Oxygen targeting in preterm infants: a physiological interpretation.

Randomized controlled trials evaluating low-target oxygen saturation (SpO2:85% to 89%) vs high-target SpO2 (91% to 95%) have shown variable results regarding mortality and morbidity in extremely preterm infants. Because of the variation inherent to the accuracy of pulse oximeters, the unspecified location of probe placement, the intrinsic relationship between SpO2 and arterial oxygen saturation (SaO2) and between SaO2 and partial pressure of oxygen (PaO2) (differences in oxygen dissociation curves for fetal and adult hemoglobin), the two comparison groups could have been more similar than dissimilar. The SpO2 values were in the target range for a shorter period of time than intended due to practical and methodological constraints. So the studies did not truly compare 'target SpO2 ranges'. In spite of this overlap, some of the studies did find significant differences in mortality prior to discharge, necrotizing enterocolitis and severe retinopathy of prematurity. These differences could potentially be secondary to time spent beyond the target range (SpO2 <85 or >95%) and could be avoided with an intermediate but wider target SpO2 range (87% to 93%). In conclusion, significant uncertainty persists about the desired target range of SpO2 in extremely preterm infants. Further studies should focus on studying newer methods of assessing oxygenation and strategies to limit hypoxemia (<85% SpO2) and hyperoxemia (>95% SpO2)

Investigating optical path in reflectance pulse oximetry using a multilayer monte carlo model

Despite the wide clinical uses of pulse-oximetry, the precise nature of the light-tissue interaction underneath the technique is not clearly understood. A heterogeneous opto-anatomical model is presented to describe the optical path in pulse oximetry

Reflectance Pulse Oximetry - Principles and Obstetric Application in the Zurich System

Transmission and reflectance are the two main modes of pulse oximetry. In obstetrics, due to the absence of a transilluminable fetal part for transmission oximetry, the only feasible option is the reflectance mode, in which sensor and detector are located on the same surface of the body part. However, none of the reflectance pulse oximeters developed for intrapartum use are fully satisfactory, as indicated by the fact that none have entered routine use. We have designed, developed, constructed and tested a reflectance pulse oximeter with the possibility to adjust the electronic circuits and signal processing in order to determine the effects of various parameters on signal amplitude and wave-form and to optimize the sensitivity and spatial arrangement of the optical elements. Following an explanation of the principles of reflectance pulse oximetry, we report our experience with the design, development, construction and field-testing of an in-house reflectance pulse oximetry system for obstetric applicatio

Pulse oximetry in the oesophagus

Pulse oximetry has been one of the most significant technological advances in clinical monitoring in the last two decades. Pulse oximetry is a non-invasive photometric technique that provides information about the arterial blood oxygen saturation (SpO(2)) and heart rate, and has widespread clinical applications. When peripheral perfusion is poor, as in states of hypovolaemia, hypothermia and vasoconstriction, oxygenation readings become unreliable or cease. The problem arises because conventional pulse oximetry sensors must be attached to the most peripheral parts of the body, such as finger, ear or toe, where pulsatile flow is most easily compromised. Since central blood flow may be preferentially preserved, this review explores a new alternative site, the oesophagus, for monitoring blood oxygen saturation by pulse oximetry. This review article presents the basic physics, technology and applications of pulse oximetry including photoplethysmography. The limitations of this technique are also discussed leading to the proposed development of the oesophageal pulse oximeter. In the majority, the report will be focused on the description of a new oesophageal photoplethysmographic/SpO(2) probe, which was developed to investigate the suitability of the oesophagus as an alternative monitoring site for the continuous measurement of SpO(2) in cases of poor peripheral circulation. The article concludes with a review of reported clinical investigations of the oesophageal pulse oximeter

