Oxygen FAQ

Up to date, expert answers to frequently asked questions (FAQ) about oxygen supply systems, respiratory care and pulse oximetry written by OCC & collaborators.

Causes of inaccuracies

Studies have shown that many low-cost pulse oximeters demonstrate highly inaccurate readings. However, some low-cost pulse oximeters have performed with similar accuracy to more expensive devices when used in healthy subjects. Please see our oximeter database for performance information on many low cost oximeters. 

References: Lipnick et al, Anesth Analg 2016

Keywords: low-cost, low cost, cheap, inaccurate

The short answer is no. There is no such thing as a pulse oximeter simulator and none can reliably predict clinical performance for all oximeters.

There are several devices that exist to ‘simulate’ or ‘test’ pulse oximeter function including the Fluke ProSim SPOT, Fluke ProSim8 and Whaleteq AECG100

These devices work by detecting LED pulses from an oximeter, then fabricating their own output signal to the oximeter sensor. The Fluke preserves any noise in the LED light signal while the others simply trigger from it and in doing so eliminate all potential errors due to LED noise (a very common problem with implications for oximeter performance). Some of these devices also have a limited range of simulated conditions (ie perfusion) and require prior calibration to the specific oximeter being tested. Thus, for oximeters already calibrated into the in vitro simulator, the simulator can help confirm that a device is working (or at least is sensing signal) as it was designed to do in the factory. For devices not previously calibrated, conclusions about performance are uncertain. 

Multiple studies report to have used these devices to ‘validate’ oximeter performance, yet performance of an uncalibrated oximeter on an in vitro simulator does not ensure good oximeter performance in reality. 

Simulators of this type are useful for determining the operating range of an oximeter.  For example the limits in terms of dark skin and low perfusion can be found.  One can determine if the device reads an erroneous value when pushed beyond its effective range or if it reports nothing.

The OpenOximetry.org Project is working to develop novel in vitro testing devices and protocols that overcome the limitations of prior devices. The hope is that newer techniques can better augment human study subject testing and predict device performance. 

 

Read here for more on oximeter performance validation requirements

Anecdotal observations have suggested potential oximeter inaccuracy when readings are obtained through tattoos or henna. Many manufacturers warn this can be a cause of inaccuracy. Controlled studies are lacking to characterize this effect, and performance may vary by oximeter.  

References: Zolfaghari et al, Emerg Med J 2015; Battito, Anesth Analg 1989 

Keywords: ink, tattoo, henna, fingerprint

There are limited data on the effect of severe anemia (hgb <7 g/dL) on pulse oximeter accuracy, and this is still an active area of research. Some studies have suggested that severe anemia may affect pulse oximeter readings. They have shown that in hypoxemic patients (SaO2 is below 80%) with very low hemoglobin concentrations, SpO2 may give falsely low readings and underestimate the real SaO2. However, for normoxic patients, anemia appears to have less of an effect on SpO2 measurements.

Another study has reported that in the setting of acute hemorrhage, pulse oximeters remain accurate even down to a hemoglobin of 2.3 g/dL in patients with SaO2 of >93% (normoxic).

However, there is still a need for further data to better understand how severe anemia affects oximetry accuracy, especially during concurrent significant hypoxemia. This is an active area of research for the UCSF Hypoxia Lab and OpenOximetry.org. 

Severe anemia and concurrent hypoxemia are more common than you might think. Using the example of malaria, one of many common causes of anemia worldwide, severe malarial anemia (Hgb <5 g/dL), accounts for nearly 1 million childhood deaths in sub-Saharan Africa (SSA) each year (18% of all childhood deaths in SSA). The prevalence of severe anemia (Hgb <7 g/dL) from any cause has been reported in nearly 1 in 10 children in SSA.

References: Severinghaus et al, Anesthesiology 1992; Jay et al, Ann Emerg Med 1994; Severinghaus et al, J Clin Monit 1990; Chan et al, Respir Med 2013

Keywords: anemia, low hemoglobin

Cooler body temperatures can affect pulse oximeter accuracy. This is because cold extremities can lead to vasoconstriction and poor perfusion, which makes it difficult for the probe to detect a good pulse signal. Warming the body part where the probe is placed can be helpful in some cases.

References: Lifebox Pulse Oximetry Learning Module 

Keywords: temperature, vasoconstriction, cold

There have been a few studies that have evaluated the effects of henna on pulse oximetry results. Most of these studies were conducted on normoxic patients (i.e. healthy patients with normal oxygen levels) and found that the SpO2 values from patient fingers with henna dye were not significantly different from values obtained on non-dyed fingers. One study showed that pulse oximeter saturations from henna dyed fingers were significantly higher in patients who were hypoxemic. This means that in the setting of hypoxemia, pulse oximeters placed on body parts with henna dye may show falsely high SpO2 readings. Another study looked at red and black henna in healthy adults and found that red henna had no effect on pulse oximeter reading, but the black henna caused difficulty in obtaining a SpO2 reading. Given these findings, it may be best to choose a finger that does not have henna dye for placement of the pulse oximeter.

