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1.  Accuracy of pulse oximeters in estimating heart rate at rest and during exercise. 
Pulse oximeters are being widely used for non-invasive, simultaneous assessment of haemoglobin oxygen saturation. They are reliable, accurate, relatively inexpensive and portable. Pulse oximeters are often used for estimating heart rate at rest and during exercise. However, at present the data available to validate their use as heart rate monitors are not sufficient. We evaluated the accuracy of two oximeters (Radiometer, ear and finger probe; Ohmeda 3700, ear probe) in monitoring heart rate during incremental exercise by comparing the pulse oximeters with simultaneous ECG readings. Data were collected on eight men (713 heart rate readings) during graded cycle ergometer and treadmill exercise to volitional fatigue. Analysis by linear regression revealed that general oximeter readings significantly correlated with those of ECG (r = 0.91, P less than 0.0001). However, comparison of heart rate at each level of work showed that oximeter readings significantly (P less than 0.05) under-estimated rates above 155 beats/min. These results indicate that the use of pulse oximeters as heart rate monitors during strenuous exercise is questionable. This inaccuracy may well originate from the instability of the probes, sweating, other artefacts during exercise, and measurement of different components in the cardiovascular cycle.
PMCID: PMC1478836  PMID: 1777787
2.  Evaluation of the Ohmeda 3700 pulse oximeter. 
Thorax  1987;42(11):892-896.
Arterial oxygen saturation values (Sao2) from 60% to 98% were measured by the Ohmeda 3700 pulse oximeter with the three types of probe available and compared with values of oxygen saturation estimated from direct arterial sampling (arterial oxygen and carbon dioxide tensions and pH) on 65 occasions. The response time of the oximeter was measured after a sudden rise in inspired oxygen concentration. Artefact rejection was assessed by arterial compression proximal to the probe site, and by simultaneous recordings of overnight Sao2 on opposite hands. The ability to recreate patterns of oscillating Sao2 from the data stored in the oximeter was also investigated. With the best probe system the oximeter measured Sao2, relative to arterial values estimated from Pao2, with a mean (SD) difference of -0.4% (1.8%). The response time was comparable with those of previous oximeters. It was not possible to generate artefactual dips in excess of 2% Sao2, and the dual overnight recordings rarely showed even small dips on one tracing alone. The stored data can recreate oscillating Sao2 signals with wavelengths down to about 35 seconds, but not below. The Ohmeda 3700 pulse oximeter appears to be suitable for unattended overnight recordings of Sao2.
PMCID: PMC461017  PMID: 3424271
3.  Accuracy of pulse oximetry and capnography in healthy and compromised horses during spontaneous and controlled ventilation 
The objective of this prospective clinical study was to evaluate the accuracy of pulse oximetry and capnography in healthy and compromised horses during general anesthesia with spontaneous and controlled ventilation. Horses anesthetized in a dorsal recumbency position for arthroscopy (n = 20) or colic surgery (n = 16) were instrumented with an earlobe probe from the pulse oximeter positioned on the tip of the tongue and a sample line inserted at the Y-piece for capnography. The horses were allowed to breathe spontaneously (SV) for the first 20 min after induction, and thereafter ventilation was controlled (IPPV). Arterial blood, for blood gas analysis, was drawn 20 min after induction and 20 min after IPPV was started. Relationships between oxygen saturation as determined by pulse oximetry (SpO2), arterial oxygen saturation (SaO2), arterial carbon dioxide partial pressure (PaCO2), and end tidal carbon dioxide (P(et)CO2), several physiological variables, and the accuracy of pulse oximetry and capnography, were evaluated by Bland–Altman or regression analysis. In the present study, both SpO2 and P(et)CO2 provided a relatively poor indication of SaO2 and PaCO2, respectively, in both healthy and compromised horses, especially during SV. A difference in heart rate obtained by pulse oximetry, ECG, or palpation is significantly correlated with any pulse oximeter inaccuracy. If blood gas analysis is not available, ventilation to P(et)CO2 of 35 to 45 mmHg should maintain the PaCO2 within a normal range. However, especially in compromised horses, it should never substitute blood gas analysis.
PMCID: PMC227048  PMID: 12889721
4.  Avoiding hyperoxemia during neonatal resuscitation: time to response of different SpO2 monitors 
Aim
To assess the time to obtain reliable oxygen saturation readings by different pulse oximeters during neonatal resuscitation in the delivery room or NICU.
Methods
Prospective study comparing three different pulse oximeters: Masimo Radical-7 compared simultaneously with Ohmeda Biox 3700 or with Nellcor N395, in newborn infants who required resuscitation. Members of the research team placed the sensors for each of the pulse oximeters being compared simultaneously, one sensor on each foot of the same baby. Care provided routinely, without interference by the research team. The time elapsed until a reliable SpO2 was obtained was recorded using a digital chronometer. Statistical comparisons included chi-square and student's T-test.
Results
Thirty-two infants were enrolled; median gestational age 32 weeks. Seventeen paired measurements were made with the Radical-7 and Biox 3700; mean time to a stable reading was 20.2 ± 7 sec for the Radical-7 and 74.2 ± 12 sec for the Biox 3700 (p = 0.02). The Radical-7 and the N- 395 were paired on 15 infants; the times to obtain a stable reading were 20.9 ± 4 sec and 67.3 ± 12 sec, respectively (p = 0.03).
