards of care to deny a patient
the benefit of the therapy for the purpose of a study (e.g.,
HBOT for decompression illness (DCI) or arterial gas
embolism (AGE));
where the disease or condition of interest is so complex
or where there are so many variables that it would be
impossible to design a study sufficiently powerful
to assess any single procedure (e.g., HBOT and gas
gangrene);
where no current higher level of evidence exists, but
experts are able to report, not only from their own
experiences but also by producing comprehensive
literature reviews from which consensus can

25provisionally be reached, pending the outcome of futurestudies (e.g., HBOT and neuroblastoma).
In such situations, an alternative approach should be sought.
In the opinion of the ECHM, the search for a consensus byexperts is a way to convert the best evidence available into
clinical guidelines.
ECHM consensus conferences aim to create an objective andcomplete review of the current literature and knowledge ona particular topic or field. This method has the advantage
of involving a diverse group of participants from a broad
range of relevant backgrounds to provide consideration of
all aspects of the chosen topic and maximum objectivity.
The opportunity to meet with other experts in the same
field and share comments and information is also a valuable
aspect of these meetings. At a consensus conference, experts
present their reviews of the literature relating to a specifictopic before a jury and an audience. Thereafter, the jury
gathers in a secluded place to discuss the presentations, andpresents its finding in a consensus statement that includes
recommendations for clinical practice based on the evidence
that was presented. These recommendations are publishedin one or more medical journals.
The application of EBM methodology to the consensus
process helps the jury members to reach a consensus andstrengthens the recommendations. Thus, each jury member
assesses the literature and the evidence presented by theexperts and grades these according to their quality. In the
ECHM conferences, each jury member used the same
grading scale (from 1 to 4) for the level of evidence asfollows:2,3
For both basic studies (tissue, cellular or subcellular level)
and for animal studies with a control group:• Level 1: Strong evidence of beneficial action;• Level 2: Evidence of beneficial action;• Level 3: Weak evidence of beneficial action;• Level 4: No evidence of beneficial action or
methodological or interpretation bias preclude any
conclusion.
For human studies:• Level 1: Strong evidence of beneficial action based on
at least two concordant, large, double-blind, RCTs withno or only weak methodological bias;• Level 2: Evidence of beneficial action based on doubleblind RCTs but with some methodological bias, orconcerning only small samples, or only a single study;• Level 3: Weak evidence of beneficial action based
only on uncontrolled studies (historical control group,cohort study);• Level 4: No evidence of beneficial action (case reportsonly) or methodological or interpretation bias preclude
any conclusion.
Jury conclusions have been made according to the level of
supporting evidence (Table 1):

Diving and Hyperbaric Medicine Volume 47 No. 1 March 201726

Table 1Consensus-based and GRADE scaling for recommendations; GRADE – Grading of Recommendations Assessment,
Development and Evaluation System
Strength of recommendation (consensus-based)
Level 1 = Strong recommendation = “We recommend…”
The course of action is considered appropriate by the large
majority of experts with no major dissension. The panel
is confident that the desirable effects of adherence to therecommendation outweigh the undesirable effects.
Level 2 = Weak recommendation = “We suggest…”
The course of action is considered appropriate by the majorityof experts but some degree of dissension exists amongst thepanel. The desirable effects of adherence to the recommendation
probably outweigh the undesirable effects.
Level 3 = Neutral recommendation = “It would be reasonable…”
The course of action could be considered appropriate in theright context.

Level of evidence (based on GRADE system)
Grade A = High level of evidence
The true effect lies close to our estimate of the effect.

No recommendation
No agreement was reached by the group of experts.

Grade D = Very low level of evidence
Our estimate of the effect is just a guess, and it is very likelythat the true effect is substantially different from our estimateof the effect.

•

•

•
•

Type 1 recommendation, which means “strongly
recommended”, recommendations or standards aresupported by Level 1 evidence;
Type 2 recommendation, which means just“recommended”, recommendations or guidelines aresupported by Level 2 evidence;
Type 3 recommendation, which means “optional”,
statements are supported only by Level 3 evidence.

