Extracorporeal blood oxygenation and ozonation (EBOO), also called ozone dialysis or recirculatory hemoperfusion (RHP), has become one of the most talked-about ways to deliver ozone systemically.

How EBOO works

Venous blood is drawn from one arm by a peristaltic pump, passed through a hollow-fiber dialyzer, and returned to the other arm. An oxygen–ozone gas mixture flows countercurrent on the opposite side of the membrane, so ozone diffuses into the blood across the fibers rather than being bubbled through it. Ozone reacts within seconds with plasma antioxidants, lipids and proteins, generating the lipid oxidation products and reactive oxygen species believed to act as the downstream biological messengers. Because blood flows continuously for about an hour, EBOO exposes far more blood to ozone than major autohemotherapy (MAH) or multi-pass hyperbaric protocols.

Dosing: two very different traditions

Practitioners often quote EBOO “doses” without realizing the literature describes two protocols that differ by more than an order of magnitude.

 Original Italian EBOO (Di Paolo & Bocci)Some individuals are doing in the (U.S.)
Ozone concentration3–4 µg/mL20–40 µg/mL typical; ~30 µg/mL common ceiling (up to 50 reported)
Blood flow75–80 mL/min (17G access)≥50 mL/min with 18G-20G
Gas flow1 L/min1 L/min
Session length60 min, up to 4.8 L blood60 min, up to 3-5 L

HARD SAFETY MEASURES

  • Start low and titrate. Because we don’t truly understand the patients’ hormesis balance clinicians should always begin a new patient low at 3.5 mcg/ml for 10 minutes while the remaining therapy is just with oxygen. 
  • Use a low pump speed. For optimal safety pump speed should NOT exceed 50 ml/min
  • Ideal blood volume treated.  For safety sticking to 3 L or less
  • Measure don’t assume. Verify generator output with an ozone analyzer/photometer and route spent gas through a destruct unit.
  • Understand that the components used are ozone resistant. Extremely important to prevent infusions of toxic contaminants.
  • ONLY use machines built with medical grade components. Quality control in the industry continues to shock me.  As there are machines using components from overseas or built overseas which are none medical grade peristaltic pump OR using a pool ozone generator in their machines.
  • Standard ozone precautions apply: G6PD status, pregnancy, active bleeding or thrombocytopenia, PEG allergy and any contraindication to heparin (including a history of HIT).
  • Must have patient evaluation and proper labs: Quantitative G6PD, CBC, CMP, GGT, LDH and strongly consider in select patients coagulation studies.

Preventing hemolysis

In practice, lysis during EBOO is more often mechanical than chemical. The usual culprits are high pump speeds through small-gauge access, excessive negative pressure on the draw line, kinked or collapsed tubing, clotting inside an under-anticoagulated dialyzer, and fiber breaches that let gas and blood mix directly, too high dosage for that individual patient or improper dialyzer used.

Choosing the dialyzer: protein adsorption and membrane chemistry

When blood meets any artificial membrane, plasma proteins adsorb within minutes. In dialysis studies the adsorbed layer forms mostly in the first 15 minutes, narrows effective pore size, and is disproportionately rich in fibrinogen (rising from under 4% of the protein in solution to 12–18% of the adsorbed layer), which drives coagulation and complement activation. This can lead to unnecessary immune reactions that could present like a “Horkheimer reaction” but is causing over stimulation/harm.  Some patients will experience a flare of MCAS or histamine. In EBOO there is a second problem: ozone crossing the membrane meets that protein layer first, oxidizing it in place, reducing gas-transfer efficiency and potentially increasing clotting in the fibers.

PVP is the weak link in most synthetic dialyzers. Nearly all polysulfone (PSf) and polyethersulfone (PES) dialyzers rely on polyvinylpyrrolidone (PVP) to make the blood-contacting surface hydrophilic and protein-repellent. Membrane studies show the PES backbone resists ozone well, but the PVP additive is substantially oxidized and may cross-link. The likely consequence (extrapolated from membrane science, not yet tested head-to-head in EBOO) is that a PVP-dependent surface loses its anti-fouling properties over an hour of continuous ozone exposure. This causes infusion of PVP and microplastic components.

Cellulose triacetate (CTA) is the published reference membrane. The most detailed U.S. ozone-dialysis protocol used a 1.5 m² CTA dialyzer. CTA contains no PVP, so there is no hydrophilic additive for ozone to strip.

Regulatory note

In the United States, 21 CFR 801.415 states that FDA regards ozone as a toxic gas with no known useful medical application, and dialyzers are cleared for hemodialysis, not ozone delivery. EBOO is therefore an off-label practice that should be performed only by trained, licensed clinicians within their state scope of practice, with documented informed consent. This article is educational and is not a treatment protocol or a claim of efficacy for any condition.

Author: Dr. Brenden Cochran, NMD, FAAO

References

  1. Di Paolo N, Bocci V, Garosi G, et al. Extracorporeal blood oxygenation and ozonation (EBOO) in man: preliminary report. Int J Artif Organs. 2000;23:131–141.
  2. Di Paolo N, Gaggiotti E, Galli F. Extracorporeal blood oxygenation and ozonation: clinical and biological implications of ozone therapy. Redox Rep. 2005;10:121–130.
  3. Di Paolo N, Bocci V, Salvo DP, et al. EBOO: a controlled trial in patients with peripheral artery disease. Int J Artif Organs. 2005;28:1039–1050.
  4. Rowen RJ, Grabovac S, Su TB. Ozone dialysis delivers three or more times the ozone than other forms of ozone blood treatment. Med Gas Res. 2023;13(2):67–71.
  5. Bocci V. Oxygen-Ozone Therapy: A Critical Evaluation. Springer; 2002.
  6. Competitive adsorption of human serum proteins on PES hemodialysis membranes. Sci Rep. 2023;13:1692.
  7. Development and investigation of a new polysulfone dialyzer with increased membrane hydrophilicity. Membranes. 2025;15(5):132.
  8. Ozone compatibility with polymer nanofiltration membranes. J Membr Sci. 2020.
  9. Takatsuji R, et al. Flexible inner surface of polysulfone membranes prevents platelet adhesive protein adsorption. Int J Artif Organs. 2024.