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Pediatrics 2011 Fouzas 740 52
Pediatrics 2011 Fouzas 740 52
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740 FOUZAS et al
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742 FOUZAS et al
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REVIEW ARTICLES
which refers only to the arterial hemo- of absorption (especially when due to black, blue, or green color and syn-
globin that is capable of transporting venous blood) will affect the signal-to- thetic nails might interfere with pulse
oxygen (functional hemoglobin ⫽ oxy- noise ratio and drive SPO2 to lower oximetry and result in an underestima-
hemoglobin/[oxyhemoglobin ⫹ deoxy- than true values.41,42 Fortunately, mo- tion of SaO2.54,55,59 This effect can be
hemoglobin]). Functional saturation tion artifacts can be recognized by avoided by mounting the probe on the
differs from fractional hemoglobin sat- motion alarms or distorted plethysmo- finger sideways.34 New-technology
uration (Fractional hemoglobin ⫽ oxy- graphic waveforms. However, rhyth- pulse oximeters are less susceptible
hemoglobin/total hemoglobin), which mic motions or vibrations with a fre- to these limitations.21,34,56–58
can be measured by most blood gas an- quency similar to heart rate (0.5–3.5 Bilirubin has no effect on pulse oxime-
alyzers with co-oximetry. The total hemo- Hz) can be particularly troublesome.41 try, because it presents a different
globin denominator in the calculation of Sophisticated read-through-motion spectrum of light absorption (at ⬃450
fractional hemoglobin might include ab- and motion-tolerant technologies con- nm). Therefore, the method can be used
normal or variant hemoglobin mole- tinue to evolve and have improved the reliably for monitoring jaundiced pa-
cules with limited oxygen-carrying prop- performance of the new-generation tients, including neonates.13,15,20,21,28,30,34
erties.30,35,36 Therefore, the terms oximeters.30,43–46 However, patients with severe hemo-
“functional” and “fractional” hemoglobin lytic jaundice might also have in-
saturation are not interchangeable.36 In Poor Perfusion
creased carboxyhemoglobin (COHb) lev-
situations such as dyshemoglobinemias, Adequate arterial pulsation at the site els, which could potentially lead to
pulse-oximetry readings do not ade- of measurement is essential for distin- erroneous pulse-oximetry readings.15 In
quately reflect the oxygen-carrying prop- guishing true signal from background addition, falsely low SPO2 values have
erties of arterial blood.15,28,35,37 It should noise.41,42 Low-perfusion states, such been reported in bronze baby
be noted also that pulse oximetry does as low cardiac output, shock, hypo- syndrome.60
not provide information regarding venti- thermia, vasoconstriction, arterial oc-
lation or acid-base status.30,38–40 clusion, or during blood pressure cuff Irregular Rhythms
inflation, might impair the functioning
Inaccurate oximetry readings can be ob-
LIMITATIONS OF PULSE OXIMETRY of the device and result in lower SPO2
served with irregular heart rhythms, es-
readings or delayed recognition of
The limitations of pulse oximetry can pecially during tachyarrhythmias.21
acute hypoxemia.13,28,46–50 For infants
be generally classified as safe or po- These artifacts can usually be recog-
with cold extremities, local rubbing or
tentially unsafe (Table 1). Safe limita- nized by observing the plethysmo-
heating before the application of the
tions refer to those circumstances in graphic wave form. Currently available
probe might temporarily improve perfu-
which the inaccuracy in the displayed devices possess signal-extraction tech-
sion; however, for hypothermic patients,
SPO2 can be suspected, and its cause is nologies that are capable of recognizing
monitoring by a forehead probe is an
recognizable. In this case the observer such events.20,21,34
alternative option.51 New-generation
is usually warned by the device
devices are equipped with signal- Electromagnetic Interference
(alarm) about the pitfall. A potentially
extraction algorithms and can perform
unsafe limitation is considered to be Electromagnetic energy from electro-
better in low-perfusion states.30,46–49
any situation in which the inaccuracy surgical cauterization units and cellu-
is difficult to recognize; the displayed Skin Pigmentation, Nail Polish, and lar phones might interfere with pulse