Conclusion
The time to a reliable reading obtained simultaneously in neonatal critical situations differs by the type of the pulse oximeter used, being significantly faster with Masimo Signal Extraction Technology. This may permit for better adjustments of inspired oxygen, aiding in the prevention of damage caused by unnecessary exposure to high or low oxygen.
doi:10.1111/j.1651-2227.2010.02097.x
PMCID: PMC3085071  PMID: 21091987
Neonatal Resuscitation; Newborn; Oxygen saturation
5.  Motion resistant pulse oximetry in neonates 
Background: Pulse oximetry is widely used in neonates. However, its reliability is often affected by motion artefact. Clinicians confronted with questionable oxygen saturation (SpO2) values often estimate the reliability by correlating heart rate (HR) obtained with the oximeter with that obtained by electrocardiogram.
Objective: To compare the effects of motion on SpO2 and HR measurements made with Masimo signal extraction technology and those made with a Nellcor N-200.
Design: Continuous pulse oximetry and HR monitoring were performed in 15 healthy, term infants (mean (SD) birth weight 3408 (458) g) undergoing circumcision, using Masimo and Nellcor pulse oximeters and a standard HR monitor (Hewlett-Packard). Simultaneous minute by minute behavioural activity codes were also assigned. Baseline data were collected for 10 minutes when the infant was quietly asleep and then continued during and after circumcision for a total duration of one hour. The oximeter HR and SpO2 values were compared and related to HR values obtained by ECG during all three periods. The effect of behavioural activity on SpO2 and HR was also evaluated.
Results: When compared with results obtained with the Nellcor, the mean SpO2 and HR were higher and the incidence of artefact lower with the Masimo during all three periods. Masimo HR more accurately predicted HR obtained with a standard monitor, with lower residual error. SpO2 and HR values obtained with the Nellcor were lower and more variable during all behavioural states, especially crying, when excessive motion artefact was most likely.
Conclusions: The data suggest that Masimo signal extraction technology may offer improvement in pulse oximetry performance, particularly in clinical situations in which extreme motion artefacts are likely.
doi:10.1136/fn.88.6.F505
PMCID: PMC1763244  PMID: 14602699
6.  Peri-operative pulse oximetry in low-income countries: a cost–effectiveness analysis 
Abstract
Objective
To evaluate the cost–effectiveness of pulse oximetry – compared with no peri-operative monitoring – during surgery in low-income countries.
Methods
We considered the use of tabletop and portable, hand-held pulse oximeters among patients of any age undergoing major surgery in low-income countries. From earlier studies we obtained baseline mortality and the effectiveness of pulse oximeters to reduce mortality. We considered the direct costs of purchasing and maintaining pulse oximeters as well as the cost of supplementary oxygen used to treat hypoxic episodes identified by oximetry. Health benefits were measured in disability-adjusted life-years (DALYs) averted and benefits and costs were both discounted at 3% per year. We used recommended cost–effectiveness thresholds – both absolute and relative to gross domestic product (GDP) per capita – to assess if pulse oximetry is a cost–effective health intervention. To test the robustness of our results we performed sensitivity analyses.
Findings
In 2013 prices, tabletop and hand-held oximeters were found to have annual costs of 310 and 95 United States dollars (US$), respectively. Assuming the two types of oximeter have identical effectiveness, a single oximeter used for 22 procedures per week averted 0.83 DALYs per annum. The tabletop and hand-held oximeters cost US$ 374 and US$ 115 per DALY averted, respectively. For any country with a GDP per capita above US$ 677 the hand-held oximeter was found to be cost–effective if it prevented just 1.7% of anaesthetic-related deaths or 0.3% of peri-operative mortality.
Conclusion
Pulse oximetry is a cost–effective intervention for low-income settings.
doi:10.2471/BLT.14.137315
PMCID: PMC4264392  PMID: 25552770
7.  Limitations of pulse oximetry. 
Anesthesia Progress  1992;39(6):194-196.
Pulse oximetry is a noninvasive, accurate, and safe method for the measurement of oxygen saturation during intravenous sedation or general anesthesia. Several factors should be considered with its use, since these variables will either alter the accuracy of the readings or may cause harm to the patient. These factors include changes in the strength of the arterial pulse, body movements, dyshemoglobinemias, plasma lipids and bilirubin, color interferences, venous pulsations, and several physical factors. Awareness of these variations will help the clinician become more knowledgeable in the use of the pulse oximeter.
PMCID: PMC2148612  PMID: 8250340
8.  Effects of divided attention and operating room noise on perception of pulse oximeter pitch changes: A laboratory study 
Anesthesiology  2013;118(2):376-381.
Background
Anesthesiology requires performing visually-oriented procedures while monitoring auditory information about a patient’s vital signs. A concern in operating rooms environments is the amount of competing information and the effects that divided attention have on patient monitoring, such as detecting auditory changes in arterial oxygen saturation via pulse oximetry.
Methods
We measured the impact of visual attentional load and auditory background noise on the ability of anesthesia residents to monitor the pulse oximeter auditory display in a laboratory setting. Accuracies and response times were recorded reflecting anesthesiologists’ abilities to detect changes in oxygen saturation across three levels of visual attention in quiet and with noise.
