Reviews
Pulse Oximetry: Principles and Limitations
The pulse oximeter has become an essential tool in the modern practice
of emergency medicine. However, despite the reliance placed on the
information this monitor offers, the underlying principles and associated
limitations of pulse oximetry are poorly understood by medical practitio-
ners. This article reviews the principles of pulse oximetry, with an eye
toward recognizing the limitations of this tool. Among these are perfor-
mance limitations in the settings of carboxyhemoglobinemia, methemo-
globinemia, motion artifact, hypotension, vasoconstriction, and anemia.
The accuracy of pulse oximetry is discussed in light of these factors, with
further discussion of applications for pulse oximetry in emergency
medicine, including both oximetric and plethysmographic operation. The
pulse oximeter is an invaluable instrument for emergency medicine
practice, but as with any test the data it offers must be critically appraised
for proper interpretation and utilization. (Am J Emerg Med 1999;17:59-67.
Copyright 1999 by W.B. Saunders Company)
Pulse oximetry has become an essential tool in the current
practice of emergency medicine. Detection of hypoxia by
clinical indicators alone is notoriously unreliable, whereas
the pulse oximeter offers real-time assessment of oxygen-
ation status on a moment-to-moment basis, reflecting effi-
cacy of interventions as well as progression of disease
processes. This technology is noninvasive, widely available,
and simple to use. Proper interpretation of pulse oximetry
data is dependent on a basic understanding of the underlying
principles and inherent limitations of the instrument. Unfor-
tunately, studies have shown a lack of knowledge among
both residents and medical staff concerning the limitations
and interpretation of pulse oximetry results? ,2 This impor-
tant topic has not been widely addressed in the emergency
medicine literature. This article reviews the principles and
limitations of pulse oximetry, with discussion of the accu-
racy and appropriate clinical uses of this invaluable tool.
HISTORY
The development of pulse oximetry has been based on
more than a hundred years of experimental and engineering
antecedents. Stokes in 1864 first recognized that oxygen in
From the Departmentof EmergencyMedicine, Universityof Cincin-
nati, Cincinnati, OH, and the Department of Emergency Medicine,
Medical College of Georgia,Augusta, GA.
Manuscript receivedAugust 1, 1997; acceptedAugust 21, 1997.
Address reprint requests to Dr Sinex, Department of Emergency
Medicine, AF-2018, Medical College of Georgia, 1120 15th St,
Augusta, GA30912.
Key Words:Oximetry,physiologic monitoring, anoxia, plethysmog-
raphy.
Copyright 1999 by W.B. Saunders Company
0735-6757/99/1701-0019510.00/(3
JAMES E. SINEX, MD
the blood was carried by its colored component. 3 This
component was isolated the following year by Hoppe-
Seyler, who further noted that the pattern of light absorption
of this substance he dubbed "haemoglobin" changed when
shaken in air. 4 Over the following decades, the optical
spectra of the reduced and oxygenated species of hemoglo-
bin (Hb) were further studied and elucidated.
The first system to use transillumination to measure in
vivo oxygen saturation was developed in 1935 by Matthes,
though difficulties with calibration made it an unwieldy
device. Wood in 1948 employed a refined version of this
"oximeter" as an anesthesia monitoring device. Unfortu-
nately, it too was fraught with practical limitations, requiring
individual calibration and a dedicated technician to operate. 5
The greatest step forward in the development of the
modern pulse oximeter occurred in 1974, interestingly
enough as an incidental finding. Before this, in order to
isolate arterial blood for transillumination, oximeters had
relied on compression and heating of the ear lobe to remove
venous and capillary blood and to "arterialize" the tissue, at
times with resultant second-degree burns. In 1974 Aoyagi,
while trying to develop a dye-dilution technique for cardiac
output determination, noted that the washout curves he was
measuring with an ear densitometer were muddied by
pulsatile variations. In working to eliminate these variations,
Aoyagi recognized that the absorbency ratios of these
pulsations at different wavelengths varied with oxygen
saturation. Employing the principles discussed in the next
section, Aoyagi developed and marketed the first pulse
oximeter in 1975. 3
The later development of reliable light-emitting diodes
(LEDs), photodetectors, and microprocessors ushered in the
current era of modern pulse oximetry. The availability and
use of this instrument boomed through the 1980s, initially in
the hands of anesthesiologists, and then throughout medical
practice.
