HANDBOOK ON HYPERBARIC MEDICINE

Handbook on Hyperbaric Medicine Edited by

DANIEL MATHIEU Centre Hospitalier Régional et Université de Lille, France

A C.I.P. Catalogue record for this book is available from the Library of Congress.

ISBN-10 ISBN-13 ISBN-10 ISBN-13

1-4020-4376-7 (HB) 978-1-4020-4376-5 (HB) 1-4020-4448-8 (e-book) 978-1-4020-4448-9 (e-book)

Published by Springer , P.O. Box 17, 3300 AA Dordrecht, The Netherlands. www.springer.com

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CONTENTS ix

Foreword D. Mathieu Contributors Preface D. J. Bakker A History of Hyperbaric Medicine F. Wattel

xi xv 1

Part I Physical and Pathophysiological Bases of Hyperbaric Oxygen Therapy Editors: B. Ratzenhofer-Komenda, J. Niinikoski, M. Hamilton-Farell 1.1. Physics of Hyperbaric Pressure W. Welslau 1.2. Biochemistry of Oxygen A. Courtière 1.3. Physiologic Effects of Increased Barometric Pressure W. Welslau 1.4. Physiologic Effects of Hyperbaric Oxygen on Oxygen Transport and Tissue Oxygen Pressure B. Ratzenhofer-Komenda, R. Favory, W. Welslau, F.M. SmolleJüttner, D. Mathieu 1.5. Physiologic Effects of Hyperbaric Oxygen on Hemodynamics and Microcirculation D. Mathieu, R. Favory, F. Collet, J.C. Linke, F. Wattel 1.6. Physiologic Effects of Hyperbaric Oxygen on Microorganisms and Host Defences Against Infection D. Mathieu, F. Wattel 1.7 Physiologic Effects of Hyperbaric Oxygen on Ischemia Reperfusion Phenomenon S. Van Poucke, P. Jorens, L. Beaucourt 1.8 Physiologic Effects of Hyperbaric Oxygen on Wound Healing Processes J. Niinikoski

v

15 25 31

49

75

103

121

135

vi 1.9 Physiologic Effects of Hyperbaric Oxygen on DNA and DNA Repair – Genotoxicity of Hyperbaric Oxygen and its Prevention C. Muth, M. Gröger, P. Radermacher, G. Speit

Contents

147

Part II: Indications for Hyperbaric Oxygen Therapy Editors: D. Mathieu, J. Schmutz, F. Cronje 2.1 Methodology for Assessing Hyperbaric Oxygen Therapy in Clinical Practice F. Wattel, D. Mathieu 2.2 Recommended Indications 2.2.1 Dysbaric Illness A. Marroni, F.J. Cronje, J. Meintjes, R. Cali-Corleo 2.2.2 Gas Embolism D. Mathieu, S. Tissier, M.L. Boulo 2.2.3 Carbon Monoxide Poisoning D. Mathieu, M. Mathieu-Nolf, J.C. Linke, R. Favory, F. Wattel 2.2.4 Necrotizing Soft Tissue Infections D. Mathieu, R. Favory, J.F. Cesari, F. Wattel 2.2.5 Intra-Cranial Abscess L. Lampl, G. Frey 2.2.6 Crush Injury and Other Acute Traumatic Ischemia A. Kemmer 2.2.7 Compromised Skin Graft and Flap T.A. Mesimeris 2.2.8 Radio-Induced Lesion in Normal Tissues D. Pasquier, J. Schmutz, E. Lartigau 2.2.9 Non-Healing Wounds D. Mathieu, J.C. Linke, F. Wattel 2.2.10 Persistent Osteomyelitis A. Kemmer, T. Stein, C. Hierholzer 2.2.11 Sudden Deafness A. Barthelemy, M. Rocco 2.2.12 Neuroblastoma A. van der Kleij, P. Sminia 2.3 Optional Indications 2.3.1 Burns P. Germonpré 2.3.2 Anoxic Encephalopathy F. Wattel 2.3.3 Pleuropulmonary Anaerobic Infections D. Mathieu