Results
Results show that visual attentional load substantially impacts the ability to detect changes in oxygen saturation levels conveyed by auditory cues signaling 99 and 98% saturation. These effects are compounded by auditory noise, with up to a 17% decline in performance. These deficits are seen in the ability to accurately detect a change in oxygen saturation and in speed of response.
Conclusions
Most anesthesia accidents are initiated by small errors that cascade into serious events. Lack of monitor vigilance and inattention are two of the more commonly cited factors. Reducing such errors is thus a priority for improving patient safety. Specifically, efforts to reduce distractors and lower background noise should be considered during induction and emergence, periods of especially high risk, when anesthesiologists must attend to many tasks and are thus susceptible to error.
doi:10.1097/ALN.0b013e31827d417b
PMCID: PMC3689317  PMID: 23263015
9.  The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock: a retrospective cohort study 
Background
Pulse oximetry is routinely used to continuously and noninvasively monitor arterial oxygen saturation (SaO2) in critically ill patients. Although pulse oximeter oxygen saturation (SpO2) has been studied in several patient populations, including the critically ill, its accuracy has never been studied in emergency department (ED) patients with severe sepsis and septic shock. Sepsis results in characteristic microcirculatory derangements that could theoretically affect pulse oximeter accuracy. The purposes of the present study were twofold: 1) to determine the accuracy of pulse oximetry relative to SaO2 obtained from ABG in ED patients with severe sepsis and septic shock, and 2) to assess the impact of specific physiologic factors on this accuracy.
Methods
This analysis consisted of a retrospective cohort of 88 consecutive ED patients with severe sepsis who had a simultaneous arterial blood gas and an SpO2 value recorded. Adult ICU patients that were admitted from any Calgary Health Region adult ED with a pre-specified, sepsis-related admission diagnosis between October 1, 2005 and September 30, 2006, were identified. Accuracy (SpO2 - SaO2) was analyzed by the method of Bland and Altman. The effects of hypoxemia, acidosis, hyperlactatemia, anemia, and the use of vasoactive drugs on bias were determined.
Results
The cohort consisted of 88 subjects, with a mean age of 57 years (19 - 89). The mean difference (SpO2 - SaO2) was 2.75% and the standard deviation of the differences was 3.1%. Subgroup analysis demonstrated that hypoxemia (SaO2 < 90) significantly affected pulse oximeter accuracy. The mean difference was 4.9% in hypoxemic patients and 1.89% in non-hypoxemic patients (p < 0.004). In 50% (11/22) of cases in which SpO2 was in the 90-93% range the SaO2 was <90%. Though pulse oximeter accuracy was not affected by acidoisis, hyperlactatementa, anemia or vasoactive drugs, these factors worsened precision.
Conclusions
Pulse oximetry overestimates ABG-determined SaO2 by a mean of 2.75% in emergency department patients with severe sepsis and septic shock. This overestimation is exacerbated by the presence of hypoxemia. When SaO2 needs to be determined with a high degree of accuracy arterial blood gases are recommended.
doi:10.1186/1471-227X-10-9
PMCID: PMC2876142  PMID: 20444248
10.  Pulse oximetry: fundamentals and technology update 
Oxygen saturation in the arterial blood (SaO2) provides information on the adequacy of respiratory function. SaO2 can be assessed noninvasively by pulse oximetry, which is based on photoplethysmographic pulses in two wavelengths, generally in the red and infrared regions. The calibration of the measured photoplethysmographic signals is performed empirically for each type of commercial pulse-oximeter sensor, utilizing in vitro measurement of SaO2 in extracted arterial blood by means of co-oximetry. Due to the discrepancy between the measurement of SaO2 by pulse oximetry and the invasive technique, the former is denoted as SpO2. Manufacturers of pulse oximeters generally claim an accuracy of 2%, evaluated by the standard deviation (SD) of the differences between SpO2 and SaO2, measured simultaneously in healthy subjects. However, an SD of 2% reflects an expected error of 4% (two SDs) or more in 5% of the examinations, which is in accordance with an error of 3%–4%, reported in clinical studies. This level of accuracy is sufficient for the detection of a significant decline in respiratory function in patients, and pulse oximetry has been accepted as a reliable technique for that purpose. The accuracy of SpO2 measurement is insufficient in several situations, such as critically ill patients receiving supplemental oxygen, and can be hazardous if it leads to elevated values of oxygen partial pressure in blood. In particular, preterm newborns are vulnerable to retinopathy of prematurity induced by high oxygen concentration in the blood. The low accuracy of SpO2 measurement in critically ill patients and newborns can be attributed to the empirical calibration process, which is performed on healthy volunteers. Other limitations of pulse oximetry include the presence of dyshemoglobins, which has been addressed by multiwavelength pulse oximetry, as well as low perfusion and motion artifacts that are partially rectified by sophisticated algorithms and also by reflection pulse oximetry.
doi:10.2147/MDER.S47319
PMCID: PMC4099100  PMID: 25031547
oxygen saturation; pulse oximetry; photoplethysmography; arterial blood; venous blood
11.  Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39 821 newborns 
Objective To evaluate the use of pulse oximetry to screen for early detection of life threatening congenital heart disease.
