New Technologies in

Pulse Oximetry
Mike McEvoy, PhD, RN, CCRN, REMT-P
Clinical Associate Professor Critical Care Medicine
Division of Cardiothoracic Surgery
Albany Medical College – Albany, New York
EMS Coordinator – Saratoga County, New York
EMS Editor – Fire Engineering magazine
 Disclosures

• I am on the speakers bureau for

Masimo Corporation.
• I am the Fire/EMS technical editor for
Fire Engineering magazine.
• I do not intend to discuss any
unlabeled or unapproved uses of
drugs or products.
 Learning Objectives
Upon completion of the presentation the


participant will:

1.Describe the evolution of pulse

oximetry technology

2.Describe non-invasive measurement

of carboxyhemoglobin,
methemoglobin, and hemoglobin

3.Describe perfusion index using pulse

oximetry

4.Describe oximetric assessment of

fluid volume status
Nurses Week 2008 – Albany Medical Center
Anesthesia
 Critical Information

• Oxygenatio
n
• Perfusion
 Pulse Oximetry

Problems:


• Accuracy
• Motion &
artifact
• Dyshemoglob
ins
• Perfusion
 Oxygenation

• Pulse Oximetry
 Oxygenation

• Pulse Oximetry
 Model of Light Absorption At
Measurement Site Without Motion

AC Variable light
absorption due
Absorption

pulsatile volume of
arterial blood
DC Constant light
absorption due to
non - pulsatile arterial
blood .
DC Constant light
Time absorption due to
venous blood .
DC Constant light absorption
due to
tissue , bone , ...
 Model of Light Absorption At
Measurement Site With Motion

AC Variable light
absorption due
Absorption

pulsatile volume of
arterial blood
DC Constant light
absorption due to
non - pulsatile arterial
blood .
AC Variable light
Time absorption due to
moving venous blood
DC Constant light
absorption due to
venous blood .
DC Constant light absorption
due to
Influence of Perfusion on Accuracy of
Conventional Pulse Oximetry During
Motion
Good Perfusion (Conventional
PO)

SpaO 2 =98
SpO 2 =93
SpvO 2 =88

Poor Perfusion
(Conventional PO)

SpaO 2 =98
SpO 2 =74
SpvO 2 =50
 Conventional Pulse Oximetry
Algorithm
Digitized, MEASUREMENT

Filtered & Post

R & IR R/IR CONFIDENCE % Saturation
Normalized Processor

3 options during motion or low perfusion:

1.Freeze last good value
2.Lengthen averaging cycle
3.Zero out
These decrease false alarms but miss true events
 A New Era for Pulse Oximetry

1998
In 1989, Diab & Kiani (Masimo, Irvine, CA)
invent Signal Extraction Pulse Oximetry
allowing oximeters to monitor patients
during motion and low perfusion.

Signal Extraction Technology launched

internationally in 1998.
 SET’s (5) Parallel Algorithms
MEASUREMENT
R / IR
( Conventional CONFIDENCE
Pulse
Oximetry )

MEASUREMENT

CONFIDENCE

Confidence Post
Based %
Digitized , MEASUREMENT
Arbitrator Processor Saturation
Filtered &
R & Normalized CONFIDENCE
IR DST
SET – 97%

MEASUREMENT

SST TM
CONFIDENCE

0 50% 66 %
97 % 100 %
SpO2
SpO2%%
MEASUREMENT
Proprietary
Algorithm 4 CONFIDENCE

Masimo SET “ Parallel

Engines ”
SET “ Parallel Engines ”
 The Solution for Patient
Motion
Discrete Saturation Transform ( DST )
In the presence of motion, SET separates the venous and
arterial saturation values resulting in accurate saturation
readings without false alarms (compared to conventional
oximetry that averages the values to produce a reading)

Variable
Constant
Variable
Averaging - Constant
inaccurate SpO2 Separating -
accurate SpO2

0 50% 66% 86% 97% 100% 0 50% 66% 86% 97% 100%

SpO2%
SpO2%

Conventional Pulse Measure Through

Oximetry Motion Pulse Oximetry
Certainty…
 SET Pulse Oximetry
• Overcomes the primary limitations of conventional technology
• Reduces false alarms by 90+%
• Increases true alarm detection to 97+%
• Accurate measurements under the most challenging conditions
•
• Evaluated in 100+ independent clinical studies

