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Pulseoximetry
FromWikipedia,thefreeencyclopedia

Pulseoximetryisanoninvasivemethodformonitoringaperson's
oxygensaturation(SO2).ItsreadingofSpO2(peripheraloxygen
saturation)isnotalwaysidenticaltothereadingofSaO2(arterial
oxygensaturation)fromarterialbloodgasanalysis,butthetwoare
reliablyenoughcorrelatedthatthesafe,convenient,noninvasive,
inexpensivepulseoximetrymethodisvaluableformeasuring
oxygensaturationinclinicaluse.

Awristmountedremotesensorpulse
oximeterwithplethysmogram.

Initsmostcommon(transmissive)applicationmode,asensor
deviceisplacedonathinpartofthepatient'sbody,usuallya
fingertiporearlobe,orinthecaseofaninfant,acrossafoot.Thedevicepassestwowavelengthsoflight
throughthebodyparttoaphotodetector.Itmeasuresthechangingabsorbanceateachofthewavelengths,
allowingittodeterminetheabsorbancesduetothepulsingarterialbloodalone,excludingvenousblood,
skin,bone,muscle,fat,and(inmostcases)nailpolish.[1]

Reflectancepulseoximetrymaybeusedasanalternativetotransmissivepulseoximeterydescribedabove.
Thismethoddoesnotrequireathinsectionoftheperson'sbodyandisthereforewellsuitedtomore
universalapplicationsuchasthefeet,foreheadandchest,butitalsohassomelimitations.Vasodilationand
poolingofvenousbloodintheheadduetocompromisedvenousreturntotheheart,asoccurswith
congenitalcyanoticheartdiseasepatients,orinpatientsintheTrendelenburgposition,cancausea
combinationofarterialandvenouspulsationsintheforeheadregionandleadtospuriousSpO2results.[2]

Contents
1 History
2 Function
3 Indication
3.1 Advantages
3.2 Limitations
3.3 Increasingusage
4 Plethvariabilityindex
5 Seealso
6 References
7 Externallinks

History

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In1935,KarlMatthes(Germanphysician19051962)developedthefirst2wavelengthearO2saturation
meterwithredandgreenfilters(laterswitchedtoredandinfraredfilters).Hismeterwasthefirstdeviceto
measureO2saturation.[3]
TheoriginaloximeterwasmadebyGlennAllanMillikaninthe1940s.[4]In1949Woodaddedapressure
capsuletosqueezebloodoutoftheearsoastoobtainanabsoluteO2saturationvaluewhenbloodwas
readmitted.Theconceptissimilartotoday'sconventionalpulseoximetry,butwasdifficulttoimplement
becauseofunstablephotocellsandlightsourcesthemethodisnotnowusedclinically.In1964Shaw
assembledthefirstabsolutereadingearoximeterbyusingeightwavelengthsoflight.Itwas
commercializedbyHewlettPackardbutitsusewaslimitedtopulmonaryfunctionsandsleeplaboratories
becauseofcostandsize.
Pulseoximetrywasdevelopedin1972,byTakuoAoyagiandMichioKishi,bioengineers,atNihonKohden
usingtheratioofredtoinfraredlightabsorptionofpulsatingcomponentsatthemeasuringsite.Susumu
Nakajima,asurgeon,andhisassociatesfirsttestedthedeviceinpatients,reportingitin1975.[5]Itwas
commercializedbyBioxin1981andNellcorin1983.Bioxwasfoundedin1979,andintroducedthefirst
pulseoximetertocommercialdistributionin1981.Bioxinitiallyfocusedonrespiratorycare,butwhenthe
companydiscoveredthattheirpulseoximeterswerebeingusedinoperatingrooms/theatrestomonitor
oxygenlevels,Bioxexpandeditsmarketingresourcestofocusonoperatingroomsinlate1982.A
competitor,Nellcor(nowpartofCovidien,Ltd.),begantocompetewithBioxfortheU.S.operatingroom
marketin1983.Priortotheintroductionofpulseoximetry,apatient'soxygenationcouldonlybe
determinedbyarterialbloodgas,asinglepointmeasurementthattakesseveralminutesforsample
collectionandprocessingbyalaboratory.Intheabsenceofoxygenation,damagetothebrainstartswithin5
minuteswithbraindeathensuingwithinanother1015minutes.Theworldwidemarketforpulseoximetry
isoverabillionUSdollars.Withtheintroductionofpulseoximetry,anoninvasive,continuousmeasureof
patient'soxygenationwaspossible,revolutionizingthepracticeofanesthesiaandgreatlyimprovingpatient
safety.Priortoitsintroduction,studiesinanesthesiajournalsestimatedU.S.patientmortalityasa
consequenceofundetectedhypoxemiaat2,000to10,000deathsperyear,withnoknownestimateof
patientmorbidity.
By1987,thestandardofcarefortheadministrationofageneralanestheticintheU.S.includedpulse
oximetry.Fromtheoperatingroom,theuseofpulseoximetryrapidlyspreadthroughoutthehospital,firstto
therecoveryroom,andthenintothevariousintensivecareunits.Pulseoximetrywasofparticularvaluein
theneonatalunitwherethepatientsdonotthrivewithinadequateoxygenation,buttoomuchoxygenand
fluctuationsinoxygenconcentrationcanleadtovisionimpairmentorblindnessfromretinopathyof
prematurity(ROP).Furthermore,obtaininganarterialbloodgasfromaneonatalpatientispainfultothe
patientandamajorcauseofneonatalanemia.[6]Motionartifactcanbeasignificantlimitationtopulse
oximetrymonitoringresultinginfrequentfalsealarmsandlossofdata.Thereasonforthisisthatduring
motionandlowperipheralperfusion,manypulseoximeterscannotdistinguishbetweenpulsatingarterial
bloodandmovingvenousblood,leadingtounderestimationofoxygensaturation.Earlystudiesofpulse
oximetryperformanceduringsubjectmotionmadeclearthevulnerabilitiesofconventionalpulseoximetry
technologiestomotionartifact.[7][8]In1995,MasimointroducedSignalExtractionTechnology(SET)that
couldmeasureaccuratelyduringpatientmotionandlowperfusionbyseparatingthearterialsignalfromthe
venousandothersignals.Sincethen,pulseoximetrymanufacturershavedevelopednewalgorithmsto

