Pulse Oximetry - UpToDate
Pulse Oximetry - UpToDate
Pulse Oximetry - UpToDate
Pulse oximetry
Author: C Crawford Mechem, MD, FACEP
Section Editor: Polly E Parsons, MD
Deputy Editor: Geraldine Finlay, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2023. | This topic last updated: Mar 04, 2022.
INTRODUCTION
interference from tissue and pulsatile flow [5]. This modification involves measuring
absorbance at two different wavelengths, one to detect oxyhemoglobin and the other to
detect deoxyhemoglobin [1].
● Emitters – Deoxyhemoglobin absorbs light maximally in the red band of the spectrum
(600 to 750 nm), and oxyhemoglobin absorbs maximally in the infrared band (850 to
1000 nm) [1]. Thus, the emitters emit light at 660 nm and 940 nm for optimal
detection of these two substances.
● Detector – The detector (also known as sensor) detects the absorbance of light from
exposed tissue. The values are processed and a saturation determined. (See
'Calibration and calculation' below.)
In general, detectors and emitters are positioned facing each other through
interposed tissue ( picture 1) [6]. Probes are most frequently placed on the anterior
and posterior aspect of fingers, toes, or ear lobes [7]. The nasal ala is another option
[8]. In infants, probes may also be placed on the palms, feet, arms, cheeks, tongue,
penis, nose, or nasal septum [9]. Forehead probes have the emitter and detector
adjacent to each other so that saturation is measured from light that is reflected back
from (not through) exposed tissue. These sites are preferentially used since they
contain a high density of vascular tissue.
Although various types of probes are available, none has shown clear superiority over
another [10-13]. When clinicians cannot get a clear reading with one probe, another is
often tried. (See 'Troubleshooting sources of error' below.)
The response time to changes in oxygenation varies but is generally delayed for most
available probes. As an example, some studies have shown that ear probes and forehead
probes respond more quickly to a change than conventional finger probes (eg, 94 versus
100 seconds for desaturation, and 23 versus 29 seconds for increases in saturation) [14,15].
to peripheral SpO2 many pulse oximeters also display pulse rate and relative pulse
amplitude [1,18].
The microprocessors of pulse oximeters are calibrated using reference tables of actual
SaO2 measurements performed using co-oximetry and compiled using data from exposing
healthy volunteers exposed to decreasing fraction of inspired oxygen (FiO2) to yield SaO2
ranging from 100 to 75 percent. Because it would be unethical to intentionally generate
lower saturations in volunteers, values for an SaO2 less than 75 percent are obtained by
extrapolation from these volunteer data. Pulse oximeter manufacturers claim that reported
values between 70 and 100 percent are accurate to within 2 to 3 percent of the true value,
corresponding with FDA standards [19,20]. In practice, the cut-off for acceptable accuracy
is felt by many clinicians to be 80 percent (which usually reflects an arterial oxygen tension
[PaO2] of approximately 50 mmHg at a pH of 7.4), and varies depending on the model of
pulse oximeter used [21].
There are many advantages of pulse oximetry over physical examination and arterial blood
gas measurement:
● Noninvasive – Blood gas analysis by arterial puncture or arterial line sampling was
for many years the only available method of detecting hypoxemia, but this technique
is painful and has potential complications [22]. In contrast, pulse oximetry allows
noninvasive measurement of arterial hemoglobin saturation without the risks
associated with arterial puncture. (See "Arterial blood gases" and "Intra-arterial
catheterization for invasive monitoring: Indications, insertion techniques, and
interpretation".)
● Inability to measure arterial oxygen tension – Since pulse oximetry does not
measure PaO2, overreliance on pulse oximetry can miss detection of clinically
significant hypoxemia in adults but particularly in children [24]. A large decrease in
PaO2 will not produce a significant fall in SaO2 until the steeper portion of the oxygen
hemoglobin dissociation curve is encountered at a PaO2 of approximately 60 to 70
mmHg. This is particularly important in patients receiving supplemental oxygen. As
an example, a fall in PaO2 in such a patient from 140 to 65 mmHg would be required
before a significant decrease in oxygen saturation is detected. Furthermore, pulse
oximetry results are signal-averaged over several seconds. Therefore, the pulse
oximeter may not detect a hypoxemic event for close to a minute after it has occurred
[25,26]. This delay may be of particular significance when the device is being used for
monitoring during intubation.