Summary of Inde pendent and Objective Studies of SET Pulse Oximetry

All Studies Comparisons to Other
182 “ Next Generation ”
Technologies
120
100
100
100
80
80

60 60

40 40
20 7 7
0 20 0
0
0
■ Favors SET ■ Neutral ■ Favors Another Technology
 Pulse Oximetry

Problems:


PAccuracy
PMotion & artifact
• Dyshemoglobins
• Perfusion
CO Poisoning: The Great Imitator

 30-50 % of CO-exposed patients

presenting to Emergency
Barker MD, et al. J Pediatr.
Departments are misdiagnosed
1988;1:233-43
Barret L, et al. Clin Toxicol.
1985;23:309-13
Grace TW, et al. JAMA. 1981;246:1698-
700
 Carbon Monoxide Poisoning
• Leading cause of poisoning deaths in
industrialized countries:
• Over 40,000 emergency room visits in
the US annually 1
• At least 3,800 deaths in the US
annually 2
• 1,400-3,000 accidental deaths in the
US annually 3,4
• Even a single exposure has the potential to
induce long-term cardiac and
neurocognitive/psychiatric sequelae:
1 • Brain
Hampson NB. Emergency department visitsdamage
for carbon monoxide at 12
poisoning months
in the Pacific Northwestafter
. J Emerg Med 1998;16(5):695-
698.
exposure is 5
US significant
2Mott JA, Wolfe MI, Alverson CJ , MacDonald SC, Bailey CR , Ball LB, Moorman JE, Somers JH, Mannino DM, Redd SC. National
Vehicle Emissions policies and practices and declining carbon monoxide-related mortality. JAMA 2002;288:988-995
3Hampson NB, Stock AL. Storm-Related Carbon Monoxide Poisoning: Lessons Learned from Recent Epidemics. Undersea Hyperb Med
4
5
2006;33(4):257-263
• Myocardial
Cobb N, Etzel RA, Unintentional Injury
Carbon monoxide-related deaths in the is aStates
United common
, 1979 through 1988. JAMA 1991;266(5):659.
Weaver LK, et al. N Engl J Med, 2002;347(14):1057-067.
6
Henry CR, Satran D, Lindgren consequence
6Henry CR, et al. JAMA. 2006;295(4):398-402.
7 B, Adkinson C, Nicholson C, Henry TD. JAMA. 2006;295(4):398-402

• Single exposure = 3 times higher

likelihood of cardiac death in 7 year
 Carbon Monoxide (CO)
• Gas:
• Colorless
• Odorless
• Tasteless
• Nonirritating

• Physical
Properties:
• Vapor Density
= 0.97
• LEL/UEL =
 Severity of Intoxication:
Morbidity Associated with COHb and Duration

Highlighted Area demonstrates current

OSHA Standard for CO:
[500ppm/30 minutes]
Consider 500 ppm/60-90 minutes….
Case Study: Even Low Exposure Levels Can
Lead to Death
5 2 y o m a le
Prominent attorney in Salt Lake City found dead in
his home after failing to show up for work
Had complained to co - workers
of nausea and other flu - like
symptoms for several days
Upon discovery of his body ,
elevated levels of CO were
discovered in the home — but
levels were relatively low ,
only 130 PPM
Faulty boiler discovered

E v e n 1 3 0 P a rts P e r M illio n O v e r a P ro lo n g e d P e rio d C a n

K ill Y o u !
Endogenous Sources of CO

• Normal heme catabolism (breakdown):

• Only biochemical reaction in the body
known to produce CO
• Hemolytic anemia

• Sepsis
 Common Sources

• Incomplete combustion of any carbon-

based material will produce carbon
monoxide. Most commons sources are:
• Automobiles, trucks, buses, boats
• Gas heaters and furnaces
• Small gasoline engines
• Portable / space heaters
• Portable gas-powered generators
• Barbecues / fireplaces
• Structure / wildland fires
• Cigarette smoke
• Methylene chloride (paint stripper)
- liver converts to CO
Show me the money…Is this
real?
§ 104 CCU admissions UAP: 3 CO toxic, 5
others minor exposure (> smoker). Balzan
Up to 10% of UAP, ACS,
et al, Postgrad Med J, 1994;70:699-702

seizure,
§ 307 acute and h/a
neuro admits: 3 CO admits
toxic (all
have CO poisoning
from group of 29 w/ decr. LOC absent
focal s/s). Balzan et al, Postgrad Med J, 1996;72:470-
3.

