Hyperbaric oxygen therapy is an adjunct to specialised burn-centre care for moderate-to-severe second-degree (deep partial-thickness) and selected third-degree thermal burns. It reduces edema and supports tissue survival in the peri-burn zone of stasis, the partially injured tissue that is potentially salvageable with timely intervention. Best outcomes occur when HBOT is started within the first 24 hours of injury. Acute thermal burn injury is recognised by Health Canada as one of the 14 conditions for which provincial health insurance covers HBOT at hospital-based programmes.
Quick Answer
Does HBOT help acute thermal burns? Hyperbaric oxygen therapy is an adjunct to specialised burn-centre care for moderate-to-severe second-degree (deep partial-thickness) and selected third-degree thermal burns. It reduces edema and supports tissue survival in the peri-burn zone of stasis, the partially injured tissue that is potentially salvageable with timely intervention. Best outcomes occur when HBOT is started within the first 24 hours of injury. Acute thermal burn injury is recognised by Health Canada as one of the 14 conditions for which provincial health insurance covers HBOT at hospital-based programmes.
Acute thermal burns are skin and soft-tissue injuries caused by exposure to heat (flame, scald, contact, flash, electrical with thermal component). The Jackson zones model classifies the injured tissue into three concentric regions: the zone of coagulation (the central area of irreversible necrosis at the highest temperature), the zone of stasis (the surrounding ring of partially injured, hypoxic, but potentially salvageable tissue), and the zone of hyperaemia (the outer ring of inflamed but viable tissue that will recover with standard care). The biological target of hyperbaric oxygen therapy in burns is the zone of stasis: keeping marginally viable tissue alive long enough that the burn does not extend deeper or wider than the original thermal injury would dictate.
Burn severity is assessed by depth (superficial, superficial partial-thickness, deep partial-thickness, full-thickness, fourth-degree with underlying tissue involvement) and total body surface area (TBSA, calculated by the Lund-Browder chart for accuracy or the rule-of-nines for rapid estimation). Adjunctive HBOT is most often considered for deep partial-thickness (deep second-degree) burns covering more than 20 percent TBSA, selected full-thickness burns with significant zone-of-stasis components, burns of the hands, face, perineum, or major joints, electrical burns with extensive deep-tissue involvement, and burns in patients with comorbidities (diabetes, peripheral vascular disease) that compromise wound healing. Minor burns and the most severe (over 60 percent TBSA, often with inhalation injury and multi-organ failure) typically do not benefit from HBOT.
Canadian burn care is concentrated at specialised burn centres including the Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre in Toronto (Canada's largest, with HBOT capability through the adjacent hyperbaric programme), the Firefighters' Burn Centre at the University of Alberta Hospital in Edmonton, the Burn Unit at Vancouver General Hospital (with the in-hospital Leon Judah Blackmore Pavilion hyperbaric programme), and the burn-care services at Hamilton General Hospital, the CHUM in Montreal, and the QEII Health Sciences Centre in Halifax. The combination of major burn-centre capability plus on-site or adjacent hyperbaric capability is the practical determinant of whether HBOT is offered as part of acute burn management.
Hyperbaric oxygen therapy treats acute thermal burns through four convergent mechanisms.
First, oxygen delivery to the zone of stasis. Inside the chamber at 2.0 to 2.4 ATA on 100 percent oxygen, plasma oxygen content rises 10- to 15-fold, raising tissue pO2 in the peri-burn zone of stasis from ischemic levels to several hundred mmHg during each session. This intermittent hyperoxia keeps marginally viable cells alive long enough that the natural-healing response can determine the final extent of injury.
Second, edema reduction through hyperoxic vasoconstriction. Burn injury triggers massive capillary leak and tissue edema that further compromises perfusion in the zone of stasis. HBOT reduces capillary permeability and tissue edema in well-oxygenated peri-burn tissue while preserving or improving oxygen delivery to the hypoxic injury zone. The resulting reduction in tissue pressure supports microvascular flow and limits the deepening of the burn.
Third, antimicrobial support. Burn wounds are highly vulnerable to infection because the protective skin barrier is disrupted and the burn eschar is a culture medium for bacteria and fungi. HBOT restores oxygen-dependent neutrophil bactericidal activity at the burn margin, supports the activity of certain antibiotics (notably aminoglycosides and fluoroquinolones), and suppresses anaerobic bacterial growth.