A Monte Carlo platform for the optical modeling of pulse oximetry

We investigated a custom Monte Carlo (MC) platform in the generation of opto-physiological models of motion artefact and perfusion in pulse oximetry. With the growing availability and accuracy of tissue optical properties in literatures, MC simulation of light-tissue interaction is providing increasingly valuable information for optical bio-monitoring research. Motion-induced artefact and loss of signal quality during low perfusion are currently the primary limitations in pulse oximetry. While most attempts to circumvent these issues have focused on signal post-processing techniques, we propose the development of improved opto-physiological models to include the characterisation of motion artefact and low perfusion. In this stage of the research, a custom MC platform is being developed for its use in determining the effects of perfusion, haemodynamics and tissue-probe optical coupling on transillumination at different positions of the human finger. The results of MC simulations indicate a useful and predictable output from the platform

Evaluation of Visible Diffuse Reflectance Spectroscopy in Liver Tissue: Validation of Tissue Saturations Using Extracorporeal Circulation

Significance: Real-time information about oxygen delivery to the hepatic graft is important to direct care and diagnose vascular compromise in the immediate post-transplant period. Aim: The current study was designed to determine the utility of visible diffuse reflectance spectroscopy (vis-DRS) for measuring liver tissue saturation in vivo. Approach: A custom-built vis-DRS probe was calibrated using phantoms with hemoglobin (Hb) and polystyrene microspheres. Ex vivo (extracorporeal circulation) and in vivo protocols were used in a swine model (n=15) with validation via blood gas analysis. Results: In vivo absorption and scattering measured by vis-DRS with and without biliverdin correction correlated closely between analyses. Lin’s concordance correlation coefficients are 0.991 for μa and 0.959 for μs\u27. Hb measured by blood test and vis-DRS with (R2=0.81) and without (R2=0.85) biliverdin correction were compared. Vis-DRS data obtained from the ex vivo protocol plotted against the PO2 derived from blood gas analysis showed a good fit for a Hill coefficient of 1.67 and P50=34  mmHg (R2=0.81). A conversion formula was developed to account for the systematic deviation, which resulted in a goodness-of-fit (R2=0.76) with the expected oxygen dissociation curve. Conclusions: We show that vis-DRS allows for real-time measurement of liver tissue saturation, an indicator for liver perfusion and oxygen delivery

Perioperative comparison of the agreement between a portable fingertip pulse oximeter vs. a conventional bedside pulse oximeter in adult patients (COMFORT trial)

Background: Low-cost, portable fingertip pulse oximeters are widely available to health professionals and the public. They are often not tested to ISO standards, or only undergo accuracy studies in healthy volunteers under ideal laboratory conditions. This study aims to pragmatically evaluate the agreement between one such device and a conventional bedside pulse oximeter in a clinical setting, in patients with varied comorbidities and skin pigmentations. Methods: A single-centre equipment comparison study was conducted. Simultaneous measurements were obtained in 220 patients with both a Contec CMS50D Fingertip Pulse Oximeter and a Nihon Kohden Life Scope MU-631 RK conventional bedside monitor. Peripheral oxygen saturations (SpO₂) and pulse rates were documented, and patient skin tone was recorded using the Fitzpatrick scale. Data was assessed using a Bland-Altman analysis with bias, precision and limits of agreement (LOA) calculated with 95% confidence intervals. A priori acceptability for LOA was determined to be 3%, in keeping with international standards. Results: Mean difference (therefore bias) between the conventional and fingertip oximeters for all data was -0,55% (95% CI -0,73 to -0,36%). Upper and lower limits of agreement (95% CI) were 2,16 (1,84 to 2,47) and -3,25 (-3,56 to -2,94) %. Regression analysis demonstrated worsening agreement with decreasing SpO₂. When samples were separated into “normal” (SpO₂ ≥ 93%) and “hypoxaemic” (SpO₂ < 93%) groups, the normal range displayed acceptable agreement between the two oximeters (bias -0,20 with LOA 2,20 to -2,27%), while the hypoxaemic group fell outside the study’s a priori limits. Heart rate measurements had mean difference (LOA) of -0,43 (-5,61 to 4,76) beats per minute. The study was not powered to detect difference among the skin tones, but demonstrated no trend for this parameter to alter the SpO₂ measurements. Conclusions: During normoxia, portable fingertip pulse oximeters are reliable indicators of SpO₂ and pulse rates in patients with various comorbidities in a pragmatic clinical context. However, they display worsening agreement with conventional pulse oximeters during hypoxaemia. Skin tones do not appear to adversely affect measurements