§ 168 acute neuro admits: 5 CO toxic (2 from

group w/ seizures) Heckerling et al, Clin Toxicol,
1990;28:29-44.

§ 48 h/a pts: 7 COHb > 10% (14.6%, all

unrelated to smoking) Heckerling et al, Am J
Emer Med, 1987;5:201-4.

§ 146 h/a pts: 4 COHb > 10% (3%, all

 Pathophysiology
• CO displaces O2 from hemoglobin binding
sites (4)
• CO prevents O2 from binding


•
• (carboxyhemoglobin)
•
•
•
• COHb increases O2 affinity, interfering with
normal release
 Messy Pathophysiology

• Complex IV of Electron Transport Chain – binds

cytochrome c oxidase

• CO does NOT bind with same affinity as O2 (requires

significant hypoxia)
Pathophysiology
• CO limits oxygen
transport
• Greater affinity (>210 x)
for hemoglobin
• Inhibits oxygen transfer
• Interferes with normal
unloading to tissues
• Binds with myoglobin
(muscle)
• Interferes with heart and
skeletal muscle fxn
• Binds to cytochrome
oxidases
• Induces anerobic
Neurologic Effect
 Delayed Neurologic
Syndrome
 Experienced by
11-30% of
patients with CO
Harper A et. al, Age and Ageing.
2004;33(2):105-9.
Poisoning (DNS)
Kao LW et. al, Emerg Med Clin North Am. 2004
Weaver LK, et al. N Engl J Med,
2002;347(14):1057-067


 Long-Term/Chronic
Sequelae
 Cognitive and
personality changes,
Abelsohn A, CMAJ 2002:166 (13):1685-
dementia,
90 seizures,
psychosis, amnesia,
Cardiac Effect
• “Myocardial injury
occurs frequently in
patients hospitalized
for moderate to severe
CO poisoning and is a
significant predictor of
mortality”
• Odds ratio’s from recent
study demonstrate that
a patient has a
3 times higher
likelihood
Myocardial Injury and of cardiac
Long-Term Mortality
Following Moderate to Severe Carbon
death
Monoxide (within
Poisoning . Henry CR,a 7 year
Satran D,
Lindgren B, Adkinson C, Nicholson C, Henry
TDfollow-up period)
. JAMA. 2006;295(4):398 -402 from
even one moderate to
Cardiac Effect
• 19 year study 8,333
Swedish males ÷
smokers, non-smokers,
never smokers.
• Never smokers split into
quartiles:
• 0.13 – 0.49% COHb
• 0.50 – 0.57%
• 0.58 – 0.66%
• 0.67 – 5.47%


• Relative risk CV event

3.7, death 2.2 highest to
COHb% as a marker of cardiovascular risk
in lowest
never smokersquartiles
: Results from a
population-based cohort study. Hedblad BO,
Engstrom G, Janzon E, Berglund G, Janzon L.
Incidence
•Scand J Pub Health. CV disease
2006;34 :609-615. &
Fetal Damage
Theoretical
effect of
different
treatments
on maternal and
fetal COHb levels
over time

Rucker J, Fisher J, Carbon Monoxide Poisoning, Chapter 63 Longo LD: The biological
effects of carbon monoxide on the pregnant woman, fetus, and newborn infant. Am J Obstet
Gynecol 1977;129: 69-103.
 Signs and Symptoms
S p C O % C lin ica l M a n ife sta tio n s
< 5% None

5 - 10 % Mild headache, tire easily

11 - 20 % Moderate headache, exertional

SOB
21 - 30 % Throbbing headache, mild
nausea, dizziness, fatigue,
31 - 40 % slightly impaired
Severe headache judgment
, vomiting ,
vertigo, altered judgment
41 - 50 % Confusion, syncope,
tachycardia
51 - 60 % Seizures, unconsciousness

Carbon Monoxide Poisoning Presents Like the Flu !

