Pulse oximetry

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Pulse oximetry

Tetherless pulse oximetry

Purpose Monitoring a person's oxygen saturation

Pulse oximetry is a noninvasive method for monitoring a person's oxygen saturation. Though
its reading of peripheral oxygen saturation (SpO2) is not always identical to the more
desirable reading of arterial oxygen saturation (SaO2) from arterial blood gas analysis, the two
are correlated well enough that the safe, convenient, noninvasive, inexpensive pulse oximetry
method is valuable for measuring oxygen saturation in clinical use.

In its most common (transmissive) application mode, a sensor device is placed on a thin part
of the patient's body, usually a fingertip or earlobe, or in the case of an infant, across a foot.
The device passes two wavelengths of light through the body part to a photodetector. It
measures the changing absorbance at each of the wavelengths, allowing it to determine the
absorbances due to the pulsing arterial blood alone, excluding venous blood, skin, bone,
muscle, fat, and (in most cases) nail polish.[1]

Reflectance pulse oximetry is a less common alternative to transmissive pulse oximetry. This
method does not require a thin section of the person's body and is therefore well suited to a
universal application such as the feet, forehead, and chest, but it also 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 anesthesia with
endotracheal intubation and mechanical ventilation or in patients in the Trendelenburg
position.[2]

Contents
  1 History
 2 Function
 3 Indication
o 3.1 Advantages
o 3.2 Limitations
o 3.3 Increasing usage
o 3.4 Early detection of COVID-19
 4 Derived measurements
 5 See also
 6 Notes
 7 References
 8 External links

History
In 1935, German physician Karl Matthes (1905–1962) developed the first two-wavelength
ear O2 saturation meter with red and green filters (later red and infrared filters). His meter
was the first device to measure O2 saturation.[3]

The original oximeter was made by Glenn Allan Millikan in the 1940s.[4] In 1949, Wood
added a pressure capsule to squeeze blood out of the ear so as to obtain an absolute O2
saturation value when blood was readmitted. The concept is similar to today's conventional
pulse oximetry, but was difficult to implement because of unstable photocells and light
sources; today this method is not used clinically. In 1964 Shaw assembled the first absolute
reading ear oximeter, which used eight wavelengths of light.

Pulse oximetry was developed in 1972, by Takuo Aoyagi and Michio Kishi, bioengineers, at
Nihon Kohden using the ratio of red to infrared light absorption of pulsating components at
the measuring site. Susumu Nakajima, a surgeon, and his associates first tested the device in
patients, reporting it in 1975.[5] It was commercialized by Biox in 1980.[6][5][7]

By 1987, the standard of care for the administration of a general anesthetic in the U.S.
included pulse oximetry. From the operating room, the use of pulse oximetry rapidly spread
throughout the hospital, first to recovery rooms, and then to intensive care units. Pulse
oximetry was of particular value in the neonatal unit where the patients do not thrive with
inadequate oxygenation, but too much oxygen and fluctuations in oxygen concentration can
lead to vision impairment or blindness from retinopathy of prematurity (ROP). Furthermore,
obtaining an arterial blood gas from a neonatal patient is painful to the patient and a major
cause of neonatal anemia.[8] Motion artifact can be a significant limitation to pulse oximetry
monitoring resulting in frequent false alarms and loss of data. This is because during motion
and low peripheral perfusion, many pulse oximeters cannot distinguish between pulsating
arterial blood and moving venous blood, leading to underestimation of oxygen saturation.
Early studies of pulse oximetry performance during subject motion made clear the
vulnerabilities of conventional pulse oximetry technologies to motion artifact.[9][10]

In 1995, Masimo introduced Signal Extraction Technology (SET) that could measure
accurately during patient motion and low perfusion by separating the arterial signal from the
venous and other signals. Since then, pulse oximetry manufacturers have developed new
algorithms to reduce some false alarms during motion[11] such as extending averaging times or
freezing values on the screen, but they do not claim to measure changing conditions during
motion and low perfusion. So, there are still important differences in performance of pulse
oximeters during challenging conditions.[12] Also in 1995, Masimo introduced perfusion
index, quantifying the amplitude of the peripheral plethysmograph waveform. Perfusion
index has been shown to help clinicians predict illness severity and early adverse respiratory
outcomes in neonates,[13][14][15] predict low superior vena cava flow in very low birth weight
infants,[16] provide an early indicator of sympathectomy after epidural anesthesia,[17] and
improve detection of critical congenital heart disease in newborns.[18]

