Pulse Oximetry in the Evaluation of Peripheral Vascular Disease

David
Jawahar, MD
Rachamalla, MD
H. R.
Alicja Rafalowski, MD
R. Ilkhani, MD
T. Bharathan, MD, FACA
and N. Anandarao, MB, BS

BROOKLYN, NEW YORK

ABSTRACT
The role of pulse oximetry in the evaluation of peripheral vascular disease (PVD) was
investigated. In addition, the value of elevating the limb to improve the sensitivity of
detection of PVD by the pulse oximeter was also determined. Pulse oximetry reading in
the toes were obtained in 40 young, healthy volunteers and in 40 randomly selected
patients referred to the vascular investigation laboratory over a period of two months. All
40 healthy volunteers had normal pulse oximetry readings. Normal pulse oximetry
reading in the toes was defined as 2 >95%
Sat O and ±2 of finger pulse oximetry reading.
In all 40 patients, pulse oximetry readings were either normal or not detected at all.
Since there was no gradation in decrease in the pulse oximetry reading with severity of
disease or with elevation of the patient’s lower extremity, an absent or no reading was
considered as an abnormal result from the test. The frequency of abnormal pulse
oximetry readings increased significantly in groups with abnormal ankle-brachial pressure
index (ABPI) and also varied significantly with elevation of the patients’ lower limbs. In
patients with no PVD detected by Doppler (ABPI >0.9), pulse oximetry readings were
normal in all. However, in patients with moderate PVD (ABPI, 0.5-0.9), 84% of the
patients’ lower limbs had normal pulse oximetry readings and 16% had an abnormal
reading at baseline level (flat). An additional 12% of the lower limbs in this group had an
abnormal reading on elevation of the limb to 12 inches. In patients with severe PVD
(ABPI < 0.5), 54% of the patients’ lower limbs had an abnormal reading at baseline and
an additional 23% had an abnormal reading at elevation of the limb to 12 inches. In

conclusion, pulse oximetry was not a sensitive test for detecting early PVD.

From the Department of Medicine, Division of Pulmonary Diseases, New York Methodist Hospital,
Brooklyn, New York.
@1997 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.