Attempts to Develop a Model

§ Heckerling et al apply criteria to validate a

predictor model for identifying CO
poisoned pts. In ED.
§ 61 patients tested, model only detects 3 of
4 pts with  COHb Heckerling et al, Am J Med
1988;84:251-6.

§ 753 acute admits med-surg, neuro, psych:

2 w/ minor COHb  Heckerling et al, Am J Emerg
Med 1990;8:301-4.

§ Conclusion: Widespread ED screening

expensive, unproductive unless
quick and cheap screening tool
became available.
Laboratory CO-oximetry

• CO-oximetry capability
found in 50% of hospital
laboratories
• Standard ABG cannot
differentiate carboxy
from oxyhemoglobin
• Invasive—need compelling
reason to order,
repeated tests to
monitor tx
• Variable time to analysis
(can take from minutes
to hours to get results)
 Limitations of Pulse
Oximetry
onal pulse oximetry can not distinguish between COHb , and
From Conventional Pulse Oximeter

SpCO - SpO 2 Gap :

The fractional difference
between actual SaO2 and
display of SpO2
(2 wavelength
oximetry) in presence of
carboxyhemoglobin

From invasive CO - Oximeter Blood Sample

[ Blood ]

Barker SJ, Tremper KK. The Effect of Carbon Monoxide Inhalation on Pulse Oximetry and Transcutaneous PO2.
Anesthesiology 1987; 66:677-679
 Rainbow Technology

Oxygenated Hb and reduced Hb absorb different amounts of Red (RD) and Infrared (IR) Light

( Two - wavelength oximeters cannot measure dyshemoglobins )

 FDA Validation
Masimo Rainbow SET Compared to Reference
Methodology

N o n in v a siv e m e a su re m e n t p ro v id e s clin ica lly

Red
e q u iv a le n t re su lts fo r H b C O w ith o u t th e n e e d
fo r in v a siv e b lo o d d ra w
 14,438 Patient Brown
University Study
• Partridge and Jay (Rhode Island Hospital,
Brown University Medical School),
assessed carbon monoxide (CO) levels of
10,856 ED patients
• 11 unsuspected cases of CO Toxicity (COT)
were discovered.
Overall mean SpCO was 3.60%
• Occult COT was 4 in 10,000 during cold, 1
in 10,000 during warm months
• They concluded “unsuspected COT may be
identified using
Non-Invasive Pulse noninvasive
CO-Oximetry COHb
Screening in the Emergency Department Identifies
Occult Carbon Monoxide Toxicity. Suner S, Partridge R, Sucov A, Valente J, Chee K,
screening
Hughes A, Jay G.and the
J Emerg prevalence
Med 2008 of COT
Department of Emergency Medicine,may
Rhode
Island Hospital, Brown Medical School, Providence, RI.
be higher than previously recognized”
UL 2034: listings for CO alarms

• Revised 1992, 1995, 1998

• Presently:
• 30 PPM for 30 days
• 70 PPM for 1 – 4 hours
• 150 PPM for 10 – 50 minutes
• 400 PPM for 4 – 15 minutes (6
min reset > 70 PPM)
• Non-alarm status CO2 < 5,000
PPM
• Non-alarm limits for methane,
- NFPA 720
butane, heptane, ethyl acetate
 CO Assessment –
Prehospital
1.Every patient, every
time.

2.All occupants at CO
alarm calls.

3.Firefighters.
Methemoglobinemia
• Methemoglobin is formed
when hemoglobin is
converted to a form that
cannot bind O2
• In methemoglobin the
ferrous (Fe+2) irons of
heme are oxidized to the
ferric (Fe+3) state
•