Design Prospective screening study with a new generation pulse oximeter before discharge from well baby nurseries in West Götaland. Cohort study comparing the detection rate of duct dependent circulation in West Götaland with that in other regions not using pulse oximetry screening. Deaths at home with undetected duct dependent circulation were included.
Setting All 5 maternity units in West Götaland and the supraregional referral centre for neonatal cardiac surgery.
Participants 39 821 screened babies born between 1 July 2004 and 31 March 2007. Total duct dependent circulation cohorts: West Götaland n=60, other referring regions n=100.
Main outcome measures Sensitivity, specificity, positive and negative predictive values, and likelihood ratio for pulse oximetry screening and for neonatal physical examination alone.
Results In West Götaland 29 babies in well baby nurseries had duct dependent circulation undetected before neonatal discharge examination. In 13 cases, pulse oximetry showed oxygen saturations ≤90%, and (in accordance with protocol) clinical staff were immediately told of the results. Of the remaining 16 cases, physical examination alone detected 10 (63%). Combining physical examination with pulse oximetry screening had a sensitivity of 24/29 (82.8% (95% CI 64.2% to 95.2%)) and detected 100% of the babies with duct dependent lung circulation. Five cases were missed (all with aortic arch obstruction). False positive rate with pulse oximetry was substantially lower than that with physical examination alone (69/39 821 (0.17%) v 729/38 413 (1.90%), P<0.0001), and 31/69 of the “false positive” cases with pulse oximetry had other pathology. Thus, referral of all cases with positive oximetry results for echocardiography resulted in only 2.3 echocardiograms with normal cardiac findings for every true positive case of duct dependent circulation. In the cohort study, the risk of leaving hospital with undiagnosed duct dependent circulation was 28/100 (28%) in other referring regions versus 5/60 (8%) in West Götaland (P=0.0025, relative risk 3.36 (95% CI 1.37 to 8.24)). In the other referring regions 11/25 (44%) of babies with transposition of the great arteries left hospital undiagnosed versus 0/18 in West Götaland (P=0.0010), and severe acidosis at diagnosis was more common (33/100 (33%) v 7/60 (12%), P=0.0025, relative risk 2.8 (1.3 to 6.0)). Excluding premature babies and Norwood surgery, babies discharged without diagnosis had higher mortality than those diagnosed in hospital (4/27 (18%) v 1/110 (0.9%), P=0.0054). No baby died from undiagnosed duct dependent circulation in West Götaland versus five babies from the other referring regions.
Conclusion Introducing pulse oximetry screening before discharge improved total detection rate of duct dependent circulation to 92%. Such screening seems cost neutral in the short term, but the probable prevention of neurological morbidity and reduced need for preoperative neonatal intensive care suggest that such screening will be cost effective long term.
doi:10.1136/bmj.a3037
PMCID: PMC2627280  PMID: 19131383
12.  Development of a Screening Tool for Sleep Disordered Breathing in Children Using the Phone Oximeter™ 
PLoS ONE  2014;9(11):e112959.
Background
Sleep disordered breathing (SDB) can lead to daytime sleepiness, growth failure and developmental delay in children. Polysomnography (PSG), the gold standard to diagnose SDB, is a highly resource-intensive test, confined to the sleep laboratory.
Aim
To combine the blood oxygen saturation (SpO2) characterization and cardiac modulation, quantified by pulse rate variability (PRV), to identify children with SDB using the Phone Oximeter, a device integrating a pulse oximeter with a smartphone.
Methods
Following ethics approval and informed consent, 160 children referred to British Columbia Children's Hospital for overnight PSG were recruited. A second pulse oximeter sensor applied to the finger adjacent to the one used for standard PSG was attached to the Phone Oximeter to record overnight pulse oximetry (SpO2 and photoplethysmogram (PPG)) alongside the PSG.
Results
We studied 146 children through the analysis of the SpO2 pattern, and PRV as an estimate of heart rate variability calculated from the PPG. SpO2 variability and SpO2 spectral power at low frequency, was significantly higher in children with SDB due to the modulation provoked by airway obstruction during sleep (p-value ). PRV analysis reflected a significant augmentation of sympathetic activity provoked by intermittent hypoxia in SDB children. A linear classifier was trained with the most discriminating features to identify children with SDB. The classifier was validated with internal and external cross-validation, providing a high negative predictive value (92.6%) and a good balance between sensitivity (88.4%) and specificity (83.6%). Combining SpO2 and PRV analysis improved the classification performance, providing an area under the receiver operating characteristic curve of 88%, beyond the 82% achieved using SpO2 analysis alone.
Conclusions
These results demonstrate that the implementation of this algorithm in the Phone Oximeter will provide an improved portable, at-home screening tool, with the capability of monitoring patients over multiple nights.
doi:10.1371/journal.pone.0112959
PMCID: PMC4234680  PMID: 25401696
13.  Use of pulse oximetry for blood pressure measurement after cardiac surgery 
Archives of Disease in Childhood  1998;78(5):457-460.