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reducesomefalsealarmsduringmotion[9]suchasextendingaveragingtimesorfreezingvaluesonthe
screen,buttheydonotclaimtomeasurechangingconditionsduringmotionandlowperfusion.So,there
arestillimportantdifferencesinperformanceofpulseoximetersduringchallengingconditions.[10]
In2004,ajuryfoundthatNellcorinfringedseveralMasimopatentsrelatedtomeasurethroughmotionand
lowperfusionsignalprocessingtechnology.In2005,theappellatecourtaffirmedtheinfringementfindings
againstNellcor,andinstructedtheDistrictCourttoenterapermanentinjunctionagainstNellcorspulse
oximeters(e.g.,N395,N595)thatwerefoundtoinfringe.InJanuary2006,MasimoandNellcorentered
intoasettlementagreement,whereNellcor,amongotherthings,agreedtodiscontinueshipmentofthepulse
oximetersthatwerefoundtoinfringeMasimospatents.
Publishedpapershavecomparedsignalextractiontechnologytootherpulseoximetrytechnologiesand
havedemonstratedconsistentfavorableresultsforsignalextractiontechnology.[11][12][13]Signalextraction
technologypulseoximetryperformancehasalsobeenshowntotranslateintohelpingcliniciansimprove
patientoutcomes.Inonestudy,retinopathyofprematurity(eyedamage)wasreducedby58%inverylow
birthweightneonatesatacenterusingsignalextractiontechnology,whiletherewasnodecreasein
retinopathyofprematurityatanothercenterwiththesamecliniciansusingthesameprotocolbutwithnon
signalextractiontechnology.[14]Otherstudieshaveshownthatsignalextractiontechnologypulseoximetry
resultsinfewerarterialbloodgasmeasurements,fasteroxygenweaningtime,lowersensorutilization,and
lowerlengthofstay.[15]Themeasurethroughmotionandlowperfusioncapabilitiesithasalsoallowitto
beusedinpreviouslyunmonitoredareassuchasthegeneralfloor,wherefalsealarmshaveplagued
conventionalpulseoximetry.Asevidenceofthis,alandmarkstudywaspublishedin2010showing
cliniciansusingsignalextractiontechnologypulseoximetryonthegeneralfloorwereabletodecreaserapid
responseteamactivations,ICUtransfers,andICUdays.[16]
In2011,anexpertworkgrouprecommendednewbornscreeningwithpulseoximetrytoincreasethe
detectionofcriticalcongenitalheartdisease(CCHD).[17]TheCCHDworkgroupcitedtheresultsoftwo
large,prospectivestudiesof59,876subjectsthatexclusivelyusedsignalextractiontechnologytoincrease
theidentificationofCCHDwithminimalfalsepositives.[18][19]TheCCHDworkgrouprecommended
newbornscreeningbeperformedwithmotiontolerantpulseoximetrythathasalsobeenvalidatedinlow
perfusionconditions.In2011,theUSSecretaryofHealthandHumanServicesaddedpulseoximetrytothe
recommendeduniformscreeningpanel.[20]Beforetheevidenceforscreeningusingsignalextraction
technology,lessthan1%ofnewbornsintheUnitedStateswerescreened.Today,TheNewbornFoundation
hasdocumentednearuniversalscreeningintheUnitedStatesandinternationalscreeningisrapidly
expanding.[21]In2014,athirdlargestudyof122,738newbornsthatalsoexclusivelyusedsignalextraction
technologyshowedsimilar,positiveresultsasthefirsttwolargestudies.[22]
Highresolutionpulseoximetry(HRPO)hasbeendevelopedforinhomesleepapneascreeningandtesting
inpatientsforwhomitisimpracticaltoperformpolysomnography.[23][24][25]Itstoresandrecordsboth
pulserateandSpO2in1secondintervalsandhasbeenshowninonestudytohelptodetectsleep
disorderedbreathinginsurgicalpatients.[26]
In1995Masimointroducedperfusionindex,quantifyingtheamplitudeoftheperipheralplethysmograph
waveform.Perfusionindexhasbeenshowntohelpclinicianspredictillnessseverityandearlyadverse
respiratoryoutcomesinneonates,[27][28][29]predictlowsuperiorvenacavaflowinverylowbirthweight
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infants,[30]provideanearlyindicatorofsympathectomyafterepiduralanesthesia,[31]andimprovedetection
ofcriticalcongenitalheartdiseaseinnewborns.[32]
In2007,Masimointroducedthefirstmeasurementoftheplethvariabilityindex(PVI),whichmultiple
clinicalstudieshaveshownprovidesanewmethodforautomatic,noninvasiveassessmentofapatient's
abilitytorespondtofluidadministration.[33][34][35]Appropriatefluidlevelsarevitaltoreducing
postoperativerisksandimprovingpatientoutcomes:fluidvolumesthataretoolow(underhydration)ortoo
high(overhydration)havebeenshowntodecreasewoundhealingandincreasetheriskofinfectionor
cardiaccomplications.[36]Recently,theNationalHealthServiceintheUnitedKingdomandtheFrench
AnesthesiaandCriticalCareSocietylistedPVImonitoringaspartoftheirsuggestedstrategiesforintra
operativefluidmanagement.[37][38]