Methemoglobinemia Causes
• Inherited: • Acquired:
• Hemoglobin • Multiple
disorder sources…
(HgM).
• Enzyme
disorders
(i.e., G6PD).
•
•
•
•
 Causes of Acquired
Methemoglobinemia
Iatrogenic Causes : Others ( community
based ):
B e n zo ca in e & C e ta ca in e  Soda and other foods
sp ra y s with phenol based
D a p so n e preservatives
E M L A C re a m s  Nitrogen based fertilizers
C h lo ro q u in e  Nitrate laden
F lu ta m id e preservatives (such as
L id o ca in e saltpeter used to cure
BBQ meats)
N itra te s
 Infantile diarrhea (high
N itric o x id e
intestinal pH promotes
N itro g ly ce rin gram-negative organism
N itro p ru ssid e growth, converts dietary
nitrates to nitrites)
N itric o x id e
PAshe-Bernal
d iaR,tric g a stro
et al. Acquired in te stin
Methemoglobinemia a l Series of 138 Cases
A Retrospective
in fe ctio n
at 2 Teaching Hospitals. Medicine Sept 2004;83(5):265-273.
Symptoms of Methemoglobinemia
SpMet % Clinical Manifestation
0-3% Normal concentration , no
symptoms

3-15% Slight skin discoloration

( palor , gray , or blue ) may
be present

15-20% Patient may be relatively

asymptomatic , cyanosis
likely

25-50% Headache , dyspnea ,

lightheadedness ,
weakness , confusion ,
palpitations , chest pain
50-70% Altered mental status ,
delirium

Methemoglobinemia Can Present Like the Flu !

Source: David C Lee, MD, Research Director, Assistant Professor, Department of Emergency
Medicine, North Shore University Hospital and New York University Medical School
 Johns Hopkins Study: Acquired
Methemoglobinemia
• Retrospective chart review at two
teaching hospitals
• All CO-Oximetry tests for 28 months
(1999-2002)
• 414 of 2,167 patients (19%) had
elevated MetHb levels
• Age range: 4 days to 86 years
• 25% of cases found accidentally
via CO-Oximetry
• Acquired MetHb led to 1 death and
3 near deaths

Ash-Bernal R, et al. Acquired Methemoglobinemia A Retrospective Series

of 138 Cases
at 2 Teaching Hospitals. Medicine Sept 2004;83(5):265-273.
 Traditional Diagnosis of MetHb

Traditional marker: “chocolate Laboratory CO-oximeter

brown” color of arterial blood
 Limitations of Pulse Oximetry
From Pulse Oximeter

The 85% SpO2 “Push”:

The difference between
actual SpO2 (blue) and
display SpO2 (red) (2
wavelength oximetry) in
presence of methemoglobin

From invasive CO-Oximeter Blood Sample

[Blood]

Barker SJ, Tremper KK, Hyatt J. Effects of Methemoglobinemia on Pulse Oximetry and Mixed Venous Oximetry. Anesthesiology
1989;70:112-117
Noninvasive Pulse CO-Oximetry

Oxygenated Hb and reduced Hb absorb different amounts of Red

(RD) and Infrared (IR) Light
( Two - wavelength oximeters cannot measure
dyshemoglobins )
 FDA Validations
Masimo Rainbow SET Compared to Reference
Methodology
14

12

SpMet (%) 10

0
0 2 4 6 8 10 12 14

HbMet (%)
Noninvasive measurement provides clinically
equivalent results for MetHb without the
need for invasive blood draw
Excellent Precision and Accuracy ( + 1 % from 0 -
25 %)
 What about hemoglobin?

SpHb added in 2008

FDA approved
accuracy + 2 g/dL

 Visible and Infrared Lights Probe Blood in
Measurement Site
Multivariate Analysis of Acquired Optical Signals Estimates
Hemoglobin Protein Density

Detection, Signal Condition & Digital Signal

Emission Site
Analog-to-Digital Conversion Processing Estimation
Various visible and infrared lights Light is received by a photo detector, which in turn Advanced algorithms process the digital signals,
are applied to the measurement generates electrical analog signals that are amplified, which are then analyzed by a multivariate estimation
site conditioned and converted to digital signals processor to predict the total hemoglobin density in
the measurement site

. Multivariat
Filtering,
. AD e Sp
Decimatio
. Converte Estimatio
E
d
n
r
n,
n Hb
nF
ro
t Averaging
g
o Algorithm
A
a
n
l

1 54
Society Technology Anesthesia
(STA) abstract 18

16

14

SpHb (g/dl)
12

10

6 y = 0.524 + 0.954 * x
R = .898
4
4 6 8 10 12 14 16 18

Hbt g/dL (control)

