Wheeling a Ventilated ICU Patient Into a Hyperbaric Chamber: A Staff Survey Maps the Steps That Get Missed

Close-up of a hyperbaric-compatible mechanical ventilator with analog pressure gauges and oxygen lines inside a clinical hyperbaric chamber

Few journeys inside a hospital are as logistically unforgiving as moving a mechanically ventilated intensive care patient into a hyperbaric oxygen chamber. The ventilator must be swapped for a pressure-rated machine, infusion pumps exchanged for chamber-compatible models, the endotracheal tube cuff refilled with fluid instead of air, and every flammable or pressure-sensitive item stripped from the bed — all before the doors seal and the pressure starts to rise. After the session, everything has to be put back.

A new study from Poland suggests that even at one of Europe’s most experienced hyperbaric centers, pieces of that choreography get dropped — and it offers the first draft of a tool designed to catch them.

Nineteen Clinicians, One Month of Honest Recall

Writing in the Journal of Clinical Medicine, Agata Miszewska and Professor Jacek Kot of the Medical University of Gdańsk surveyed nineteen healthcare professionals — thirteen nurses and six physicians — at the Department of Hyperbaric Medicine and Sea Rescue in Gdynia, part of the university’s National Centre for Hyperbaric Medicine. Nearly two-thirds had more than a decade of experience at the center, and almost all had used clinical checklists before.

The anonymous questionnaire asked a disarmingly simple question: in the past month, which peri-procedural tasks had you personally seen omitted, delayed, or performed incompletely when a ventilated ICU patient went for hyperbaric oxygen therapy? The center treats exactly the categories of critically ill patients for whom HBOT is an established, FDA-cleared intervention — carbon monoxide poisoning, necrotizing soft tissue infections, crush injuries, air or gas embolism, severe decompression illness, and acute thermal burns — and it runs an unusually integrated model in which the ICU sits in the same building as the chamber and the same team follows the patient throughout.

Before the Doors Close

The most striking signal concerned airway rescue readiness. Fourteen of nineteen respondents — 73.7 percent — reported having seen the intubation set not prepared for transfer at least once during the study month. The authors are careful with context here: for years the chamber sat on the same floor as the ICU, transfers were short and intra-departmental, and the full airway kit may not have travelled with every patient as a matter of routine habit rather than negligence. But broader critical-care transport literature is unambiguous that backup airway equipment should be verified before a ventilated patient moves anywhere, and the finding supports making that confirmation explicit and written.

Other pre-session gaps clustered around the chamber’s physical constraints. Forty-two percent of respondents had seen the anti-decubitus mattress pump left connected — a problem because the electrically powered pump cannot go into the hyperbaric environment. More than a third had seen hazardous materials not removed or replaced on the patient’s bed, and nearly a third had seen the self-inflating resuscitation bag not prepared.

The Way Back Out

If preparation failures dominated before treatment, restoration failures dominated after it. The single most reported post-session item was a distinctly hyperbaric one: replacing fluid with air in the endotracheal tube cuff, flagged by 57.9 percent of respondents. During a session the cuff is deliberately filled with liquid, because a gas-filled cuff would shrink and expand with pressure changes under Boyle’s law, risking air leaks or tracheal injury. Forgetting to reverse that adaptation back in the ICU is the kind of error that only exists in hyperbaric medicine — which is precisely why generic ICU transport checklists do not cover it.

Over half of respondents had also seen the mattress pump not reconnected, and roughly a quarter had seen intravenous infusions interrupted for the session not promptly restarted, capnography not reconnected, or supportive materials not returned to the bed.

A Map of Vulnerability, Not a Verdict

The authors repeatedly resist overreading their own data. These are staff-reported perceptions from a single month at a single center — not verified omission rates, not patient-level event counts, and not evidence that anyone was harmed. Several checklist items, including switching the patient to the HBOT-dedicated ventilator, drew zero reported lapses, which the authors note could reflect strong standardization as easily as blind spots in recall.

Framed through a human-factors lens, the point of the exercise is that dropped steps are properties of a work system, not indictments of individuals. Attending staff inside a chamber may themselves experience reduced cognitive performance under pressure, and critical care already runs on time pressure and team coordination. The survey’s purpose was to locate where the system leans on memory when it should lean on structure.

The First Peri-HBOT Checklist Prototype

The findings fed directly into a preliminary two-phase checklist prototype — one pass before the session covering airway, transfer, and chamber-readiness tasks, and a second pass afterward covering restoration of standard ICU support. The authors stress it is a locally derived prototype, published in full as a supplement, that still needs usability testing, refinement, and multicentre validation before anyone should treat it as a standard. No internationally accepted checklist currently exists for this pathway, and the study positions itself as a first step rather than a finished answer.

The paper also surfaces a workforce recommendation buried in the hyperbaric literature: that medical personnel perform at least one hundred HBOT sessions annually with critically ill patients to maintain proficiency — a bar few centers worldwide can meet, and one that makes cognitive aids like checklists more important, not less, at lower-volume facilities.

The Regulatory Backdrop

The Gdynia study lands at a moment when operational safety in hyperbaric medicine is under unusual scrutiny. In August 2025, the U.S. Food and Drug Administration issued a letter to health care providers urging strict adherence to manufacturer instructions for HBOT devices, citing reports of serious injuries and deaths linked to chamber fires. The agency’s consumer guidance continues to emphasize that HBOT is cleared only for specific indications — the emergency conditions treated at centers like Gdynia among them — while warning against unproven wellness applications where safety infrastructure may be thinner.

That distinction matters here. The vulnerabilities the Polish team catalogued are not the hazards of strip-mall “mild hyperbaric” wellness pods; they are the residual friction points inside a mature, hospital-based program doing everything by the book. If skipped steps surface even there, the study implies, centers with less integration and less experience have every reason to write the steps down.

HBOToday Editorial publishes evidence-based reporting on hyperbaric oxygen therapy research, regulation, and clinical practice. Nothing in this article constitutes medical advice.

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