PULSE OXIMETRY

& CCHD
SCREENING
Dr Anusha R
DrNB Neonatology resident

Moderator – DR Tushar B Parikh

DM Neonatology
Consultant KEM Hospital, Pune
 Clinical tools to measure oxygenation

1. Arterial blood gas sample

• Accurate, invasive, expensive, intermittent measurements only
2. Transcutaneous oxygen – TcPO2
• Continuous measurement possible, noninvasive, sensor requires to be
heated to allow measurement
• Site of sensor needs to be changed frequently to avoid burn
• Cumbersome to use
3. Pulse oximetry
4. Co-oximetry
 PHYSICS OF PULSE OXIMETRY

• Beer-Lambert law, states that the concentration of an unknown solute

in a solvent can be determined by light absorption, i.e.

• L (out) = L (in) – (DCa)

Where,
L = Intensity of light used
C = Concentration of solute in the solution
D = Distance in travelled by light in the solution (path length)
a = Absorption coefficient of solute.
 Physical principles-pulse oximetry

1. The presence of a pulsatile signal generated by the arterial blood

flow.

2. The difference in the absorption spectra of oxyhemoglobin (HbO)

and reduced hemoglobin (HbH).
 PRACTICAL WORKING OF PULSE OXIMETER

• Probe of pulse oximeter consists of two light emitting diodes

• It emits equal intensities of red and infrared light in sequence into
pulsatile tissue bed.
• Variable amount of these lights are absorbed by oxygenated and
reduced hemoglobin.
• A photodetector placed on the opposite side senses the ratio of red and
infrared
• The built in microprocessor - assesses and digitally displays the
saturation
 How does the pulse oximeter work?
• The sensor detects how much oxygen is in your blood, depending on the
amount of oxygenated and deoxygenated hemoglobin, which in-turn
depends the ratio of the amount of red light absorbed as compared to
amount of infrared light absorbed by the respective hemoglobins .
• Reduced hemoglobin absorbs more red light than infrared light
• And oxygenated hemoglobin absorbs more infrared than red
• Only the pulsatile change in light transmission through living tissue is
measured to calculate arterial saturation
• Thus, absorption of light by venous blood, skin pigments, tissue and
bone is automatically eliminated from consideration.
 USEFULNESS OF PULSE OXIMETRY
1. It provides the fifth “vital parameter”, besides temperature, pulse
,respiration and blood pressure
2. It is a useful adjunct in the assessment of response to resuscitation.
3. It aids in titration of oxygen in newborns.
4. It can act as apnea monitor (indicating bradycardia and desaturation).
5. It is a valuable companion during transport of newborns.
6. Valuable for diagnosing critical congenital heart disease.
 Site of attachment

1. Finger tip
2. Handheld
3. Wrist
4. Ear lobule
5. Feet
6. Forehead
 Correlation of PaO2 and SpO2/Oxygen-Hb
dissociation curve
• As this curve reaches flat upper end, further increase in
PaO2 causes a little change in saturation.
• At (around 100%), one never knows how high the
actual PaO2 might be.
• A shift to right means less saturation at given PaO2.
• At <80% sPO2 precision of pulse oximeter decreases
dramatically due to steep curve of O2 dissociation
curve.
 Limitations of Pulse Oximetry

1. Hypovolemic states or low perfusion states.

2. Dyshemoglobinemias—COHb, Meth Hb.
3. Dyes and pigments including nail polish, henna
4. Optical interference from external light sources (phototherapy)
5. Excess movement artifacts.
6. As software varies between manufactures, inter-use of sensors by
different manufacturers gives false results
 Pitfalls and Precautions
1. The accuracy of pulse oximetry is about ±4 to 5% at or above 80% saturation.
Accuracy declines below 80%.
2. Less accurate in severe anemia
3. Unable to distinguish different types of hemoglobins.
4. No value in estimation of adequacy of ventilation
5. Lag monitor phenomenon—often a fall in partial pressure of oxygen precedes
the fall in oxygen saturations
6. If probe does not fit properly, the light can be shunted from the LEDs directly to
photodetector affecting the accuracy of the measurement
 Causes of unreliable SpO2 readings

1. Causes of falsely normal or elevated SpO2

Carbon monoxide poisoning
Sickle cell anemia vasoocclusive crises

2. Causes of falsely low SpO2

Venous pulsations, excessive movement, pigmented dyes, abnormal hemoglobin,
Severe anemia (with concomitant hypoxemia)

3. Causes of falsely low or high SpO2

Methemoglobinemia
Sulfhemoglobinemia
Unexpectedly low pulse oximetry measurements associated with variant
hemoglobins