PRINCIPLES
The principle of pulse oximetry is that of spectral
analysis: the detection and quantitation of components in
solution by their unique light absorption characteristics. The
central tenet of spectral analysis is the Beer-Lambert law,
which states that the concentration of an absorbing sub-
stance in solution can be determined from the intensity of
light transmitted through that solution, given the intensity
and wavelength of incident light, the transmission path
length, and the characteristic absorbance of that substance at
a specific wavelength (the extinction coefficient).5 Restated,
59
60 AMERICAN JOURNAL OF EMERGENCY MEDICINE Volume 17, Number 1 January 1999
absorbance is dependent on solute concentration (eg, oxygen-
ated and reduced Hb), and absorbance can be determined by
transmitting light of a specific wavelength across a solution
(or tissue) and measuring its intensity on the other side.
To arrive at oxygen saturation, the relative concentrations
of reduced Hb and oxyhemoglobin (O~Hb) must be known,
and a wavelength of light must be used that each chromo-
phobe will preferentially absorb. Figure 1 illustrates the
difference in absorbance spectra for reduced Hb and O2Hb
within the red to near-infrared wavelengths. The substantial
variance demonstrated within this range is fortunate for two
reasons. First, red and near-infrared light readily penetrate
tissue, whereas blue, green, and yellow light, as well as
longer-wavelength infrared light, tend to be significantly
absorbed by tissue and water. Second, LEDs, which can
reliably emit a specific wavelength of light, are widely
available within the red to near-infrared range for use as
light sources. 6 The two wavelengths commonly used are
those at roughly 660nm (red) and 940nm (near-infrared),
although some pulse oximeters use slightly different wave-
lengths. Note from the absorbance spectra (Figure 1) that at
660nm, reduced Hb absorbs light roughly ten times more
readily than does O2Hb (with extinction or absorbance
shown on a logarithmic scale). The reverse is true at 940nm,
where O2Hb absorbs more light.
Two LEDs in the pulse oximeter probe each emit light of
specific wavelength through a cutaneous vascular bed, such
as that of the digits or the ear lobe. A photodiode detector at
the far side measures the intensity of transmitted light at
each wavelength, from which oxygen saturation can be
derived. This would be adequate in a simple solution
containing only reduced and oxygenated Hb. However,
several obstacles to measuring arterial oxygen saturation
arise in practice, such as the scatter, reflection, and absor-
bance of light by other tissue and blood components. To
1 signal (AC 660nm/DC 660nm) to the infrared signal (AC
i
(Red) (Infrared)
660nm 940nm
~02Hb
~-1
-2 I I I I . I
600 700 800 900 1000
Wavelength (nm)
FIGURE 1. Hemoglobin extinction curve of oxyhemoglobin
(HbO~) and reduced hemoglobin (Hb). (Courtesy of Ohmeda,
Louisville, CO.)
van absorption
(Due arterialpulsatile)
--Arte~ bloodabsorption
=~ ' . " #~ ".='~" .=..,#..=..~=.~,.==
t,.,- ~ . = . . , ~ . # . = . . ~ ; .~ . . . ~ . ~ . . ~ . ~
--Ven( bloodabsorption
e~
~--0the ~sueabsorption
Time
FIGURE 2. Tissue composite demonstrating comparative light
absorption of dynamic and static components. (Courtesy of
Ohmeda.)
work properly, the system must be able to isolate the
absorbance of arterial blood components from that of venous
blood, connective tissue, and other absorbers. The pulse
oximeter does this by exploiting the pulsatile nature of
arterial blood and determining the pulse-added component
of the signal (Figure 2). By measuring transmitted light
several hundred times per second, the pulse oximeter is able
to distinguish the variable, pulsatile component of arterial
blood (which can be referred to as the alternating current
signal, or AC) from the unchanging, static component of the
signal (ie, the direct current signal, or DC) made up of the
tissue, venous blood, and nonpulsatile arterial blood. The
pulsatile component, generally comprising 1% to 5% of the
total signal] can then be isolated by canceling out the static
components. Dividing the AC level by the DC level at each
wavelength also compensates for changes in incident light
intensity, removing another complicating variable from the
equation. Performing this operation at each wavelength will
isolate the relative absorbance of reduced and oxygenated
Hb, the major absorbers in arterial blood. The ratio of the red
940nm/DC 940nm) reflects a similar ratio of reduced to
oxygenated Hb, which can then be converted to oxygen
saturation.
LIMITATIONS
The inherent limitations of pulse oximetry in various
clinical settings must be recognized in order to appropriately
interpret results. The major limitations can be divided into
three categories: those arising from calibration assumptions,
optical interference, and signal artifact. Other sources of
potential error also will be examined.
