Safe administration of hyperbaric oxygen after bleomycin a case series of 15 patients

Introduction: Supplemental oxygen has been reported to cause pulmonary complications after bleomycin. We describe the safe administration of hyperbaric oxygen (HBO₂) after bleomycin in 15 patients. Methods: Paper and electronic records were reviewed for bleomycin-exposed patients at the Duke Center for Hyperbaric Medicine and Environmental Physiology from 1979 to 2010. Results: Fourteen bleomycin-exposed patients received HBO₂ at Duke under a special-precautions protocol. One was treated for DCS elsewhere. The protocol included: pretreatment evaluation; chest radiograph; spirometry; blood gases; a single, 2-atmospheres absolute (atm abs), 120-minute HBO₂ treatment; and a gradual acceleration over one week to a twice-daily schedule contingent on clinical and laboratory findings. Bleomycin indications were: head-and-neck squamous cell carcinomas (11), Hodgkin's lymphoma (2), other carcinomas (2). HBO₂ indications were: osteoradionecrosis (10), soft-tissue radionecrosis (3), DCS (1) and a provocative oxygen toxicity test for a military aviator (1). Total bleomycin doses ranged from 40 to 225u/m ² (mean ± SD, 105 ± 57) given in conjunction with other chemotherapies and/or radiation. Radiation was 63.3 ± 31.72 Gy (mean ± SD), none to the chest with the exception of one patient treated for DCS elsewhere. Other chemotherapies included: vinblastine (11), methotrexate (11), CCNU (6) cisplatinum (7), dacarbazin (2), Adriamycin (1), and vincristine (1). Median age at time of HBO₂ was 52 years (range 22-77). Median bleomycin-to-HBO₂ latency was 34 months (range 1-279). Three patients received HBO₂ within six months, and seven patients received HBO₂ within two years of their last bleomycin exposure. There were no adverse pre-to-post HBO₂ changes in: arterial blood gases, spirometry, chest radiograph findings or clinical reports. There were no persistent post-HBO₂ pulmonary complications on follow-up. Post-HBO₂ data were available for 40%, 53%, 87% and 100% of these parameters respectively. Discussion: Bleomycin and oxygen can individually cause acute pulmonary toxicity. However, evidence for increased long-term susceptibility based on their synergy may be overstated.