During the 2004 ECHM consensus conference, after having
listened to the experts and with the assistance of literature
reviewers, the jury graded the existing evidence using
the scale we have described above (levels from A to F).3
Conditions where the use of HBOT was supported by level
A, B or C evidence were considered as accepted indications.
However, in order to make the jury discussion and decision
on conditions not considered accepted indications for HBOT
more transparent, the levels D, E, and F were also reportedwith the jury’s evaluation of the existing evidence.
For the 2016 European Consensus Conference, the ECHM
decided to adopt the modified GRADE system for evidence
analysis,7,8 together with the DELPHI system for consensus
evaluation.9,10 As for the previous conferences, ECHM asked
a panel of experts in each field to prepare reports based ona literature survey, a synthesis of the evidence for each anda proposal for recommendations (Table 1).6−8

Grade B = Moderate level of evidence
The true effect is likely to be close to our estimate of the effect,
but there is a possibility that it is substantially different.
Grade C = Low level of evidence
The true effect may be substantially different from our estimateof the effect.

•

Results
Recommendations on the clinical indications for HBOT havebeen presented separately for accepted indications (Table 2),
non-accepted indications (Table 3) and those conditions inwhich HBOT is not recommended (Table 4).
ACCEPTED INDICATIONS
Carbon monoxide (CO) poisoning•••

In order to take into account the changes proposed to improve
the quality of guidelines elaboration, we introduce two
additional steps:• All the reports were circulated within the expert groupand each expert was asked to weight the clinicalimportance and the level of evidence each proposed
recommendation (Delphi method).

During the conference, reports and expert opinions
were presented and discussed. The audience then voted
on each recommendation and the agreement between
audience participants was measured and reported. Finalconsensual recommendations with weighted evidence
and audience confidence were then issued.
We expect that, using such a methodology, every
individual reading the conference conclusions will be
immediately able to assess the strength of each statement
and how it could be applied in their own practice.

•

We recommend HBOT in the treatment of CO poisoning(Type 1 recommendation, Level B evidence).
We recommend 100% oxygen be applied immediately
to any CO poisoned person as a first aid treatment (Type
1 recommendation, Level C evidence).
We recommend HBOT for every CO poisoned person who
presents with altered consciousness alteration, clinicalneurological, cardiac, respiratory or psychological signs
whatsoever the carboxyhaemoglobin level at the timeof hospital admission (Type 1 recommendation, Level
B evidence).
We recommend HBOT in CO-poisoned pregnant
women whatever their clinical presentation and27

Diving and Hyperbaric Medicine Volume 47 No. 1 March 2017

Table 2
Recommendations on the indications accepted for HBOT (there was no Level A evidence)

Condition

Level of evidence
B
C

Type 1
CO poisoning
X		
Open fractures with crush injury
X		Prevention of osteoradionecrosis afterX		dental extraction
Osteoradionecrosis (mandible)
X		Soft tissue radionecrosis (cystitis, proctitis)
X		
Decompression illness 		X
Gas embolism		
X
Anaerobic or mixed bacterial infections		
X
Sudden deafnessX		Type 2Diabetic foot lesions
X		Femoral head necrosis
X		
Compromised skin grafts and musculo-		X
cutaneous flaps
Central retinal artery occlusion (CRAO)		
X
Crush Injury without fracture		
X
Osteoradionecrosis (bones other than mandible)		
X
Radio-induced lesions of soft tissues		X(other than cystitis and proctitis)
Surgery and implant in irradiated tissue		
X(preventive treatment)
Ischaemic ulcers		
X
Refractory chronic osteomyelitis		
X
Burns, 2nd degree more than 20% BSA		
X
Pneumatosis cystoides intestinalis		
X
Neuroblastoma, stage IV 		
X
Type 3Brain injury (acute and chronic TBI, chronic stroke,		
X
post anoxic encephalopathy) in highly selected patientsRadio-induced lesions of larynx		
X
Radio-induced lesions of the CNS 		X
Post-vascular procedure reperfusion syndrome		
X
Limb replantation		
X
Selected non-healing wounds secondary		
X
to systemic processes
Sickle cell disease		
X
Interstitial cystitis		
X••

carboxyhaemoglobin level at hospital admission (Type
1 recommendation, Level B evidence).
It would be reasonable to treat patients with minor CO
poisoning either by 12 hours normobaric oxygen or
HBOT (Type 3 recommendation, Level B evidence).
We do not recommend treating with HBOT asymptomaticpatients seen more than 24 hours after the end of CO
exposure (Type 1 recommendation, Level C evidence).

