At a glance:
You can download our comprehensive guide to ozone therapy by clicking here.
Extracorporeal blood ozone and oxygenation (EBOO) is a medical procedure that involves:
There are two needles inserted, one in each arm. A pump pulls blood from one arm, mixes it with ozone gas, and reinfuses it into the other arm.
Some people also call it “ozone dialysis” or “recirculatory hemoperfusion” (RHP), including in the published literature. RHP is a fancy term that means you reintroduce the blood after adding gas to it. However, EBOO is NOT dialysis, as we’ll cover why later.
A primary difference between EBOO and standard IV ozone therapy is the volume of blood being ozonated. Since there is a line in each arm, they can put all the blood in the body through the therapy. A typical session utilizes anywhere from two to seven liters of blood.
Proven benefits [1, 2]
Theoretical benefits
What the patient experiences
Click here to download our ozone therapy guide
EBOO is not specifically indicated for different diseases than a standard ozone therapy IV. However, the scientific committee of ozone therapy indicates it over standard ozone therapy IV in certain cases.
Common indications where EBOO can be used include [2]:
We have a complete list of diseases treated with ozone therapy here.
While these are both IV ozone therapies, they differ significantly in their methodologies, applications, and specific treatment processes, including:
EBOO involves passing the patient’s blood (1.5-3L) through an extracorporeal circuit in a machine where it is mixed with ozone and oxygen before being reinfused into the patient.
This process treats a large volume of blood in a continuous loop and can process the entire blood volume over the course of the treatment.
Ozone autohemotherapy, on the other hand, involves drawing a smaller amount of blood (typically between 100–200 ml), mixing it with ozone, and then re-infusing it back to the patient. This mixing process can be done in a bag, without requiring a machine.
EBOO processes a much larger volume of blood compared to ozone autohemotherapy. In a typical EBOO session, your entire blood volume can be treated, cycling through the system multiple times.
Ozone Major Autohemotherapy deals with only 100-300 mL of blood per treatment session, which limits the scope of its immediate biochemical impact but still provides significant systemic benefits.
EBOO requires the use of anticoagulants (blood thinners) to prevent clotting as the blood passes through the EBOO machine. This is crucial due to the larger volume and prolonged blood exposure outside the body.
Ozone autohemotherapy usually does not require anticoagulants since only a small amount of blood is outside the body for a short period. However, many of our colleagues’ protocols add heparin to the blood during autohemotherapy. Sensibly, autohemotherapy uses lower doses of blood thinners than EBOO.
Click here to download our ozone therapy guide
EBOO needs a large machine to circulate the blood and infuse it with ozone. Some practitioners also add a dialysis process (which is not part of EBOO) to add to the health benefit. Therefore, EBOO can only be done in a medical office.
Whereas, autohemotherapy does not require a large machine beyond an ozone generator, and equipment and supplies for IV therapy.
EBOO is generally used for more severe or systemic conditions due to its comprehensive blood treatment and detoxification capabilities. It is often employed in cases where a quick and significant modulation of blood properties is necessary, or when autohemotherapy isn’t sufficient.
Ozone Autohemotherapy is commonly used for a wide range of conditions such as
AHT is an easier and less invasive application making it suitable for routine or preventive care.
EBOO can take 60 - 90 minutes, whereas autohemotherapy takes 30 - 45 minutes.
Unfortunately, there are no good comparative studies between EBOO and other ozone therapy IVs, such as major autohemotherapy.
There certainly is a heightened potential of a placebo effect, due to the “more is better” mentality and the intensive experience/visuals. However, because ozone therapy works as a hormesis, more is not necessarily better.
That leaves us with clinical evaluations by doctors on what they see performs better. We have outlined all the different forms of IV ozone therapy here.
EBOO delivers the most ozone, but it’s not better than other IV ozone therapies in all situations. Most importantly, we recommend taking the advice of your practitioner who understands your history and needs.
The International Scientific Committee of Ozone Therapy recommends EBOO over standard IV ozone therapy in some critical conditions where standard treatments may be ineffective or insufficient. These include:
Clinically, doctors and patients seem to think EBOO therapy is better in cases of considerable infections and burdened immune systems like these:
Beyond what is listed above, It is difficult to compare EBOO and MaH — potential placebo and financial motives cloud an unbiased comparison. Standard ozone therapy IV (MaH) seems to have similar success stories and cases.
EBOO provides a more intense experience and visualization because the patient sees dark blood leaving their body and bright red blood (due to oxygenation) returning to their vein. This can contribute to stronger placebo effects.