SPO2 is erroneous, but the observer is Artificial Nails oximeters and lead to erroneous SPO2
not warned about the pitfall. readings.61 Special devices with fiber-
In theory, skin pigmentation presents
a constant level of absorption that is optic technology should be used dur-
Safe Limitations ing MRI to avoid both interference with
subtracted in the calculation of SPO2
Motion Artifacts and, therefore, should not influence image quality and potentially danger-
the performance of the device.12,34 ous heating of the sensor with conse-
Motion artifact represents the most
However, dark skin pigmentation has quent thermal injury.61,62
common limitation of pulse oxime-
try.13,15,28 Because the normally pulsa- been incriminated for erroneous SPO2
Potentially Unsafe Limitations
tile (arterial) component of light ab- readings, especially at SaO2 values of
sorption represents no more than 5% ⬍80%.21,52,53 Calibration Assumptions
of the total absorbed energy, any mo- Although data regarding the impact of As stated already, the displayed SPO2 is
tion that alters the remaining fraction nail polish are conflicting,54–58 polish of the result of the conversion of the ratio
FOUZAS et al
Increased noise caused by changes in nonpulsatile False alarms Stabilize sensor
component of light absorption Change sensor position
Use new-generation pulse oximeters
Poor perfusion Decreased signal caused by decreased pulsatile (arterial) Lower SPO2 readings Evaluate plethysmographic waveform
component of light absorption Check and correct skin temperature and peripheral perfusion
Place sensor more centrally
Use new-generation pulse oximetersb
Skin pigmentation Probably caused by calibration assumptions for dark skin Lower or less reliable SPO2 readings at lower SaO2 Use new-generation pulse oximetersb
pigmentation values
Nail polish and artificial nails Decreased signal because of decreased light absorption with Lower SPO2 readings Change sensor position
artificial nails or nail polish of black, blue, or green color
Irregular rhythms Increased noise caused by tachyarrhythmias Lower or less reliable SPO2 readings Evaluate plethysmographic waveform
Use new-generation pulse oximetersb
Electromagnetic interference External electromagnetic energy interference caused by Lower SPO2 readings Evaluate plethysmographic waveform
electrosurgical cauterization units, cellular phones, or MRI False alarms Avoid external electromagnetic energy sources
devices Heating of the sensor and thermal injury (MRI) Use pulse oximeters with fiber-optic technology (MRI)
Potentially unsafe limitationsa
Calibration Device-specific calibration algorithms derived by correlating SPO2 readings of ⬍80%–85% are less accurate Use new-generation pulse oximetersb
light absorption ratios over a SaO2 spectrum of 80%–100% especially at the extremes of the age spectrum
in healthy young adults
Lower SPO2 values calculated by mathematical equations
Time lag Software-related delay between sudden changes in blood Delay in detecting clinically important desaturation, Use new-generation pulse oximetersb
oxygenation and SPO2 readings which may exceed 15–20 s Do not use pulse oximetry as a substitute for
cardiorespiratory monitoring in critically ill patients
Probe positioning The emitted light energy is projected tangentially to the Lower SPO2 readings Place sensor with the emitter and the detector exactly
detector because of inappropriate sensor placement opposite to each other
(“penumbra” or “optical shunting” effect) Use probes of appropriate size in neonates and infants
Ambient light interference Intense external light energy (as in phototherapy) may Lower SPO2 readings Use new-generation pulse oximetersb
interfere with the photodetector (“flooding” effect) Cover the sensor
Abnormal hemoglobin COHb presents red-light absorption similar to oxyhemoglobin In carboxyhemoglobinemia pulse oximetry Check arterial SaO2 if abnormal hemoglobin molecules are
molecules overestimates blood oxygenation suspected (ie, carbon monoxide intoxication)
Methemoglobin absorbs equal amount of energy in the red In significant methemoglobinemia, SPO2 tends Suspect abnormal hemoglobin molecules if the SaO2–SPO2
and infrared spectra, which affects the ratio of absorption toward 85% difference exceeds 5%
c Pulse co-oximeters are capable of detecting abnormal hemoglobin molecules by using multiwavelength technology.