Blood pressure measurement using pulse oximeter waveform change was compared with an oscillometric measurement and the gold standard, intra-arterial measurement, in children after cardiac surgery. Forty six patients were enrolled and divided into groups according to weight. Simultaneous blood pressure measurements were obtained from the arterial catheter, the oscillometric device, and the pulse oximeter. Pulse oximeter measurements were obtained with a blood pressure cuff proximal to the oximeter probe. The blood pressure measurements from the pulse oximeter method correlated better with intra-arterial measurements than those from the oscillometric device (0.77-0.96 v 0.42-0.83). The absolute differences between the pulse oximeter and intra-arterial measurements were significantly smaller than between the oscillometric and intra-arterial measurements in children less than 15.0 kg. The pulse oximeter waveform change is an accurate and reliable way to measure blood pressure in children non-invasively, and is superior to the oscillometric method for small patients.


PMCID: PMC1717578  PMID: 9659094
14.  Non-Invasive Measurements of Carboxyhemoglobin and Methemoglobin in Children with Sickle Cell Disease 
Pediatric Pulmonology  2012;47(8):808-815.
SUMMARY
Assessment of oxyhemoglobin saturation in patients with sickle cell disease (SCD) is vital for prompt recognition of hypoxemia. The accuracy of pulse oximeter measurements of blood oxygenation in SCD patients is variable, partially due to carboxyhemoglobin (COHb) and methemoglobin (MetHb), which decrease the oxygen content of blood. This study evaluated the accuracy and reliability of a non-invasive pulse co-oximeter in measuring COHb and MetHb percentages (SpCO and SpMet) in children with SCD. We hypothesized that measurements of COHb and MetHb by non-invasive pulse co-oximetry agree within acceptable clinical accuracy with those made by invasive whole blood co-oximetry. Fifty children with SCD-SS underwent pulse co-oximetry and blood co-oximetry while breathing room air. Non-invasive COHb and MetHb readings were compared to the corresponding blood measurements. The pulse co-oximeter bias was 0.1% for COHb and −0.22% for MetHb. The precision of the measured SpCO was ±2.1% within a COHb range of 0.4–6.1%, and the precision of the measured SpMet was ±0.33% within a MetHb range of 0.1–1.1%. Non-invasive pulse co-oximetry was useful in measuring COHb and MetHb levels in children with SCD. Although the non-invasive technique slightly overestimated the invasive COHb measurements and slightly underestimated the invasive MetHb measurements, there was close agreement between the two methods.
doi:10.1002/ppul.22504
PMCID: PMC3368100  PMID: 22328189
sickle cell anemia; pediatrics; oximetry; blood gas analysis; hemoglobins
15.  A preliminary study on the monitoring of mixed venous oxygen saturation through the left main bronchus 
Critical Care  2005;10(1):R7.
Introduction
The study sought to assess the feasibility and accuracy of measuring mixed venous oxygen saturation (SvO2) through the left main bronchus (SpO2trachea)
Methods
Twenty hybrid pigs of each sex were studied. After anesthesia, a Robertshaw double-lumen tracheal tube with a single-use pediatric pulse oximeter attached to the left lateral surface was introduced toward the left main bronchus of the pig by means of a fibrobronchoscope. Measurements of SpO2trachea and oxygen saturation from pulmonary artery samples (SvO2blood) were performed with an intracuff pressure of 0 to 60 cmH2O. After equilibration, hemorrhagic shock was induced in these pigs by bleeding to a mean arterial blood pressure of 40 mmHg. With the intracuff pressure maintained at 60 cmH2O, SpO2trachea and SvO2blood were obtained respectively during the pre-shock period, immediately after the onset of shock, 15 and 30 minutes after shock, and 15, 30, and 60 minutes after resuscitation.
Results
SpO2trachea was the same as SvO2blood at an intracuff pressure of 10, 20, 40, and 60 cmH2O, but was reduced when the intracuff pressure was zero (p < 0.001 compared with SvO2blood) in hemodynamically stable states. Changes of SpO2trachea and SvO2blood corresponded with varieties of cardiac output during the hemorrhagic shock period. There was a significant correlation between the two methods at different time points.
Conclusion
Measurement of the left main bronchus SpO2 is feasible and provides similar readings to SvO2blood in hemodynamically stable or in low saturation states. Tracheal oximetry readings are not primarily derived from the tracheal mucosa. The technique merits further evaluation.
doi:10.1186/cc3914
PMCID: PMC1550812  PMID: 16356208
16.  Advanced Pulse Oximetry System for Remote Monitoring and Management 
Pulse oximetry data such as saturation of peripheral oxygen (SpO2) and pulse rate are vital signals for early diagnosis of heart disease. Therefore, various pulse oximeters have been developed continuously. However, some of the existing pulse oximeters are not equipped with communication capabilities, and consequently, the continuous monitoring of patient health is restricted. Moreover, even though certain oximeters have been built as network models, they focus on exchanging only pulse oximetry data, and they do not provide sufficient device management functions. In this paper, we propose an advanced pulse oximetry system for remote monitoring and management. The system consists of a networked pulse oximeter and a personal monitoring server. The proposed pulse oximeter measures a patient's pulse oximetry data and transmits the data to the personal monitoring server. The personal monitoring server then analyzes the received data and displays the results to the patient. Furthermore, for device management purposes, operational errors that occur in the pulse oximeter are reported to the personal monitoring server, and the system configurations of the pulse oximeter, such as thresholds and measurement targets, are modified by the server. We verify that the proposed pulse oximetry system operates efficiently and that it is appropriate for monitoring and managing a pulse oximeter in real time.
doi:10.1155/2012/930582
PMCID: PMC3424223  PMID: 22933841
17.  Supplemental oxygen after outpatient oral and maxillofacial surgery. 
Anesthesia Progress  1992;39(1-2):24-27.