Click here to download our ozone therapy guide
EBOO offers distinct advantages and benefits over other forms of ozone therapy, particularly through its comprehensive treatment of the entire blood volume and its integration with other therapeutic modalities such as dialysis-like filtration. Here are the primary biological and physiological mechanisms of action that are unique to EBOO:
EBOO treats a larger volume of blood compared to autohemotherapy (AHT) or other localized ozone treatments. This allows for the modulation of biochemical properties throughout the entire circulatory system, enhancing the systemic effects of ozone therapy.
This comprehensive treatment can have a more pronounced systemic impact, improving blood oxygenation and temporarily increasing oxidative stress. With EBOO some of these effects are not achievable with smaller volume treatments.
Ozone breaks down substances and many microorganisms on contact. IV ozone therapy tends to work by ozone reacting with the blood components. Some EBOO practitioners believe that this therapy has some detoxification benefits, as ozone and peroxides break down some toxins and pathogens in the blood [4].
Some EBOO clinics add other treatments that may help with detoxification coupled with EBOO, such as:
By infusing ozone and oxygen into the blood, EBOO directly increases the amount of oxygen available for cellular metabolism and mitochondrial function. This is why ozone therapy temporarily boosts energy [2].
Both the improved oxygenation and thinner blood can be particularly beneficial for conditions involving impaired circulation or lack of oxygen to tissues, especially for ischemic or circulation disorders. The tissue oxygenation, increased energy production, and activated antioxidant responses are crucial for healing and normal cellular functions.
The immune system relies on oxidative species to communicate. By temporarily increasing oxidative stress in the blood, EBOO can stimulate the immune system by increasing the production of cytokines and activating some immune cells [4].
This activation helps the body to more effectively combat infections, manage autoimmune diseases and can even play a role in cancer therapy by boosting the body's natural defenses. In many cases, cases that don’t heal with other therapies respond or resolve with ozone therapy.
The initial hormetic effects of ozone therapy include a temporary increase in oxidative stress, which increases inflammation at first. Subsequently, the immune system and antioxidant response have a reset, finally settling with a net reduction in oxidative stress and inflammation. This means therapies like EBOO tend to help with conditions that don’t heal due to chronic inflammation [2].
This reduction in inflammation and oxidative stress can alleviate symptoms in chronic inflammatory diseases such as arthritis such as reduce pain. It may also contribute to the healing of inflammatory injuries.
Ozone has strong oxidizing properties that can destroy bacteria, viruses, and fungi. By treating all the blood passing through the EBOO system, it ensures that these pathogens are exposed to ozone, reducing the microbial load in the body.
This is particularly useful in reducing the number of pathogens in blood-borne infections or systemic infections that are difficult to manage with antibiotics alone.
Click here to download our ozone therapy guide
There are very few EBOO clinical studies, especially ones that compare with other types of IV ozone therapy, or even placebo or standard of care. Here are the available clinical studies that report the clinical outcomes, excluding ones that only describe EBOO methodologies.
A review presented a clinical and experimental investigation into EBOO, comparing it with traditional autohemotherapy (AHT). For the study, a high-efficiency apparatus allowing the treatment of up to 4800 ml of heparinized blood with an oxygen-ozone mixture (0.5-1 µg/ml oxygen) at 75 - 85 ml/min of blood flow in one hour of extracorporeal circulation was used.
The study involved more than 1200 treatments in 82 patients. The standard therapeutic cycle comprised 14 sessions over seven weeks, each lasting one hour. EBOO was found to alter biochemical markers related to oxidative stress significantly:
EBOO showed promising results in treating severe peripheral arterial disease, coronary disease, cholesterol embolism, severe dyslipidemia, Madelung disease, and sudden deafness of vascular origin.
The study also confirms EBOO's therapeutic potential, highlighting its advantages over traditional AHT in treating larger volumes of blood and integrating seamlessly with hemodialysis [2].
A randomized clinical trial evaluated the effectiveness of EBOO in treating skin lesions associated with peripheral artery disease (PAD), comparing its efficacy with intravenous prostacyclin therapy in 28 PAD patients.
The protocol used involved:
The primary efficacy measures included the regression of skin lesions, pain reduction, improvement in quality of life, and vascularization. In addition, the blood was collected to test for oxidative stress status before, in the middle, and after the EBOO treatment. All patients also received 0.5 grams per day and 600 mg/day of n-acetylcysteine away from the treatment to ensure optimal antioxidant capacity.
