Pulse oximetry

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Pulse oximetry is a non-invasive method allowing the monitoring of the oxygenation of a patient's blood.

A sensor is placed on a thin part of the patient's anatomy, usually a fingertip or earlobe, or in the case of a neonate, across a foot, and a light containing both red and infrared wavelengths is passed from one side to the other. Changing absorbance of each of the two wavelengths is measured, allowing determination of the absorbances due to the pulsing arterial blood alone, excluding venous blood, skin, bone, muscle, fat, and (in most cases) fingernail polish. Based upon the ratio of changing absorbance of the red and infrared light caused by the difference in color between oxygen-bound (bright red) and oxygen unbound (dark red or blue, in severe cases) blood hemoglobin, a measure of oxygenation (the per cent of hemoglobin molecules bound with oxygen molecules) can be made.


This 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. Assessing a patient's need for oxygen is the mose essential element to life; no human life thrives in the absence of oxygen (cellular or gross). Although pulse oximetry 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 pulse oximetry 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.


In 1935 Matthes developed the first 2-wavelength ear O2 saturation meter with red and green filters, later switched to red and infrared filters. This was the first device to measure O2 saturation.

In 1949 Wood added a pressure capsule to squeeze blood out of ear to obtain zero setting in an effort to obtain absolute O2 saturation value when blood was readmitted. The concept is similar to today's conventional pulse oximetry but suffered due to unstable photocells and light sources. This method is not used clinically. In 1964 Shaw assembled the first absolute reading ear oximeter by using eight wavelengths of light. Commercialized by Hewlett Packard, its use was limited to pulmonary functions and sleep laboratories due to cost and size.

Pulse oximetry was developed in 1972, by Aoyagi at Nihon Kohden using the ratio of red to infrared light absorption of pulsating components at the measuring site. It was commercialized by BIOX/Ohmeda in 1981 and Nellcor in 1983. Nellcor Incorporated in 1982, and introduced it into the US operating room market in 1983. Prior to its introduction, a patient's oxygenation was determined by a painful arterial blood gas, a single point measure which typically took a minimum of 20-30 minutes processing by a laboratory. (In the absence of oxygenation, damage to the brain starts in 5 minutes with brain death in another 10-15 minutes). In the US alone, approximately $2 billion was spent annually on this measurement. With the introduction of pulse oximetry, a non-invasive, continuous measure of patient's oxygenation was possible, revolutionizing the practice of anesthesia and greatly improving patient safety. Prior to its introduction, studies in anesthesia journals estimated US patient mortality as a consequence of undetected hypoxemia at 2,000 to 10,000 deaths per year, with no known estimate of patient morbidity.

By 1987, the standard of care for the administration of a general anesthetic in the US included pulse oximetry. From the operating room, the use of pulse oximetry rapidly spread throughout the hospital, first in the recovery room, and then into the various intensive care units. Pulse oximetry was of particular value in the neonatal unit where the patients do not thrive with inadequate oxygenation, but also can be blinded with too much oxygen. Furthermore, obtaining an arterial blood gas from a neonatal patient is extremely difficult.

In 1989, Diab and Kiani at Masimo Corporation invent Signal Extraction Pulse Oximetry (Masimo SET) using many proprietary breakthrough technologies and algorithms to separate the arterial signal from the non-arterial noise (e.g. venous blood movement during motion). The result was the first pulse oximetry technology scientifically and clinically proven to be accurate during conditions of patient motion and low perfusionThe technology was launched commercially in 1995.

With SET technology as the foundation, Masimo introduced a new oximetry technology in 2005 called pulse co-oximetry that allows clinicians to go beyond oxygen saturation to continuously and non-invasively measure carboxyhemoglobin, methemoglobin, pulse rate pleth variability index, and perfusion index. Called Rainbow SET technology, it uses multiple (7+) wavelengths of light and sophisticated signal processing including parallel engines and adaptive filters to calculate dyshemoglobin saturation values, allowing clinicians to detect and treat potentially life threatening conditions earlier than ever before.


This is a measure solely of oxygenation, not of ventilation, and is not a substitute for blood gases checked in a laboratory as it gives no indication of carbon dioxide levels, blood pH, or sodium bicarbonate levels. The metabolism of oxygen can be readily measured by monitoring expired CO2. Saturation figures also give no information about blood oxygen content, as a patient can be severely anemic but still fully saturated.

Falsely low readings may be caused by hypoperfusion of the extremity being used for monitoring (often due to the part being cold or from vasoconstriction secondary to the use of vasopressor agents); incorrect sensor application; highly calloused skin; and movement (such as shivering), especially during hypoperfusion. To ensure accuracy, the sensor should return a steady pulse and/or pulse waveform. Falsely high or falsely low readings will occur when hemoglobin is bound to something other than oxygen. In cases of carbon monoxide poisoning, the falsely high reading may delay the recognition of hypoxemia (low blood oxygen level). Methemoglobinemia characteristically causes pulse oximetry readings in the mid-80s. Cyanide poisoning can also give a high reading because it reduces oxygen extraction from arterial blood (the reading is not false, as arterial blood oxygen is indeed high in early cyanide poisoning).

It should be noted that pulse oximetry only reads the percentage of bound hemoglobin. It can be bound to other gasses such as carbon monoxide and still read high even though the patient is hypoxic.The only noninvasive methodology that allows for the continuous and noninvasive measurement of the dyshemoglobins carboxyhemoglobin and methemoglobin is called pulse co-oximetry.

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