Arterial oxygen saturation (SpO2) was monitored postoperatively with pulse oximetry in 72 dental patients. Intravenous general anesthesia was employed in 57 patients. All of these patients received supplemental oxygen intraoperatively, and of these, 29 received supplemental oxygen postoperatively. Fifteen patients received only local anesthesia without supplemental oxygen and served as the control group. Continuous pulse oximetry revealed 43 episodes of arterial oxygen desaturation (SpO2 decreases greater than 3% from baseline) in patients who did not receive postanesthesia supplemental oxygen and eight episodes of desaturation in patients who did receive postanesthesia oxygen. Patients with a smoking history had more episodes of desaturation than did nonsmokers in the group that received general anesthesia and breathed room air postoperatively. The total amount of methohexital administered had no significant effect on the number of patients with desaturation episodes. These observations emphasize the need for postoperative oxygen for patients who undergo general anesthesia for outpatient oral and maxillofacial surgery.
PMCID: PMC2148726  PMID: 8507020
18.  Novel Wearable and Wireless Ring-Type Pulse Oximeter with Multi-Detectors 
Sensors (Basel, Switzerland)  2014;14(9):17586-17599.
The pulse oximeter is a popular instrument to monitor the arterial oxygen saturation (SPO2). Although a fingertip-type pulse oximeter is the mainstream one on the market at present, it is still inconvenient for long-term monitoring, in particular, with respect to motion. Therefore, the development of a wearable pulse oximeter, such as a finger base-type pulse oximeter, can effectively solve the above issue. However, the tissue structure of the finger base is complex, and there is lack of detailed information on the effect of the light source and detector placement on measuring SPO2. In this study, the practicability of a ring-type pulse oximeter with a multi-detector was investigated by optical human tissue simulation. The optimal design of a ring-type pulse oximeter that can provide the best efficiency of measuring SPO2 was discussed. The efficiency of ring-type pulse oximeters with a single detector and a multi-detector was also discussed. Finally, a wearable and wireless ring-type pulse oximeter was also implemented to validate the simulation results and was compared with the commercial fingertip-type pulse oximeter.
doi:10.3390/s140917586
PMCID: PMC4208240  PMID: 25244586
pulse oximeter; arterial oxygen saturation; finger base; optical human tissue simulation; multi-detector
19.  Determining the effect of implant surgery on blood oxygen saturation of the adjacent tooth 
Dental Research Journal  2012;9(4):433-436.
Background:
Implant surgery requires local anesthesia and drilling. This surgery may affect the blood circulation of the adjacent teeth. In this study, we evaluated the blood oxygen saturation of the healthy adjacent tooth with a pulse oximeter, during implant surgery.
Materials and Methods:
In this clinical trial study, 15 healthy adult patients, who were candidates for anterior implant surgery and had healthy anterior adjacent teeth, were selected. Blood oxygen saturation of the adjacent tooth and index finger was measured with a pulse oximeter, before and after local anesthetic injection, and also immediately and one hour after completion of surgery. The collected data were analyzed with a Paired Samples Test and Spearman's Correlation Coefficient. (the significance level was at alpha P < 0.05).
Results:
The mean value of peripheral finger blood Spo2 before local anesthetic injection was 98.2% and remained stable during surgery. In the adjacent tooth, the mean values of the pulpal Spo2, before and after local anesthesia, were 87.73 and 79.27%, respectively; immediately after surgery it was 86.13% and one hour after surgery was 86.4%. The decrease in the value of pulpal Spo2 after local anesthesia compared to before the injection was significant. Also there was an inverse relationship between the numbers of utilized local anesthetic cartridges and the value of pulpal Spo2 after local anesthesia.
Conclusion:
After giving local anesthesia, the mean value of Spo2 in the adjacent tooth, because of the vasoconstructive effect of epinephrine, was decreased to about 8%. According to this study, the effect of the local anesthetic drug, containing epinephrine, on the blood circulation in the adjacent tooth was significantly more than the trauma from the implant surgery. We wonder if this temporary decrease in blood flow in the adjacent toot is clinically important or not. To answer this question more studies are required.
PMCID: PMC3491330  PMID: 23162584
Dental implants; dental pulp; oximetry
20.  Noninvasive blood gas monitoring: a review for use in the adult critical care unit. Technology Subcommittee of the Working Group on Critical Care, Ontario Ministry of Health. 
OBJECTIVE: To evaluate the accuracy, reliability, clinical effectiveness and economic impact of bedside pulse oximetry and capnometry as used routinely in the adult critical care environment. DATA SOURCES: The key words "oximetry," "carbon dioxide/analysis" and "evaluation studies" were used to search MEDLINE for all relevant articles published from January 1985 to January 1991. STUDY SELECTION: Articles were included for review if they were original research studies designed to clinically evaluate pulse oximetry or capnometry, or both, were published in English and described a critically ill adult population. Eleven articles met these criteria; seven evaluated pulse oximetry, three evaluated capnometry and one evaluated both. DATA EXTRACTION: The data were evaluated by means of five validity criteria: study setting and subjects, diagnostic accuracy, reliability, clinical effectiveness and economic impact. RESULTS: No study satisfied all our criteria. Most of the studies were designed to evaluate diagnostic accuracy only, and clinically relevant information was lacking. The accuracy of pulse oximetry was clinically acceptable in five of the eight studies. However, in two of them physiologic extremes, skin pigmentation and an arterial saturation of less than 90% resulted in unacceptable error. The diagnostic accuracy of capnometry was unacceptable. CONCLUSIONS: Pulse oximetry may expedite accurate and continuous monitoring of oxygenation at the bedside of the critically ill adult patients. Nevertheless, there are clinical limitations, and caution is needed before oximeters are accepted for routine use. The routine bedside use of capnometry should be discouraged.