Calibration Assumptions
Initially the conversion from absorbancy ratios to arterial
oxygen saturation was based directly on Beer-Lambert
calculation, but the effects of reflection and scattering of
light even within the pulsatile fraction of arterial blood led to
gross overestimation of oxygen saturation. 3 Better results
have come from using experimentally derived calibration
curves (Figure 3). These curves are based on measurements
in healthy young volunteers after induction of hypoxemia
with coincident determination of oxygen saturation by both
pulse oximeter and in vitro laboratory co-oximeter.
JAMES E. SINEX PULSE OXIMETRY: PRINCIPLES AND LIMITATIONS 61

100 determine the relative absorbances of reduced Hb and O2Hb,

the pulse oximeter is unable to distinguish COHb and
80
MetHb. As such, the pulse oximeter measures a functional
saturation:
70 -

6o Functional SaO2 = [O2Hb/(OaHb + Hb)]

o"
o 50
[,3
40
30
20
10
0 Fractional SaO 2
o o o o o o o o o o o o
Q o o o o o o o o o o o
c; o c; ,: .-: ,-: ,: ~: & & ~i &
IR
FIGURE 3. Relationship of red/infrared ratio to oxygen satura-
tion, as typical pulse oximeter calibration curve. (Reprinted with
permission. 6 Courtesy of Ohmeda.)
An unavoidable limitation, therefore, is that pulse oxim-
eters can only be as accurate as their empirical calibration
curves. Understandably, researchers were limited in the
degree of hypoxemia inducible in these volunteers, to an
Sao2 of approximately 75% to 80%. Therefore, the shape of
the curve below these levels must be extrapolated, with
obvious implications for the accuracy of pulse oximetry at
low oxygen saturations. Early accuracy studies showed such
great inaccuracy and bias at low oxygen saturation that
manufacturers revised early calibration curves and soft-
ware. 8 More recent studies, however, continue to show
significant bias, increasing as oxygen saturation decreases, 9
although it has been justifiably pointed out that few, if any,
clinical treatment decisions will hinge on whether the
oxygen saturation is actually 50% o r 6 0 % . 3
Healthy young adults have usually comprised the subject
groups used for calibration. One manufacturer was even said
to have used two Olympic athletes in calibration trials. 4 As
such, the applicability of data from such a narrow population
to patients at the extremes of ages and with various medical
problems has been questioned.
Optical Interference
Many substances in the blood, both endogenous and
exogenous, can interfere optically with pulse oximetry, even
when controlling for the contributions of the static compo-
nents of arterial blood. This interference generally takes the
form of false absorbers, or components besides reduced Hb
and O2Hb that will absorb light within the red and near-
infrared wavelengths used in pulse oximetry.
100%. (Equation 1)
A multiwavelength co-oximeter, also known as a labora-
tory co-oximeter, uses four different wavelengths in vitro to
measure all four species of Hb. When quantities of all four
species are known, a fractional saturation can be calculated:
o o o o
o o o o
= [OzHb/(OzHb -t- Hb + COHb + MetHb)]
& ~ ~ ,4
100%. (Equation 2)
Although levels of COHb and MetHb should be negli-
gible in the normal nonsmoking patient, making a functional
saturation an adequate approximation of "true" Hb satura-
tion, such is not always the case. Figure 4 demonstrates that
both COHb and MetHb will absorb light within the red to
near-infrared range used by pulse oximetry. By absorbing
light incorrectly attributed to reduced Hb and O2Hb, these
false absorbers will lead to error in the determination of
relative absorptions of Hb and O2Hb by the pulse oximeter,
with propagated error in the displayed functional saturation.
Therefore, oxygen saturation by pulse oximetry ( S p O 2 ) is
only equivalent to functional saturation when insignificant
levels of COHb and MetHb are present, and never equiva-
lent to fractional saturation, which can only be determined
by an in vitro multiwavelength co-oximeter.