COMPLICATIONS
Because of the noninvasive aspect of pulse oximetry, local complications are extremely
rare, especially when compared with arterial blood gas monitoring.
Digital injury has been reported on rare occasions in critically ill patients, although it is
more likely that the injury is due to the underlying poor digital perfusion and/or use of
vasopressors [31].
Burns have also been reported in patients undergoing magnetic resonance imaging (MRI),
although this complication can be avoided by temporarily removing the probe during MRI
[9,32]. This complication is believed to result from the generation of electrical skin currents
beneath the pulse oximeter cables, which act as an antenna. Notably, no permanent
adverse effects have been reported. (See "Patient evaluation for metallic or electrical
implants, devices, or foreign bodies before magnetic resonance imaging", section on
'Assessing implants, devices, or foreign bodies for MRI'.)
APPLICATIONS
Pulse oximetry is indicated in any clinical setting where hypoxemia may occur. These
settings include patient monitoring in emergency departments, operating rooms,
emergency medical services (EMS) systems, postoperative recovery areas, endoscopy
suites, sleep and exercise laboratories, oral surgery suites, cardiac catheterization suites,
facilities that perform conscious sedation, labor and delivery wards, inter-facility patient
transfer units, altitude facilities, aerospace medicine facilities, and patients' homes
[6,27,33-41]:
Despite its widespread use, the value of oximetry has been poorly studied with no trials
showing a convincing benefit on clinically meaningful outcome (eg, mortality, myocardial
infarction, resource allocation [26]). Nonetheless, examples where routine use of pulse
oximetry has some value include the following:
● In a pediatric intensive care unit (ICU), using pulse oximetry decreases the number of
blood gases obtained and limits the duration of oxygen therapy, without jeopardizing
patient outcome [35]. (See "Acute severe asthma exacerbations in children younger
than 12 years: Intensive care unit management" and "Overview of neonatal
respiratory distress and disorders of transition".)
● In postoperative patients, routine pulse oximetry has been shown to decrease the
need for rapid response team activation and transfer to the ICU [45]. In a randomized
trial of 20,000 perioperative patients pulse oximetry use was associated with lower
rates of hypoxemia when compared with patients in whom oximetry was not used
(0.4 versus 8 percent) [39]. (See "Overview of post-anesthetic care for adult patients".)
● In newborns, pulse oximetry has value as a routine outpatient screen for congenital
heart disease. (See "Newborn screening for critical congenital heart disease using
pulse oximetry".)
● The medical response to the COVID-19 pandemic has included new applications for
pulse oximetry. Because of increasingly limited healthcare resources, including
hospital beds, many COVID positive patients are being managed at home. Patients
can remain relatively asymptomatic despite disease progression with hypoxemia,
placing them at risk for rapid deterioration. Pulse oximetry is being used both to
assist in deciding which infected patients can be safely discharged from the
emergency department and which patients being managed at home should present
to the emergency department for further assessment and possible admission. A
pulse oximetry reading in the 92 to 96 percent range is often used as an indication of
adequate oxygenation in these patients. However, given the rapidly evolving
understanding of the infection’s complex pathophysiology, pulse oximetry results
should be considered in the broader context of the patient’s overall clinical condition
[46]. Novel use of home pulse oximetry monitoring in COVID-19 patients discharged
from the emergency department identifies need for hospitalization [47,48].
for analysis. (See "Arterial blood gases" and "Venous blood gases and other alternatives to
arterial blood gases" and 'Advantages and disadvantages' above and 'Calibration and
calculation' above and 'Troubleshooting sources of error' below.)
Important differences between arterial saturation and arterial oxygen tension should be
noted:
● SpO2 and SaO2 reflect the main mechanism by which oxygen is carried to peripheral
tissue (ie, 98 percent of arterial oxygen content is normally carried by hemoglobin).
