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Oxygen Saturation
Brant B. Hafen; Sandeep Sharma.
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Last Update: October 27, 2018.

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Introduction
Oxygen saturation is an essential element in the management and
understanding of patient care. Oxygen is tightly regulated within the body
because hypoxemia can lead to many acute adverse effects on individual
organ systems. These include the brain, heart, and kidneys. Oxygen
saturation is a measure of how much hemoglobin is currently bound to
oxygen compared to how much hemoglobin remains unbound. At the
molecular level, hemoglobin consists of four globular protein subunits. Each
subunit is associated with a heme group. Each molecule of hemoglobin
subsequently has four heme binding sites readily available to bind oxygen.
Therefore, during the transport of oxygen in the blood, hemoglobin is capable
of carrying up to four oxygen molecules. Due to the critical nature of tissue
oxygen consumption in the body, it is essential to be able to monitor current
oxygen saturation. A pulse oximeter can be used to measure oxygen
saturation. It is a noninvasive device that is placed over a person's finger. It
measures light wavelengths to determine the ratio of the current levels of
oxygenated hemoglobin to deoxygenated hemoglobin. The use of pulse
oximetry has become a standard of care in medicine. It is often regarded as a
fifth vital sign. As such, it is crucial for medical practitioners to understand
the functions and limitations of pulse oximetry. They should also have a basic
knowledge of oxygen saturation. 
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Anatomy
Within the body, oxygen consumption can be defined as the product of the
arterial-venous oxygen saturation differences and blood flow. The body
consumes oxygen partially through aerobic metabolism. In this process,
oxygen is used to convert glucose to adenosine triphosphate (ATP). An
important aspect of this process is the oxygen-hemoglobin dissociation curve.
In the blood, hemoglobin binds free oxygen rapidly to form oxyhemoglobin
leaving only a small percentage of free oxygen dissolved in the plasma. The
oxygen-hemoglobin dissociation curve is a plot of percent saturation of
hemoglobin as a function of the partial pressure of oxygen (PO2). At a PO2
of 100 mmHg, hemoglobin will be 100% saturated with oxygen, meaning all
four heme groups are bound. Each gram of hemoglobin is capable of
carrying 1.34 mL of oxygen. The solubility coefficient of oxygen in plasma is
0.003. This coefficient represents the volume of oxygen in mL that will
dissolve in 100mL of plasma for each 1 mmHg increment in the PO2. A
formula then calculates the oxygen content, so that Oxygen Content = (0.003
× PO2) + (1.34 × Hemoglobin × Oxygen Saturation). This formula
demonstrates that dissolved oxygen is a sufficiently small fraction of total
oxygen in the blood; therefore, the oxygen content of blood can be
considered equal to the oxyhemoglobin levels. [1]
As the PO2 decreases, the percentage of saturated hemoglobin also decreases.
The oxygen-hemoglobin dissociation curve has a sigmoidal shape due to the
binding nature of hemoglobin. With each oxygen molecule bound,
hemoglobin undergoes a conformational change to allow subsequent oxygens
to bind. Each oxygen that binds to hemoglobin increases its affinity to bind
more oxygen, meaning the affinity for the fourth oxygen molecule is the
highest. 
In the lungs, alveolar gas has a PO2 of 100 mmHg. However, due to the high
affinity for the fourth oxygen molecule, oxygen saturation will remain high
even at a PO2 of 60 mmHg. As the PO2 decreases, hemoglobin saturation
will eventually fall rapidly, at a PO2 of 40 mmHg hemoglobin is 75%
saturated. Meanwhile, at a PO2 of 25 mmHg, hemoglobin is 50% saturated.
This is referred to as P50, where 50% of heme groups of each hemoglobin
have a molecule of oxygen bound. The nature of oxygen saturation becomes
increasingly important in light of the effects of right and left shifts. A variety
of factors can cause these shifts.
A right shift of the oxygen saturation curve indicates decreased oxygen
affinity of hemoglobin which will allow more oxygen to be available to
tissues.[2] The mnemonic, "CADET, face Right!" can help to remember
factors that can lead to a right shift. Here, "CADET" stands for PCO2, acid,
2,3-diphosphoglycerate, exercise, and temperature. The hemoglobin
dissociation curve shifts right with an increase in each of these factors.
A left shift of the oxygen saturation curve indicates an increase in oxygen
affinity of hemoglobin which reduces oxygen availability to the tissues.
Factors that cause a left shift in the oxygen-hemoglobin dissociation curve
include decreases in temperature, PCO2, acidity, and 2,3-bisphosphoglyceric
acid, formerly named 2,3-diphosphoglycerate.
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Indications
Due to the noninvasive nature and relative importance of pulse oximetry
readings, there are very few situations where it is not indicated. Pulse
oximetry can provide a rapid tool to assess oxygenation accurately. It is
particularly useful in emergency situations for this reason. Cyanosis may not
develop until oxygen saturation reaches about 67%. As such, pulse oximetry
is extremely useful because the signs and symptoms of hypoxemia may not
be visible on physical examination. 