EBOO-treated patients showed highly significant regression of skin lesions compared to those receiving prostacyclin. Additional benefits observed in the EBOO group included significant improvements in:
Despite these improvements, no significant changes were noted in blood vessel regrowth in lower limbs in either group. This suggests that EBOO might help with PAD by directly oxygenating the tissues rather than regrowing the blood vessels. Importantly, no side effects or complications were reported during the 210 EBOO treatments, underscoring EBOO’s safety [5].
In a case report, a 67-year-old female dialysis patient developed necrotizing fasciitis skin lesions that tested positive for Streptococcus pyogenes. Traditional therapies including multiple antibiotics, fever-reducing medications, and surgeries to remove infected tissues were ineffective. She also developed a deep bedsore on her sacrum. The patient was pre-comatose and close to death [6].
With the consent of the patient’s relatives and the hospital ethics committee, EBOO was administered for 1 hour twice a week. After the 2nd treatment, the fever reduced and she regained consciousness. Subsequently, the study authors applied ozone water and oil to the skin lesions.
After the 5th EBOO session and about 10 days of topical treatment, the necrotic sores healed . The patient recovered her appetite and was able to leave the bed. By the 14th session, the lesion had healed almost completely.
An observational study of 253 patients with widespread psoriasis vulgaris investigated the effectiveness of various blood treatments, including ozone therapy.
Ozone therapy led to significantly faster and more pronounced improvements. Plasmapheresis, especially when combined with light treatment or ozone treatment of the returned blood, was found to be the most effective treatment modality.
In conclusion, ozone therapy is a highly beneficial part of the complex treatment regimen for patients with widespread psoriasis vulgaris. These methods not only improve the clinical outcome but also enhance the quality of life by effectively reducing the severity of symptoms [7].
Note: We’re not recommending any type of ozone therapy in pregnant women, only reporting on this Russian study results. If you’re pregnant, any decision on interventions needs to involve you and your doctor. Typically, a perfectly healthy pregnancy doesn’t warrant ozone therapy.
A clinical trial investigated the efficacy of extracorporeal blood purification with medical ozone treatment in the management of placental insufficiency in 127 pregnant women.
Traditional treatment significantly decreased placental growth factor (PGF) levels and increased vascular endothelial growth factor (VEGF) levels during pregnancy compared to the study group, suggesting less efficacy in managing placental insufficiency. The patients received either standard treatment or plasmapheresis with ozone therapy at 0.4 mg/L on 400 mL blood volume. The study found that the ozone group had significantly reduced complication rates during labor and the postpartum period, and improved perinatal outcomes, including:
This approach optimizes therapeutic outcomes and reduces complications during labor and improves perinatal results, highlighting its potential as a high-efficacy treatment option in complex cases of placental insufficiency [8].
An animal study evaluated the effects of extracorporeal blood treatment using an ozone-oxygen mixture on various physiological and metabolic processes in dogs, both under normal conditions and in models of experimentally induced shock lung.
Ozone treatment significantly enhanced lung ventilation and improved gas exchange and blood oxygenation in the lungs across both groups. There was a notable activation of glycogenolysis, glycolysis, and overall metabolic processes within the lung tissue. Specifically, the uptake of palmitate from the blood by the lungs increased in intact dogs, and the uptake of lactate and pyruvate was elevated in dogs with shock lungs. Additionally, there was an increase in the blood levels of molecular lipid peroxidation products in both groups of dogs.
Extracorporeal treatment with an ozone-oxygen mixture significantly improves pulmonary function and metabolic processes in both healthy dogs and those with induced shock lung. These enhancements highlight the potential of ozone-oxygen extracorporeal treatment as a therapeutic tool, particularly in critical care settings where pulmonary issues and shock states are prevalent [9].
An in vitro and in vivo model investigated the use of ozone in extracorporeal ozone blood treatment to reduce Escherichia coli (E. coli) concentrations in blood as a potential therapy for sepsis.
In human blood samples, ozone treatment reduced E. coli concentrations by 27%, decreasing from an average of 1941 to 1422 CFU/mL. In the sepsis model using swine, 9 out of 10 animals survived. Ozone treatment did not affect circulatory, respiratory, or metabolic parameters, nor did it impact E. coli concentrations in arterial blood or organs. Treatment increased blood oxygen levels and decreased carbon dioxide levels. Methemoglobin levels, a marker for oxidative stress, were unaffected.
Given the substantial mortality associated with sepsis and increasing antibiotic resistance, ozone therapy could represent a novel and effective treatment option that needs further investigation to determine its efficacy and safety in clinical settings [10].
The earliest evidence of EBOO’s use is by Dr. Paolo in Italy during the 90s.It was then adopted by Dr. Velio Bocci, the father of ozone therapy, and then the International Scientific Committee of Ozone Therapy.