References: Çiçek et al, Emerg Med J 2011; Samman et al, Saudi Med J 2006; al-Majed et al, Trop Geogr Med 1994

Keywords: henna, henna dye, henna paste

Poor oximeter performance (i.e. either inaccurate or absence of a reading) during low perfusion is a known phenomenon in clinical and laboratory settings. If a patient is cold or has peripheral vasoconstriction and poor perfusion, the pulse oximeter may have difficulty detecting a good pulse signal on the fingertip. This affects some oximeters more than others. Some oximeters perform wandering readings while others may produce steady but inaccurate results. At present, there is no requirement by certifying bodies to test oximeter accuracy under controlled or standardized conditions of low perfusion. Nonetheless, some manufacturers and labs do this testing routinely. The OpenOximetry.org Project is working to publish these data in our database while developing and advocating for standards for performance during low perfusion.

References: Lifebox Pulse Oximetry Learning Module 

Keywords: vasoconstriction, poor perfusion, cold

Motion such as patient shivering, tremor, or other movements may affect the probe’s ability to detect an accurate signal. It may give an erroneous value if there is too much motion or prevent the device from obtaining a reading at all.  At present, there is no requirement by certifying bodies to test oximeter accuracy under controlled or standardized conditions of motion. Nonetheless, some manufacturers and labs do this testing routinely. The OpenOximetry.org Project is working to publish these data in our database while developing and advocating for standards for performance during motion. 

References: Lifebox Pulse Oximetry Learning Module

Keywords: tremor, shiver, movement, motion

Nail polish or nail varnish can impact pulse oximeter accuracy, so it is best to remove the polish to allow the light from the probe to pass through the tissue. If it cannot be removed, placing the probe on the toe or on the fingertip sideways can be an option. 

Certain colors of nail polish may lead to underestimation of SaO2 by pulse oximetry. Studies have shown that in healthy adults, blue, green, black, and brown nail polish appear to interfere the most with pulse oximeter SpO2 readings. In fact, they can cause readings of up to a 3-5% underestimation in oxygen saturation.

Another study, which examined different nail polish colors on 50 critically ill patients, showed that all colors interfered with pulse oximetry readings, but that the most significant interference was due to black, purple, and dark blue polish. All other nail polish colors had a lesser effect on pulse oximeter readings. 

Regarding gel nail polish, a study in 17 healthy adults tested several colors of gel-based manicure, and concluded that certain colors of gel polish resulted in a significant overestimation of SpO2, although their results varied when using different brands of pulse oximeter.

References: Lifebox Pulse Oximetry Learning Module, Ralston et al, Anaesthesia 1991; Adler et al, Acad Emerg Med 1998; Hinkelbein et al, Resuscitation 2007; Yönt et al, Intensive Crit Care Nurs 2014; Coté et al, Anesth Analg 1988; Yek et al, Singapore Med J 2019

Keywords: nail polish, varnish, nail color

The effect of skin pigmentation on pulse oximeter accuracy remains poorly characterized. Pulse oximeters may be less accurate in patients with darker skin, especially at lower oxygen saturations. Of note, this inaccuracy can tend to overestimate oxygen saturation, which may lead to false reassurance during clinically real hypoxemia. The amount of inaccuracy varies significantly between different devices, manufacturers, and probes. The OpenOximetry.org Project is actively working to better understand the impact of pigment on oximeter accuracy and to develop new strategies to eliminate this source of error.

References: Okunlola et al, Resp Care, Nov 2021, Bickler et al, Anesthesiology 2005; Feiner et al, Anesth Analg 2007; Adler et al, Acad Emerg Med 1998; Bothma et al, S Afr Med J 1996; Zeballos et al, Am Rev Respir Dis 1991; Ries et al, Chest 1989; Emery J Perinatol 1987; Sjoding et al, N Engl J Med 2020

Keywords: skin, pigment, skin tone, accuracy

Pulse oximeter measurements can be influenced by many variables such as skin pigment, body temperature, nail polish, movement, and perfusion. If the waveform tracing is erratic and low amplitude, this might be due to a weak signal or due to the patient moving. This can make it difficult for the oximeter to interpret the oxygen saturation accurately. Common reasons for poor waveform can include poor perfusion, irregular heart rate, or poor probe placement.  All of these factors can cause both underestimation and overestimation errors in oxygen saturation readings.

References: Lifebox Pulse Oximetry Learning Module 

Keywords: waveform, perfusion, battery, error

A pulse oximeter photoplethysmograph (commonly referred to as a ‘pleth’) is a graphical display of the pulse oximeter signal over time. Its appearance can vary widely under different clinical scenarios. In healthy patients, the graph should appear as asymmetric humps similar in appearance to an arterial pressure waveform though usually with less level of detail (i.e. the dicrotic notch may not be visible). The waveform should appear at intervals that match the heart rate and regularity. 

Patient motion, tremor and poor perfusion are common factors that affect the pleth. The pleth is an extremely useful feature to help clinicians quickly determine the quality of the oximeter signal. Of note, in the face of a low signal (or low perfusion) some oximeters may auto adjust the scale of the display (y axis) to increase the visual amplitude of the pleth. This can be misleading to clinicians who must also pay attention to signal quality indicators when available. 

References: Jubran, Crit Care 2015 

Keywords: pleth, waveform, PPG

 

 

The locations for placing pulse oximeters vary by the type of device and probes available, including whether it is a transmittance or a reflectance device. Transmittance devices shine light through a part of the body, so they must be placed on a relatively thin or translucent area such as a fingertip, earlobe, nose or the foot of an infant. It is important that the body part is placed far enough into the probe so that the light shines through the tissue rather than to the side of it. Reflectance devices do not require light to pass through tissue, so they can be placed in a variety of locations including the patient’s forehead, wrist, foot, or chest.

References: Lifebox Pulse Oximetry Learning Module

Keywords: body part, location, placement, finger

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