163

173 217 239 263 291 305 329 363 401 429 451 469

479 495 509

Contents 2.3.4 Post Vascular Procedure Reperfusion Syndrome and Limb Replantation J. Schmutz 2.3.5 Acute Ischemic Ophthalmological Disorders A. Weinberger, U. Siekmann 2.3.6 Pneumatosis Cystoides Intestinalis J. Niinikoski 2.4 Controversial and Non Indications 2.4.1 Femoral Head Necrosis L. Ditri, M. Montanari,Y. Melamed, D. Reis 2.4.2 Cerebrovascular Incidents (Stroke) F. Cronje, W. Duim, A. Marroni, R. Cali-Corleo 2.4.3 Post-Sternotomy Mediastinitis A. Barthelemy 2.4.4 Sickle Cell Disease H. Medhaoui 2.4.5 Brain Injury and Spinal Cord Injury J. Schmutz 2.4.6 Myocardial Infarction J. Schmutz 2.4.7 Malignant Otitis Externa J. Schmutz 2.4.8 Other Controversial or Non Indications J. Schmutz

vii

521 527 537

547 553 567 577 585 591 597 601

Part III: Practice of hyperbaric medicine Editors: J. Kot, A. Kemmer, P. Germonpré 3.1. Hyperbaric Chamber and Equipment J. Kot, R. Houman,P. Müller 3.2. Organization of a Hyperbaric Center J. Kot, Z. Sicko 3.3. Patient Management A. Kemmer, C. Muth, D. Mathieu 3.4. A Cost-Effectiveness Evaluation of Hyperbaric Oxygen Therapy A. Marroni, P. Longobardi, R. Cali-Corleo 3.5. Education and Training of Hyperbaric Centre personnel J. Desola 3.6. Safety in Hyperbaric Medicine J. Kot, R. Houman,R. Gough-Allen

611 637 651

671 679 691

viii 3.7. Complications of Hyperbaric Oxygen Therapy 3.7.1 Barotraumatism F. Roque, A. Simão 3.7.2 Oxygen Toxicity N. Bitterman, H. Bitterman 3.8. Organisation of Hyperbaric Medicine in Europe D. Bakker,A. Marroni, D. Mathieu 3.9. Research in Hyperbaric Medicine P. Germonpré, D. Mathieu

Contents

715 731 767 779

Annex List of Hyperbaric Therapeutic Centres in Europe P. Germonpré, J. Kot

793

Index

805

FOREWORD The Co-operation On Science and Technology (COST) programme is a European initiative with the objective of implementing and improving cooperation between European research teams in the fields of Science and Technology. Thanks to the efforts of our Belgian colleagues, a specific Action was launched in December 1998 – specifically devoted to Hyperbaric Oxygen Therapy (Action COST B14). The participants included nineteen European countries, members, or associates of the European Union. The main objectives of COST B14 were to expand the knowledge-base for the rational use of HBO; to issue guidelines for the implementation and development of clinical HBO centres; and to provide scientifically sound recommendations for HBO in the treatment of various diseases and conditions. This Action has since been completed and the Management Committee decided to publish this Handbook to introduce the outcome of COST B14 as well as to incorporate the results of experimental and clinical research performed over the last 6 years. This Handbook is intended as a reference document for researchers and clinicians alike – to be used both in the research laboratory and in everyday hyperbaric clinical practice; it also provides support material for teachers and will assist students in obtaining European Committee for Hyperbaric Medicine (ECHM) level II and III qualifications in hyperbaric medicine. Contributors to this handbook have to be thanked for their enthusiasm and efforts. We also wish to express our gratitude to our English reviewers, Martin Hamilton-Farell and Frans Cronje; to Audrey Degeldere for her excellent secretarial work; to Springer for its great assistance; and to the COST secretariat for their strong and continuous support of our efforts. The Management Committee considers this Handbook both a reference and benchmark – the culmination of the COST B14 action. We hope this Handbook will be welcomed and avidly used by the international scientific community.

