There is general agreement among the three guideline developers that HBO2 therapy may be an appropriate adjuvant intervention for selected patients. IWGDF makes a weak recommendation on the basis of moderate-quality evidence for the consideration of systemic HBO2 therapy in order to accelerate healing of DFUs. Further blinded and randomized trials are required to confirm its cost-effectiveness, as well as to identify the population most likely to benefit from its use, notes the guideline developer. SVS/APMA/SVM suggests the use of HBO2 therapy in patients with DFUs who have adequate perfusion that fails to respond to 4 to 6 weeks of conservative management. Considering the cost and the burden of prolonged daily treatment, the developer encourages careful patient selection and suggests the use of transcutaneous oximetry to help stratify patients and predict those most likely to benefit.

HBO2 therapy for the treatment of DFUs is the focus of the UHMS guideline. The developer makes recommendations for its use according to the grade of the DFU in the Wagner wound classification system. UHMS explains that, despite consensus between foot and ankle surgeons and hyperbaric physicians that the Wagner grade is archaic and inadequate, most of the historical and contemporary studies and most reimbursement determinations with regard to the use of HBO2 for DFUs are based on the Wagner DFU wound appearances. In order to reduce the risk of major amputation and incomplete healing, UHMS suggests adding HBO2 to the standard of care in patients with Wagner Grade 3 (deep tissue involvement and abscess, osteomyelitis, or tendonitis) or greater DFUs who have just undergone surgical debridement of the infected foot as well as in patients with Wagner Grade 3 or greater DFUs that have shown no significant improvement after 30 or more days of treatment. The developer suggests against using HBO2 in patients with Wagner Grade 2 or lower DFUs.