••
Open fractures with crush injury•

We recommend HBOT in the treatment of open fractures
and/or with crush injury (Type 1 recommendation, Level

Agreement level
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Strong agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement

B evidence).
We recommend early application of HBOT following
severe open fractures because it can reduce complications
such as tissue necrosis and infection. Gustilo 3B and 3C
injuries are considered indications for HBOT and lesssevere injuries should be considered for treatment whenhost- or injury-related risk factors are present (Type 1
recommendation, Level B evidence).
We suggest that HBOT may offer benefit in crush
injuries with open wounds but without fracture, where
tissue viability is at risk or where there is significant
risk of infection (Type 2 recommendation, Level C
evidence).

Diving and Hyperbaric Medicine Volume 47 No. 1 March 2017

28

•

•

•

It would be reasonable to provide HBOT for closed
crush injuries where tissue viability is clinicallyjudged to be at risk (Type 3 recommendation, Level C
evidence).
It would be reasonable to provide HBOT for closed
crush injuries where there is a potential for compartment
syndrome, but where compartment syndrome requiring
fasciotomy is not established and where it is possible
to monitor progress and response to treatment either
clinically or via compartment pressure or oxygenation
monitoring (Type 3 recommendation, Level C evidence).
We recommend that HBOT centres treating crush
injury should have equipment for transcutaneous
oximetry measurement (TCOM) under pressure as
this has predictive value in some situations (Type 1
recommendation, Level B evidence).

•

•
•

•
•

Radionecrosis or radition-induced lesions
•
•
•
•
•
•
•

•
•

We recommend HBOT in the treatment of mandibularosteoradionecrosis (Type 1 recommendation, Level B
evidence).
We recommend HBOT for the prevention of mandibularosteoradionecrosis after dental extraction (Type 1
recommendation, Level B evidence).
We recommend HBOT in the treatment of haemorrhagic
radiation cystitis (Type 1 recommendation, Level B
evidence).
We recommend HBOT in the treatment of radiation
proctitis (Type 1 recommendation, Level A evidence).
We suggest HBOT in the treatment of osteoradionecrosisof other bone than the mandible (Type 2 recommendation,
Level C evidence).
We suggest HBOT for preventing loss of osseointegrated
implants in irradiated bone (Type 2 recommendation,
Level C evidence).
We suggest HBOT in the treatment of soft-tissue
radionecrosis (other than cystitis and proctitis),in particular in the head and neck area (Type 2
recommendation, Level C evidence).
It would be reasonable to use HBOT for treating or
preventing radio-induced lesions of the larynx (Type 3
recommendation, Level C evidence).
It would be reasonable to use HBOT in the treatmentof radio-induced lesions of the central nervous system(Type 3 recommendation, Level C evidence).

Gas embolism
•
•

•

•

•

Decompression illness (DCI)••••

We recommend HBOT in the treatment of DCI (Type
1 recommendation, Level C evidence).
We recommend 100% normobaric oxygen first aid (Type
1 recommendation, Level C evidence).
We recommend intravenous fluid resuscitation with
non-glucose containing crystalloid solutions (Type 1
recommendation, Level C evidence).

We recommend HBOT/recompression therapy tables(US Navy Treatment Table 6 or helium/oxygen (Heliox)
Comex Cx30 or equivalent) for the initial treatmentof DCI (Type 1 recommendation, Level C evidence).
US Navy Treatment Table 5 can be used as the firstrecompression schedule for selected mild cases.
We recommend appropriate HBOT treatment tables forresidual manifestations of DCI (Type 1 recommendation,
Level C evidence).
We recommend the use of low-molecular weight
heparin for the prophylaxis of deep venous thrombosis
for immobile or paralyzed cases of DCI (Type 1
recommendation, Level C evidence).
We suggest the use of lignocaine (lidocaine) and Heliox
recompression tables for serious neurological DCI (Type
2 recommendation, Level C evidence).
We suggest oral tenoxicam (or similar NSAID)
for appropriately selected DCI cases (Type 2
recommendation, Level B evidence).