The direction and degree of error for each of the
dyshemoglobins can be anticipated by examining the Hb
extinction curves. In most nonsmokers, COHb levels will be
less than 2%. Heavy smokers have shown levels as high as
10% to 20%. Levels can be much higher still in significant
carbon monoxide exposure. Figure 4 shows that COHb
absorbs very little light at 940nm. However, at 660nm,
COHb absorbs light much like O2Hb. Thus by two wave-
length pulse oximetry, COHb will "look like" OzHb in the
lo I
1: methemogloNn
O
.1 reduced
oglobin

Dyshemoglobinemias
~ " - - - - - - . - . - . . ~ r earboxyhemaglobfn
b o x y he
The most significant potential false absorbers in the .01 I I I I I I I~""~ I I
600 64O 680 720 760 80O 84O 880 920 960 1000
circulation are carboxyhemoglobin (COHb) and methemo-
Logf Wavelength (nm)
globin (MetHb). To understand the effects of these Hb
species on oximetry, the difference between functional and FIGURE 4. Hemoglobin extinction curve, demonstrating relative
fractional Hb saturation must first be defined. absorptions of the four major classes of hemoglobin. (Reprinted
At the wavelengths of light commonly employed to with permission. 6 Courtesy of Ohmeda.)
62 AMERICAN JOURNAL OF EMERGENCY MEDICINE Volume 17, Number 1 January 1999
red range, with essentially no impact in the infrared.
Therefore, the effect on SpO2 would be to overestimate true
oxygen saturation. In experimental carbon monoxide expo-
sure in animals, SpO2 overestimated fi'actional saturation by
an amount roughly proportional to the COHb level (or
SpO2 = SaO2 + %COHb). ~ In this study, the oximeter read
up to 90% SpO2 in the presence of a COHb level of 70% and
an O2Hb level of only 30%. Human case reports support
these findings. 11,I2 More recently, a study of pulse oximetry
in 16 adults with carbon monoxide exposure showed the
same degree of overestimation, referred to by the authors as
the "pulse oximetry gap" of CO intoxication.13
Likewise, MetHb levels are less than 1% in normal
subjects. MetHb is formed as the iron in hemoglobin is
oxidized from the ferrous to the ferric state. MetHb levels
may be high congenitally or as a result of exposure to a
number of agents, most notably anesthetics, sulfa drugs, and
nitrites? 4,15 Figure 4 shows that at 660nm, MetHb looks
much like reduced Hb. However, more importantly, at
940nm the extinction or absorbance of MetHb is markedly
greater than that of either Hb or O2Hb. As a result, MetHb
will contribute greatly to the perceived absorption of both
these species, and will increase both the numerator and the
denominator of the ratio of relative absorbances the oxim-
eter calculates, driving this ratio towards 1. Note in Figure 3
that when the ratio of pulse-added red absorbance to infrared
absorbance is 1, the calibrated saturation is roughly 85%. 5
What are the expected and observed results of this? An
animal study showed that SpO2 decreased with increasing
MetHb levels of up to 40% to a plateau near a pulse oximetry
reading of 85%. 16As a human example, Eisenkraft reported
a patient with a MetHb level of 5% and a Pao2 of 587 mmHg
on 100% oxygen who showed an SpOz of only 92% to 93%,
which he attributed solely to methemoglobin effects. ~5
Again, these results are consistent with what would be
expected based on the extinction curves. Furthermore, at a
low "true" oxygen saturation in the presence of methemoglo-
binemia, it could be theorized that SpO2 would increase
towards 85%, though such has not been clearly demon-
strated. The observation has been made that methemoglobin-
emia could be suspected based solely on a persistent
unexplained low pulse oximetry saturation. 14,16
In summary, both COHb and MetHb can have significant
effects on pulse oximetry readings when present in supranor-
real concentrations. When the presence of these abnormal
Hb species is suspected, pulse oximetry should be supple-
mented by in vitro multiwavelength co-oximetry. However,
it is worth recognizing that in the absence of changing levels
of these dyshemoglobins, pulse oximetry maintains its
utility as a monitor of oxygen saturation trends.
Fetal Hb has been found to have no significant effect on
pulse oximetry. 17,18 This is consistent with the observation
that fetal Hb absorbances are the same as those of adult Hb
values at the wavelengths utilized by pulse oximetry. 19
Interestingly, fetal Hb may be misread as COHb by the
particular wavelengths used by the in vitro co-oximeter?
Bilirubin and Intravenous Dyes
Hyperbilirubinemia itself does not appear to interfere with
pulse oximetry. 1721,22 However, patients with hyperbilirubi-
nemia can have high true COHb levels, as carbon monoxide
is produced with bilirubin in the breakdown of Hb. ~2 This is
particularly relevant in hemolytic jaundice. Bilirubin can
cause artifactual increases in both COHb and MetHb levels
as measured by in vitro co-oximeter because of the overlap
of its absorption spectra with these Hb species. 21 Similar to
the presence of fetal Fib, then, hyperbilirubinemia is a
situation in which pulse oximetry can be more accurate than
the in vitro co-oximeter.
