Pulse oximetry
Pulse oximetry is a noninvasive method for monitoring blood oxygen saturation. Peripheral oxygen saturation readings are typically within 2% accuracy of the more accurate reading of arterial oxygen saturation from arterial blood gas analysis.
A standard pulse oximeter passes two wavelengths of light through tissue to a photodetector. Taking advantage of the pulsate flow of arterial blood, it measures the change in absorbance over the course of a cardiac cycle, allowing it to determine the absorbance due to arterial blood alone, excluding unchanging absorbance due to venous blood, skin, bone, muscle, fat, and, in many cases, nail polish. The two wavelengths measure the quantities of bound and unbound hemoglobin, and from their ratio, the percentage of bound hemoglobin is computed.
The most common approach is transmissive pulse oximetry. In this approach, one side of a thin part of the patient's body, usually a fingertip or earlobe, is illuminated, and the photodetector is on the other side. Fingertips and earlobes have disproportionately high blood flow relative to their size, in order to keep warm, but this will be lacking in hypothermic patients. Other convenient sites include an infant's foot or an unconscious patient's cheek or tongue.
Reflectance pulse oximetry is a less common alternative, placing the photodetector on the same surface as the illumination. This method does not require a thin section of the person's body and therefore may be used almost anywhere on the body, such as the forehead, chest, or feet, but it still has some limitations. Vasodilation and pooling of venous blood in the head due to compromised venous return to the heart can cause a combination of arterial and venous pulsations in the forehead region and lead to spurious SpO2 results. Such conditions occur while undergoing anaesthesia with endotracheal intubation and mechanical ventilation or in patients in the Trendelenburg position.
Medical uses
A pulse oximeter is a medical device that indirectly monitors the oxygen saturation of a patient's blood and changes in blood volume in the skin, producing a photoplethysmogram that may be further processed into [|other measurements]. The pulse oximeter may be incorporated into a multiparameter patient monitor. Most monitors also display the pulse rate. Portable, battery-operated pulse oximeters are also available for transport or home blood-oxygen monitoring.Advantages
Pulse oximetry is particularly convenient for noninvasive continuous measurement of blood oxygen saturation. In contrast, blood gas levels must otherwise be determined in a laboratory on a drawn blood sample. Pulse oximetry is useful in any setting where a patient's oxygenation is unstable, including intensive care, operating, recovery, emergency and hospital ward settings, pilots in unpressurized aircraft, for assessment of any patient's oxygenation, and determining the effectiveness of or need for supplemental oxygen. Although a pulse oximeter is used to monitor oxygenation, it cannot determine the metabolism of oxygen, or the amount of oxygen being used by a patient. For this purpose, it is necessary to also measure carbon dioxide levels. It is possible that it can also be used to detect abnormalities in ventilation. However, the use of a pulse oximeter to detect hypoventilation is impaired with the use of supplemental oxygen, as it is only when patients breathe room air that abnormalities in respiratory function can be detected reliably with its use. Therefore, the routine administration of supplemental oxygen may be unwarranted if the patient is able to maintain adequate oxygenation in room air, since it can result in hypoventilation going undetected.Because of their simplicity of use and the ability to provide continuous and immediate oxygen saturation values, pulse oximeters are of critical importance in emergency medicine and are also very useful for patients with respiratory or cardiac problems, especially COPD, or for diagnosis of some sleep disorders such as apnea and hypopnea. For patients with obstructive sleep apnea, pulse oximetry readings will be in the 70–90% range for much of the time spent attempting to sleep.
Portable battery-operated pulse oximeters are useful for pilots operating in non-pressurized aircraft above or in the U.S. where supplemental oxygen is required. Portable pulse oximeters are also useful for mountain climbers and athletes whose oxygen levels may decrease at high altitudes or with exercise. Some portable pulse oximeters employ software that charts a patient's blood oxygen and pulse, serving as a reminder to check blood oxygen levels.
Connectivity advancements have made it possible for patients to have their blood oxygen saturation continuously monitored without a cabled connection to a hospital monitor, without sacrificing the flow of patient data back to bedside monitors and centralized patient surveillance systems.
For patients with COVID-19, pulse oximetry helps with early detection of silent hypoxia, in which the patients still look and feel comfortable, but their SpO2 is dangerously low. This happens to patients either in the hospital or at home. Low SpO2 may indicate severe COVID-19-related pneumonia, requiring a ventilator.