American Journal of Hematology, Volume: 85, Issue: 11, Pages: 882-885, First published: 25 October 2010, DOI: (10.1002/ajh.21810)
• Pulse oximetry readings can be misleading in the setting of carbon monoxide (CO)
exposure or methemoglobinemia because these devices use only 2 wavelengths of
light (the red and the infrared spectrum), which detect oxygenated and deoxygenated
hemoglobin only and not any other form of hemoglobin.
 Question 1
A 3 year old girl was rescued from housefire. She developed complaints of
nausea, headache, skin colour was pink/cherry red and had no cyanosis. She
became unconscious on arrival to ER. Pulse oximetry shows oxygen
saturations of 99%. Arterial blood gas records a normal Pa02. Which of the
following conditions you should look for?
a. Carbon monoxide poisoning
b. Methemoglobinemia
c. Red nail polish
d. Cyanide poisoning
e. Peripheral vasoconstriction
 Question 2
A normally well 2 month old neonate is noted to have marked peripheral cyanosis.
Pulse oximetry shows oxygen saturations of 79% though a follow up arterial blood
gas records a normal Pa02.2DECHO was normal. Which of the following conditions
might explain the discrepancy between clinical signs, pulse oximetry and arterial
PaO2?
a. Carbon monoxide poisoning
b. Methaemoglobinaemia
c. Red nail polish
d. Cyanide poisoning
e. Peripheral vasoconstriction
 Methaemoglobinaemia
• (MetHb). MetHb contains an oxidised form of haemoglobin, ferric (Fe3 +)
Hb which cannot bind oxygen.
• MetHb- the average haemoglobin oxygen saturation is reduced causing
cyanosis and low saturations as measured by pulse oximetry.
• Arterial blood gas analysis does not take into account the presence of
methaemoglobin and so shows high PaO2 levels, reflecting the near full
saturation of normal ferrous (Fe2+) Hb, even in the presence of cyanosis.
• Methemoglobin causes a large absorbance at both 660 and 940 nm, making
SpO2 unreliable in a patient with methemoglobinemia.

• Light reflection is similar to that in reduced hemoglobin.

• Pulse oximetry may show a depressed oxygen saturation, but the decrease does not
accurately correlate with the level of methemoglobinemia.

• In fact, as methemoglobin levels reach 30% or higher, the pulse oximetry reading
converges on approximately 85%.
 Cyanide poisoning
• Cyanide causes inhibition of oxygen utilization, so arterial oxygen
unloading may not occur leading to high venous oxygen saturation.
• High pulse oximeter readings in cyanide poisoning reflect the true
state of haemoglobin oxygen saturation
• But do not reflect the profound hypoxia occurring at the tissue level.
 Pulse Oximetry Versus Co-oximetry

• The gold standard for estimation of oxygenation, is the determination

of partial pressure of oxygen (PaO2) by co-oximetry or ABG
• The fundamental difference is that pulse oximetry accounts for only
oxyhemoglobin and reduced hemoglobin,
• Whereas in co-oximetry other forms of hemoglobin like
methemoglobin, carboxyhemoglobin are also accounted for.
• CO-oximeters use 4 wavelengths of light and are capable of detecting
carboxyhemoglobin and methemoglobin as well as hemoglobin and
oxyhemoglobin.
• Some newer co-oximeters use 5 wavelengths and are also able to
measure sulfhemoglobin.
• The percent of oxyhemoglobin measured by CO-oximetry is an
accurate measure of the arterial oxygen saturation.
SIGNAL EXTRACTION TECHNOLOGY
(MASIMO)
• Masimo SET employs five algorithms using adaptive filters, working in parallel to
ensure accurate measurement in difficult situations like motion or low perfusion
• Further there are now next generation pulse oximeters by Masimo—the rainbow
SET pulse co-oximetry, which uses seven algorithms
• Enabling this device to measure non-invasively, total hemoglobin (Sp Hb),
respiratory rate (RRa), pleth variability index (PVI), oxygen content, and levels of
carboxyhemoglobin (SpCO) and methemoglobin (Sp Met).
What makes Masimo SET different from conventional
pulse oximetry?
• Conventional pulse oximetry assumes that it is the arterial blood
which moves in a pulsatile manner
• It fails to distinguish venous from arterial blood.
• Masimo SET identifies the venous blood signals, isolates it, and using
adaptive filters, cancels the noise and extracts the arterial signal.
• This technology will work during patient motion artifact, low
perfusion states with low signal output and during intense ambient
light exposures.
 CCHD SCREENING
• States with legislation mandating screening achieved a 33% reduction
in early cardiac deaths due to CCHD compared with states with no
policy or a nonmandatory policy.
 Revised algorithm for CCHD screening with pulse oximetry.

Gerard R. Martin et al. Pediatrics 2020;146:e20191650

©2020 by American Academy of Pediatrics

 Modifying the CCHD Screening Algorithm

• The new algorithm has 2 key differences:

(1) requiring 95% or greater in both the right hand and foot to be
considered passing and
(2) having only 1 retest instead of 2.
• These changes are expected to simplify the algorithm interpretation
• Increase the overall sensitivity of POS.
• However, these changes may also slightly increase the false-positive
rate.
• CCHD screening -performed between 24 and 48 hours of life (HOL)
• Screening closer to 48 HOL increases likelihood to detect emerging
ductal dependent CCHD
• Earlier screening can lead to false positive results because of the
transition from fetal to neonatal circulation and stabilization of systemic
oxygen saturation levels.
• If discharge prior to 24 HOL is planned, complete as close to discharge as
possible.
 Diseases screened by POS
These seven defects are
• Hypoplastic left heart syndrome,
• Pulmonary atresia,
• Tetralogy of fallot,
• Total anomalous pulmonary venous return,
• Transposition of the great arteries,
• Tricuspid atresia, and
• Truncus arteriosus.
 CCHD Screening in the NICU
• NICU infants, when medically appropriate, should be screened as part of the
discharge process.
• The presence of lung disease and other illness makes the interpretation of complex
• For those infants who have not had echocardiography performed as part of their
care, the CCHD screening protocol should be followed once they have been
weaned from supplemental oxygen.
 Points to Remember
• Inaccurate readings : Poor tissue perfusion, exposure of probe to
light ,movement artifact, abnormal hemoglobins
• Oxygen saturation monitors are unreliable in detecting hyperoxia at
high saturation values.
• The error in reading is 2% in the range of 95–100%. Therefore, a
saturation reading of 96% may be as low as 94% or as high as 98%.
• Pulse oximetry screening is imperative for all neonates to detect
critical congenital heart disease.
THANK YOU