Question 17

Describe the principles of measurement of arterial haemoglobin O2 saturation using a pulse oximeter (60% marks). Outline the limitations of this technique (40% marks).

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College Answer

Most candidates provided a reasonable structured sequence of how a pulse oximeter generates a value. Nearly all candidates described the Beer-Lambert laws correctly, but few specifically described the basic principles of absorption spectrophotometry. Most candidates had a reasonable list of extrinsic factors that can interfere with pulse oximeter performance, but few described the intrinsic/inherent limitations of the device that can cause SpO2 to be different to SaO2, such as functional versus fractional saturation.


  • Principles fundamental to pulse oximetry
    • Different absorption of different light wavelengths by haemoglobin species
    • Isolation of the pulsatile arterial signal because of pulse-related changes in optical distance 
  • Different light absorption by haemoglobin species:
    • Two wavelengths (660 and 940 nm) are used in pulse oximettry
    • Deoxyhaemoglobin absorbs more light at 660nm and oxyhaemoglobin absorbs more light at 940 nm.
  • Quantification of haemoglobin species concentration
    • Beer Law: the concentration of a given solute in a solvent is determined by the amount of light that is absorbed by the solute at a specific wavelength
    • Thus, concentration of oxyhaemoglobin and deoxyhaemoglobin can be determined from their absorption of the two wavelengths
  • Determination of pulsatile signal
    • Absorption-over-time signal from arterial blood is pulsatile, whereas signal from venous haemoglobin and tissue is not.
    • When the arteries pulsate, the distance travelled by light though them changes
    • One can therefore use Lambert's Law (equal parts in the same absorbing medium absorb equal fractions of the light that enters them).
    • Thus, one can compare the ratio of pulsatile and nonpulsatile absorbance to produce R, the ratio of absorbance at any given time 
    • R = (AC660 / DC660) / (AC940/DC940)
  • Calibration with empirically measured data
    • R is meaningless unless it can be related to oxygen saturation;
    • A series of saturation measurements and R values have been collected from healthy individuals in the 100-75% saturation range, and extrapolated to 0%
    • This array of data is used by the pulse oximeter control circuit as a lookup table to p
  • Correction for ambient light
    • The pulse oximeter LEDs strobe at a high frequency (400-900 Hz)
    • When the LED is off, the photometer measures the absorption of ambient light, and subtracts  this from the signal measured when the LEDs are on.
    • This eliminates the contribution of (most) ambient light
  • Essential design elements of a pulse oximeter include:
    • LED light sources
    • A photometer
    • A control circuit
    • A user interfce with display and alarm functions
  • Limitations of pulse oximetry are:
    • The inevitable difference with ABG oximetry due to processing artifact
    • Inability to detect PO2 or discriminate between haemoglobin species e.g carboxyhaemoglobin (i.e. the pulse oximeter is incapable of discriminating between fractional saturation, the fraction of total haemoglobin which happens to be oxygenated, from functional saturation, the fraction of effective haemoglobin which is oxygenated and can participate in gas exchange.
    • Spurious results in the presence of carboxyhaemoglobin and methaemoglobin
    • Errors to detect pulse with poor perfusion, nonpulsatile ECMO flow or patient movement
    • Increasing inaccuracy in the extrapolated range of calibration values (low oxygen saturation, below 50%)


Sinex, James E. "Pulse oximetry: principles and limitations." The American journal of emergency medicine 17.1 (1999): 59-66.

Jubran, Amal. "Pulse oximetry." Critical care 3.2 (1999): R11.

Jubran, Amal. "Pulse oximetry." Applied Physiology in Intensive Care Medicine 1. Springer, Berlin, Heidelberg, 2012. 51-54.

Jubran, Amal. "Pulse oximetry." Critical Care 19.1 (2015): 272.

Kamat, Vijaylakshmi. "Pulse oximetry." Indian J Anaesth 46.4 (2002): 261-8.

Kyriacou, Panayiotis, Karthik Budidha, and Tomas Y. Abay. "Optical techniques for blood and tissue oxygenation." Encyclopedia of Biomedical Engineering, ed R. Narayan (Oxford: Elsevier) (2019): 461-472.

Severinghaus, John W., and Shin O. Koh. "Effect of anemia on pulse oximeter accuracy at low saturation." Journal of clinical monitoring 6.2 (1990): 85-88.

Fluck, Robert R., et al. "Does ambient light affect the accuracy of pulse oximetry?." Respiratory care 48.7 (2003): 677-680.

Amar, David, et al. "Fluorescent light interferes with pulse oximetry." Journal of clinical monitoring 5.2 (1989): 135-136.

Block, Frank E. "Interference in a pulse oximeter from a fiberoptic light source." Journal of clinical monitoring 3.3 (1987): 210-211.

American Association for Respiratory Care. AARC Clinical Practice Guideline: Pulse oximetry. Respir Care 1991;36(12):1406–1409

Ralston, A. C., R. K. Webb, and W. B. Runciman. "Potential errors in pulse oximetry: I. Pulse oximeter evaluation." Anaesthesia 46.3 (1991): 202-206.

Webb, R. K., A. C. Ralston, and W. B. Runciman. "Potential errors in pulse oximetry: II. Effects of changes in saturation and signal quality.Anaesthesia 46.3 (1991): 207-212.

Singh, Anupam Kumar, et al. "Comparative evaluation of accuracy of pulse oximeters and factors affecting their performance in a tertiary intensive care unit." Journal of clinical and diagnostic research: JCDR 11.6 (2017): OC05.

Severinghaus, J. W. "Pulse oximetry uses and limitations." ASA Convention. 1989.

Ralston, A. C., R. K. Webb, and W. B. Runciman. "Potential errors in pulse oximetry III: effects of interference, dyes, dyshaemoglobins and other pigments." Anaesthesia 46.4 (1991): 291-295.

Severinghaus, John W. "Takuo Aoyagi: discovery of pulse oximetry." Anesthesia & Analgesia 105.6 (2007): S1-S4.

Tremper, Kevin K. "Pulse oximetry." Chest 95.4 (1989): 713-715.

Feiner, John R., John W. Severinghaus, and Philip E. Bickler. "Dark skin decreases the accuracy of pulse oximeters at low oxygen saturation: the effects of oximeter probe type and gender." Anesthesia & Analgesia 105.6 (2007): S18-S23.

Pologe, Jonas A. "Pulse oximetry: technical aspects of machine design." International anesthesiology clinics 25.3 (1987): 137-153.

Webster, John G. Design of pulse oximeters. CRC Press, 1997.