Intravenous dyes are known to have potentially profound
effects on pulse oximetry readings, resulting in falsely low
measured oxygen saturations. Methylene blue, with very
high absorbance at 660nm, causes an impressive spurious
decrease in SpO2 .23-25 As little as 5 mL of methylene blue
administered to human subjects can decrease SpO2 dramati-
cally, in one subject to as low as 1%. 24Lesser decreases from
baseline SpOz occur after intravenous administration of
indocyanine green and indigo carmine. 24 Onset of these
changes occurs 30 to 45 seconds after dye administration,
with recovery to baseline oxygen saturation within 3 min-
utes. Dye clearance is prolonged in debilitated, very young,
or elderly subjects. In animal studies, administration of
fluorescein has been observed to have no effect on pulse
oximetryY False desaturation with these intravenous dyes is
also observed with the in vitro co-oximeter.
The effects of methylene blue are of interest for other
reasons as well. This dye is used in the treatment of
methemoglobinemia, which has its own effect on pulse
oximetry. Additionally, methylene blue administration can
cause an initial increase and then decrease in cardiac output,
with resultant independent effects on oxygen deliveryY
Signal Artifact
Most commonly, problems in pulse oximetry arise from
signal artifact. The presence of a sharp pulsatile waveform
displayed on those oximeter models featuring a plethysmo-
graph is no guarantee against signal artifact. Signal artifact
results from false sources of signal or from a low signal-to-
noise ratio. False signal can arise from detection of nontrans-
mitted light (ambient sources or optical shunt) or from
nonarterial sources of alternating signal. A low signal-to-
noise ratio results from inadequate signal complicated by an
excess of physiological or technical noise.
False Signal
The simple oximetry system as outlined above incorrectly
assumes that the sum of the light absorbed and the light
transmitted is equal to the incident fight, with no other light
loss or gain affected the detector. Ambient light, however, is
potentially a major source of interference. Recognizing this,
designers divided the LED and detector activities into three
sensing periods, cycling at hundreds of times per second.
Two of these periods use light emitted by the LEDs at each
of the two incident wavelengths. In the third period neither
LED is activated, and the photodiode detector measures only
ambient light, the influence of which is subsequently
eliminated from the LED-illuminated sensing periods.
However, cases of ambient light interference still oc-
cur. 3'26'27 Implicated sources include fluorescent lighting,
surgical lamps, fiberoptic instruments, and sunlight. 4,28 Coy-
JAMES E, SINEX PULSE OXIMETRY: PRINCIPLES AND LIMITATIONS
ering the probe with an opaque shield offers a simple
solution.
Optical shunting occurs when light from the LED reaches
the photodetector without passing through an arterial bed. 29,3
This occurs most commonly with inappropriate probe selec-
tion, as when a digit probe is placed on the ear lobe, or with
probe malposition, with a finger probe being "cocked" on
the finger.
In both ambient light interference and optical shunt, the
end result is the addition of false signal to both wavelengths
tested. 31 As with methemoglobinemia, the result will be a
ratio of relative absorbances approaching unity, with a
corresponding displayed SpO2 of 85%. At normal satura-
tions this will manifest as a falsely lowered saturation. More
dangerously, errors caused by ambient light interference and
optical shunt will lead to overestimations of saturation in
patients with a true SaO2 of less than 85%. This overestima-
tion has been demonstrated with probe malposition in
hypoxic patients. 32
Nonarterial sources of alternating signal most commonly
result from motion artifact. Most motion has been said to
originate in movement of the oximeter probe in relation to
skin, with the common sense suggestion offered that the
cable be taped to the dorsum of the hand when using digit
probes. 33 Shivering is widely believed to interfere, 34 al-
though pulse oximetry has been found to remain effective
during tonic-clonic seizure. 35 False readings caused by
patient motion during cardiopulmonary resuscitation have
been described. 36 Repetitive cough and the cycling of
ventilators offer other common potential sources of interfer-
ence. Of particular interest to aeromedical practice, several
oximeters have been tested during helicopter flight, with no
apparent effect from vibration. 37-39When interference does
occur from motion artifact it again tends to be additive into
both the red and infrared channels, with a resultant absor-
bance ratio near 1 and an SpO2 approaching 85%.