Published papers have compared signal extraction technology to other pulse oximetry
technologies and have demonstrated consistently favorable results for signal extraction
technology.[9][12][19] Signal extraction technology pulse oximetry performance has also been
shown to translate into helping clinicians improve patient outcomes. In one study, retinopathy
of prematurity (eye damage) was reduced by 58% in very low birth weight neonates at a
center using signal extraction technology, while there was no decrease in retinopathy of
prematurity at another center with the same clinicians using the same protocol but with non-
signal extraction technology.[20] Other studies have shown that signal extraction technology
pulse oximetry results in fewer arterial blood gas measurements, faster oxygen weaning time,
lower sensor utilization, and lower length of stay.[21] The measure-through motion and low
perfusion capabilities it has also allow it to be used in previously unmonitored areas such as
the general floor, where false alarms have plagued conventional pulse oximetry. As evidence
of this, a landmark study was published in 2010 showing that clinicians at Dartmouth-
Hitchcock Medical Center using signal extraction technology pulse oximetry on the general
floor were able to decrease rapid response team activations, ICU transfers, and ICU days.[22]
In 2020, a follow-up retrospective study at the same institution showed that over ten years of
using pulse oximetry with signal extraction technology, coupled with a patient surveillance
system, there were zero patient deaths and no patients were harmed by opioid-induced
respiratory depression while continuous monitoring was in use.[23]

In 2007, Masimo introduced the first measurement of the pleth variability index (PVI), which
multiple clinical studies have shown provides a new method for automatic, noninvasive
assessment of a patient's ability to respond to fluid administration.[24][25][26] Appropriate fluid
levels are vital to reducing postoperative risks and improving patient outcomes: fluid volumes
that are too low (under-hydration) or too high (over-hydration) have been shown to decrease
wound healing and increase the risk of infection or cardiac complications.[27] Recently, the
National Health Service in the United Kingdom and the French Anesthesia and Critical Care
Society listed PVI monitoring as part of their suggested strategies for intra-operative fluid
management.[28][29]

In 2011, an expert workgroup recommended newborn screening with pulse oximetry to

increase the detection of critical congenital heart disease (CCHD).[30] The CCHD workgroup
cited the results of two large, prospective studies of 59,876 subjects that exclusively used
signal extraction technology to increase the identification of CCHD with minimal false
positives.[31][32] The CCHD workgroup recommended newborn screening be performed with
motion tolerant pulse oximetry that has also been validated in low perfusion conditions. In
2011, the US Secretary of Health and Human Services added pulse oximetry to the
recommended uniform screening panel.[33] Before the evidence for screening using signal
extraction technology, less than 1% of newborns in the United States were screened. Today,
The Newborn Foundation has documented near universal screening in the United States and
international screening is rapidly expanding.[34] In 2014, a third large study of 122,738
newborns that also exclusively used signal extraction technology showed similar, positive
results as the first two large studies.[35]

High-resolution pulse oximetry (HRPO) has been developed for in-home sleep apnea
screening and testing in patients for whom it is impractical to perform polysomnography.[36]
[37]
It stores and records both pulse rate and SpO2 in 1 second intervals and has been shown in
one study to help to detect sleep disordered breathing in surgical patients.[38]

Function

Absorption spectra of oxygenated hemoglobin (HbO2) and deoxygenated hemoglobin (Hb)

for red and infrared wavelengths

The inner side of a pulse oximeter

A blood-oxygen monitor displays the percentage of blood that is loaded with oxygen. More
specifically, it measures what percentage of hemoglobin, the protein in blood that carries
oxygen, is loaded. Acceptable normal ranges for patients without pulmonary pathology are
from 95 to 99 percent. For a patient breathing room air at or near sea level, an estimate of
arterial pO2 can be made from the blood-oxygen monitor "saturation of peripheral oxygen"
(SpO2) reading.
A typical pulse oximeter uses an electronic processor and a pair of small light-emitting diodes
(LEDs) facing a photodiode through a translucent part of the patient's body, usually a
fingertip or an earlobe. One LED is red, with wavelength of 660 nm, and the other is infrared
with a wavelength of 940 nm. Absorption of light at these wavelengths differs significantly
between blood loaded with oxygen and blood lacking oxygen. Oxygenated hemoglobin
absorbs more infrared light and allows more red light to pass through. Deoxygenated
hemoglobin allows more infrared light to pass through and absorbs more red light. The LEDs
sequence through their cycle of one on, then the other, then both off about thirty times per
second which allows the photodiode to respond to the red and infrared light separately and
also adjust for the ambient light baseline.[39]

The amount of light that is transmitted (in other words, that is not absorbed) is measured, and
separate normalized signals are produced for each wavelength. These signals fluctuate in time
because the amount of arterial blood that is present increases (literally pulses) with each
heartbeat. By subtracting the minimum transmitted light from the transmitted light in each
wavelength, the effects of other tissues are corrected for, generating a continuous signal for
pulsatile arterial blood.[40] The ratio of the red light measurement to the infrared light
measurement is then calculated by the processor (which represents the ratio of oxygenated
hemoglobin to deoxygenated hemoglobin), and this ratio is then converted to SpO2 by the
processor via a lookup table[40] based on the Beer–Lambert law.[39] The signal separation also
serves other purposes: a plethysmograph waveform ("pleth wave") representing the pulsatile
signal is usually displayed for a visual indication of the pulses as well as signal quality,[41] and
a numeric ratio between the pulsatile and baseline absorbance ("perfusion index") can be used
to evaluate perfusion.[25]