We recommend HBOT in the treatment of gas embolism(Type 1 recommendation, Level C evidence).
We recommend the use of HBOT in cases of arterial andvenous gas embolism with neurological and/or cardiac
manifestations. Even if a short interval (< 6 h) between
embolism and hyperbaric treatment is associated witha better outcome, response to hyperbaric treatment with
substantial clinical improvement has been observed inmany case reports with a longer interval and even insmall series of patients after 24 hours or more (Type 1
recommendation, Level B evidence).
We recommend the immediate administration of 100%
oxygen in case of noticed embolism. However, even
if the signs/symptoms resolve, because secondary
deterioration can occur later, HBOT is still recommended(Type 1 recommendation, Level B evidence).
We do not recommend high pressure treatment
tables (>405 kPa) because of lack of good evidence.
Consideration of the use of heliox or nitrox at
higher pressure must be undertaken by each unit
based on experience and logistic arguments (Type 2
recommendation, Level B evidence).
We suggest the use of adjunctive therapy for isolated
AGE, such as lidocaine (Type 2 recommendation,
Level B evidence) aspirin and/or NSAID (Type 3
recommendation, Level C evidence).
It would be reasonable to use anticoagulants as adjunctive
therapy for isolated AGE (Type 3 recommendation,
Level C evidence).

Anaerobic and mixed bacterial infections•

We recommend HBOT in the treatment of anaerobic
and mixed bacterial infections (Type 1 recommendation,
Level C evidence).

Diving and Hyperbaric Medicine Volume 47 No. 1 March 2017

•

•

•

•

We recommend HBOT for the treatment of necrotizing
soft tissue infections in all locations, particularly
perineal gangrene. (Type 1 recommendation, Level C
evidence).
We recommend HBOT be integrated in a treatment
protocol combined with immediate and adequate
surgery and antibiotics targeting the most probableanaerobic and aerobic involved bacteria (Type 1
recommendation, Level C evidence).
We recommend HBOT be integrated in the treatment
protocol of intra-cranial abscess when one of thefollowing criteria is met: multiple abscesses; abscessin a deep or dominant location; compromised host;contra-indication to surgery, lack of response or further
deterioration in spite of standard treatment (Type 1
recommendation, Level C evidence).
We suggest HBOT be integrated as a second-line measurein the treatment of other anaerobic or mixed anaerobicaerobic tissue infections such as pleuropulmonary or
peritoneal infection (Type 2 recommendation, Level
C evidence).

Sudden deafness (idiopathic sudden sensorineural hearing
loss, ISSNHL)
•
•

•

•

We recommend HBOT in the treatment of ISSNHL(Type 1 recommendation, Level B evidence).
We recommend HBOT combined with medical therapy
in patients with acute ISSNHL who present within two
weeks of disease onset (Type 1 recommendation, Level
B evidence).
We do not recommend the use of HBOT alone or
combined with medical therapy in patients with
ISSNHL who present after six months of disease onset(Type 1 recommendation, Level C evidence).
It would be reasonable to use HBOT as an adjunct tocorticosteroids in patients presenting after the first two
weeks but not later than one month, particularly, inpatients with severe and profound hearing loss (Type 3
recommendation, Level C evidence).

•

•

•

Delayed wound healing••••

We suggest using HBOT in the treatment of diabetic footlesions (Type 2 recommendation, Level B evidence).
We suggest using HBOT in the treatment of ischaemic
ulcers (Type 2 recommendation, Level C evidence).
It would be reasonable to use HBOT in the treatment
of selected non-healing wounds secondary to systemic
processes (Type 3 recommendation, Level C evidence).
We recommend HBOT in ischaemic lesions (ulcers or
gangrene) without surgically treatable arterial lesions
or after vascular surgery:a. In the diabetic patient, the use of HBOT is
recommended in the presence of a chronic criticalischaemia as defined by the European Consensus
Conference on Critical Ischemia (see note below),