Prof D. Mathieu President of the Management Committee COST B14 Action Hyperbaric Oxygen Therapy ix

CONTRIBUTORS Bakker, Dirk Jan

Department of Surgery/Hyperbaric Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands

Barthelemy, Alain

Centre Hyperbare, Hôpital Sainte Marguerite, Marseille, France

Beaucourt, Luc

Unit of Hyperbaric Medicine, Department of Emergency Medicine, University Hospital, Antwerp, Belgium

Bitterman, Haim

Technion-Israel Institute of Technolog, Haifa, Israel

Bitterman, Noemi

Technion-Israel Institute of Technolog, Haifa, Israel

Boulo, Marie

Service d’Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Centre Hospitalier Régional et Universitaire, Lille, France

Cali-Corleo, Ramiro

Head of the Division of Baromedicine at the University of Malta and the Hyperbaric Unit, Malta

Cesari, Jean-François

Service d'Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Centre Hospitalier Régional et Universitaire, Lille, France

Collet, François

Service d'Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Centre Hospitalier Régional Universitaire, Lille, France

Courtière, Alain

Institut de Médecine Navale du Service de Santé des Armées, Toulon Naval, France

Cronje, Frans

Medical Director, Eugene Marais Hospital Hyperbaric Oxygen Therapy Center, Pretoria, South Africa.

Desola, Jordi

CRIS, Hyperbaric Therapy Unit (CRIS-UTH), Dos de maig Hospital, Barcelona, Spain

Ditri, Luciano

OTI Medicale, Vicenza, Italy

Duim, Wiebren

Medical Director, Life Health Care Group Stroke Therapy Center, Little Company of Mary Hospital, Pretoria, South Africa.

Favory, Raphael

Service d`Urgences Respiratoires, de Réanimation Médicale et de Médecine Hyperbare, Hopital Calmette, Centre Hospitalier Régional et Universitaire, Lille, France

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Contributors

xii Frey, Günter

Dept. of Anesthesiology and Intensive Care Medicine, Federal Armed Forces Hospital, Ulm, Germany

Germonpre, Peter

Centre for Hyperbaric Oxygen Therapy, Military Hospital Brussels, Belgium

Gough-Allen, Roly

Sea-Long Europe Medical Systems Inc, Plymouth United Kingdom.

Gröger, Michael

Sektion Anaesthesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany

Hamilton-Farell, Martin

Whipps Cross University Hospital, Leytonstone, London, United Kingdom

Hierholzer, Christian

BG Trauma Center, Berufsgenossenschaftliche Unfallklinik, Murnau, Germany

Houman, Robert

Centre for Hyperbaric Oxygen Therapy, Military Hospital Brussels, Belgium

Jorens, Philippe

Department of Intensive Care Medicine, University Hospital, Antwerp, Belgium

Kemmer, Armin

Department of Anaesthesia & Intensive Care Medicine, Centre for Hyperbaric Oxygen Therapy, Berufsgenossenschaftliche Unfallklinik, Murnau, Germany

Kot, Jacek

National Center for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine in Gdynia, Medical University of GdaĔsk, Poland

Lampl, Lorenz

Dept. of Anesthesiology and Intensive Care Medicine, Federal Armed Forces Hospital, Ulm, Germany

Lartigau, Eric

Department of Radiation Oncology, Centre O. Lambret, University od Lille, France

Linke, Jean-Christophe

Service d'Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Centre Hospitalier Régional et Universitaire, Lille, France

Longobardi, Pasquale

Medical Director, Centro Iperbarico, Ravenna, Italy

Marroni, Alessandro

President and Medical Director, DAN Europe Foundation, Roseto, Italy

Mathieu, Daniel

Service d`Urgences Respiratoires, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Centre Hospitalier Régional et Universitaire, Lille, France

Contributors

xiii

Mathieu-Nolf, Monique

Centre Anti-Poison, Centre Hospitalier Régional et Universitaire, Lille, France

Mehdaoui, Hossein

Criticial care and hyperbaric oxygen therapy unit, University Hospital, Fort de France, Martinique, French West India

Meintjes, Jack

Medical Advisor and Senior Lecturer, Department of Community Health, Division of Occupational Health, University of Stellenbosch, South Africa.

Melamed, Yehuda

Rambam Medical Centre, Orthopedic and HBO Medical Department, Haifa, Israel

Mesimeris, Theodore A.