Pulse oximetry is indicated in any clinical setting where hypoxemia may
occur. These settings include patient monitoring in emergency departments,
operating rooms, emergency medical services systems, postoperative
recovery areas, endoscopy suites, sleep and exercise laboratories, oral surgery
suites, cardiac catheterization suites, facilities that perform conscious
sedation, labor and delivery wards, interfacility patient transfer units, altitude
facilities, aerospace medicine facilities, and even patients' homes. [3]
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Contraindications
Pulse oximetry is rarely contraindicated, but understanding its limitations is
helpful. A relative contraindication may be a need to measure pH, PaCO2,
total hemoglobin, and abnormal hemoglobins as in the setting of carbon
monoxide toxicity. It is also essential to monitor the location of the probe for
changes in skin conditions such as blisters or damage to the nail bed. Patients
with burns may also require the probe to be repositioned every two to four
hours.
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Equipment
The pulse oximeter consists of a probe containing LEDs and a photodetector.
The LEDs emit light at fixed, selected wavelengths. The photodetector
measures the amount of light transmitted through a selected vascular bed
such as a fingertip or earlobe. Pulse oximetry uses the Beer-Lambert law of
light absorption. This law describes how light is absorbed when it passes
through a clear solvent, such as plasma, that contains a solute that absorbs
light at a specific wavelength, such as hemoglobin.[4] The absorption spectra
of oxygenated and reduced hemoglobin differ. For this reason, arterial blood
appears red while venous blood appears blue. However, because living tissue
absorbs light, it is difficult to determine the ratio of saturation of hemoglobin
in the body. The oximeter probe overcomes this difficulty by emitting pulses
of light, one red and one infrared. A detector is placed opposite the lights on
the other side of the tissue. The diodes switch on and off in rapid sequence,
and the detector measures the differences. The measurements are fed into an
algorithm in a microprocessor where the oxyhemoglobin saturation is
calculated and eventually displayed to the user. [3]
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Personnel
All medical personnel should train with a basic understanding of the use of
pulse oximetry. Advanced users will find it helpful to understand the
relationship of the pulse oximetry readings to blood hemoglobin
concentrations, and how they are affected by the oxygen-hemoglobin
dissociation curve.
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Preparation
The most important consideration when preparing to apply the pulse oximeter
is placing the monitor where the light will be able to shine through to the
detector. Consider multiple factors before placing the pulse oximeter. Nail
polish should be removed, and the finger wiped with an alcohol preparation.
Examine the finger for other objects such as excess pigmentation. For
example, tattoos may block light as it passes through the tissue. High-
intensity ambient light has also been shown to interfere with the accuracy of
pulse oximetry readings. Before application, the rubber shield should be
intact on the pulse oximeter to help reduce ambient light input.
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Technique
After verifying the appropriate placement site, place the pulse oximeter so
that the light will penetrate through the tissue and be picked up by the
detector. When placing the pulse oximeter on a fingertip, it is essential that
the probe fits the finger well. It should not be too tight or too loose. Take
extra caution to make sure the probe does not restrict circulation to the digit
as this may provide an inaccurate reading. Ear probes are made for the
earlobe. In an emergency situation, the pulse oximeter may have to be placed
on the fingertip sideways as nail polish or pigment may obstruct the light.
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Complications
Complications from using a pulse oximeter are rare. However, it is necessary
to be aware of the probe site as blisters or nail damage may occur with
extended use. Tissue injury may also occur in the setting of incompatible
probes or during a substitution in the form of electrical shock or burns. It is
also essential to know how to improve the measurements of pulse oximeters.
Possible ways to improve pulse oximeter signals include:
 Warm and rub the skin
 Apply a topical vasodilator
 Try a different probe site, especially the ear
 Try a different probe
 Use a different machine[3]
Factors that may reduce the accuracy of pulse oximeter signals include:
 Nail Polish[5]
 Pigmentation of the skin
 High-intensity ambient lighting
 Excessive patient movement, or motion artifacts
 Decreased perfusion
 Presence of abnormal hemoglobin, carboxyhemoglobin
 Intravascular dyes
 Reduced accuracy with saturations below 83%
One significant risk of using a pulse oximeter is the possibility of treating an
incorrect reading as accurate. False-negative results for hypoxemia and false-
positive results for normoxemia or hypoxemia can occur. In these situations,
a patient may receive inappropriate treatment, leading to harm.
False normal or high readings can occur in multiple different settings.
Carboxyhemoglobin absorbs light at 660 nanometers, which is roughly the
same as oxyhemoglobin. Thus, in situations where carboxyhemoglobin is
high, a false normal reading may occur.[6] When glycohemoglobin A1c
levels are greater than 7%, such as in patients with type 2 diabetes, an
overestimation of arterial oxygen saturation may occur.[7] These situations
may require an arterial blood gas to determine oxygen saturation accurately.