How to prepare for an EBOO therapy session
The number of sessions needed depends on what you’re trying to accomplish.Someone with a more severe chronic illness may have the following protocol for a total of 11 sessions:
People can often experience benefits in 2–3 sessions but best results are generally seen in 6 - 10 treatments.
A healthy person may use EBOO once or twice a year as a preventative measure, to improve bodily function, or to optimize their performance in an athletic event (increased stamina and more energy).
Long lasting post-viral infections are often assisted in 2 - 6 treatments according to anecdotal reports.
Although a setup similar to dialysis is used, it is not a dialysis therapy.
Why does this often get confused?
Four reasons:
The reason the blood turns bright red is not because it’s been cleaned. It’s because the oxygen is binding to the red blood cells, turning them bright red.
Medical ozone gas is 99% oxygen and about 1% ozone. So, the blood is also getting exposed to a high level of oxygen which is picked up by hemoglobin in your red blood cells. The change to bright red is not due to the ozone.You could turn the ozone generator off and flow in pure oxygen to get the same color change.
Click here to download our ozone therapy guide
The filter in EBOO is not used in the way that is required for a dialysis treatment. EBOO repurposes dialysis machines with a different filter in order to diffuse ozone gas into the blood.
In a normal dialysis setup, the blood flows through these tiny straws, pulling out the clean elements of the blood and reinfusing them back into the patient.
In EBOO therapy, rather than putting the blood through the straws, they put the ozone through them so it can diffuse through the blood. So, the blood never goes through the filtration process the dialysis filter is designed for.
The reason this is important to understand is because businesses and doctors market EBOO as a “blood purification process” when it is not. If someone is in need of dialysis, they should get a dialysis treatment because EBOO won’t do a filtration of the blood.
Below is how a normal dialysis treatment works
In EBOO, the blood flows where the dialysate normally would. Then the ozone is infused via the tiny straws, where the blood would normally go. No filtration mechanism is actually happening. Rather, the filter has been repurposed and no longer serves its original function.
Some blood is discarded into a bucket during the treatment. This is usually overoxidized blood cells or heavy parts of the blood that can’t be forced through and back into the body.
If you’re a patient, you don’t really need to understand this portion beyond the fact that it’s not filtering your blood. However, if you’re a practitioner or just interested, you can attend our training for a more detailed explanation.
During EBOO therapy, only 1% of the gas is ozone. The other 99% is oxygen. Therefore, a large blood volume is directly oxygenated.
There is potentially a benefit to oxygenating all the blood in the body but it is relatively unknown.
Hyperbaric oxygen done with hard-cased enclosures going up to 3 atmospheres is also a great way to noninvasively oxygenate your system. Hyperbaric oxygen does not have all the same benefits as ozone therapy but will force oxygen into the blood, plasma, joints, and other parts of the body. There is a growing body of literature on the antimicrobial, anti-inflammatory, immunomodulatory, and even anti-aging benefits of hyperbaric oxygen therapy. Some of these might be applicable to EBOO.
EBOO therapy is a safe therapy when done correctly under a knowledgeable practitioner and with the appropriate equipment.
While EBOO and IV ozone therapy in general is very safe, EBOO may be the riskier ozone therapy procedure as it involves a greater blood volume being outside your body. Therefore, it’s crucial to choose the right medical supervision for your treatment.
The practitioner should be particularly careful about the following:
To qualify for EBOO:
While EBOO is a powerful therapeutic technique offering substantial benefits in treating various medical conditions, like all medical treatments, it has potential side effects. Understanding these is crucial for maximizing the therapy’s benefits while minimizing risks. Here are the primary side effects associated with EBOO:
Because EBOO involves blood circulation outside the body, there's a risk of blood coagulating in the tubing or machine. To prevent this, anticoagulants are used during the procedure. However, the blood can still clot due to aggravation from the pumps.
The use of anticoagulants such as heparin can lead to bleeding complications, especially if not dosed correctly. Patients with bleeding disorders or those on concurrent anticoagulant therapy are particularly at risk.
Some blood components, such as fats, can cause the tubing to clog. In most cases, these can be fixed with regular flicking of the tubes. However, an expert practitioner will need to determine if it’s necessary to replace the tubes.
EBOO requires blood vessel access, typically through a catheter that may be inserted into a large vein.
This can lead to:
Proper sterile techniques and careful monitoring of the catheter site are essential to minimize these risks.