● The PaO2 only measures the proportion that is dissolved in plasma (ie, the remaining
2 percent), representing the minor mechanism for oxygen transport. Although
arterial blood gas analysis can measure arterial saturation, the PaO2 is commonly
used to estimate arterial oxyhemoglobin saturation and oxygen content because the
dissolved and hemoglobin-bound oxygen pools are in equilibrium. However, changes
in pH, temperature, and the concentration of 2,3-diphosphoglycerate alter the PO2-
SaO2 relationship, and may result in misleading calculations of oxyhemoglobin
saturation ( figure 3). (See "Structure and function of normal hemoglobins" and
"Measures of oxygenation and mechanisms of hypoxemia".)
Similarly, there is no optimal level of oxygen saturation above which tissue hyperoxia
occurs since hyperoxia cannot be assessed with oximetry or arterial blood gas analysis.
Thus, clinicians should titrate oxygen according to the specific etiology, while attempting to
avoid any theoretical potential for tissue hypoxia. As examples:
Pulse oximetry is subject to artifactual and patient-related sources of error. The best
defense against error is a high index of suspicion. If a saturation reading is in doubt, a
health care worker can perform a quick quality assurance test by putting the probe on his
or her own finger as near as possible to the original patient site [17]. This ensures that
abnormal readings are not due to equipment error. The clinician should then investigate
other potential sources of error, most of which are easily resolved ( table 1).
● Malposition or poor attachment to the skin can result in either a falsely elevated or
depressed reading (light from only one of the two light-emitting diodes passes
through the tissue) [55].
A similar problem can occur in infants and small children because the small size of
fingers or other tissues may result in differences in the path length of one light
source compared to the other.
Many of these problems can be resolved by ensuring the probe is properly attached
with the light sources and detectors opposite each other in a nontangential path (eg,
switch to a separate digit or use a different probe such as an ear or forehead probe)
[56].
● Placement of the sensor on the same extremity as a blood pressure cuff or arterial
line can cause erroneous readings and should be avoided [57].
Motion or noise artifact — A poor signal-to-noise ratio will cause signal artifact and
falsely lower oximetry readings [4,18,58]. This most commonly results from motion due to
shivering, seizure activity, pressure on the sensor, or transport of the patient by ambulance
or helicopter. The waveform will typically appear erratic and lose its normal shape. Newer
pulse oximeters appear to be less influenced by motion artifact [59,60].
Hypoperfusion — Pulse oximetry readings can be falsely low due to signal failure in the
setting of hemodynamic instability or poor limb perfusion from extremity elevation,
vasoconstriction, or peripheral vascular disease [49,53,61].
In adults, the accuracy of standard pulse oximeters decreases dramatically when systolic
blood pressure falls below 80 mmHg, generally resulting in underestimation of the actual
arterial oxygen saturation [62]. Both falsely low and falsely elevated levels have been
reported in septic patients [63,64]. Repositioning the probe or using an alternate site may
help.
There are conflicting data regarding superiority of forehead versus finger probes in
hypoperfused states such that switching from one to another type of probe is appropriate
when an inadequate tracing due to hypoperfusion is suspected [10,11,13]. When in doubt
an arterial blood gas should be drawn.
Best illustrating the impact of skin pigmentation is a multicenter study that compared
pulse oximetry with arterial blood gas analysis in over 10,000 adult inpatients [74]. Values
in Black individuals were compared with light-skinned individuals. In two separate cohorts,
pulse oximetry ranging between 92 and 96 percent overestimated oxygen saturation as
measured by ABG in 12 to 17 percent of Black individuals compared with 4 to 6 percent of
White individuals. Given the importance placed on the use of pulse-oximetry to risk-stratify
COVID patients, the US Food and Drug Administration and the Centers for Disease Control
and Prevention highlighted the concerns raised in that study [79,80].
In other studies, an increased incidence of both signal detection errors and readings that
were erroneously elevated by 4 percent or more have been described in Black patients
[9,71]. A study from Singapore compared pulse oximetry readings with ABG-determined
oxygen saturation in Chinese, Malay, and Indian patients in an intensive care unit. Pulse
oximetry readings overestimated oxygen saturation in patients with darker skin
pigmentation [81]. Similarly, in another study there was greater variability in oxygen
saturation levels in patients who self-identified as Black, followed by Hispanic, Asian, and
White [82]. Moreover, patients with “hidden” hypoxemia subsequently experienced higher
organ dysfunction scores and in-hospital mortality.