REVIEW ARTICLES
of absorption ratios into percent satu- propriate size for neonates and equal amounts of energy in the red and
ration by using specific calibration al- infants.13,28,34 infrared spectrums14 (Fig 1). In signifi-
gorithms. These algorithms are de- cant methemoglobinemia (MetHb ⬎
rived by correlating the ratio of the Ambient Light Interference 30%), the ratio of absorption ratios will
absorption ratios with arterial gas Intense white or infrared light might tend toward the unit (SPO2 ⬃ 85%),
SaO2 measurements in healthy young interfere with pulse oximetry and lead thus underestimating high saturation
volunteers over a range of desatura- to falsely low SPO2 readings. This phe- values and overestimating severe hy-
tion values. Because it is unethical to nomenon, known as the “flooding” ef- poxemia.71,73,74 If the difference be-
desaturate volunteers below SaO2 lev- fect, is caused by the excessive in- tween SaO2 and SPO2 (the “SaO2–SPO2
els of ⬃80%, lower SPO2 values are de- crease of the light energy that literally gap”) exceeds 5%, the presence of ab-
rived by extrapolation and, therefore, floods the photodetector and drives normal hemoglobin molecules should
are less accurate.15,17,24,29,34 Moreover, the ratio of absorption ratios toward be investigated by co-oximetry.72,73
because the subjects recruited for cal- the unit; this corresponds to an SPO2 Pulse co-oximeters, by taking advan-
ibration purposes are healthy young of 85%.16 Although new-generation tage of novel multiwavelength technol-
adults, the applicability of calibration devices can detect light interfer- ogies, have been shown to accurately
data to patients at the age extremes ence,16,21,34,68 health care professionals, measure both COHb and MetHb.71,75–78
has been questioned.13,15,25,30,34 particularly those who handle neo-
nates exposed to phototherapy, must Fetal hemoglobin and hemoglobin S
Time Lag in the Detection of Hypoxic be aware of this potential limitation. present light-absorption characteris-
Events Ambient light interference can be tics similar to those of adult hemoglo-
avoided by simply covering the sensor bin and do not interfere with pulse
Most conventional pulse oximeters
with nontransparent material. oximetry.14,79–81 However, physicians
present a clinically significant delay
should remember that abnormal he-
between a sudden change in blood ox-
Abnormal Hemoglobin Molecules moglobin molecules affect ODC (Fig 3);
ygenation and the related change in
Abnormal or variant hemoglobin mole- thus, the displayed SPO2 value might
the displayed SPO2 values. This time lag
depends on the complexity of the algo- cules might interfere with pulse oxim- not reliably reflect tissue oxygenation,
rithms used and might exceed 15 to etry and lead to inaccurate results particularly for children with sickle
20 seconds.34,63–65 Although new- that might influence clinical decision- cell disease.30,82
generation devices have improved re- making.69 Carboxyhemoglobinemia Anemia does not seem to affect the ac-
sponse times, and desaturation events represents the most dangerous limita- curacy of pulse oximetry, at least for
can be detected earlier if the probe is tion of pulse oximetry, because in the hemoglobin levels of ⬎5 g/dL and
placed more centrally (eg, at the ear presence of COHb the method overes- if cardiovascular function is pre-
lobe),13,21,63 pulse oximetry should not timates arterial oxygenation. This served.34,80,83,84 Similarly, polycythemia
be used as a substitute for cardiore- effect is caused by the specific charac- does not seem to interfere with pulse
spiratory monitoring in critically ill teristics of COHb, which exhibits red- oximetry.80
patients.30,34 light absorption similar to that of oxy-
hemoglobin14 (Fig 1). Therefore, Venous Pulsation
Probe Positioning increased COHb levels affect the ratio
of absorption ratios and cause the In case of significant tricuspid regurgi-
Lower SPO2 readings might occur when
pulse oximeter to overread by ⬃1% for tation and in hyperdynamic circulation
the probe is inappropriately placed,
every 1% increase of circulating states, the pulsatile variation of ve-
especially on the small fingers of neo-
COHb.70,71 Therefore, SPO2 values nous blood might affect signal-to-noise
nates and infants.13,28 In this case, the
should be verified by SaO2 measure- ratio and result in erroneous SPO2
emitted light can be projected tangen-
ments using a co-oximetry method readings.85,86
tially to the detector, sometimes with-
out crossing an arterial bed, phenom- when the presence of COHb is sus-
pected (eg, carbon monoxide Intravenous Dyes
ena which have been described as the
“penumbra” and “optical shunting” ef- intoxication).21,69,72,73 Intravenous dyes such as methylene
fects, respectively.66,67 This pitfall can Methemoglobinemia also represents blue (actually used as a first-line treat-