Function
Abloodoxygenmonitordisplaysthepercentageof
bloodthatisloadedwithoxygen.Morespecifically,it
measureswhatpercentageofhemoglobin,theproteinin
bloodthatcarriesoxygen,isloaded.Acceptablenormal
rangesforpatientswithoutpulmonarypathologyare
from95to99percent.Forapatientbreathingroomair
atornearsealevel,anestimateofarterialpO2canbe
madefromthebloodoxygenmonitor"saturationof
peripheraloxygen"(SpO2)reading.
Atypicalpulseoximeterutilizesanelectronicprocessor
andapairofsmalllightemittingdiodes(LEDs)facing
Absorptionspectraofoxygenatedhemoglobin
aphotodiodethroughatranslucentpartofthepatient's
(HbO2)anddeoxygenatedhemoglobin(Hb)forred
body,usuallyafingertiporanearlobe.OneLEDisred,
andinfraredwavelengths
withwavelengthof660nm,andtheotherisinfrared
withawavelengthof940nm.Absorptionoflightat
thesewavelengthsdifferssignificantlybetweenbloodloadedwithoxygenandbloodlackingoxygen.
Oxygenatedhemoglobinabsorbsmoreinfraredlightandallowsmoreredlighttopassthrough.
Deoxygenatedhemoglobinallowsmoreinfraredlighttopassthroughandabsorbsmoreredlight.The
LEDssequencethroughtheircycleofoneon,thentheother,thenbothoffaboutthirtytimespersecond
whichallowsthephotodiodetorespondtotheredandinfraredlightseparatelyandalsoadjustforthe
ambientlightbaseline.[39]Theamountoflightthatistransmitted(inotherwords,thatisnotabsorbed)is
measured,andseparatenormalizedsignalsareproducedforeachwavelength.Thesesignalsfluctuatein
timebecausetheamountofarterialbloodthatispresentincreases(literallypulses)witheachheartbeat.By
subtractingtheminimumtransmittedlightfromthepeaktransmittedlightineachwavelength,theeffectsof
othertissuesiscorrectedfor.[40]Theratiooftheredlightmeasurementtotheinfraredlightmeasurementis
thencalculatedbytheprocessor(whichrepresentstheratioofoxygenatedhemoglobintodeoxygenated
hemoglobin),andthisratioisthenconvertedtoSpO2bytheprocessorviaalookuptable[40]basedonthe
BeerLambertlaw.[39]