PMCID: PMC1488288  PMID: 1562943
21.  Pulse oximetry at the roadside: a study of pulse oximetry in immediate care. 
BMJ : British Medical Journal  1989;298(6675):711-713.
The measurement of tissue oxygen saturation with a pulse oximeter is of proved value in the hospital setting. The development of a portable oximeter has allowed this investigation to be performed during the prehospital phase of a patient's care. Pulse oximetry was performed at the roadside in 25 patients with abnormal trauma scores and found to be of benefit in detecting and monitoring hypoxia in patients with airway obstruction, depressed respiration due to head injury, and, in particular, with closed chest injuries. There were no practical difficulties associated with the use of the instrument either at the roadside or in a moving ambulance. The portable pulse oximeter is a valuable aid in the prehospital monitoring of patients with trauma.
Images
PMCID: PMC1836004  PMID: 2496817
22.  Trends in survival among extremely-low-birth-weight infants (less than 1000 g) without significant bronchopulmonary dysplasia 
BMC Pediatrics  2012;12:63.
Objective
The aim of this study was to analyze the evolution from 1997 to 2009 of survival without significant (moderate and severe) bronchopulmonary dysplasia (SWsBPD) in extremely-low-birth-weight (ELBW) infants and to determine the influence of changes in resuscitation, nutrition and mechanical ventilation on the survival rate.
Study design
In this study, 415 premature infants with birth weights below 1000 g (ELBW) were divided into three chronological subgroups: 1997 to 2000 (n = 65), 2001 to 2005 (n = 178) and 2006 to 2009 (n = 172).
Between 1997 and 2000, respiratory resuscitation in the delivery room was performed via a bag and mask (Ambu®, Ballerup, Sweden) with 40-50% oxygen. If this procedure was not effective, oral endotracheal intubation was always performed. Pulse oximetry was never used. Starting on January 1, 2001, a change in the delivery room respiratory policy was established for ELBW infants. Oxygenation and heart rate were monitored using a pulse oximeter (Nellcor®) attached to the newborn’s right hand. If resuscitation was required, ventilation was performed using a face mask, and intermittent positive pressure was controlled via a ventilator (Babylog2, Drägger). In 2001, a policy of aggressive nutrition was also initiated with the early provision of parenteral amino acids. We used standardized parenteral nutrition to feed ELBW infants during the first 12–24 hours of life. Lipids were given on the first day. The glucose concentration administered was increased by 1 mg/kg/minute each day until levels reached 8 mg/kg/minute. Enteral nutrition was started with trophic feeding of milk. In 2006, volume guarantee treatment was instituted and administered together with synchronized intermittent mandatory ventilation (SIMV + VG). The complications of prematurity were treated similarly throughout the study period. Patent ductus arteriosus was only treated when hemodynamically significant. Surgical closure of the patent ductus arteriosus was performed when two courses of indomethacin or ibuprofen were not sufficient to close it.
Mild BPD were defined by a supplemental oxygen requirement at 28 days of life and moderate BPD if breathing room air or a need for <30% oxygen at 36 weeks postmenstrual age or discharge from the NICU, whichever came first. Severe BPD was defined by a supplemental oxygen requirement at 28 days of life and a need for greater than or equal to 30% oxygen use and/or positive pressure support (IPPV or nCPAP) at 36 weeks postmenstrual age or discharge, whichever came first. Moderate and severe BPD have been considered together as “significant BPD”. The goal of pulse oximetry was to maintain a hemoglobin saturation of between 88% and 93%. Patients were considered to not need oxygen supplementation when it could be permanently withdrawn. The distribution of the variables was not normal based on a Kolmogorov-Smirnov test (p < 0.05 in all cases). Therefore, quantitative variables were expressed as the median and interquartile range (IQR; 25th-75th percentile). Statistical analysis of the data was performed using nonparametric techniques (Kruskal-Wallis test and Mann–Whitney U test). A chi-square analysis was used to analyze qualitative variables. Potential confounding variables were those possibly related to BPD in survivors (p between 0.05 and 0.3 in univariate analysis). Logistic regression analysis was performed with variables related to BPD in survivors (p < 0.05) and potential confounding variables. The forward stepwise method adjusted for confounding factors was used to select the variables, and the enter method using selected variables was used to obtain the odds ratios.