Safety
Continuous monitoring with pulse oximetry is generally considered safe for most patients for up to 8 hours. However, prolonged use in certain types of patients can cause burns due to the heat emitted by the infrared LED, which reaches up to 43°C. Additionally, pulse oximeters occasionally develop electrical faults which causes them to heat up above this temperature. Patients at greater risk include those with delicate or fragile skin, such as infants, particularly premature infants, and the elderly. Additional risks for injury include lack of pain response where the probe is placed, such as having an insensate limb, or being unconscious or under anesthesia, or having communication difficulties. Patients who are at high risk for injury should have the site of their probe moved frequently, i.e. every hour, whereas patients who are at lower risk should have theirs moved every 2-4 hours.Limitations
Fundamental limitations
Pulse oximetry solely measures hemoglobin saturation, not ventilation and is not a complete measure of respiratory sufficiency. It is not a substitute for blood gases checked in a laboratory, because it gives no indication of base deficit, carbon dioxide levels, blood pH, or bicarbonate concentration. The metabolism of oxygen can readily be measured by monitoring expired CO2, but saturation figures give no information about blood oxygen content. Most of the oxygen in the blood is carried by hemoglobin; in severe anemia, the blood contains less hemoglobin, which despite being saturated cannot carry as much oxygen.Pulse oximetry also is not a complete measure of circulatory oxygen sufficiency. If there is insufficient bloodflow or insufficient hemoglobin in the blood, tissues can suffer hypoxia despite high arterial oxygen saturation.
Since pulse oximetry measures only the percentage of bound hemoglobin, a falsely high or falsely low reading will occur when hemoglobin binds to something other than oxygen:
- Hemoglobin has a higher affinity to carbon monoxide than it does to oxygen. Therefore, in cases of carbon monoxide poisoning, most hemoglobin might be bound not to oxygen but to carbon monoxide. A pulse oximeter would correctly report most hemoglobin to be bound, but nevertheless the patient would be in a state of hypoxemia and subsequently hypoxia.
- Cyanide poisoning gives a high reading because it reduces oxygen extraction from arterial blood. In this case, the reading is not false, as arterial blood oxygen is indeed high early in cyanide poisoning: the patient is not hypoxemic, but is hypoxic.
- Methemoglobinemia characteristically causes pulse oximetry readings in the mid-80s.
- COPD may cause false readings.
Conditions affecting accuracy
Because pulse oximeter devices are calibrated for healthy subjects, their accuracy is poor for critically ill patients and preterm newborns. Erroneously low readings may be caused by hypoperfusion of the extremity being used for monitoring ; incorrect sensor application; highly calloused skin; or movement, especially during hypoperfusion. To ensure accuracy, the sensor should return a steady pulse and/or pulse waveform. Pulse oximetry technologies differ in their abilities to provide accurate data during conditions of motion and low perfusion. Obesity, hypotension, and some hemoglobin variants can reduce the accuracy of the results. Some home pulse oximeters have low sampling rates, which can significantly underestimate dips in blood oxygen levels.The accuracy of pulse oximetry deteriorates considerably for readings below 80%. Research has suggested that error rates in common pulse oximeter devices may be higher for adults with dark skin color, leading to claims of encoding systemic racism in countries with multi-racial populations such as the United States. One of the earliest studies on this topic occurred in 1976, which reported reading errors in dark-skinned patients that reflected lower blood oxygen saturation values. Further studies indicate that while accuracy with dark skin is good at higher, healthy saturation levels, some devices overestimate the saturation at lower levels, which may lead to hypoxia not being detected. A study that reviewed thousands of cases of occult hypoxemia, where patients were found to have oxygen saturation below 88% per arterial blood gas measurement despite pulse oximeter readings indicating 92% to 96% oxygen saturation, found that black patients were three times as likely as white patients to have their low oxygen saturation missed by pulse oximeters. Another research study investigated patients in the hospital with COVID-19 and found that occult hypoxemia occurred in 28.5% of black patients compared to only 17.2% of white patients. There has been research to indicate that black COVID-19 patients were 29% less likely to receive supplemental oxygen in a timely manner and three times more likely to have hypoxemia. A further study, which used a MIMIC-IV critical care dataset of both pulse oximeter readings and oxygen saturation levels detected in blood samples, demonstrated that black, Hispanic, and Asian patients had higher SpO2 readings than white patients for a given blood oxygen saturation level measured in blood samples. As a result, black, Hispanic, and Asian patients also received lower rates of supplemental oxygen than white patients. It is suggested that melanin can interfere with the absorption of light used to measure the level of oxygenated blood, often measured from a person's finger. Further studies and computer simulations show that the increased amounts of melanin found in people with darker skin scatter the photons of light used by the pulse oximeters, decreasing the accuracy of the measurements. As the studies used to calibrate the devices typically oversample people with lighter skin, the parameters for pulse oximeters are set based on information that is not equitably balanced to account for diverse skin colors. This inaccuracy can lead to potentially missing people who need treatment, as pulse oximetry is used for the screening of sleep apnea and other types of sleep-disordered breathing, which in the United States are conditions more prevalent among minorities. This bias is a significant concern, as a 2% decrease is important for respiratory rehabilitation, studies of sleep apnea, and athletes performing physical efforts; it can lead to severe complications for the patient, requiring an external oxygen supply or even hospitalization.
Another concern regarding pulse oximetry bias is that insurance companies and hospital systems increasingly use these numbers to inform their decisions. Pulse oximetry measurements are used to identify candidates for reimbursement. Similarly, pulse oximetry data is being incorporated into algorithms for clinicians. Early Warning Scores, which provide a record for analyzing a patient's clinical status and alerting clinicians if needed, incorporate algorithms with pulse oximetry information and can result in misinformed patient records.