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Indication
Apulseoximeterisamedicaldevicethatindirectlymonitorsthe
oxygensaturationofapatient'sblood(asopposedtomeasuring
oxygensaturationdirectlythroughabloodsample)andchangesin
bloodvolumeintheskin,producingaphotoplethysmogram.The
pulseoximetermaybeincorporatedintoamultiparameterpatient
monitor.Mostmonitorsalsodisplaythepulserate.Portable,battery
operatedpulseoximetersarealsoavailablefortransportorhome
bloodoxygenmonitoring.

Advantages

Apulseoximeterprobeappliedtoa
person'sfinger

Pulseoximetryisparticularlyconvenientfornoninvasive
continuousmeasurementofbloodoxygensaturation.Incontrast,
bloodgaslevelsmustotherwisebedeterminedinalaboratoryonadrawnbloodsample.Pulseoximetryis
usefulinanysettingwhereapatient'soxygenationisunstable,includingintensivecare,operating,recovery,
emergencyandhospitalwardsettings,pilotsinunpressurizedaircraft,forassessmentofanypatient's
oxygenation,anddeterminingtheeffectivenessoforneedforsupplementaloxygen.Althoughapulse
oximeterisusedtomonitoroxygenation,itcannotdeterminethemetabolismofoxygen,ortheamountof
oxygenbeingusedbyapatient.Forthispurpose,itisnecessarytoalsomeasurecarbondioxide(CO2)
levels.Itispossiblethatitcanalsobeusedtodetectabnormalitiesinventilation.However,theuseofa
pulseoximetertodetecthypoventilationisimpairedwiththeuseofsupplementaloxygen,asitisonlywhen
patientsbreatheroomairthatabnormalitiesinrespiratoryfunctioncanbedetectedreliablywithitsuse.
Therefore,theroutineadministrationofsupplementaloxygenmaybeunwarrantedifthepatientisableto
maintainadequateoxygenationinroomair,sinceitcanresultinhypoventilationgoingundetected.[41]
Becauseoftheirsimplicityofuseandtheabilitytoprovidecontinuousandimmediateoxygensaturation
values,pulseoximetersareofcriticalimportanceinemergencymedicineandarealsoveryusefulfor
patientswithrespiratoryorcardiacproblems,especiallyCOPD,orfordiagnosisofsomesleepdisorders
suchasapneaandhypopnea.[42]Portablebatteryoperatedpulseoximetersareusefulforpilotsoperatingin
anonpressurizedaircraftabove10,000feet(12,500feetintheU.S.)[43]wheresupplementaloxygenis
required.Portablepulseoximetersarealsousefulformountainclimbersandathleteswhoseoxygenlevels
maydecreaseathighaltitudesorwithexercise.Someportablepulseoximetersemploysoftwarethatcharts
apatient'sbloodoxygenandpulse,servingasaremindertocheckbloodoxygenlevels.

