How to Deliver Hyperbaric Oxygen Therapy for Combat-Associated PTSD
How should clinicians implement and monitor the evidence-based hyperbaric oxygen therapy protocol for veterans with combat-associated posttraumatic stress disorder?
When hyperbaric oxygen therapy is used for treatment-refractory combat-associated posttraumatic stress disorder, the article supports a very specific protocol rather than general hyperbaric exposure. This guide applies to delivery of the exact medical-grade regimen studied in veterans without known traumatic brain injury.
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Use the tested session schedule
Deliver 60 daily sessions, 5 days per week. Protocol completion was limited to 14 weeks in case of missed sessions, although isolated extensions were allowed in specific COVID-19-related circumstances during the trial.
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Administer the exact oxygen and pressure exposure
Each HBOT session should consist of 90 minutes of exposure to 100% oxygen at 2 atmospheres absolute. Include 5-minute air breaks every 20 minutes, matching the evidence-based protocol used in the randomized sham-controlled trial.
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Continue preexisting psychiatric care during HBOT
Patients in both groups continued psychological and pharmacologic treatments as they had before study inclusion, although some were not in active treatment at entry. Document any changes in psychotherapy frequency or medication dosing during the HBOT course.
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Monitor symptoms and adverse events every 2 weeks
Schedule investigator or clinician meetings every 2 weeks during the HBOT period to monitor symptoms and evaluate potential adverse events. This is the monitoring cadence described in the study protocol.
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Track PTSD response with CAPS-5
Assess PTSD severity at baseline, 1 to 4 weeks after the last session, and 3 months after the last session using CAPS-5. Define treatment response as a 30% reduction from baseline CAPS score, and define remission as a CAPS score lower than 20.
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Assess depressive symptoms alongside PTSD symptoms
Use the Beck Depression Inventory-II and the DASS-21 at the same assessment points used for CAPS-5: baseline, 1 to 4 weeks after the last session, and 3 months after the last session. In the trial, depressive symptoms improved significantly, while DASS-21 anxiety and stress domains did not reach statistical significance.
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Watch specifically for barotrauma and memory surfacing
Expect mostly mild, self-limited adverse events, but monitor for ear pain with tympanic membrane redness or hematoma consistent with self-remitting barotrauma. Also monitor for surfacing of new memories with distress, which occurred in 7 HBOT-treated patients, lasted several days, and then resolved; the article advises that this risk is one reason treatment should be delivered only by teams experienced in PTSD care.
Clinical Considerations
- The findings apply to the exact protocol tested and should not be generalized to lower-dose hyperbaric exposure or other untested regimens.
- The authors specifically caution against using these results to justify treatment in nonmedical grade facilities, home-use chambers, or clinics without a professional multidisciplinary medical team.
- Although HBOT improved PTSD and depression measures, DASS-21 anxiety and stress domains did not reach statistical significance in this study.
- The clinical analysis included 28 patients per group, so the evidence base remains relatively small despite statistically significant results.
Bottom Line
If HBOT is used for combat-associated posttraumatic stress disorder, use the full medical-grade protocol tested in the trial and monitor closely for clinical response, mild barotrauma, and distressing surfacing of new memories.
