Pulse Oximetry
Pulse Oximetry
Milestones of pulse oximetry
In 1974 Takuo Aoyagi working for Nihon Kohden
Corp. reported the crucial discovery leading to
marketing of the first pulse oximeter using filtered
light (commercial failure)
In the late 1970s Scott Wilber developed the first
pulse oximeter for Biox Corp. using a sensor with
light emitting diodes (LED) as light sources and
photodiodes as detectors
In the early 1980s anesthesiologist William New
realized the clinical opportunity and founded Nellcor
Inc. to produce Nellcor N100 pulse oximeter
Pulse Oximetry
Principles of operation
The pulse oximeter estimates SaO2 (arterial
oxygen saturation) by measuring pulsatile
signals (SpO2) across perfused tissues at two
different wavelengths (660 nm and 940 nm*)
The absorbance of transmitted light in red
(660 nm) and infrared (940 nm) spectra are
different for O2Hb (oxyhemoglobin), Hb
(reduced hemoglobin not carrying oxygen),
COHb (carboxyhemoglobin) and MetHb
(methemoglobin)
*Datex pulse oximeters use 910 nm wavelength
Pulse Oximetry
Hemoglobin Extinction Curves
10
Log Extinction Coefficient
Methemoglobin
1.0
Oxyhemoglobin
0.1
Reduced hemoglobin
Carboxyhemoglobin
0.01
660 940
Wavelength (nm)
Pulse Oximetry
Principles of operation
Pulse oximeters detect the capillary pulse
wave and determine the pulse-added
absorbance at both wavelengths (660 and 940
nm) and then calculate the ratio (R) of these
absorbances
AC660/DC660 AC = pulsatile component
R=
AC940/DC940 DC = baseline component
= absorbance of tissue, venous
and capillary blood and
non-pulsatile arterial blood
Pulse Oximetry
Principles of operation
Typical pulse oximeter calibration curve*
100
80
60
*Based on experimental
SpO2 studies in human volunteers
40
20
0
0,4 0,8 1,2 1,6 2,0 2,4 2,8 3,4
AC660/DC660
R=
AC940/DC940
Pulse Oximetry
Principles of operation
Standard pulse oximeters are unable to deal with
COHb and MetHb (it would take four instead of
two wavelengths to measure these fractions)
Therefore standard pulse oximeters measure
”functional oxygen saturation”, which is fairly
close approximation of fractional oxygen
saturation in normal conditions, when COHb
and MetHb levels are low
If the fraction of COHb or MetHb increases, the
error of saturation estimate increases
Pulse Oximetry
Principles of operation
O2Hb
Functional SpO2* =
O2Hb + Hb
O2Hb
Fractional SpO2* =
O2Hb + Hb + COHb + MetHb
In this context either SpO2 or SaO2 is used
Pulse Oximetry
Clinical practice
Pulse oximeters are standard mass monitors of
oxygenation for all clinical purposes and
environments
Suitable probes can be placed in fingers, toes,
ear lobes, cheek, tongue, nose, nostrils or any
convenient place producing sufficient pulse
wave
Pulse oximeters monitor the rear end of tissue
oxygenation sequence. Therefore the alarming
saturation readings may leave little time to
avoid profound hypoxia (children)
Pulse Oximetry
Clinical practice Normal SaO2 at sea level is
approximately 96%, at 5000 ft
(1500 m) 92% and at 10 000 ft
(3000 m) 88%.
Oxygen dissociation curve
shows that major changes
of O2 partial pressure may
occur when SaO2 changes
between 97% and 90%.
Below 90% small changes of
pO2 cause major changes in
SaO2 (steep part of the curve)
Pulse Oximetry
Clinical practice
Pulse oximeters have also been used
to monitor the circulation of upper and lower
extremities after vascular and orthopedic
surgeries
to evaluate the vitality of bowel loops during
bowel resections and anastamosis
as an aid in Allen´s test (checking the
collateral arterial flow to palmar arches by
occluding either radial of ulnar artery)
Plethysmography
Most pulse oximeters show the pulse wave
based on photoelectric plethysmography
During cardiac cycle the blood
volume of the finger tip changes
Absorption changes at 940 nm
(910 nm) are mainly due to
changes in local blood volume
Changes of digital artery
diameter during cardiac cycle
Plethysmography
The form and the amplitude of
plethysmographic wave depends on the state
of peripheral circulation
Normal Vascular Tone Vasoconstriction
Fear
Pain
Low Temperature
Hypovolemia
Hypocarbia
etc.
Plethysmography
The form and the amplitude of
plethysmographic wave depends on the state
of peripheral circulation
Vasodilatation Low Systemic
Vascular Resistance
Sedation
Anesthetics Sepsis
Hypercarbia Hepatic Coma
etc. etc.
Pulse Oximetry
Error sources, COHb
COHb absorbance is similar to O2Hb at 660
nm and nil at 940 nm
The absorbance properties of COHb are
reflected by the red or pink appearance
typical to patients with carbonmonoxide
poisoning
The effect of COHb on SpO2 values has been
estimated in Oanimal studies:
Hb + 0.9 x COHb
2
SpO2 =
O2Hb + Hb + COHb + MetHb
Pulse Oximetry
Error sources, MetHb
MetHb has the same absorbance as reduced
hemoglobin at 660 nm and greater
absorbance than other hemoglobins at 940
nm
Due to these properties patients with high
methemoglobin levels have dark brownish
blood
High MetHb levels causes large pulsatile
absorbance signals at both wavelengths
forcing the R ratio toward unity
Pulse Oximetry
Error sources, MetHb
According to typical pulse oximeter
calibration curve R value 1 corresponds to
SpO2 reading 85%
In the presence of high MetHb levels SpO2
readings settle around 85% independent of
the actual SaO2
The SpO2 readings are erroneously low when
SaO2 is above 85% and erroneously high
when SaO2 is below 85%
Pulse Oximetry
Error sources, dyes
Pulse oximeters are sensitive to dyes used
intravenously for enhancement of organ
visualization during certain surgical procedures
Commonly used dyes are methylene blue,
indigo carmine and indocyanine green
Dyes cause a transient fall of SpO2 readings
The effect is most pronounced with methylene
blue, intermediate with indocyanine green and
minimal with indigo carmine
Pulse Oximetry
Error sources, miscellaneous
Ambient, flickering light
Patient motion
Low perfusion and vasoconstriction
Electrosurgery
Nail polish (dark and blue tones?)
Henna stain