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Lessons Learned from Pulse Oximetry
Juliann M. Di Fiore Rainbow Babies & Children’s Hospital
Case Western Reserve University Cleveland, OH
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Conflicts of Interest
• No conflicts of interest to disclose
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Background
• Due to the high incidence of desaturation events in preterm infants, non-invasive continuous measurement of oxygenation is needed to stabilize this fragile infant cohort.
• Pulse oximetry has become the most widely used modality to detect desaturation events in the NICU setting.
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Purpose
• Identify the available features of pulse oximetry monitoring
• Discuss the limitations of current pulse oximeters
• Describe how to maximize monitoring strategies in the NICU
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Calibration: Healthy Adults
Johnston: Arch Dis Child Fetal Neonatal Ed, 2011
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SpO2 vs SaO2: Infants <33wks GA with an umbilical arterial line.
Rosychuk: Neonatol, 2012
Mean Difference Overall, 1.85% SpO2 85-89%, 2.4% SpO2 91-95%, 1.87%
65 70 75 80 85 90 95 100
65
70
100
95
90
85
80
75
SpO
2
SaO2
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SpO2 vs SaO2: Newborn Lambs
Dawson: Arch Dis Child Fetal Neonatal Ed, 2014
Mean Difference SaO2 ≥70%, 3% SaO2 <70%, 13-17%
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SpO2 in the NICU Setting
SpO2
ECG
ABD
RC
Sum
Martin et al, 2012
10 sec
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Factors Influencing Arterial O2 Desaturation during Apnea
alveolus
venous
arterial
METABOLIC O2
CONSUMPTION
PULMONARY
O2 STORES
TOTAL BLOOD O2 CAPACITY
SLOPE OF Hb/O2
DISSOCIATION
CURVE
Adapted from Sands SA: PLOS Computational Biology 2009
O2 UPTAKE BY ALVEOLI
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Intermittent Hypoxia During Early Postnatal Life
Di Fiore: J Pediatr, 2010
24-28wks gestation, n=79
-
IH defined as <80% for 10sec-3min
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Nuisance Alarms!
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Documentation of Alarms
0
50
100
150
200
250
Video documentation Nursing Notes
Num
ber o
f Ala
rms (
per d
ay)
Events Requiring Intervention
Brockmann: Arch Dis Child Fetal Neonatal Ed, 2013
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How do We Reduce Alarms?
Avoid Alarm Fatigue • Reduce false alarms • Identify desaturation events
that require intervention
Maintain Stable Oxygenation • Increase time in target • Decrease time in Hyperoxia/Hypoxia
What are we try to achieve?
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Pulse Oximeter Parameters
• Motion Artifact Filter • Alarm threshold • Averaging time • Alarm delay
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Standards for Oximeter Settings
• There are currently no published universal standards for oximeter settings
• Limited data on making recommendations
• Every unit must set their own standards
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Motion Artifact Filter
• The most common cause of false alarms • Early generation pulse oximeters
• Assumed arterial pulse is the only source of blood moving at the monitoring site.
• During motion venous blood also moves – Signal failure, SpO2=0 – Falsely low SpO2
– Red/infrared= 1, false SpO2 = 82%
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New Generation Algorithms
• Masimo SET Technology • Adaptive filters that identify the
energy present at each saturation level from 1-100%
• Scan for the energy peak which is reported as the infant’s SpO2
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Motion Artifact 26 neonates
Hay: J Perinatol, 2002
Masimo SET* Nellcor N-200
Events Duration (min)
Events Duration (min)
“False” hypoxemia 50 25.8 213 174.6
“False” bradycardia 1 0.1 41 38.9
Data drop-outs 11 5.4 217 214.4
True bradycardia 12/14 (86%) 2/14 (14%)
New Generation vs Conventional Oximeter
* p<0.05
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False Alarms: Additional Causes
• Excessive light interference – flooding of the photodetector
• Probe position • Low pulse volume
– Hypovolemic shock, dysrhythmias
• Low pulsatile flow – Vasoconstriction/Hypothermia
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True Alarms
How do we reduce alarms due to minor events that do not
require intervention?