Fourth, support for fibroblast and angiogenic activity. The same VEGF-mediated angiogenesis that underpins HBOT's benefit in chronic wounds contributes to definitive healing of the burn wound bed, reduces hypertrophic scarring, and supports the take of skin grafts when surgical reconstruction is required.
Typical Treatment Protocol
Standard adjunctive protocol is 2.0 to 2.4 ATA on 100 percent oxygen for 90 minutes per session, with the first session ideally delivered within 24 hours of injury (the period when the zone of stasis is most vulnerable). Two sessions are delivered in the first 24 hours, then once daily for 5 to 14 sessions depending on burn severity, surgical course, and clinical response. Total course can extend to 30 sessions for the most severe burns or for burns requiring staged reconstructive surgery. HBOT is delivered as an adjunct to standard burn-centre care, not as a substitute. The standard sequence is initial fluid resuscitation (Parkland or modified Brooke formula), wound assessment and burn-centre admission, primary debridement of devitalised tissue, IV antibiotics and antifungals as indicated, and adjunctive HBOT in parallel with the surgical and wound-care management. Critically ill burn patients receive HBOT in multiplace chambers that accommodate ventilator-dependent and infusion-dependent support with hyperbaric-trained nurse and physician inside the chamber.
Level B - Moderate Evidence
Supported by controlled studies and clinical evidence
The Cianci series and other case-control cohorts (Cianci 2013, others) suggest adjunctive HBOT is associated with reduced fluid-resuscitation requirements, shorter hospital length of stay, fewer skin-grafting procedures, and improved survival in moderate-to-severe burns covering more than 20 percent TBSA.
A Cochrane Review of HBOT for thermal burns (Villanueva 2004, updated 2019) concluded that the available evidence is mixed and predominantly observational, with the strongest signals for reduction in length of stay and grafting requirements. Randomised trials are limited; the evidence base is similar to other emergency adjunctive HBOT indications where observational data informs practice.
The biological window for HBOT in thermal burns is the first 24 to 48 hours after injury, when the zone of stasis is most vulnerable to progression. Earlier intervention produces better outcomes; benefit diminishes (but does not disappear) with delay.
Standard adjunctive protocol is 2.0 to 2.4 ATA on 100 percent oxygen for 90 minutes per session, two sessions in the first 24 hours, then once daily for 5 to 14 sessions, with extension to 30 sessions for the most severe burns or those requiring staged reconstruction.
HBOT is most useful for deep partial-thickness (deep second-degree) burns covering more than 20 percent TBSA, selected full-thickness burns with significant zone-of-stasis components, burns of functionally critical sites (hands, face, perineum, major joints), and electrical burns with extensive deep-tissue involvement.
Canadian burn-related HBOT is concentrated at the small number of centres combining major burn-centre capability with on-site or adjacent hyperbaric capability: Sunnybrook (Ross Tilley Burn Centre + Toronto General hyperbaric programme via UHN), Vancouver General Hospital, University of Alberta Hospital + Misericordia Edmonton, and Hamilton General Hospital.
Highest-evidence-tier studies tagged to this condition in the Canada Hyperbarics research database, ranked by evidence tier (1 = meta-analysis or RCT, 2 = cohort, 3 = case series), most recent first.
Acta Anaesthesiol Scand · 2015 · RCT
Undersea Hyperb Med · 2013 · Review
Diving Hyperb Med · 2013 · RCT
Cochrane · 2004 · Systematic Review
Experimental dermatology · 2022 · Clinical Study
Most patients with significant thermal burns arrive at hospital by ambulance and are typically transferred from the receiving emergency department to a specialised burn centre. The burn-care team performs initial fluid resuscitation, wound assessment, primary debridement of devitalised tissue, and (if needed) airway management for inhalation injury. Adjunctive HBOT is considered as part of the early management plan, often within the first 24 hours.
For critically ill burn patients, HBOT is delivered in multiplace chambers that accommodate stretchers, ventilators, infusion pumps, and a hyperbaric-trained nurse and physician inside the chamber alongside other patients. For stable burn patients, monoplace chambers can also be used. Pressurisation takes five to ten minutes, the treatment phase is on 100 percent oxygen at 2.0 to 2.4 ATA for 90 minutes, and decompression takes another five to ten minutes.