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I 1-~, I..
Introduction
The initial assessment of patients with peripheral
vascular disease (PVD) includes a thorough his-
tory and physical examination. Noninvasive tech-
niques have assumed an increasingly important
role in the management of patients with PVD.
With ultrasound techniques, the measurement of
the ankle-brachial pressure index (ABPI) in the
lower extremity of a supine patient at rest is the
best indicator of the presence or absence of &dquo;he-
modynamically significant&dquo; arterial occlusive dis-
eased The pulse oximeter is a widely available,
easy to use, portable instrument for measuring
oxygen saturation in the fingers and ear lobes. It
has been used extensively during anesthesia and
in critical care units.2 The pulse oximeter’s plethys-
mographic capability has been proposed as a mon-
itor of circulatory adequacy.3Pulse oximetry is not
being used currently for the evaluation of PVD of
the lower extremities. There have been isolated
conflicting reports on the value of pulse oximetry
in the diagnoses of PVD.4,5 Pallor on elevation of
the limb indicates ischemia and is a useful sign in
the evaluation of PVD. On the basis of this idea,
we investigated if pulse oximetry would change
on elevation of a limb and improve the sensitivity
in the diagnosis of PVD.
The purpose of our study was twofold: first,
to measure oxygen saturation in the toes and to
determine whether there was any decrease in
oxygen saturation on elevation of the patients’
lower limbs and, second, to compare pulse oxime-
try with Doppler-measured ankle-brachial pres-
sure index.
Patients and Methods
We conducted aprospective study involving 40
patients with suspected PVD and 40 healthy, non-
smoking, nondiabetic, asymptomatic control sub-
jects. The control subjects were medical residents
and nurses who were less than forty years of age.
The patients were randomly selected from all
those sent to the vascular laboratory for evalua-
tion of PVD. Pulse oximetry was done on all ten
toes on both lower limbs in all the subjects at
three levels: flat, elevation to 6 inches, and ele-
vation to 12 inches. Among the 40 patients sus-
pected of having PVD, 79 lower limbs were test-
ed. When pulse oximeter readings were detected
on the great toe, these were obtainable 92% of
the time in the second toe, 89% in the third toe,
79% in the fourth toe, and 73% of the time in the
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fifth toe. Since sensitivity was greatest in the big
toe, readings from the big toe were used for eval-
uation in study. The oximeter readings were
our
with
compared finger pulse oximetry readings.
Pulse oximetry readings in the toes were consid-
ered normal when the oxygen saturation (02
as
Sat) greater than 95% and ±2 of finger pulse
was
oximetry readings. The patients suspected of hav-
ing PVD later underwent Doppler ultrasound with
measurement of resting ankle-brachial pressure
index and also detection and quantification of
flow. Since the volunteers were less than forty
years old without any symptoms of PVD, duplex
scanning with measurement of ABPI was not per-
formed. Patients were divided into three groups:
(1) those with ABPI >0.9, (2) those with ABPI
0.5 to 0.9, and (3) those with ABPI <0.5.
Results
All the asymptomatic healthy young volunteers
had normal pulse oximetry readings of all toes,
and there was no change in the readings when
their lower limbs were elevated to 6 and then to
12 inches.
The frequency of abnormal pulse oximetry
readings differed significantly between the three
ABPI groups in the flat, as well as in the elevated
positions (Fisher’s Exact Test P=.0044 and .0002,
respectively). The 12-inch elevation did not sig-
nificantly increase the number of abnormal read-
ings in the moderate PVD group (P<0.25) but did
in the severe PVD group (P<0.03).
In patients who had an ABPI of > 0.9, 100%
of the lower limbs had normal pulse oximeter
readings of the toes and there was no decrease in
the oximeter readings on elevation of the limb to
12 inches (Table I). In patients who had an ABPI
of 0.5 to 0.9, 84% of the lower limbs had normal
pulse oximeter readings in the great toe while
16% had an abnormal test reading. However, on
elevation of the limb to 12 inches, 28% of the
limbs had an abnormal test reading. In patients
who had an ABPI of <0.5, 54% of the limbs had
an abnormal test reading on pulse oximetry at the
flat level, and 77% had an abnormal test reading
on elevation of the limb to 12 inches.
Discussion
~I
Vascular disease is widespread health problem.
a
Arteriography remains the
gold standard for ac-
curate diagnosis and evaluation of peripheral ar-
 TableI
Pulse Oximetry Reading
rPulse oximetry reading in the toes >95% O2 Sat. and ±2 of finger pulse
**Absent or no reading by the pulse oximeter.
ABPI=ankle-brachial pressure index, PVD=peripheral vascular disease.
terial disease. However, it is invasive and does
not provide the physiological assessment or the
hemodynamic impairment associated with the
vascular disease. Recently, noninvasive diagnostic
techniques have been widely used for supple-
menting clinical examination in the evaluation of
patients with peripheral vascular disease.
Duplex scanning and color flow mapping rep-
resent the most accurate and versatile of all non-
invasive vascular diagnostic techniques. Duplex
scanning of the vessels (arteries) offers increased
sensitivity and specificity and can localize and
characterize the extent of vascular lesions.6 The
major limitation of these devices are their cost,
complexity, and relative lack of portability. The
ankle systolic blood pressure divided by the upper
limb pressure (ankle-brachial pressure index
[ABPI]) is a very good indicator of the presence
or absence of &dquo;hemodynamically significant&dquo; ar-
terial occlusive disease. The ABPI test is used ex-
tensively and requires only basic Doppler ultra-
sound equipment. In our study, the ABPI corre-
lated very well with duplex scanning. Normally,
the ABPI is greater than or equal to 0.90. Patients
with extremity pain with exercise (claudication)
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oximetry.
will usually have an ABPI between 0.5 and 0.9.
Patients with ischemic foot pain at rest usually
have an ABPI <0.5.
Transcutaneous oxygen measurement is a use-
ful method known to assess the functional status
of skin and blood flow.However, it has not been
used commonly because it is time consuming and
cumbersome and requires frequent calibration.
Tissue pulse oximetry detects pulsatile flow
in the extremities. The absorbance characteristics
of arterial oxygenated and venous reduced he-
moglobin are different and these absorbance
characteristics are reflected as values of oxygen
saturation by the pulse oximeter in a pulsatile
manner. Pulse oximetry has become the standard
of care in the operating room, recovery room, in-
tensive care units, and other clinical settings.2
There are reported anecdotal uses including, de-
termining ductus arteriosus patency,8assuring pa-
tency of major arterial grafts,9 indicating artery
compression in shoulder arthroscopy,i° and as-
sessing circulatory adequacy of the upper limb
when an unconscious patient is placed in the lat-
eral or prone position with upper limbs elevated
or hyperabducted for surgery.&dquo; Cardiopulmonary
 resting and exercise tests 12 and sleep abnormality In our study, in patients who had normal
studiesl3 are now more easily and accurately lower limb vascular supply, pulse oximetry was
done with oximetry. Pulse oximetry was useful as very sensitive in detecting the normal pulsatile
a simple bedside test to identify ulnar collateral flow of blood. However, pulse oximetry failed to
flow. 14 In general, pulse oximetry is used to de- detect about three fourths of the limbs with mod-
tect arterial oxygen saturation and is used on the erate disease and about one fourth of the limbs
fingers. When peripheral vasoconstriction or hy- with severe peripheral vascular disease.
potension limits finger perfusion, the ears are the
next most common site of use. At low saturation, Conclusion
the ear reading is closer to arterial oxygen satu-
ration than the finger reading in most tested
Pulse oximetry was not a sensitive test for detect-
oximeters.15 Probes have also been mounted on ing peripheral vascular disease.
the tongue,16 cheek,17 nose,18 and forehead.19
There have been isolated, conflicting reports on Acknowledgment
the usefulness of pulse oximetry in the evaluation We thank Ms. Laura Lamb-Susca, RN, RVT, for
of peripheral vascular disease. In one study,44 her help in measurements.
pulse oximetry was noted to be a more sensitive
index of peripheral perfusion than transcutaneous David Jawahar, MD
oximetry or Doppler flowmetry. In another re- 501 Sixth Street
&dquo;
port,5pulse oximetry had no value in the assess- Apt. 12J
ment of peripheral arterial circulation. Brooklyn, NY 11215

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