Limitations
Pulseoximetrymeasuressolelyhemoglobinsaturation,notventilationandisnotacompletemeasureof
respiratorysufficiency.Itisnotasubstituteforbloodgasescheckedinalaboratory,becauseitgivesno
indicationofbasedeficit,carbondioxidelevels,bloodpH,orbicarbonate(HCO3)concentration.The
metabolismofoxygencanbereadilymeasuredbymonitoringexpiredCO2,butsaturationfiguresgiveno
informationaboutbloodoxygencontent.Mostoftheoxygeninthebloodiscarriedbyhemoglobinin
severeanemia,thebloodwillcarrylesstotaloxygen,despitethehemoglobinbeing100%saturated.

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Erroneouslylowreadingsmaybecausedbyhypoperfusionoftheextremitybeingusedformonitoring
(oftenduetoalimbbeingcold,orfromvasoconstrictionsecondarytotheuseofvasopressoragents)
incorrectsensorapplicationhighlycallousedskinormovement(suchasshivering),especiallyduring
hypoperfusion.Toensureaccuracy,thesensorshouldreturnasteadypulseand/orpulsewaveform.Pulse
oximetrytechnologiesdifferintheirabilitiestoprovideaccuratedataduringconditionsofmotionandlow
perfusion.[12][44]
Pulseoximetryalsoisnotacompletemeasureofcirculatorysufficiency.Ifthereisinsufficientbloodflow
orinsufficienthemoglobinintheblood(anemia),tissuescansufferhypoxiadespitehighoxygensaturation
inthebloodthatdoesarrive.In2008,apulseoximeterthatcanalsomeasurehemoglobinlevelsinaddition
tooxygensaturationwasintroducedbyMasimo.Inadditiontothestandardtwowavelengthsoflight,the
devicesusemultipleadditionalwavelengthsoflighttoquantifyhemoglobin.
Sincepulseoximetryonlymeasuresthepercentageofboundhemoglobin,afalselyhighorfalselylow
readingwilloccurwhenhemoglobinbindstosomethingotherthanoxygen:
Hemoglobinhasahigheraffinitytocarbonmonoxidethanoxygen,andahighreadingmayoccur
despitethepatientactuallybeinghypoxemic.Incasesofcarbonmonoxidepoisoning,thisinaccuracy
maydelaytherecognitionofhypoxia(lowbloodoxygenlevel).
Cyanidepoisoninggivesahighreading,becauseitreducesoxygenextractionfromarterialblood.In
thiscase,thereadingisnotfalse,asarterialbloodoxygenisindeedhighinearlycyanidepoisoning.
Methemoglobinemiacharacteristicallycausespulseoximetryreadingsinthemid80s.
AnoninvasivemethodthatallowscontinuousmeasurementofthedyshemoglobinsisthepulseCO
oximeter,whichwasinventedin2005byMasimo.Itprovidescliniciansawaytomeasurethe
dyshemoglobinscarboxyhemoglobinandmethemoglobinalongwithtotalhemoglobin.

Increasingusage
AccordingtoareportbyiDataResearchtheU.S.pulseoximetrymonitoringmarketforequipmentand
sensorswasover700millionUSDin2011.[45]In2008,morethanhalfofthemajorinternationally
exportingmedicalequipmentmanufacturersinChinawereproducersofpulseoximeters.[46]
InJune2009,videogamecompanyNintendoannouncedanupcomingperipheralfortheWiiconsole,
dubbedthe"VitalitySensor",whichconsistsofapulseoximeter.Thismarkstheonsetoftheuseofthis
devicefornonmedical,entertainmentpurposes.[47][48]

Plethvariabilityindex
Plethvariabilityindex(PVI)isameasureofthevariabilityoftheplethysmographicwaveform
amplitude.[49]APVIofmorethan14%confersahigherchanceofrespondingtovolumeexpanders.[49]

Seealso
Arterialbloodgas
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Capnography
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IntegratedPulmonaryIndex
Respiratorymonitoring
Medicalequipment
Mechanicalventilation
Oxygensensor

Oxygensaturation
Photoplethysmogram,measuringofcarbondioxide
(CO2)intherespiratorygases
Sleepapnea

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