•

•

•

29

if TCOM readings under hyperbaric conditions (253kPa, 100% oxygen) are higher than 100 mmHg (Type
1 recommendation, level A evidence).
b. In the arteriosclerotic patient, HBOT is recommended
in case of a chronic critical ischaemia (see note
below), if TCOM readings under hyperbaric
conditions (253 kPa, 100% oxygen) are higher
than 50 mmHg (Type 2 recommendation, Level B
evidence).
c. Note: Chronic critical ischaemia can be recognised
when there is: periodic pain, persistent at rest,
needing regular analgesic treatment for more than
two weeks, or ulceration or gangrene of foot or toeswith ankle systolic pressure <50 mmHg in the nondiabetic or toes systolic pressure < 30 mmHg in the
diabetic.11
d. However, despite the strong agreement on the validityof the criteria listed above to properly select patientsfor HBOT, the jury acknowledges the fact not all
hyperbaric centres are able to perform TCOM under
hyperbaric conditions (253 kPa, 100% oxygen).
Therefore, owing to this limitation, we suggest
HBOT in diabetic foot ulcers (grade 3 and above ofWagner classification, stage B, grade 3 and above ofUniversity of Texas classification) that have failed
to respond to adequate basic wound care after fourweeks (Type 2 recommendation, Level B evidence).
For the same reason as above, it would be reasonable
to use HBOT in delayed-healing (chronic), nondiabetic wounds and in recurrent, multiple non-healing
wounds due to vasculitis (especially those who have
not responded to immunosuppressive therapy) (Type 3
recommendation, Level C evidence).
We recommend, as standard of care, that HBOT should
always be used as part of a holistic, multidisciplinary,treatment plan with ongoing wound care on a regularbasis and not as a stand-alone therapy (Type 1
recommendation, Level B evidence).
We recommend that, prior to HBOT, standard woundcare has been provided during at least four weeks(including appropriate debridement, vascular screening
for significant peripheral arterial disease and/or local
wound hypoxia, adequate offloading and infection
management) (Type 1 recommendation, Level C
evidence).
We recommend that, prior to HBOT, vascular screening,
including imaging procedures, is undertaken in order toevaluate if any revascularization procedure is indicated(Type 1 recommendation, Level C evidence).
We recommend the use of TCOM as the best techniqueto monitor the local tissue pressure of oxygen and toselect patients for HBOT (Type 1 recommendation,
Level C evidence).
We suggest that the therapeutic dose of HBOT (pressure,time and length of treatment course) should be adapted
to patient, type of chronic wound and evolution (Type
2 recommendation, Level C evidence).

Diving and Hyperbaric Medicine Volume 47 No. 1 March 201730•

It would be reasonable to consider HBOT as part ofa multi-interventional approach in the treatment ofchronic calciphylaxis (Type 3 recommendation, Level
C evidence).

Compromised skin graft and flap
•
•

•

•

•

We suggest using HBOT in the treatment of compromisedskin graft and flap (Type 2 recommendation, Level C
evidence).
We recommend HBOT in all cases of compromised skingrafts and flaps as soon as possible after the diagnosisof compromised grafts/tissues (Type 1 recommendation,
Level B evidence).
We suggest tissue viability be evaluated by clinicaljudgement and more objective methods including
measurement of TCOM or assessment of capillaries
by laser Doppler (Type 1 recommendation, Level B
evidence).
We suggest HBOT at a pressure between 203 and253 kPa for at least 60 minutes per session (preferably
90–120 min), repeated two or three times in first day,then twice per day or once daily until tissues declared
alive or necrotic (Type 2 recommendation, Level C
evidence).
We recommend HBOT be used both pre- and postoperatively in cases where there is an increased risk
for compromised skin grafts and flaps, e.g., irradiatedor infected wound bed, immuno-compromised patient(Type 1 recommendation, Level C evidence).

before any significant clinical effect should be expected.
(Type 1 recommendation, Level C evidence).
Femoral head necrosis (FHN)
•
•

•
•

Burns
•
•

Limb replantation•
It would be reasonable to consider HBOT for limb
replantation (Type 3 recommendation, Level C evidence).
Post-vascular procedure reperfusion syndrome•

It would be reasonable to consider HBOT for post-vascular
procedure reperfusion syndrome (Type 3 recommendation,
Level C evidence).

•

Refractory chronic osteomyelitis••••

We suggest HBOT be used in the treatment in chronic
refractory osteomyelitis (Type 2 recommendation, Level
C evidence).
We suggest compromised hosts be identified as, inparticular, they may benefit from HBOT (Type 2
recommendation, Level C evidence).
We suggest HBOT protocol be individualized basedon the condition and compliance of the patient (Type 2
recommendation, Level C evidence).
We recommend the effects of HBOT be evaluatedrepeatedly during and after treatment using the same
diagnostic methods as used pre HBOT. HBOT treatment
should last at least 11−12 weeks, approx. 60 sessions,

We suggest HBOT be used in the treatment of theinitial stage of FHN (Type 2 recommendation, Level
B evidence).
We suggest daily treatment of ≥ 60 min, 100% oxygen,
5−6 days a week, and 4−5 weeks per cycle, at 243–253
kPa, at the initial stage of FHN (Type 2 recommendation,
Level B evidence).
We suggest scheduling MRI and orthopaedic clinicalevaluation at 3−4 weeks from the end of the HBOT cycle(Type 2 recommendation, Level C evidence).
We do not recommend HBOT be used as an isolated
treatment but be integrated in a multidisciplinary
protocol including minimizing weight-bearing,weight reduction, physiotherapy where applicable andsmoking cessation through the HBOT course (Type 1
recommendation, Level C evidence).