Although different oximeter models employ different data
processing, the dozens of saturation values acquired per
second are typically averaged over a period of 2 to 16
seconds before a reading is given, serving in part to limit the
impact of motion artifact. 7 However, this averaging period
will also delay presentation of data, extending time to first
reading as well as response time to saturation changes. The
trade-off between limiting artifact and extending response
time can be adjusted on many oximeters by variable
averaging period settings. Oximeters also attempt to mini-
mize motion artifact with internal algorithms that eliminate
or differentially weigh outlier readings which are likely due
to motion. 5 In a similar fashion, some instruments couple
oximetry readings to electrocardiograph signal. 34
In addition to extracorporeal motion, there are other
sources of false alternating signal. Arterial pulsations can be
transmitted into the venous circulation in venous congestion,
causing artificially lowered oxygen saturation readings. 4
This same phenomenon occurs in tricuspid regurgitation.
Arterial pulsations with a large dicrotic notch, as in aortic
regurgitation, combined aortic stenosis and regurgitation, or
idiopathic hypertophic subaortic stenosis, can be processed
incorrectly at twice the true heart rate. This will have little
impact on oxygen saturation but has obvious effects on
displayed heart rate. 34
63
Low Signal-To-Noise Ratio
The "pulse search" period when a pulse oximeter probe is
first placed is spent not only in acquiring a good pulse but
also in finding an intensity of light sufficient to transmit
through the tissue in question? The pulse oximeter will
increase the amplitude of incident light in a stepwise fashion
by up to a billion times. 5 Recall that under the best of
circumstances the pulsatile or AC component of signal
comprises only 1% to 5% of total signal. As incident light
amplitude increases in efforts to pick up AC signal, artifac-
tual signal or noise will likewise be amplified. Although
most modern pulse oximeters have complex algorithms to
distinguish noise from signal, and will only accept a certain
signal-to-noise ratio, at times this noise can be processed and
presented as signal. 34
Low signal-to-noise ratio results from absent or low-
amplitude pulses, arising from a multitude of causes includ-
ing hypotension, hypovolemia, hypothermia, and peripheral
vascular disease. Iatrogenic causes, including blood pressure
cuff inflation and administration of vasoconstrictors, will
likewise decrease signal. In other words, low signal-to-noise
ratio can be a potential problem in the majority of seriously
ill patients, in whom accurate information is most needed.
The low-perfusion limits of pulse oximetry have been
studied by inducing extremity hypotension and vasoconstric-
tion in volunteers by various methods, al The failure thresh-
olds were found to be significantly lower than those
commonly seen clinically, leading the investigators to
suggest that failure to detect signal is more often caused by
local vasoconstriction rather than systemic hypotension.
So the question becomes what to do in such cases,
particularly those in which the oximeter is unable to find a
pulse. Obviously, potential underlying cardiorespiratory
problems need to be addressed first. In an effort to acquire a
suitable pulse oximeter signal, a simple change in probe
location may suffice. Ear lobe probes have been found in
some cases to produce better signal as compared with digit
probes. 3 This is supported by evidence that the ear lobe is
less vasoactive than the finger pad or nail bed, and so is less
susceptible to vasoconstrictive effects.42
As another alternative, digital blocks have been found to
be quite effective in regaining signal in cases of peripheral
vasoconstriction.43-45 Such peripheral "clamping down" is
probably most often seen in emergency practice in the
hypothermic patient, including the majority of seriously ill
patients who typically are exposed fully for assessment.
Ostensibly, the block works by blocking digital sympathetic
innervation, with subsequent relative vasodilatation. The
digital block itself should not interfere with the detection or
correction of any systemic problems that could also underlie
loss of signal. Sometimes simple local heat or massage will
accomplish the same effect. Anecdotally, topical nitroglycer-
ine has been employed with variable effect.34
To the same end, intraarterial vasodilators have also been
used, instilled through ipsilateral radial lines. 46 Diluted
boluses of nitroglycerine (10 ~g) and hydralazine (1 nag)
have been reported to restore pulse oximeter function with
no adverse hemodynamic effect. Clearly, however, this is not
a practical intervention in the majority of patients.