be avoided by positioning the emitter an important but less dangerous limi- ment for severe methemoglobinemia),
and the detector exactly opposite to tation of pulse oximetry.69 Methemo- indocyanine green, and indigo carmine
each other and by using probes of ap- globin (MetHb) absorbs approximately might cause lower SPO2 readings.15,34,87,88
746 FOUZAS et al
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tomatic infants and children with an tions of peripheral perfusion, SPO2 val- titration of inspired oxygen concentra-
SPO2 of ⱕ92% should be treated with ues can be reliably measured ⬃2 min- tion, it cannot reliably prevent hyper-
oxygen and admitted to the hospital.128 utes after birth.137,139,140 Use of new- oxic events.13,19,30,34 SPO2 values of
However, despite its very good positive generation devices and sensors of ⬎92% do not accurately correlate with
predictive value, the method cannot re- appropriate size, as well as probe at- PaO2, as is clearly depicted by the
liably exclude the disease in emer- tachment to a preductal location (ie, shape of the ODC (Fig 3). At such high
gency settings.127,129 Pulse oximetry is right upper extremity), preferably be- SPO2 values, small variations of SPO2
mandatory for monitoring hospitalized fore connecting the probe to the de- might relate to disproportionally
patients with pneumonia to guide man- vice, might result in more accurate wider variations of PaO2.145 Therefore,
agement and to assess response to and timely readings.133,134 However, caution is required when interpreting
treatment. It is recommended that the health care professionals should be pulse-oximetry readings in situations
SPO2 be maintained at ⬎92% with a aware that, even in uncompromised in which hyperoxia is to be avoided, es-
fraction of inspired oxygen of ⬍0.6; neonates, an increase in SPO2 at levels pecially in case of preterm and low
otherwise, transfer to intensive care of ⬎90% might take ⬎10 minutes to birth weight neonates for whom exces-
should be considered.128 achieve.135–140 Therefore, pulse oxime- sive oxygen administration can be par-
try should be used in conjunction with, ticularly harmful.146–151 Although a
Cardiovascular Applications but not as a substitute for, clinical as- single best range has not been estab-
Pulse oximetry can be used for heart sessment during the transitional pe- lished yet, there is convincing evidence
rate monitoring or might serve more riod after birth.133,134 that SPO2 values between 85% and 93%
specialized applications, such as the are sufficient to maintain normox-
assessment of peripheral perfusion Neonatal Screening for Congenital
emia152 and to decrease the incidence
and hemodynamic status.130,131 The ple- Heart Disease
of retinopathy of prematurity in in-
thysmographic waveform has been Pulse oximetry has been proposed as a fants receiving supplemental oxy-
shown to be useful in the estimation of reasonable screening tool for the early gen.148–151 In extremely preterm neo-
blood pressure when manometry detection of asymptomatic newborns nates, however, lower SPO2 targets (ie,
fails.131 It can also offer a semi- with critical congenital heart disease 85%– 89%) have been associated with
quantitative evaluation of “pulsus (CCHD).141,142 Single lower-extremity an increased risk of mortality com-
paradoxus” by identifying an exagger- SPO2 values obtained after 24 postnatal pared with higher SPO2 levels (ie, 91%–
ated decrease of pulse-wave ampli- hours seem to be convenient for large- 95%).153 Further ongoing trials on this
tude during inspiration.132 scale screening.142 An SPO2 threshold issue are expected to resolve the un-
of ⱕ95% at low altitudes seems to be certainties surrounding optimum SPO2
Neonatal Resuscitation appropriate.142 Although the method range in premature neonates receiv-
Assessment of skin color is not a reli- has been shown to have excellent spec- ing supplemental oxygen.154
able indicator of oxygenation status ificity and negative predictive value,
during the immediate postnatal pe- its sensitivity and false-positive rate NOVEL TECHNOLOGIES AND FUTURE
riod.133 Moreover, the optimal manage- might vary substantially.142–144 The DIRECTIONS
ment of oxygenation during neonatal cost/benefit balance of routine univer-
resuscitation is critical, because there sal screening has not been well quan- Pulse oximetry has been proven to be
is strong evidence that both hypoxia tified; however, important cost savings an extremely useful tool in patient as-
and hyperoxia can be harmful.134 The could emerge because of early diagno- sessment and monitoring in pediatric
feasibility and reliability of pulse oxim- sis and treatment of infants with practice. However, its widespread use
etry during neonatal resuscitation CCHD.141 Future studies, designed to over the last 3 decades has also re-
have been proven in several stud- assess the impact of routine neonatal vealed its inherent limitations.