We suggest HBOT be used in the treatment of second
degree burns >20% body surface area (BSA) (Type 2
recommendation, Level C evidence).
We recommend that only highly specialised HBOT
centres, in the immediate vicinity of a burns centre, treat
burns as an adjunct to classical burns care, taking careof optimal monitoring and fluid management. (Type 1
recommendation, Level C evidence).
We suggest that the most benefit is obtained insevere scald burns patients (>20% BSA), with alarge proportion of partial-thickness burns (Type 2
recommendation, Level C evidence).
We suggest that burns to the face (ear, nose), neck,hands and fingers and perineum may benefit even if thetotal surface burned is <20% (Type 2 recommendation,
Level C evidence).
We suggest that HBOT be initiated within six (at themost eight) hours after the burn injury, and that two
sessions per day (at 253 kPa, 100% oxygen) be given
for a minimum of three days (Type 2 recommendation,
Level C evidence).

Central retinal artery occlusion (CRAO)•

We suggest considering HBOT for patients sufferingfrom CRAO, to be applied as soon as possible (Type 2
recommendation, Level C evidence).

Pneumatosis cystoides intestinalis•

We suggest HBOT in the treatment of pneumatosis
cystoides intestinalis (Type 2 recommendation, Level
C evidence).

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Diving and Hyperbaric Medicine Volume 47 No. 1 March 2017

Table 3•

Recommendations on the non-accepted indications for HBOT;
all have only Level D evidence

Level of evidence
Condition
D
Post sternotomyX
mediastinitis		
Malignant otitis externa
X
Acute myocardialX
infarction
Retinitis pigmentosa
X
Facial (Bell’s) palsy
X

Agreement
Agreement•
Agreement
Agreement
Agreement
Agreement

It would be reasonable to consider HBOT in the frameof an investigational clinical study in a highly selectedgroup of patients with chronic stroke who have clear
evidence of metabolically dysfunctional brain regionsthat are mismatching with the necrotic brain regions(Type 3 recommendation, Level C evidence).
It would be reasonable to use HBOT as an adjunctive
measure in the treatment of post anoxic encephalopathy
after near hanging (Type 3 recommendation, Level C
evidence).

Neuroblastoma•

Table 4

We suggest HBOT in the treatment of neuroblastoma
stage IV (Type 2 recommendation, Level C evidence).

Recommendations on those indications for which HBOT should
not be used; no Level A evidence

NON-ACCEPTED INDICATIONS (TABLE 3)

Level of evidence
ConditionA
B
C
Autism spectrum		 X
disorders		
Placental insufficiency			
X
Multiple sclerosis		 X		Cerebral palsy		 X		Tinnitus		X		Acute phase of stroke			
X

Owing to very low levels of evidence (Grade D), no specificrecommendations on HBOT are given for the following
clinical conditions:• Post sternotomy mediastinitis• Malignant otitis externa• Acute myocardial infarction• Retinitis pigmentosa• Facial (Bell’s) palsy

Agreement
Agreement
Agreement
Agreement
Agreement
Agreement
Agreement

Sickle cell disease••

It would be reasonable to consider HBOT as a secondline treatment in sickle cell disease crisis in addition to
opioids (Type 3 recommendation, Level C evidence).
It would be reasonable to consider HBOT as an adjunctto standard wound care in patient with non-healing skinulcer due to sickle cell disease (Type 3 recommendation,
Level C evidence).

Interstitial cystitis•

It would be reasonable to consider HBOT for interstitial
cystitis (Type 3 recommendation, Level C evidence).

CONDITIONS FOR WHICH HBOT IS NOT INDICATED(TYPE 1 INDICATION, TABLE 4)
Evidence of lack of clinical effect of HBOT allows Type 1
recommendations to be given for not using HBOT in:• Autism spectrum disorders (Type 1 recommendation,
Level B evidence)• Placental insufficiency (Type 1 recommendation, Level
C evidence)• Multiple sclerosis (Type 1 recommendation, Level B
evidence)• Cerebral palsy (Type 1 recommendation, Level B
evidence)• Tinnitus (Type 1 recommendation, Level B evidence)• Acute phase of stroke (Type 1 recommendation, Level
C evidence).