Hyperbaric Department, Thessaloniki, Greece

Montanari, Michele

OTI Medicale Vicenza, Italy

Müller, Peter

London Hyperbaric Medicine., Whipps Cross University Hospital, Leytonstone, London, United Kingdom

Muth, Claude

Sektion Anaesthesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany

Niinikoski, Juha

Department of Surgery, University of Turku, Turku, Finland

Pasquier, David

Department of Radiation Oncology, Centre O. Lambret, University of Lille, France

Radermacher, Peter

Sektion Anaesthesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, 89073 Ulm, Germany

General

Hospital

St.Paul,

Ratzenhofer-Komenda, Beatrice Dept. of Anaesthesiology and Intensive Care, University Medical School, Graz, Austria Reis, Daniel

Rambam Medical Centre, Orthopedic and HBO Medical Department, Haifa, Israel

Rocco, Monica

Centro di Medicina Iperbarica, Istituto di Anestesia e Rianimazione, Universita "La Sapienza", Roma, Italy

Roque, Filipe

Centro de Medicina Hiperbárica-Hospital da Marinha, Lisbon, Portugal

Schmutz, Jörg

SUHMS, Consultant for Hyperbaric Medicine, University of Basel Basel, Switzerland

Contributors

xiv Sicko, Zdzislaw

National Center for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine, Medical University of GdaĔsk, Gdynia, Poland

Siekmann, Ullrich

HBO-Zentrum Euregio and Universitätsklinikum der RWTH Aachen, Abteilung Anästhesiologie, Aachen, Germany

Simão, Antonio Gata

Centro de Medicina Hiperbárica, Hospital da Marinha, Lisbon, Portugal

Sminia, Peter

Department Radiation Oncology, division Radiobiology, VU University Medical Center, Amsterdam, The Netherlands.

Smolle-Jüttner, Freyja Maria

Dept. of Surgery, Division of Thoracic Surgery and Hyperbaric Medicine, University Medical School, Graz, Austria

Speit, Günter

Abteilung Germany

Stein, Thomas

BG Trauma Center, Berufsgenossenschaftliche Unfallklinik, Murnau, Germany

Tissier, Stéphanie

Service d’Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Centre Hospitalier Régional et Universitaire, Lille, France

Van der Kleij, Adrian

Department of Surgery/Hyperbaric Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands

Van Poucke, Sven

Unit of Hyperbaric Medicine, Department of Emergency Medicine, University Hospital, Antwerp, Belgium

Wattel, Francis

Service d'Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Centre Hospitalier et Universitaire, Lille, France

Weinberger, Andreas

Universitätsklinikum der RWTH Aachen, Abteilung Augenheilkunde, Aachen, Germany

Welslau, Wilhelm

Gesellschaft für Tauch- und Überdruckmedizin [German Society for Diving and Hyperbaric Medicine], Seeboeck gasse 17, Wien, Austria

Humangenetik,

Universitätsklinikum,

Ulm,

PREFACE

Dirk Jan Bakker President of the European Committee for Hyperbaric Medicine. Department of Surgery/Hyperbaric Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands

On the second day of my surgical residency in the end of 1968, under professor Boerema in the “Wilhelmina Gasthuis” in Amsterdam, I found myself in the hyperbaric chamber, supervising the treatment of a patient with gas gangrene. When I witnessed the sudden awakening of a very serious victim of carbon monoxide poisoning, in the middle of the night two nights later, I was definitively won over to the side of Hyperbaric Medicine. These, together with palliative surgical procedures in small children (until 1972), were practically the only indications we had at that time. The role of hyperbaric oxygen was investigated in many different diseases, and also experimentally; but these three were the most successful clinical indications (besides decompression illness and gas emboli). A lot has changed since then. Many supposed indications have come and disappeared again; a few have stayed and proved to be successful, and new indications have been found. The situation in Europe was that every physician with a chamber at his or her disposal treated the indications he or she believed in and had experience with. Every four, and subsequently three, years we gathered at the hospital or university of one of our colleagues and discussed what we had done in the previous years. This was established as the International Congress on Hyperbaric Medicine (ICHM) in 1963. A great deal of scientific and clinical work was done; and the Proceedings of these Congresses are witness thereof. If you take the opportunity to read these books carefully, you will be surprised by the good scientific work that was done in those days. It is a pity that much of it has been forgotten or duplicated in later years. An example of the thoroughness of the work is that in almost every animal experiment a control group was included; this, unfortunately, was lacking in most clinical series. The reason was that “experience-based” and