Click here to download our ozone therapy guide
If ozone is administered at over 75 ug/mL, or if the patient’s blood has certain vulnerabilities, red blood cells can burst (hemolysis), releasing hemoglobin into the blood. When there is too much hemoglobin in the blood, it can lead to complications like acute kidney injury.
This is why it’s crucial to use machines that accurately measure ozone volume, especially for EBOO therapy.
While the controlled oxidative stress induced by ozone is therapeutic, excessive or improperly managed ozone exposure can overwhelm the body's antioxidant defenses.This can lead to cellular damage and exacerbation of oxidative stress-related conditions, potentially affecting cellular function and integrity across various tissues.
Improper handling of the ozone gas or errors in the extracorporeal circuit could introduce air into the bloodstream (embolism).
Air embolisms can be serious, leading to blockages in blood vessels which can cause:
Any procedure involving extracorporeal circulation and repeated vascular access inherently carries a risk of introducing pathogens into the bloodstream.
Infections can range from local site infections to systemic infections, depending on the extent and nature of the contamination.
Rarely, individuals might have allergic or other types of negative reactions to the ozone itself, heparin, or other substances used during the procedure.
These reactions can range from mild itching and rash to severe anaphylaxis, requiring immediate medical intervention.
To minimize these side effects, it is best to start with smaller-scale IV ozone therapy, such as autohemotherapy first, if possible. This will uncover any possible allergic or immune reactions to materials used in both procedures.
In addition, EBOO must be performed under strict medical supervision with adequate patient assessment and preparation. Monitoring during and after the procedure is essential to quickly identify and manage any adverse events.
Additionally, the practitioner should take careful note of symptoms, history, and individual risk factors such as pre-existing conditions, medication use, and overall health status to ensure the safety and effectiveness of the therapy.
Click here to download our ozone therapy guide
Herxheimer reactions refer to adverse reactions to debris from microbes that die from ozone’s antimicrobial effects. It can lead to flu-like symptoms, fatigue, or temporary worsening of the original symptoms before improvement.
To minimize Herxheimer reactions, it’s best to:
Dr. Velio Bocci, the father of ozone therapy, expressed concern in his book about the use of dialysis filters in EBOO [11],
“This [use of ozone resistant materials] is essential to prevent leakage of toxic compounds into the blood and this can happen with dialysis filters”
Another study by Dr. Paolo, the inventor of EBOO, evaluated dialysis filters that are often used in EBOO [12],
“In fact, dialysis filters… are not ozone-resistant and therefore they react with ozone, and they release unwanted chemicals potentially harmful for the patient … On the basis of the present findings, it is hoped that anyone incautiously using dialysis filters for blood extravascular ozonation should correctly use the appropriate device.”
The picture above shows a microscopic look at an EBOO filter after an ozone therapy session. The authors speculated that the dark spots are due to oxidation from the ozone gas and the release of the plastics into the blood.
This same concern has been verified in multiple studies.
What does this mean for you?
Plastic and toxic compounds are going into your blood if the wrong EBOO filter is used.
Here’s an example of a filter similar to what was observed in the studies.
So, what are the appropriate materials to be used during EBOO?
“They are hydrophobic, permeable only to gasses and, unlike dialysis filters, do not form any ultrafiltrate. The exchange of oxygen, ozone and carbon dioxide occurs through the membrane without any bubble formation” - New medical drug
Polypropylene hydrophobic fibers coated in phosphorylcholine
You can look up EBOO clinics on https://aaot.us/. Here are some US-based clinics that offer EBOO therapy.
These centers are renowned for their expertise in ozone therapy and offer state-of-the-art treatment options for a variety of health conditions. It's advisable to contact them directly to inquire about specific treatments, availability, and any prerequisites for scheduling a session.
A typical EBOO ozone therapy session ranges from $1,500 - $3,000, depending on location and type of clinic. Clinics will venture outside of these ranges depending on their business, additions or subtractions to the therapy, and protocol being used.
Generally, it’s advised for medical practitioners to go through formal ozone therapy training prior to getting started with EBOO therapy.
Link to video demonstrating the equipment
List of equipment required for EBOO therapy, most of which will need to be sterile:
There is no research indicating that UBI should be used in EBOO therapy. However, given their overlapping benefits, UBI may synergize with EBOO.
There were studies done by Vasogen that displayed the use of light therapy during a standard dose of ozone in the form of an intramuscular injection – minor autohemotherapy. It was not an IV.
Nonetheless, some practitioners feel that adding light therapeutics is beneficial despite no specific research of combining EBOO and light therapy.
There doesn’t appear to be any safety concern with adding light therapy to ozone therapy.