Two sessions are delivered in the first 24 hours, then once daily for 5 to 14 sessions, with course extension as needed. The burn surgical team monitors wound progression at each visit, and HBOT continues alongside debridement, dressing changes, skin grafting (when needed), and definitive reconstruction. Recovery from severe burns is typically prolonged, with rehabilitation needs (mobilisation, scar management, occupational therapy, psychological support) extending well beyond the acute hyperbaric course.
Acute thermal burn injury is recognised by Health Canada as one of the 14 conditions for which hyperbaric oxygen is the established adjunctive treatment. In practice, HBOT for burns is delivered only at the small number of Canadian centres that combine major burn-centre capability with on-site or directly adjacent hyperbaric capability.
The principal centres are: Sunnybrook Health Sciences Centre in Toronto, where the Ross Tilley Burn Centre is Canada's largest burn unit and has access to hyperbaric medicine through the adjacent programme; Vancouver General Hospital, where the Burn Unit and the Leon Judah Blackmore Pavilion hyperbaric programme are co-located in the same hospital; the University of Alberta Hospital and the adjacent Misericordia Edmonton hyperbaric programme (operated by Covenant Health); Hamilton General Hospital, with both burn-care and hyperbaric capability; and the CHUM in Montreal with referral to the Hôpital du Sacré-Cœur de Montréal hyperbaric programme.
In Ontario, the Ross Tilley Burn Centre and Sunnybrook coordinate burn-related HBOT referrals; OHIP covers treatment at the three Ontario hospital programmes. In British Columbia, the VGH Burn Unit and adjacent hyperbaric programme handle burn-related HBOT under MSP. In Alberta, the University of Alberta Hospital burn centre coordinates HBOT referrals to Misericordia Edmonton (AHCIP code 13.99I). Quebec, Nova Scotia, Newfoundland and Labrador, and Saskatchewan also cover burn-related HBOT at their respective hospital programmes when burn-care and hyperbaric capability are co-located. For patients in provinces or territories without combined burn-and-HBOT capability, inter-provincial referral is arranged through the receiving province's transfer service, most commonly to the Ross Tilley Burn Centre at Sunnybrook (for eastern and central Canada) or the University of Alberta Hospital (for prairie and territorial patients).
Hyperbaric oxygen therapy for the 14 Health Canada-recognised conditions, including Acute Thermal Burns, is delivered at the 11 hospital hyperbaric programmes located in seven provinces (Ontario, Quebec, British Columbia, Alberta, Nova Scotia, Newfoundland and Labrador, and Saskatchewan). The six provinces and territories without an in-province hospital programme (Manitoba, New Brunswick, Prince Edward Island, Yukon, Northwest Territories, and Nunavut) route patients to the nearest receiving hospital programme. Use the links below for province-specific coverage, referral pathway, and emergency routing details.
Hospital + Private
OHIP (Ontario Health Insurance Plan)
Hospital Only
MSP (Medical Services Plan)
Hospital + Private
Alberta Health / AHCIP
Hospital Only
RAMQ
Disrupted
Saskatchewan Health Authority
No Hospital Chamber
Manitoba Health
Hospital Only
MSI (Medical Services Insurance)
No Hospital Chamber
Medicare NB
Hospital Only
MCP (Medical Care Plan)
Out-of-Province Referral
Health PEI
Out-of-Province Referral
Yukon Health and Social Services
Out-of-Province Referral
NWT Health and Social Services
Out-of-Province Referral
Nunavut Department of Health
For acute or emergency presentations of Acute Thermal Burns, call 911 first. The receiving emergency department coordinates urgent transfer to the nearest hospital hyperbaric programme through the relevant provincial transfer network (CritiCall Ontario at 1-800-668-4357, BC Patient Transfer Network, EHS Nova Scotia, or equivalent). For diving-related emergencies, the Divers Alert Network (DAN) emergency hotline is 1-919-684-9111.