Monte Carlo investigation of light-tissue interaction in photoplethysmography

Photoplethysmography (PPG) is a non-invasive photometric technique which measures changes in the volume of blood in the biological tissue. PPG is well-known for its application in pulse oximetry used for the continuous monitoring of arterial blood oxygen saturation (SpO2). Over the past decade, there has been a plethora of research in the field of PPG, with potential applications beyond pulse oximetry and heart rate monitoring. Such applications explore the utilisation of PPG for the assessment of various bio-markers relating to vascular mechanics, haemodynamics and many others. With the growing research interest in the field of PPG, a comprehensive understanding of the light-tissue interaction-based working principle underlying the technique is essential. This thesis is focussed on the investigation of the fundamental light-tissue interactions in PPG using the Monte Carlo method. Tissue models have been developed in this thesis which were characterised by the optical properties (e.g., wavelength- dependent coefficients of scattering and absorption etc.), the anatomical features (e.g., stratification and dimension of tissue layers and sublayers etc.), and the physiological parameters (water and blood content in tissue layers etc.). The Monte Carlo strategy was verified, and was initially implemented to model the light propagation through a monolayer perfused dermal tissue volume in a reflective mode PPG at the red and near-infrared wavelengths, usually used in pulse oximetry. Results illustrated the distribution of the scattering-absorption interaction events, and quantified the optical pathlength, penetration depth and detected reflectance with the variable sensor geometry (i.e., source-detector separation) and physiological states (i.e., the volume of blood and oxygen saturation) of the tissue. The monolayer model was also employed to produce the plot resembling the ‘calibration curve’ used in pulse oximetry. With the knowledge gained from the monolayer-model study, a similar investigation was performed on a heterogeneous tissue structure of a human finger which was executed in both reflective and transmissive geometrical settings. The calibration curves produced from the detected reflectance and transmittance exhibited a high correlation. The absorbances of red and near-infrared light by individual layers of the finger were quantified at systole and diastole. To the relative absorbance, the contributions of dermis and bone were the maximum and the minimum, respectively. The dependence of the optical pathlength on the source-detector separation and the operating wavelength was quantified by the Differential Pathlength Factor (DPF), which was assessed for the reflective mode PPG by simulating light propagation through a human forearm tissue volume. The DPF values were used in experimentally obtained PPG signal in order to determine the time-change in the concentration of oxyhaemoglobin and deoxyhaemoglobin. Cross-talk and absolute errors were calculated between the simulated and approximated DPFs. The results presented in the thesis contribute greatly to the understanding on PPG light-tissue interaction. Such knowledge could also greatly contribute to the development of the new generation PPG sensors for various applications

Non-invasive calibration method for pulse oximeters

In case of a healthy subject the normal SpO2 value is 97 &plusmn; 2% on see level. Modern, finger probe based pulse oximeters are measuring the SpO2 level with 1-2% error. The dispersion between subjects can reach 4%, thus such accuracy is not really demanded by the majority of clinicians. Moreover, in case of fetal pulse oximetry 5% measuring error is accepted. Considering these factors we investigated the feasibility of a non-invasive calibration method with a self-developed pulse oximeter. This method is carried out without blood sampling. Pulse oximeters are measuring the R rate, which is proportional to the SpO2 value. Calibrating an oximeter means finding the function between the R and SpO2. A calibrated pulse oximeter was used as reference. In the case of every subject 15 minutes long measurements were performed. The reference device and our oximeter were attached to the subject at the same time, while artificial air with 14% oxygen content was inhaled by the subject for ten minutes. The SpO2 was measured by the reference oximeter and the R rate by our oximeter. Based on 511 measured data pairs the relationship was determined between 86-100%. The relationship was estimated by linear regression. Although the original relation is non-linear, linear estimation can be used in this small range of SpO2 with good accuracy. The average error of the calibrated device is 2.76%, which is appropriate in medical practice. This method is easier and cheaper as the invasive calibration, but the calibrated device will have slightly bigger measuring error