However, a study of infants with cyanotic heart disease and baseline hypoxemia did not
show a bias in pulse oximetry measurements in dark-pigmented versus light-pigmented
patients [73].
Sickle hemoglobin — Patients with sickle cell disease are at risk of hypoxemia caused by
a number of pulmonary complications, which are discussed separately. (See "Overview of
the pulmonary complications of sickle cell disease".).
Severe anemia — In vitro and animal studies suggest that pulse oximetry readings may
be affected by profoundly decreased hemoglobin concentration [27]. In vivo, low
hemoglobin concentrations appear to cause falsely low readings when the SaO2 is below
80 percent [9]. However, this effect is not clinically significant until the hemoglobin level is
less than 5 g/dL [53,98].
Venous pulsations may occur when an adhesive probe is too tight around the finger
resulting in falsely low readings. Similarly, pulsations can also occur when the probe is in a
dependent position (eg, forehead probe in a patient in the Trendelenburg position) and
rarely in patients with arteriovenous shunting.
When venous pulsations are suspected, loosening the probe, repositioning the probe or
the patient, and/or drawing an arterial blood gas should be attempted.
Nail polish — The use of nail polish can potentially affect pulse oximeter readings if the
polish absorbs light at 660 nm and/or 940 nm [4,101-104]. A small study of volunteers
wearing black, green, and blue nail polish revealed a drop in SaO2 of 3, 5, and 6 percent,
respectively [17]. Red nail polish does not appear to have an effect on pulse oximetry
readings. Newer devices appear to be less affected with the greatest reductions in SpO2
found in those with black or brown polish not exceeding 2 percent [105].
The problem may be avoided by mounting the probe on the finger sideways, rather than in
a dorsal-ventral orientation (eg, single measurements in an outpatient facility) or removing
the nail polish (eg, patients in a critical care unit) [9]. An alternate site can also be used (eg,
earlobe, forehead, or toe provided similar nail polish is not on the toe).
Artificial acrylic nails may also affect the accuracy of pulse oximetry readings, depending
on the device used. This problem can be solved by mounting the probe sideways, using an
alternative site, or removing one of the acrylic nails by soaking in acetone [106].
Others — All the causes of an inadequate signal such as motion artifact, poor probe
positioning, hypoperfusion, and hypothermia may result in low readings. (See 'Inadequate
waveform' above.)
Fetal hemoglobin gives pulse oximetry readings clinically indistinguishable from those of
adult hemoglobin such that pulse oximetry is as reliable in newborns as in adult SpO2 [18].
CO-OXIMETRY
Abnormal hemoglobins or hemoglobin variants may interfere with pulse oximetry if their
absorption properties are similar to those of oxyhemoglobin or deoxyhemoglobin.
Conventional pulse oximeters which use two light emitting diodes can only detect these
two substances and cannot detect abnormal forms of hemoglobins. Multi-wavelength co-
oximeters use several, rather than two, wavelengths of light (eg, four to eight) to detect
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4/16/23, 11:01 PM Pulse oximetry - UpToDate
● Pulse oximetry is a rapid, noninvasive tool that can provide continuous assessment of
oxygenation and is associated with few complications. However, it cannot detect
hyperoxemia or arterial oxygen or carbon dioxide tension. (See 'Advantages and
disadvantages' above and 'Complications' above.)
● Pulse oximetry is indicated in any setting where hypoxemia may occur. It provides
accurate assessment of tissue oxygenation in most patients. However, clinicians
should pay attention to trends on oximetry, and when treating patients with
supplemental oxygen for hypoxemia, clinicians should target levels that are desirable
for the specific etiology, while simultaneously avoiding oxygen toxicity. The clinician
should be aware of the limitations and errors associated with pulse oximetry and
have a low threshold to obtain arterial blood for analysis. (See 'Applications' above
and 'Interpreting the results' above.)
● Pulse oximetry is subject to artifactual and patient-related sources of error. The best
defense against error is a high index of suspicion. If a saturation reading is in doubt,
equipment error can be quickly ruled out by putting the probe on the healthcare
worker’s own finger. Once assured that equipment is functioning, the clinician should
investigate for other potential sources of error, most of which are readily identified
and resolvable ( table 1). (See 'Troubleshooting sources of error' above.)
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