Untreated pneumothorax is the only absolute contraindication. Burn patients with significant inhalation injury require airway assessment and stabilisation before chamber entry; ventilated burn patients with a secured airway can be treated in multiplace chambers with appropriate critical-care support. Relative contraindications include severe haemodynamic instability requiring continuous high-dose vasopressor titration (chamber-side titration is more difficult), uncontrolled seizure disorder, severe chronic obstructive pulmonary disease with bullous lung disease, and concurrent treatment with bleomycin or disulfiram. None of these typically override the hyperbaric decision in a patient with a significant zone-of-stasis burn that would otherwise progress to deeper or more extensive injury.
No. HBOT is considered for moderate-to-severe burns, particularly deep partial-thickness (deep second-degree) burns covering more than 20 percent total body surface area, selected full-thickness burns with significant zone-of-stasis components, burns of functionally critical sites (hands, face, perineum, major joints), and electrical burns with deep-tissue involvement. Minor burns and burns over 60 percent TBSA with multi-organ failure typically do not benefit from HBOT. The decision is made by the burn-care team in consultation with hyperbaric medicine.
Ideally within the first 24 hours of injury. The zone of stasis (the partially injured tissue surrounding the central burn) is most vulnerable to progression in the first 24 to 48 hours, and early HBOT helps prevent the burn from extending deeper or wider than the original thermal injury would dictate. Two sessions in the first 24 hours are standard.
Case-control cohorts and observational data suggest adjunctive HBOT is associated with reduced fluid resuscitation needs, shorter hospital length of stay, fewer skin-grafting procedures, and improved survival in moderate-to-severe burns. The evidence is predominantly observational; randomised trials are limited. The Cochrane Review concludes the available evidence is mixed but with consistent signals for reduction in length of stay and grafting.
Yes, where the burn-care and hyperbaric capability are co-located at the same hospital or institution. The principal Canadian centres are the Ross Tilley Burn Centre at Sunnybrook (with HBOT through UHN), Vancouver General Hospital, the University of Alberta Hospital with adjacent Misericordia Edmonton, and Hamilton General Hospital. OHIP, MSP, AHCIP, RAMQ, MSI, MCP, and Saskatchewan Health all cover burn-related HBOT at the appropriate hospital programmes.
The zone of stasis is the ring of partially injured, hypoxic, but potentially salvageable tissue surrounding the central area of irreversible burn necrosis (the zone of coagulation). It is the primary biological target of HBOT in burns. By restoring tissue oxygenation in this zone, HBOT keeps marginally viable cells alive long enough that the burn does not extend deeper or wider than the original thermal injury would dictate.
Typical course is 5 to 14 sessions: two sessions in the first 24 hours (the period of maximum biological benefit), then once-daily sessions through the first one to two weeks. The course can extend to 30 sessions for the most severe burns or those requiring staged reconstructive surgery. Total course is guided by burn severity, surgical course, and wound-bed response.
In some cases, yes. Adjunctive HBOT preserves zone-of-stasis tissue that would otherwise progress to full-thickness necrosis requiring grafting. The Cianci series and other observational data suggest fewer grafting procedures and shorter hospital length of stay in moderate-to-severe burns treated with adjunctive HBOT. The decision is made by the burn-care team based on serial wound assessment.
Yes, particularly for electrical injuries with significant deep-tissue involvement (muscle, fascia, bone) below the visible skin burn. The current path through tissue creates extensive zone-of-stasis injury that benefits from the same biological mechanisms as thermal burns. Electrical injuries are also typically associated with crush-injury physiology, another recognised hyperbaric indication.
For ventilated and critically injured patients, the chamber session feels like routine ICU care with the addition of pressurisation. Multiplace chambers accommodate stretchers, ventilators, infusion pumps, and a hyperbaric-trained nurse and physician inside the chamber. Pressurisation takes five to ten minutes and feels like an aircraft descent. The treatment phase at 2.0 to 2.4 ATA on 100 percent oxygen lasts 90 minutes. Decompression takes another five to ten minutes. The patient is continuously monitored throughout.
The principal Canadian centres are: Ross Tilley Burn Centre at Sunnybrook (Toronto, Ontario), Vancouver General Hospital (BC), University of Alberta Hospital with adjacent Misericordia Edmonton (Alberta), Hamilton General Hospital (Ontario), and the CHUM (Montreal, with referral to Hôpital du Sacré-Cœur). The Canada Hyperbarics verified directory at canadahyperbarics.ca/facilities/ lists all 11 hyperbaric programmes; the burn-care team at the receiving hospital coordinates the referral.