Pulse Oximetry: Beyond SpO2

Respir Care. 2016 Dec;61(12):1671-1680. doi: 10.4187/respcare.05208.


Newer pulse oximetry technology is available that uses multiple wavelengths of light and is thereby able to measure more than 2 forms of hemoglobin, including carboxyhemoglobin (SpCO), methemoglobin (SpMet), and total hemoglobin (SpHb). Several studies have shown relatively low bias, but poor precision, for SpCO compared with HbCO. Evaluations of SpMet have been conducted primarily in normal subjects. Clinical evaluations of SpHb suggest that it might not yet be accurate enough to make transfusion decisions. Respiratory waveform variability of the pulse oximeter plethysmogram might be useful to assess pulsus paradoxus in patients with airway obstruction; it might also be used to measure the breathing frequency. The change in pulse pressure over the respiratory cycle has been used to assess fluid responsiveness in mechanically ventilated patients, and similarly, the pulse oximetry plethysmogram waveform amplitude variability might be used to assess fluid responsiveness. However, there are limitations to this approach, and it remains to be determined how well it can be applied clinically using existing pulse oximetry technology. The pulse oximeter signal is probably useful for applications beyond SpO2 However, the current technology is not mature, and improvements are necessary. With technology improvements, the use of pulse oximetry to detect SpCO, SpMet, SpHb, pulsus paradoxus, breathing frequency, and fluid responsiveness is likely to improve in the future.

Keywords: breathing frequency; carboxyhemoglobin; fluid responsiveness; methemoglobin; oxygen saturation; pulse oximetry; pulsus paradoxus.

MeSH terms

  • Blood Pressure
  • Carboxyhemoglobin / analysis*
  • Hemoglobins / analysis*
  • Humans
  • Methemoglobin / analysis*
  • Oximetry / trends*
  • Plethysmography / methods
  • Respiration


  • Hemoglobins
  • Methemoglobin
  • Carboxyhemoglobin