19 surgery patients and 9 volunteers
458 data pairs
Bias, precision and ARMS were -0.039, 1.09, 1.09
respectively
STA abstract – Case Report (17 hours)

12
SpHb Clinical Applications
T
M

• Blood management during

surgery
• Initiate timely blood transfusions
• Avoid unnecessary transfusions
• Detect acute hemorrhage in
the ICU
• Intervene immediately to avoid
morbidity
• Determine what fluids and how much
to administer
• Reduce lab draws (and iatrogenic
anemia)
• Diagnosis and management
 Peripheral Perfusion
• Early recognition of impaired organ
perfusion is important to avoid
tissue hypoxia that ultimately could
lead to organ failure. During
circulatory shock, skin blood flow
decreases to preserve vital organ
perfusion. This results in the clinical
signs of poor peripheral perfusion,
Bond RF: A review of the skin and muscle hemodynamics during
hemorrhagic hypotension and shock. Adv Shock Res 1982; 8: 53-70
such as a cold, pale, clammy, and
Lima, et al.: Use of Peripheral Perfusion Index Derived from the Pulse
mottled skin.
Oximetry Signal as a non-invasive indicator of perfusion. Critical
Care Medicine 2002
 Perfusion Index

Saturation

Infrared

Red
 Infrared Signal
Perfusion index is the ratio of the variable absorption (AC)
to the non-variable (DC) of the infrared signal.

0.254-0.253 = 0.001 AC

0.253- 0 = 0.253 DC

0.001/0.253 = 0.4%
PI display ranges from 0.02%
(very weak) to 20% (very strong)
 Perfusion Index
• Perfusion Index is an objective
method for measuring a patient’s
peripheral perfusion
• Perfusion Index is an early indicator
of deterioration
Datex-Ohmeda PIr ®

Range 0.3%-10%

Most Patients
>0.7%

Increases the
validity of the
SpO2 by locating
the strongest
pulse signal
P h ilip s

Range 0.3%-10%

Optimal >1.0%

< 0.3% is
marginal
reposition the
site
 Masimo

Range 0.02%- 20.0% Select site with
highest value
•


P e rfu sio n In d e x
 Correlation of PI with
Peripheral Flow

Slope – 0 . 98
r 2 – 0 . 88

Ozaki, et al. Anesth 1993

What is the “Normal” PI value?
• 108 healthy adults and 37
critically ill patients
(finger sensors)
• PI range: 0.3% to 10%,
median 1.4%
• ROC used to determine
the “cutoff” value
• 1.4% PI best discriminated
normal from abnormal
Lima, et al. CCM 2002
 Clinical Uses for PI
Normals have been suggested to be:


 >1.4% adults, >1.27% neonates

1.Site selection (PI varies between
patients and sites)
2.Chorioamnionitis (placental
membrane/amniotic fluid infection)
3.Effectiveness of Servoflorane
anesthesia
4.Monitor onset/effectiveness of
epidural anesthesia
5.Predict illness severity scores (good
correlation)
6.Monitor/quantify peripheral perfusion
7.Detect shock states
Photoplethysmography

Absorpt
R

ion
IR
Pleth Waveform

Photodetect
or

Time
Pleth Waveform
A rt lin e co m p a re d to P u lse
O x P le th
 Definition of PVI
• Pleth Variability Index (PVI) is a
measure of dynamic changes in PI
that occur during the respiratory
cycle
•
•
•


• PVI is a percentage from 1 to 100%: 1

= no variability and 100 = maximum
variability
 PVI and Fluid Status

• High variability (high PVI) =

volume depletion
• Ability to observe and
intervene in real time
• 15 – 50% of patients are fluid
non-responders
• The ventricle more sensitive
to respiratory changes is
more responsive to preload
Research on PI and PVI
Ongoing…
Pulse CO-Oximetry: A Better
Picture
Problems:
 S o lu tio n s :
S ig n a l
• Accuracy E x tra ctio n
• Motion & Te ch n o lo g y
( SET )
artifact
R a in b o w
• Dyshemoglob te ch n o lo g y
ins P e rfu sio n
• Perfusion In d e x ( P I)
P le th
Questions?

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