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Alarm Thresholds
0
20
40
60
80
100
120
80-97% 85-95%
Num
ber o
f Ala
rms (
per d
ay)
Oxygen Saturation Target
Ketco: Pediatrics, 2015
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Averaging Time
Time
SaO
2 (%
)
100
70
90
80
short averaging time (3 sec)
long averaging time (21 sec)
Farré: SLEEP, 1998
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0
20
40
60
80
100
0 5 10 15 20
SpO
2 (%
)
2 sec average
Effect of Increasing Averaging Time
Averaging time
No. of IH events
2 sec 26
8 sec 11
16 sec 6
0
20
40
60
80
100
0 5 10 15 20
SpO
2 (%
)
Time (min)
8 sec average
0
20
40
60
80
100
0 5 10 15 20 Time (min)
16 sec averaging
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70
80
90
100
110
120
Averaging Time
0
500
1000
1500
2000
Averaging Time (sec)
Num
ber o
f IH
eve
nts
<20 sec
≥20 sec
Vagedes: Arch Dis Child Fetal Neonatal Ed, 2012
3 5 8 10 12 14 16
3 5 8 10 12 14 16
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Averaging Time
• Long • Reduce motion artifact and false alarms • Distort the true oxygen saturation waveform • Falsely increase long desaturation events • Understate event severity • Delay response time
• Short • Increase response time • Provide more accurate detection of short events and
event severity • Dramatically increase nuisance alarms
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70
80
90
100
110
120
Reduce Alarms to Short Events
0
500
1000
1500
2000
Averaging Time (sec)
Num
ber o
f IH
eve
nts
<20 sec
≥20 sec
Vagedes: Arch Dis Child Fetal Neonatal Ed, 2012
3 5 8 10 12 14 16
3 5 8 10 12 14 16
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0
20
40
60
80
100
0 5 10 15 20
SpO
2 (%
)
2 sec average
Monitor Alarm Delay
Averaging time
Alarms with No delay
Alarms with 15 sec delay
2 sec 26 12
8 sec 11 10
SpO
2 (%
)
0
20
40
60
80
100
0 5 10 15 20 Time (min)
8 sec average
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Monitor Alarm Delay
• Eliminates alarms due to short desaturation events
• Does not alter the true oxygen saturation waveform
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Accurate Documentation
0
10
20
30
40
50
60
In Target ≥98% 80-84%
Perc
ent T
ime
Nurse Transcription Oximeter
*
* *
*p <.0001 vs Transcribed, 24 VLBW infants Ruis: J Perinatol, 2014
85-93%
Bedside visual tool to increase time in target
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Use of Histograms in Vermont Oxford Network
Pulse oximeters capable of generating histograms All monitors 46.7% Some monitors 20.7% No monitors 32.6%
Center uses histogram for daily care or QI Never 72.8% Sometimes 19.6% Routinely 7.6%
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What About the Future of Pulse Oximetry in the NICU?
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IH and Retinopathy of Prematurity
Di Fiore: J Pediatr, 2010
2sec average
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Pattern of Intermittent Hypoxia Events
Di Fiore: Pediatr Res 2012
80 _
SpO
2 (%
)
Duration:
Time Interval: (Between Events)
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Duration of Intermittent Hypoxemia
Di Fiore: Pediatr Res, 2012
Postnatal Age (days)
Mea
n Du
ratio
n (s
)
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Di Fiore: Pediatr Res, 2012
SpO
2 (%
)
80 -
Time Interval Between IH
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Intermittent Hypoxemia and Morbidity
• 972 ELBW infants • 16 sec averaging time • IH defined as <80% • Percentage of time with hypoxemia
– 100 x total duration of hypoxemic episodes/ total duration of the recording
Canadian Oxygen Trial (COT)
Poets: JAMA, 2015
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Time with SpO2 <80% and Outcome at 18 months of Age
IH <1min IH≥1min
Outcomes
OR (95% CI)
RR (95% CI)
P value
OR (95% CI)
RR (95% CI)
P value
Late Death or Disability
1.04 (.61-1.77)
1.01 (.77-1.32)
.88 3.4 (1.95-5.93)
1.66 (1.35-2.05)
<.001
Cognitive/ language delay
.96 (.56-1.64)
.96 (.72-1.29)
.87 2.88 (1.65-5.02)
1.61 (1.29-2.03)
<.001
Motor Impairment
2.27 (.90-5.74)
1.90 (.90-4.04)
.08 5.20 (2.48-10.92)
3.51 (2.16-5.72)
<.001
Severe ROP 1.84 (0.86-3.95)
1.46 (0.86-2.47)
.12 2.95 (1.47-5.90)
1.93 (1.26-2.98)
.002
Poets: JAMA, 2015
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Alarm based on high risk patterns of intermittent hypoxemia that are
associated with morbidity
Create a Smarter Pulse Oximeter
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Automated Control Systems
0
10
20
30
40
50
60
70
In Target >98% <80%
Tim
e (%
)
Auto
Manual
*
* *
van Kaam: J Pediatr, 2015
0
2
4
6
8
10
12
14
16
#IH <80% (>60sec)
Num
ber o
f Eve
nts
*p<.05 Auto vs Manual
*
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Summary
• There are currently no published standards for oximeter settings
• Oximeter settings such as the alarm threshold, alarm delay and averaging time can reduce nuisance alarms
• Histograms can provide overall information on time in target
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Future Clinical Applications
• “Smarter” oximeters with alarm settings based on high risk patterns of intermittent hypoxemia
• Automated control systems to increase time in target and reduce staff fatigue
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THANK YOU!