64 AMERICAN JOURNAL OF EMERGENCY MEDICINE Volume 17, Number 1 January 1999
Other Limitations
Anemia appears to adversely affect the accuracy of pulse
oximetry, although the mechanism is unclear, and it may do
so only in the presence of hypoxia. In theory, anemia should
not affect pulse oximetry at all, as the ratio of relative
absorbances should be preserved and unchanged by changes
in total hemoglobin concentration within the sample. How-
ever, a retrospective study found an underestimation of
oxygen saturation by pulse oximetry in anemic subjects,
inversely proportional to Hb concentration and most pro-
nounced at an SpO2 less than roughly 80%. 47An experimen-
tal in vitro study48 and an animal study49 both showed a
similar trend with coincident anemia and hypoxemia. The
observation has been made that the direction of error is
fortuitous, presenting an exaggeration of apparent hypox-
emia, as anemic patients are more susceptible to the
deleterious effects of desaturation. 47 With normal oxygen
saturation, an earlier dog study found pulse oximetry to be
consistently accurate with a near-zero bias in subjects with a
hematocrit of at least 10, but found a bias of 5.4% in subjects
with a hematocrit less than 10. 5 Encouragingly, a recent
study of nonhypoxic human patients with acute anemia from
hemorrhage down to a Hb value as low as 2.3 g/dL showed
good accuracy with pulse oximetry.51
Skin pigmentation has shown variable effects on pulse
oximetry.5244 Primarily, dark pigmentation appears to make
adequate light penetration more difficult, with significantly
more signal detection failures. It has been suggested that the
less pigmented nail beds may offer particularly good probe
sites in these patients. 34More concerning are some studies of
pigmentation effects which have shown overestimations of
oxygen saturation, both in models 54 and in human subjects. 5a
The mechanism of such artifact, if present, is unclear, and
could arise from optical interference, low signal-to-noise
effects, or as a reflection of the relative lack of darkly
pigmented subjects in calibration trials. Studies with larger
patient groups are indicated.
Similarly, there is evidence for the effects of nail polish on
pulse oximetry, but little consensus on occurrence or de-
gree. 55-57When demonstrated, most interference appears to
arise from blue or black polish. It is probably advisable to
avoid possible interference by using other probe sites,
removing the nail polish, or even simply placing the probe
sideways on the digit to remove the nail from the transmis-
sion path.
Although LEDs are reliable sources of narrow wavelength
light in most cases, there can be slight variability between
LEDs in actual wavelength emitted. 5 A very small error in
wavelength can translate into a large error in absorbance
interpretation, particularly at the steep portions of the curve
in the red range (Figure 1). In general, LEDs that emit light
too far from standard are rejected by the manufacturer.
However, some manufacturers have dealt with this problem
in the past by compensatory changes in software and data
processing. The danger arises in switching probes in such
cases, coupling an LED with processing software calibrated
to a different wavelength of incident light. This problem
most likely will not arise in modern oximeters, but users
should be aware nonetheless.
Finally, it should be recognized that in patients receiving
supplementary oxygen at high Fio2 and showing a high SpO2
(99% to 100%), there can be a dramatic decrease in Pao2
before a corresponding decrease in oxygen saturation is
manifested due to the shape of the oxygen-Hb dissociation
curve.
ACCURACY
Hundreds of studies have examined the accuracy of pulse
oximeters, with fair consistency in findings. Reviews have
summarized these studies nicely and have illustrated the
difficulty in answering the seemingly simple question of
accuracy.3,5,6,34,58
In general, manufacturers presently report pulse oximeter
accuracy to one standard deviation of <+__3% at arterial
oxygen saturations of >70%. These claims are largely
supported in the most recent reviews of studies addressing
accuracy. 34,58It should be recognized, however, that this bias
or error is reported at one standard deviation only, and so
must be doubled or tripled to express a 95% or 99%
confidence interval, respectively. This may seem a surpris-
ingly wide range of error and is probably contrary to most
clinician's preconceptions of accuracy. This only under-
scores the importance of widespread recognition of that
range. Again, this range of error must be reassessed in every
situation in light of the limitations as previously discussed.
Methodological issues should be briefly discussed to put
the results of these studies into proper context. Subject
groups have been highly variable, ranging from healthy
volunteers to the critically ill. Correspondingly, study set-
tings have varied from rigidly controlled laboratories in
some studies to intensive care units and emergency depart-
ments in others.
The "gold standard" of comparison now is generally
recognized to be the in vitro four-wavelength co-oximeter,
with a reported accuracy for fractional saturation of ___1% at
two standard deviations. 3 Some studies, however, have
utilized two wavelength in vitro co-oximeters as standards,
with the same limitations inherent in use of only two
wavelengths as pulse oximeters. Still others have used
calculated SaO2 from arterial blood gas samples. The
problem with such calculated oxygen saturations is that,
because of shifts in the O2Hb dissociation curve, correction
factors for variables like temperature, pH, and 2,3-
diphosphoglycerate concentration must be inserted for accu-
rate results. Most often, however, standard corrections are
used with potential resulting impact on accuracy.