ies.135–138 Thus, SPO2 monitoring in the screening by pulse oximetry on mor- The theoretical model of conventional
delivery room is currently recom- bidity, mortality, and hospital costs re- pulse oximetry assumes that the arte-
mended for neonates with persistent lated to CCHD, are expected to clarify rial blood is the only light-absorbing
cyanosis, when assisted ventilation this issue.144 pulsatile component. However, this as-
and supplementary oxygen adminis- sumption has been challenged by SPO2
tration are required, or when neonatal Prevention of Hyperoxia readings during motion that fall to
resuscitation is anticipated (high-risk Although for ventilator-dependent pa- ⬍85% (which corresponds to a ratio
deliveries).133 Under acceptable condi- tients pulse oximetry can assist in the of absorption ratios equal to 1); this
748 FOUZAS et al
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HOW MUCH IS ENOUGH?: Many of my friends exercise all the time, whereas
others hardly ever do. When I ask those not exercising why they don’t, most say
they don’t have enough time, that it is too hard to start, or that exercising just a
few minutes a day is unlikely to be beneficial. Exercise physiologists and others
have long wondered just how much aerobic exercise each day or each week is
necessary to produce a health benefit in adults. As reported in USA Today
(Fitness & Food: August 2, 2011), it turns out that it doesn’t take much at all.
Federal guidelines suggest that adults should engage in 150 minutes of
moderate-intensity activity each week; this is still a reasonable goal. However,
new data suggest that almost any amount of exercise may be beneficial. Adults
engaging in as little as 10 to 15 minutes/day of moderate-intensity exercise
accrue some benefit in the prevention of heart disease. In studies evaluating the
risk of heart disease in sedentary and exercising adults, the most dramatic
health benefits were seen in those who went from not exercising at all to
exercising a little bit. The data also show that there is an indirect relationship
between the amount of exercise and the risk of heart disease. Compared to
sedentary people, those who engaged in 150 minutes of moderate-intensity
exercise each week had a 14% reduced risk of heart disease. Those who exer-
cised 300 minutes/week had a 20% risk reduction, and a 25% risk reduction if
they exercised 750 minutes/week. Women, for unknown reasons, derive a
greater benefit from exercise than men. Bursts of activity followed by long
periods of inactivity, however, were not beneficial. This suggests that for better
health, one needs to keep moving. Although researchers have not been able to
quantify the exact health benefit to 75 minutes of weekly moderate-intensity
exercise, the American College of Sports Medicine recently revised its guide-
lines. Although the guidelines still recommend that adults engage in at least 150
minutes of moderate-intensity exercise each week to achieve weight reduction
and help maximize the health benefits of exercise, just a little exercise, such as
75 minutes/week, is likely to be beneficial. The data are fairly clear. To borrow a
marketing phrase from Nike: just do it.
Noted by WVR, MD
752 FOUZAS et al
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Pulse Oximetry in Pediatric Practice
Sotirios Fouzas, Kostas N. Priftis and Michael B. Anthracopoulos
Pediatrics 2011;128;740; originally published online September 19, 2011;
DOI: 10.1542/peds.2011-0271
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