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Preface

“consensus-based” medicine were the rule rather than the exception. Many of the young investigators who presented their work later became giants in their respective medical fields. This is the reason that the International Congress on Hyperbaric Medicine is looking for funds to reprint these old Proceedings. The Undersea Medical Society (UMS later the UHMS, Undersea and Hyperbaric Medical Society, established in 1967) was the first society that selected a Hyperbaric Oxygen Therapy Committee, to identify and classify the various clinical indications on the basis of the scientific evidence that existed. The first Committee Report was published in 1977 and many followed in later years. Gradually, over the years, the insurance companies took these reports as a guide for payment for the treatment of patients with the recommended indications. The situation in Europe at that time was that we followed more or less the indications from the UHMS Committee Report. The contacts between the different hyperbaric centres were rare and restricted to the occasional symposium or congress. Contacts with the Soviet Union and the far east were, if they existed, extremely rare. Also the different languages were a big problem (Russian and Chinese for example). An example of this is the Proceedings of the VIIth International Congress on Hyperbaric Medicine, held in Moscow in 1981, which were published in 1983 completely in Russian without any translation. This situation changed in 1989 when the necessity of founding a committee, with the goal of raising the quality and profile of Hyperbaric Medicine, emerged during an informal discussion in Milan. The three editors of this new book were all present on that occasion, as was the author of this Preface. The first informal meeting took place in November 1989; and this date can be considered the initiation of the European Committee for Hyperbaric Medicine (ECHM). The first Plenary Meeting with all diving and hyperbaric representatives from the different European countries took place in Amsterdam in August 1990, during the Joint Meeting on Diving and Hyperbaric Medicine (of the International Congress, the Undersea and Hyperbaric Medical Society, and the European Undersea and Biomedical Society, EUBS). The official founding of the ECHM took place again in Milan, in 1991. The goals for the Committee were defined as: 1). Studying and defining common indications for hyperbaric therapy; research and therapy protocols; common standards for therapeutic and technical procedures; equipment and personnel; cost-benefit and costeffectiveness criteria.

Preface

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2). Acting as a representative body for the European Health Authorities of the European Union (EU) in Brussels (Belgium). 3). Promoting further cooperation among existing scientific organisations involved in the field of Diving and Hyperbaric Medicine (for instance the European Undersea Biomedical, later Baromedical, Society, which was originally established in 1965). The most important mission of the ECHM was to define European Standards for Hyperbaric Medicine practice regarding indications, patient care and quality assurance, equipment and quality control, personnel and training policies and research. This all was very much in line and at the same time as the rise of the Evidence-Based Medicine (EBM) movement (in Canada) and the Cochrane Library for meta-analyses of randomised trials, and the weighing and determining of the evidence. This was not an easy task for many of us, as experienced clinicians with many years of clinical practice behind us. We had to get used to another way of looking at our results and a different way of planning of our clinical scientific work. This no longer included retrospective studies or retrospectively studied large cohorts of treated patients, but rather inclined towards prospective, randomised, placebo-controlled and blinded trials, the so-called randomised controlled trials (RCT’s), which were considered the ‘gold standard’. In some indications, where we already had large clinical experience and we had already treated many patients, trials were considered unethical; and gradually it became clear that extensive experience was also evidence, but less convincing than the RCT ’s. I think we struggled and succeeded well with these changes; and we showed that Hyperbaric Medicine is a modern and effective therapeutic modality, judged by the standards of 2005. Of course things can always be done better; and we must strive continuously to determine the best evidence. We have that in common with many other medical specialists, some of whom have not made as much progress as us. We started our work on indications (among many other matters) in 1991; and we organised the “First European Consensus Conference on Hyperbaric Medicine” in Lille (France) in September 1994. A list of indications, accepted in most countries in Europe, was judged by an independent Jury, applying the rules of evidence-based medicine. This list proved to be very important because the practitioners of Hyperbaric Medicine in Europe now had a European list of approved indications for their own clarity and to discuss with the various insurance companies for treatment reimbursement. Moreover we had decided together for which indications more evidence was needed before we could accept