Data analyses also have been variable, with early studies
employing primarily regression analysis and correlation
coefficients. Such measures were found to be inadequate,
reflecting a known association between Sao2 and SpO2
rather than addressing accuracy. A better measure has been
bias, or the mean value of (Sa02 - SpO2), in conjunction
with precision, or the standard deviation of bias. 3,5,34 Bias
represents systematic differences between methods of mea-
surement, with precision reflecting variability.
Revisions in manufacturer algorithms and software, at
times prompted by the findings of the studies themselves,
further complicate accuracy assessments. As such, results
can become dated almost by nature of their own existence.
JAMES E. SINEX PULSE OXIMETRY: PRINCIPLES AND LIMITATIONS
APPLICATIONS
Potential applications of pulse oximetry in emergency
medicine are widespread. In general, the pulse oximeter has
found a role in every situation in which information on
oxygenation status would prove helpful. The utility of the
oximeter in this role is fairly obvious. However, some have
used the plethysmographic, or pulse detection, feature of the
oximeter for various situations as well.
Oximetric
The pulse oximeter has found its greatest utility as a
monitor for desaturation or hypoxia, and in this capacity the
oximeter is an excellent tool. With continuous monitoring in
the emergency setting, the pulse oximeter can rapidly detect
progression of hypoxia and reflect efficacy of treatment. 59
Oximeter monitoring has been shown to reduce both the
frequency of hypoxic episodes and the duration of hypoxia
during emergency endotracheal intubation. 6 Unfortunately,
the tendency in all but the most critically ill patients is to use
the pulse oximeter as a "spot-check" of oxygen saturation.
The pulse oximeter certainly can be used in this fashion, and
has been shown to detect clinically unrecognized hypoxia in
emergency department patients. 61-63 However, in this role,
questions of accuracy loom larger, and as discussed the
oximeter is subject to many limitations and sources of
artifact. It cannot be stressed enough that the clinician must
critically assess the results given by the pulse oximeter in
every situation. It further bears mentioning that the pulse
oximeter assesses the adequacy of oxygenation, but in no
way measures adequacy of ventilation.
Plethysmographic
The use of the oximeter as a plethysmograph is much
more controversial. Its ability to detect nonpalpable pulses
has been used as an assessment of perfusion in a number of
situations, ranging from verification of adequacy of chest
compressions during cardiopulmonary resuscitation 64 and
assessing ulnar collateral flow in a modified Allen's test 65-67
to assessing vitality of replanted and revascularized extremi-
ties.68
The critical question then is whether a pulsatile signal
sufficient to generate a pulse waveform on the oximeter can
serve as a guarantee of adequate perfusion. Most evidence is
only anecdotal, so this question remains largely unan-
swered. 34 Of particular concern is the experimental finding
that blood flows determined by laser Doppler to be as low as
4% to 8.6% of baseline were detected as pulsatile signal by a
pulse oximeter. 69 At the current state of knowledge, then,
such uses of the pulse oximeter should be met with
skepticism and probably avoided. It should be recognized as
well that the pulsatile signal displayed by the oximeter is
usually automatically scaled as the oximeter increases
incident light amplitude in an effort to detect signal and so
does not reflect absolute pulse amplitude.
One possible exception is the determination of systolic
blood pressure, either by reappearance of pulsatile wave-
form during cuff deflation38,39,7 or by disappearance of
waveform during inflation. 41,71,72 The pulse oximeter may
find particular utility in this role during helicopter transport,
65
in which other methods of assessing blood pressure are often
difficult or impossible. 38,39It must be stressed, however, that
inflation or deflation must be done very slowly because of
some delay in response from the pulse oximeter (2 to 3
mmHg per second).
FUTURE TRENDS
At present, the pulse oximeters generally avai!able for use
in critical care and emergency department settings all
employ transmitted light. Reflectance oximeters, which
detect "back-scatter" of light from LEDs placed side-by-
side with detectors, are already in use in anesthesia and in
obstetrics (with placement of a probe on the fetal presenting
part). Potential advantages of reflectance operation include
the ability to place the probe on virtually any site on the
body, and to demonstrate an earlier response to hypoxia with
placement of a probe more centrally, on the torso. Further-
more, reflection oximetry of retinal blood has been exam-
ined as a measure of cerebral oxygenation,73 and an instru-
ment that continuously measures both saturation and
perfusion has been developed by combining a reflectance
oximeter with a laser Doppler flowmeter.74 However, cur-
rently available reflectance oximeters suffer in comparison
with transmission oximetry in terms of accuracy and suscep-
tibility to noise. 58,75,76As such, they are not yet appropriate
for emergency practice.
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