Brain injury in highly selected patients
PRACTICE OF HYPERBARIC OXYGEN TREATMENT•••

It would be reasonable to consider HBOT in acutemoderate-severe traumatic brain injury (TBI) patientsand in a highly selected group of patients withchronic TBI who have clear evidence of metabolically
dysfunctional brain region(s) (Type 3 recommendation,
Level B evidence).
We recommend HBOT use in TBI to be used only in thecontext of an investigational study protocol approved byan ethics committee and performed according to clinicalresearch good practice (Type 1 recommendation).
We do not recommend HBOT use in the acute phaseof stroke (Type 1 recommendation, Level C evidence).

•••

We recommend that all European hyperbaric facilities
comply as a minimum with the European Code of Good
Practice and this ECHM list of clinical indications for
HBOT as the basis for accreditation processes andnational reimbursement policies.
We recommend conditions in which HBOT is considered
not to be indicated are discussed in a benefit/risk balance
for each specific patient before using HBOT.
We recommend medical education and training of
hyperbaric centre medical staff comply with thestandards developed and mutually agreed by ECHM andDiving and Hyperbaric Medicine Volume 47 No. 1 March 2017

32

•

•
•

the European Diving Technology Committee (EDTC).
We recommend education and training of hyperbaric
centre non-medical staff comply with the standards
developed by the European Baromedical Association
for nurses, operators and technicians (EBAss) andagreed by ECHM.
We recommend physicians involved in hyperbaric
centres are trained and participate in clinical as well asbasic research.
We recommend the hyperbaric community at large
increases its participation in the research effort in orderto improve the level of evidence supporting the ECHM
recommendations.

References

Acknowledgements
We would like to acknowledge all the many participants in thisstepwise process; also, the European Underwater and Baromedical
Society, European Diving Technology Committee (EDTC) and theEuropean Baromedical Association for their active support during
the organisation of the conference and preparation and distributionof the recommendations.
Declaration of interests: nil
Submitted: 19 October 2016; revised 02 January 2017
Accepted: 23 January 2016
Daniel Mathieu1,2, Alessandro Marroni1,3, Jacek Kot1,4
European Committee for Hyperbaric Medicine
Critical Care Department, Medical University and Hospital of
Lille, France
3
DAN Europe Research Division, Roseto degli Abruzzi, Italy
4
National Center for Hyperbaric Medicine, Institute of Maritime
and Tropical Medicine, Medical University of Gdansk, Poland
1

2

1

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Address for correspondence:
Jacek Kot
Head of the National Center for Hyperbaric Medicine
Institute of Maritime and Tropical Medicine
Medical University of Gdansk
Polandjkot@gumed.edu.pl
List of collaborators (in alphabetic order):Lluis Amselem (Spain), Peter Atkey (UK), Dirk Bakker (TheNetherlands), Costantino Balestra (Belgium), Jean Yves Berney(Switzerland), Jean Eric Blatteau (France), Gerardo Bosco (Italy),
Francois Burman (South Africa), Enrico Camporesi (USA), Danilo
Cialoni (Italy), Maide Cimsit (Turkey), Ramiro Cali-Corleo(Malta), Frans Cronje (South Africa), Jordi Desola (Spain),
Marco Gelsomino (Switzerland), Peter Germonpré (Belgium),
Karin Hasmiller (Germany), Eric Jansen (Denmark), Jacek Kot(Poland), Claude Lae (Switzerland), Folke Lind (Sweden), Magnus
Londahl (Sweden), Pasquale Longobardi (Italy), Alessandro
Marroni (Italy), Daniel Mathieu (France), Ian Millar (Australia),
Peter Mueller (Germany), Mesut Mutluoglu (Turkey), ClausMartin Muth (Germany), Erika Parmentier-Decrucq (France),
Michel Pellegrini (Switzerland), Massimo Pieri (Italy), Rodrigue
Pignel (Switzerland), Peter Radermacher (Germany), Beatrice
Ratzenhofer-Komenda (Austria), Vincent Souday (France), Günalp
Uzun (Turkey), Rob van Hulst (The Netherlands), Giuliano Vezzani(Italy), Francis Wattel (France), Robert Weenink (The Netherlands),
Wilhelm Welslau (Germany), Vincenzo Zanon (Italy), Juerg
Wendling (Switzerland).