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Shi C, Goodall M, Dumville J, Hill J, Norman G, Hamer O, Clegg A, Watkins CL, Georgiou G, Hodkinson A, Lightbody CE, Dark P, Cullum N. The accuracy of pulse oximetry in measuring oxygen saturation by levels of skin pigmentation: a systematic review and meta-analysis. BMC Med 2022; 20:267. [PMID: 35971142 PMCID: PMC9377806 DOI: 10.1186/s12916-022-02452-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND During the COVID-19 pandemic, there have been concerns regarding potential bias in pulse oximetry measurements for people with high levels of skin pigmentation. We systematically reviewed the effects of skin pigmentation on the accuracy of oxygen saturation measurement by pulse oximetry (SpO2) compared with the gold standard SaO2 measured by CO-oximetry. METHODS We searched Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform (up to December 2021) for studies with SpO2-SaO2 comparisons and measuring the impact of skin pigmentation or ethnicity on pulse oximetry accuracy. We performed meta-analyses for mean bias (the primary outcome in this review) and its standard deviations (SDs) across studies included for each subgroup of skin pigmentation and ethnicity and used these pooled mean biases and SDs to calculate accuracy root-mean-square (Arms) and 95% limits of agreement. The review was registered with the Open Science Framework ( https://osf.io/gm7ty ). RESULTS We included 32 studies (6505 participants): 15 measured skin pigmentation and 22 referred to ethnicity. Compared with standard SaO2 measurement, pulse oximetry probably overestimates oxygen saturation in people with the high level of skin pigmentation (pooled mean bias 1.11%; 95% confidence interval 0.29 to 1.93%) and people described as Black/African American (1.52%; 0.95 to 2.09%) (moderate- and low-certainty evidence). The bias of pulse oximetry measurements for people with other levels of skin pigmentation or those from other ethnic groups is either more uncertain or suggests no overestimation. Whilst the extent of mean bias is small or negligible for all subgroups evaluated, the associated imprecision is unacceptably large (pooled SDs > 1%). When the extent of measurement bias and precision is considered jointly, pulse oximetry measurements for all the subgroups appear acceptably accurate (with Arms < 4%). CONCLUSIONS Pulse oximetry may overestimate oxygen saturation in people with high levels of skin pigmentation and people whose ethnicity is reported as Black/African American, compared with SaO2. The extent of overestimation may be small in hospital settings but unknown in community settings. REVIEW PROTOCOL REGISTRATION: https://osf.io/gm7ty.
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Affiliation(s)
- Chunhu Shi
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Jean McFarlane Building, Oxford Rd, Manchester, M13 9PL, UK.
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK.
| | - Mark Goodall
- Institute of Population Health, University of Liverpool, Liverpool, L69 3GF, UK
- NIHR Applied Research Collaboration North West Coast (ARC-NWC), Manchester, UK
| | - Jo Dumville
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Jean McFarlane Building, Oxford Rd, Manchester, M13 9PL, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
| | - James Hill
- NIHR Applied Research Collaboration North West Coast (ARC-NWC), Manchester, UK
- Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Gill Norman
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Jean McFarlane Building, Oxford Rd, Manchester, M13 9PL, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
| | - Oliver Hamer
- NIHR Applied Research Collaboration North West Coast (ARC-NWC), Manchester, UK
- Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Andrew Clegg
- NIHR Applied Research Collaboration North West Coast (ARC-NWC), Manchester, UK
- Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Caroline Leigh Watkins
- NIHR Applied Research Collaboration North West Coast (ARC-NWC), Manchester, UK
- Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - George Georgiou
- NIHR Applied Research Collaboration North West Coast (ARC-NWC), Manchester, UK
- Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Alexander Hodkinson
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, M13 9PL, UK
| | | | - Paul Dark
- NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, M13 9WL, UK
- Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, M6 8HD, Greater Manchester, UK
| | - Nicky Cullum
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Jean McFarlane Building, Oxford Rd, Manchester, M13 9PL, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
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