It is also necessary to consider the clinical diagnosis when evaluating a
patient with hypoxemic symptoms, as in the case of carbon monoxide
toxicity. 
False low readings can also occur in multiple settings. Below are some
situations that may cause falsely low readings to occur.
 Methemoglobinemia
 Sulfhemoglobinemia
 Sickle hemoglobin
 Abnormal inherited forms of hemoglobin[8]
 Severe anemia
 Venous congestion
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Clinical Significance
The human eye's ability to detect hypoxemia is poor. The presence of central
cyanosis, a blue coloration of the tongue and mucous membranes, is the most
reliable predictor; it occurs at an oxyhemoglobin saturation of about 75%.
[3] Pulse oximetry provides a convenient, noninvasive method to measure
blood oxygen saturation continuously. It can also help to eliminate medical
errors. Pulse oximetry has a sensitivity of 92% and a specificity of 90% when
detecting hypoxia at a threshold of 92% oxygen saturation.[9]
There is no set standard of oxygen saturation where hypoxemia occurs. It is
generally accepted that a normal resting oxygen saturation of less than 95% is
considered abnormal.[10] Therefore, it remains vital to observe patients for
the clinical markers of hypoxemia. The brain is the most sensitive organ, and
visual, cognitive, and electroencephalographic changes develop when the
oxyhemoglobin saturation is less than 80% to 85%. It is unclear whether
there are long-term deficits from hypoxemia. Patients with nocturnal
hypoxemia do not seem to develop life-threatening complications despite
abnormally low oxygen saturation.[3]
Pulse oximetry should be regarded as an accurate measurement of the
patient's overall oxygen saturation. While few studies have demonstrated a
decrease in mortality from the use of pulse oximetry, it can be safely
determined that it provides more benefit than harm. Clinicians should be
aware of the limitations and errors associated with pulse oximetry. They
should use their best clinical judgment when deciding whether further
workup is needed. In the case of hypoxemia, a physician should always
consider whether an arterial blood sample would provide a more accurate
measure of oxygen saturation than pulse oximetry.
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Questions
To access free multiple choice questions on this topic, click here.
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References
1.
Hanning CD, Alexander-Williams JM. Pulse oximetry: a practical
review. BMJ. 1995 Aug 05;311(7001):367-70.[PMC free article]
[PubMed]
2.
Kaufman DP, Dhamoon AS. StatPearls [Internet]. StatPearls
Publishing; Treasure Island (FL): Oct 27, 2018. Physiology,
Oxyhemoglobin Dissociation Curve. [PubMed]
3.
Clause D, Detry B, Rodenstein D, Liistro G. Stability of
oxyhemoglobin affinity in patients with obstructive sleep apnea-
hypopnea syndrome without daytime hypoxemia. J. Appl.
Physiol. 2008 Dec;105(6):1809-12. [PubMed]
4.
 Bongard F, Sue D. Pulse oximetry and capnography in intensive and
transitional care units. West. J. Med. 1992 Jan;156(1):57-64. [PMC
free article] [PubMed]
5.
Grace RF. Pulse oximetry. Gold standard or false sense of
security? Med. J. Aust. 1994 May 16;160(10):638-44.[PubMed]
6.
Hinkelbein J, Koehler H, Genzwuerker HV, Fiedler F. Artificial
acrylic finger nails may alter pulse oximetry
measurement. Resuscitation. 2007 Jul;74(1):75-82. [PubMed]
7.
Pu LJ, Shen Y, Lu L, Zhang RY, Zhang Q, Shen WF. Increased
blood glycohemoglobin A1c levels lead to overestimation of arterial
oxygen saturation by pulse oximetry in patients with type 2
diabetes. Cardiovasc Diabetol. 2012 Sep 17;11:110. [PMC free
article] [PubMed]
8.
Sarikonda KV, Ribeiro RS, Herrick JL, Hoyer JD. Hemoglobin
lansing: a novel hemoglobin variant causing falsely decreased
oxygen saturation by pulse oximetry. Am. J. Hematol. 2009
Aug;84(8):541. [PubMed]
9.
American Thoracic Society; American College of Chest Physicians.
ATS/ACCP Statement on cardiopulmonary exercise testing. Am. J.
Respir. Crit. Care Med. 2003 Jan 15;167(2):211-77. [PubMed]
10.
Lee WW, Mayberry K, Crapo R, Jensen RL. The accuracy of pulse
oximetry in the emergency department. Am J Emerg Med. 2000
Jul;18(4):427-31. [PubMed]
Copyright © 2018, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
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Bookshelf ID: NBK525974PMID: 30247849

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In this Page
 Introduction
 Anatomy
 Indications
 Contraindications
 Equipment
 Personnel
 Preparation
 Technique
 Complications
 Clinical Significance
 Questions
 References

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