Results and conclusion
There was an increase in the rate of SWsBPD (1997 to 2000: 58.5%; 2001 to 2005: 74.2%; and 2006 to 2009: 75.0%; p = 0.032). In survivors, the occurrence of significant BPD decreased after 2001 (9.5% vs. 2.3%; p = 0.013). The factors associated with improved SWsBPD were delivery by caesarean section, a reduced endotracheal intubation rate and a reduced duration of mechanical ventilation.While the mortality of ELBW infants has not changed since 2001, the frequency of SWsBPD has significantly increased (75.0%) in association with increased caesarean sections and reductions in the endotracheal intubation rate, as well as the duration of mechanical ventilation.
doi:10.1186/1471-2431-12-63
PMCID: PMC3507706  PMID: 22682000
Bronchopulmonary dysplasia; Chronic lung disease; Extremely low birth weight infants; Preterm infants
23.  Oxygen targeting in preterm infants using the Masimo SET Radical pulse oximeter 
Background
A pretrial clinical improvement project for the BOOST-II UK trial of oxygen saturation targeting revealed an artefact affecting saturation profiles obtained from the Masimo Set Radical pulse oximeter.
Methods
Saturation was recorded every 10 s for up to 2 weeks in 176 oxygen dependent preterm infants in 35 UK and Irish neonatal units between August 2006 and April 2009 using Masimo SET Radical pulse oximeters. Frequency distributions of % time at each saturation were plotted. An artefact affecting the saturation distribution was found to be attributable to the oximeter's internal calibration algorithm. Revised software was installed and saturation distributions obtained were compared with four other current oximeters in paired studies.
Results
There was a reduction in saturation values of 87–90%. Values above 87% were elevated by up to 2%, giving a relative excess of higher values. The software revision eliminated this, improving the distribution of saturation values. In paired comparisons with four current commercially available oximeters, Masimo oximeters with the revised software returned similar saturation distributions.
Conclusions
A characteristic of the software algorithm reduces the frequency of saturations of 87–90% and increases the frequency of higher values returned by the Masimo SET Radical pulse oximeter. This effect, which remains within the recommended standards for accuracy, is removed by installing revised software (board firmware V4.8 or higher). Because this observation is likely to influence oxygen targeting, it should be considered in the analysis of the oxygen trial results to maximise their generalisability.
doi:10.1136/adc.2010.206011
PMCID: PMC3195299  PMID: 21378398
24.  Screening by Pulse CO-Oximetry for Environmental Tobacco Smoke Exposure in Preanesthetic Children 
Paediatric anaesthesia  2012;22(9):859-864.
Objective
The purpose of this study was to evaluate the ability of multiple wavelength pulse CO-oximetry (SpCO) to screen for environmental tobacco smoke (ETS) exposure in children.
Background
Exposure to ETS is associated with an increased risk of perioperative respiratory complications in children. It is often difficult to obtain an accurate history for ETS exposure, so a preoperative screening tool is desirable. Carbon monoxide is a measurable product of tobacco combustion. Multiple wavelength pulse CO-oximetry is a recently developed point-of-care monitor.
Methods
Following IRB approval and parental consent, 220 children aged 1–16 years having outpatient surgical procedures were enrolled. SpCO was measured preoperatively 3 times with the Radical-7 Rainbow SET CO-oximeter (Masimo, Irvine, CA). Immediately following induction of anesthesia, a blood sample for laboratory measurement of carboxyhemoglobin (COHb) and serum cotinine was obtained. Regression analysis determined the correlation of SpCO with serum cotinine values. Receiver operator characteristic (ROC) curves analyzed the discriminating ability of SpCO or COHb to predict ETS exposure based on cotinine cutoff values known to be present in children exposed to ETS. Agreement of SpCO and COHb values was assessed using Bland-Altman plots.
Results
SpCO did not correlate with cotinine (R2=0.005). Both SpCO and COHb had poor discriminating ability for ETS exposure (area under the ROC curve = 0.606 and 0.562, respectively). SpCO values had poor agreement with COHb values.
Conclusions
The point-of-care multiple wavelength pulse CO-oximeter does not appear to be a useful preoperative screening tool for ETS exposure in children.
doi:10.1111/j.1460-9592.2012.03867.x
PMCID: PMC3407336  PMID: 22587734
Child; tobacco smoke; carbon monoxide; carboxyhemoglobin; oximetry
25.  Do changes in pulse oximeter oxygen saturation predict equivalent changes in arterial oxygen saturation? 
Critical Care  2003;7(4):R67-R71.
Introduction
This study investigates the relation between changes in pulse oximeter oxygen saturation (SpO2) and changes in arterial oxygen saturation (SaO2) in the critically ill, and the effects of acidosis and anaemia on precision of using pulse oximetry to predict SaO2.
Patients and methods
Forty-one consecutive patients were recruited from a nine-bed general intensive care unit into a 2-month study. Patients with significant jaundice (bilirubin >40 μmol/l) or inadequate pulse oximetry tracing were excluded.
Results
A total of 1085 paired readings demonstrated only moderate correlation (r= 0.606; P < 0.01) between changes in SpO2 and those in SaO2, and the pulse oximeter tended to overestimate actual changes in SaO2. Anaemia increased the degree of positive bias whereas acidosis reduced it. However, the magnitude of these changes was small.
Conclusion
Changes in SpO2 do not reliably predict equivalent changes in SaO2 in the critically ill. Neither anaemia nor acidosis alters the relation between SpO2 and SaO2 to any clinically important extent.
PMCID: PMC270702  PMID: 12930558
acidosis; anaemia; arterial oxygen saturation; critical care; pulse oximetry

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