Hyperbaric Oxygen - When to Use and When to Avoid

Recently, I completed continuing medical education credits through the Georgia Osteopathic Medical Association during its annual Virtual Fall Conference. I was also a presenter for this conference, so it felt like a worthwhile investment of both time and resources. As a functional medicine internist, one lecture piqued my interest—an in-depth discussion of hyperbaric oxygen therapy (HBOT) in both conventional medical settings and the growing functional medicine/spa industry. I wanted to share a brief summary of the legitimate uses of HBOT, along with some important concerns about certain facilities offering this therapy.

Does this look safe? Does this look effective? This is a soft, "home hyperbaric chamber" marketed online for $1,500 that provides subtherapeutic 1.5 atmospheres of oxygen. The grainy photo from the sales website seems appropriate.

Approved Uses of Hyperbaric Oxygen Therapy

HBOT has 15 FDA- and Undersea and Hyperbaric Medical Society–approved indications. While listening to the lecture, I double-checked the Wikipedia list and found it to be accurate. You’ll find a clarified list of the approved conditions at the end of this post.

To qualify as true hyperbaric oxygen therapy—and to provide meaningful therapeutic benefit—the treatment must be delivered at a minimum of 2 atmospheres (2 ATM) for at least 60-90 minutes daily. This level of pressure is necessary to deliver 100% oxygen directly to the tissues, which is the basis of HBOT’s medical effect.

How Are Spas and Functional Medicine Clinics Offering HBOT?

Some spas and functional medicine practices market HBOT for conditions that are not approved indications. This is a case of buyer beware! Patients pursuing these treatments should expect to pay entirely out of pocket, as insurance companies rarely cover off-label uses, and these facilities do not accept insurance. Even for several approved conditions, insurers may still deny reimbursement. For example, the indication for idiopathic sudden sensorineural hearing loss was added approximately 3–4 years ago, yet many insurance payors still refuse to cover HBOT for this condition.

In Georgia, only licensed and trained physicians (and physician extenders with physician oversight) may practice HBOT. Training is at least 40 hours.

Some facilities offer "Mild HBOT," which is oxygen delivery under 2.0 ATA.

Frighteningly, a quick online search shows "HBOT" chambers for sale directly to consumers for $1,500-$5,000. The Undersea and Hyperbaric Medical Society has a safety warning for the public: "The growing presence of soft-sided bag chambers in the marketplace has led to several questions and concerns for many of us in the hyperbaric community. It is important to know that soft sided bag chambers and the facilities in which they are operating are subject to the same safety requirements as any hard-sided chambers..."

The Very Real Risks of Improper HBOT

HBOT, although very safe when performed correctly, is not a benign therapy. In 2025, the United States reported two HBOT-related deaths, both occurring in functional medicine or spa-type facilities. Prior to this, a chamber explosion in 2023 injured two people, and in 2009, a single fire at a Florida clinic resulted in two fatalities—a 4-year-old boy and his grandmother. These incidents, while still uncommon, appear to be increasing.

In every fatal case, the facilities involved were not accredited for HBOT and lacked essential safety measures, including routine inspections, proper grounding systems, and appropriate patient preparation protocols. Additionally, in all of these cases, HBOT was being used for unapproved conditions, including cerebral palsy, sleep apnea, autism, and, in one instance, general wellness.

These tragic events were instantaneous, caused by hyperbaric chambers igniting and turning into fireballs. Oxygen is highly flammable, and once ignition occurs within a pressurized oxygen chamber, the outcome is almost universally fatal.

Because of these risks, it is in a patient’s best interest to receive HBOT only at an accredited facility with proper safety protocols, trained staff, and appropriate medical oversight.

Emerging Areas of Research

Researchers continue to investigate HBOT for additional conditions, including:

• Acute and chronic COVID-19

• PTSD

• Traumatic brain injury (TBI)

• Crohn’s disease

• Other inflammatory or neurologic conditions

While early findings are interesting, these uses remain experimental, and HBOT should not be used outside of clinical trials, particularly outside of accredited medical centers.

15 FDA- and Undersea and Hyperbaric Medical Society–approved indications

• Air or gas embolism

• Carbon monoxide poisoning (with or without cyanide poisoning, but not for cyanide poisoning alone)

• Clostridial myositis and myonecrosis (gas gangrene)

• Crush injury, compartment syndrome, and other acute traumatic ischemias

• Decompression sickness

• Arterial insufficiency (includes several conditions: central retinal artery occlusion, problem wounds with poor blood flow, severe diabetic foot ulcers present for at least 30 days, graft-vs-host disease, pyoderma gangranosum, calciphylaxis, and more but not for chronic arterial insufficiency)

• Exceptional blood loss (anemia)

• Intracranial abscess

• Necrotizing soft tissue infections (necrotizing fasciitis)

• Osteomyelitis (refractory and chronic)

• Delayed radiation injury (soft-tissue and bony necrosis)

• Skin grafts and flaps (compromised)

• Thermal burns (early)

• Idiopathic sudden sensorineural hearing loss

• Avascular necrosis

Further Reading:

Ten Guidelines for Patients and Referring Physicians In Selecting Safe Hyperbaric Oxygen Treatments (Submitted April 2025) - Version 4-17-25

https://www.uhms.org/images/Safety-Articles/Hyperbaric%20Safety%20bullet%20%20v4.17.25%20Clean-u.pdf