Why COVID-19 Silent Hypoxemia Is Baffling to Physicians

Am J Respir Crit Care Med. 2020 Aug 1;202(3):356-360. doi: 10.1164/rccm.202006-2157CP.


Patients with coronavirus disease (COVID-19) are described as exhibiting oxygen levels incompatible with life without dyspnea. The pairing-dubbed happy hypoxia but more precisely termed silent hypoxemia-is especially bewildering to physicians and is considered as defying basic biology. This combination has attracted extensive coverage in media but has not been discussed in medical journals. It is possible that coronavirus has an idiosyncratic action on receptors involved in chemosensitivity to oxygen, but well-established pathophysiological mechanisms can account for most, if not all, cases of silent hypoxemia. These mechanisms include the way dyspnea and the respiratory centers respond to low levels of oxygen, the way the prevailing carbon dioxide tension (PaCO2) blunts the brain's response to hypoxia, effects of disease and age on control of breathing, inaccuracy of pulse oximetry at low oxygen saturations, and temperature-induced shifts in the oxygen dissociation curve. Without knowledge of these mechanisms, physicians caring for patients with hypoxemia free of dyspnea are operating in the dark, placing vulnerable patients with COVID-19 at considerable risk. In conclusion, features of COVID-19 that physicians find baffling become less strange when viewed in light of long-established principles of respiratory physiology; an understanding of these mechanisms will enhance patient care if the much-anticipated second wave emerges.

Keywords: COVID-19; control of breathing; dyspnea; hypoxemia; pulse oximetry.

Publication types

  • Case Reports
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Betacoronavirus*
  • COVID-19
  • Coronavirus Infections / blood
  • Coronavirus Infections / complications*
  • Coronavirus Infections / diagnosis*
  • Dyspnea / blood
  • Dyspnea / diagnosis
  • Dyspnea / virology*
  • Humans
  • Hypoxia / blood
  • Hypoxia / diagnosis*
  • Hypoxia / virology*
  • Male
  • Middle Aged
  • Oximetry
  • Oxygen / blood
  • Pandemics
  • Pneumonia, Viral / blood
  • Pneumonia, Viral / complications*
  • Pneumonia, Viral / diagnosis*
  • SARS-CoV-2


  • Oxygen