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them (indicating more study); and, not the least important, we had defined what were not indications for hyperbaric oxygen treatment. This work on indications is still going on with regular Symposia, Workshops and Consensus Conferences (the latest in Lille again, in December 2004). As a result of this work, a Handbook on Hyperbaric Medicine was published by Springer in 1996 under the editorial supervision of Giorgio Oriani from Milan (Italy), Alessandro Marroni from Roseto degli Abruzzi (Italy) and Francis Wattel from Lille (France). This was the first comprehensive book that appeared in Europe on hyperbaric medicine, a major achievement. Besides the physiology and patho-physiology of oxygen and hyperbaric oxygen, the various clinical indications were described. Also, organisational aspects of hyperbaric therapy, and the treatment of diving accidents, were reviewed. A view to the future, and possible future indications, were given in the stimulating section ‘New Frontiers’. One of the innovations which made us proud was that so many different doctors and scientific investigators from so many European countries worked together so harmoniously. Naturally, this book sold out rather quickly. The plans for a new and updated European Handbook were quickly made, but the execution of this plan took some time. Fortunately, about five years ago, the COST B14 action was started. Sponsored by the European Union, many hyperbaric specialists were able to meet in various cities of Europe, discussing and developing protocols for treatment and for scientific investigations in the field of Hyperbaric Medicine. In presenting and discussing the results of this action with the authorities, it became soon clear that we were offered the possibility of writing and publishing a book on Hyperbaric Medicine. It is the great merit of Daniel Mathieu (President-elect of the ECHM) and Francis Wattel (past President) that they realized immediately the possibilities that were offered here. In the framework of the COST action, however, it was necessary to publish the book in August/September of this year, 2005. The authors of the various chapters had to be colleagues who had taken part in the COST action’s work. Without any hesitation, the editors of this book started working; selecting authors, encouraging them, setting deadlines for contributions and doing all the work necessary for the writing of the manuscript. Looking at the content of the book nothing has been done in haste. We find well considered contributions in a logical order to set out and explain the whole field of Hyperbaric Medicine. Part One starts with the physical and patho-physiological bases of hyperbaric oxygen therapy under the trusted editorial guidance of Martin Hamilton-Farell, Beatrice Ratzenhofer-Komenda and Juha Niinikoski from Finland. Contributions on the physics of increased pressure and on the influence of hyperbaric oxygen on DNA and DNA-repair are present.

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Part Two describes the various recommended, optional and controversial indications. This is mainly the result of all the work done for the Lille Consensus Meeting. Editors are Daniel Mathieu, together with Jörg Schmutz from Switzerland and Frans Cronje from South Africa, all experienced clinicians and investigators from the outset of the era of modern hyperbaric medicine. The 50 pages devoted to controversial and non-indications do not represent so much the importance of these indications, but more the thoroughness with which the authors have studied and weighed the evidence and drawn their conclusions. It is extremely important to know what not to treat and on what basis of evidence. The lack of this in the past has caused us a lot of trouble and problems with fellow scientists and clinicians, and also the health authorities in some countries. Part Three is devoted to the practice of hyperbaric oxygen (HBO) therapy. Jacek Kot from Poland, Armin Kemmer from Germany and Peter Germonpre from Belgium write and edit contributions on chamber building and equipment, the organisation of a centre, selection of patients for treatment and monitoring them in the hyperbaric chamber, training of personnel, safety in the hyperbaric environment and the economic aspects of HBO, aspects which are often misunderstood or underestimated, complications, research in HBO and the organisation of Hyperbaric Medicine in Europe at this moment. The publication of this new Handbook on Hyperbaric Medicine is indeed again a major achievement and another highlight in the history of the European Committee for Hyperbaric Medicine. The editors and the contributors can be congratulated with all their work in writing this book. I sincerely hope that this book will be disseminated initially all over Europe, but also that it reaches colleagues in other parts of the world. I trust that it will be carefully studied and followed in the directions that it offers. If anything changes (science is always moving ahead), the European Committee will address it in a future Symposium, Workshop or Consensus Conference and in cooperation with our sister organisations. Let this first edition be sold out very quickly.