Indication

A pulse oximeter probe applied to a person's finger

A pulse oximeter is a medical device that indirectly monitors the oxygen saturation of a
patient's blood (as opposed to measuring oxygen saturation directly through a blood sample)
and changes in blood volume in the skin, producing a photoplethysmogram that may be
further processed into other measurements.[41] 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 (CO2) 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.[42]

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.[43] Portable battery-
operated pulse oximeters are useful for pilots operating in non-pressurized aircraft above
10,000 feet (3,000 m) or 12,500 feet (3,800 m) in the U.S.[44] 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.[45]

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 (HCO3−) concentration. The metabolism of oxygen can be readily 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.

Erroneously low readings may be caused by hypoperfusion of the extremity being used for
monitoring (often due to a limb being cold, or from vasoconstriction secondary to the use of
vasopressor agents); incorrect sensor application; highly calloused skin; or movement (such
as shivering), 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.[12][9]

Pulse oximetry also is not a complete measure of circulatory oxygen sufficiency. If there is
insufficient bloodflow or insufficient hemoglobin in the blood (anemia), 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, and a
high reading may occur despite the patient's actually being hypoxemic. In cases of
carbon monoxide poisoning, this inaccuracy may delay the recognition of hypoxia
(low cellular oxygen level).
 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 in early cyanide poisoning.[clarification needed]
 Methemoglobinemia characteristically causes pulse oximetry readings in the mid-80s.
 COPD [especially chronic bronchitis] may cause false readings.[46]

A noninvasive method that allows continuous measurement of the dyshemoglobins is the

pulse CO-oximeter, which was built in 2005 by Masimo.[47] By using additional wavelengths,
[48]
it provides clinicians a way to measure the dyshemoglobins, carboxyhemoglobin, and
methemoglobin along with total hemoglobin.[49]

Increasing usage

According to a report by iData Research the U.S. pulse oximetry monitoring market for
equipment and sensors was over 700 million USD in 2011.[50]

In 2008, more than half of the major internationally exporting medical equipment
manufacturers in China were producers of pulse oximeters.[51]

Early detection of COVID-19

Pulse oximeters are used to help with the early detection of COVID-19 infections, which may
cause initially unnoticeable low arterial oxygen saturation and hypoxia. The New York Times
reported that "health officials are divided on whether home monitoring with a pulse oximeter
should be recommended on a widespread basis during Covid-19. Studies of reliability show
mixed results, and there’s little guidance on how to choose one. But many doctors are
advising patients to get one, making it the go-to gadget of the pandemic."[52]

Derived measurements
See also: Photoplethysmogram

Due to changes in blood volumes in the skin, a plethysmographic variation can be seen in the
light signal received (transmittance) by the sensor on an oximeter. The variation can be
described as a periodic function, which in turn can be split into a DC component (the peak
value)[a] and an AC component (peak minus valley).[53] The ratio of the AC component to the
DC component, expressed as a percentage, is known as the (peripheral) perfusion index
(Pi) for a pulse, and typically has a range of 0.02% to 20%.[54] An earlier measurement called
the pulse oximetry plethysmographic (POP) only measures the "AC" component, and is
derived manually from monitor pixels.[55][25]
Pleth variability index (PVI) is a measure of the variability of the perfusion index, which
occurs during breathing cycles. Mathematically it is calculated as (Pimax - Pimin)/Pimax × 100%,
where the maximum and minimum Pi values are from one or many breathing cycles.[53] It has
been shown to be a useful, noninvasive indicator of continuous fluid responsiveness for
patients undergoing fluid management.[25] Pulse oximetry plethysmographic waveform
amplitude (ΔPOP) is an analogous earlier technique for use on the manually-derived POP,
calculated as (POPmax - POPmin)/(POPmax + POPmin)*2.[55]

See also
 Arterial blood gas
 Capnography
 Integrated pulmonary index
 Respiratory monitoring
 Medical equipment
 Mechanical ventilation
 Oxygen sensor
 Oxygen saturation
 Photoplethysmogram, measuring of carbon dioxide (CO2) in the respiratory gases
 Sleep apnea
 Ulaif

Notes
1.

1. This definition used by Masimo varies from the mean value used in signal
processing; it is meant to measure the pulsatile arterial blood absorbance over the
baseline absorbance.

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In the Trendelenburg position, the body is laid supine, or flat on the back on a 15–30 degree
incline with the feet elevated above the head. The reverse Trendelenburg position,
similarly, places the body supine on an incline but with the head now being elevated.