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Dünnwald, T.; Niederseer, D. Pulse Oximetry. Encyclopedia. Available online: (accessed on 22 April 2024).
Dünnwald T, Niederseer D. Pulse Oximetry. Encyclopedia. Available at: Accessed April 22, 2024.
Dünnwald, Tobias, David Niederseer. "Pulse Oximetry" Encyclopedia, (accessed April 22, 2024).
Dünnwald, T., & Niederseer, D. (2021, February 23). Pulse Oximetry. In Encyclopedia.
Dünnwald, Tobias and David Niederseer. "Pulse Oximetry." Encyclopedia. Web. 23 February, 2021.
Pulse Oximetry

Finger pulse oximeters are widely used to monitor physiological responses to high-altitude exposure, the progress of acclimatization, and/or the potential development of high-altitude related diseases. 

pulse oximetry high altitude acclimatization rest and exercise acute mountain sickness

1. Introduction

Wearable sensors can provide athletes, coaches, patients and physicians with useful physiological data, e.g., on the actual cardiovascular and respiratory stress of the individual[1][2][3]. Such information may be gathered by continuous or spot measurements depending on specific objectives. For example, the monitoring of bio-vital markers like heart rate and peripheral oxygen saturation has become a standard of patient care[4] but is also frequently applied by people visiting high altitudes for sight-seeing, trekking, skiing or climbing[5][6]. Simple and inexpensive devices, finger pulse oximeters, are widely used to monitor physiological responses to high-altitude exposure, the progress of acclimatization, and/or the potential development of high-altitude related diseases[7][8][9]. Although there is increasing evidence for the usefulness of pulse oximetry at high altitude some controversy remains[10][11]. This is largely due to differences in individual preconditions, different evaluation purposes, different measurement methods, not considering limitations of devices in certain conditions, the use of different devices, and the lacking ability to interpret data correctly[12]

2. Basic Principles of Functioning, Most Relevant Pitfalls and Possible Countermeasures for Pulse Oximetry Particularly Concerning Healthy People Going to High Altitudes

The introduction of pulse oximetry represents one of the most important technological advances in medicine, permitting to continuously, non-invasively and simultaneously monitor SpO2 of hemoglobin in the arterial blood and HR. These vital parameters provide exceptionally important information on well-being of the individual, e.g., patients in the hospital setting, in emergency situations at home or in the field, but also in people going to high altitudes.

Hemoglobin (Hb) is a prominent protein complex in erythrocytes. Based on its ability to bind oxygen (O2) it is essential for the transport of O2 from the alveoli to tissues. Hb exists in two forms: (1) the deoxyhemoglobin (HHb) without attached O2 and (2) the oxyhemoglobin (O2Hb) with bound O2 molecules. O2 molecules change the light absorption of Hb at specific wave lengths[6][13].

This effect can be observed even under normal light conditions since well oxygenated (arterial) blood with high O2Hb concentration exhibits a bright red staining, while venous (deoxygenated) blood appears dark red for the eye. Pulse oximetry makes advantage of this optical effect of diverging light absorption of Hb and utilizing red light at wavelength of 660nm and near-infrared (IR) light at 940 nm to estimate SpO2. The distinct feature of these two wavelengths is that red light is more strongly absorbed by HHb than by O2Hb, whereas infrared light exhibits the opposite characteristic (see Figure 2). For both wavelengths, the absorption during systole (AAC) and diastole (ADC) is measured and the modulation ratio R is calculated, where R is expressed as:


Figure 2. Light absorption spectrum of deoxyhemoglobin (HHb) and oxyhemoglobin (O2Hb). Different absorption for HHb and O2Hb at red light (660 nm) compared to infrared light (940 nm) is visible. (This Figure is based on data from Prahl, 1998[20]).

Based on a comparison of R to an empirically generated calibration curve, the SpO2 value is estimated[13][14][15]. The data for this calibration curve was acquired from adult healthy volunteers and includes saturation values from 70% to 100%[12][13][15][16][17]. By utilizing multiple wavelengths, selected instruments are also capable of determining the most important dyshemoglobins—carboxyhemoglobin (SpCO) and methemoglobin (SpMet)—in addition to oxy- and deoxyhemoglobin[14][18][19].

Sensors commonly used in pulse oximetry can be categorized into two types, according to the measurement method: (1) Transmission sensors, where the emitter and receiver are placed opposite to each other and the light passes through the tissue (e.g., finger- or earlobe sensors), and (2) reflection sensors, where the emitter and receiver are placed next to each other and the backscattered light is analyzed (e.g., forehead- or wrist sensors)[14]. Because of the easy-to-use and wide clinical acceptance, pulse oximetry has become a well-established indirect method for continuous and noninvasive monitoring of blood oxygenation[21]. By default, medical pulse oximeters comply with the international standard for pulse oximeter manufacture ISO 80601-2-61 and must maintain high accuracy (average root mean square error Arms ≤ 4%) in SpO2 reading within the range of 70–100% when compared to arterial oxygen saturation (SaO2) obtained from arterial blood gas (ABG) analysis. The FDA recommends Arms values of ≤3.0% for transmission sensors and ≤3.5% for ear clip and reflectance sensors[22]. This also implies that not each oximeter would provide exactly the same reading if theoretically measured in the same individual, at the same time and at the same location. However, the variance should be within the limits specified. Assuming faultless handling of the instrument, these variations are attributable to technical variations, e.g., different signal averaging times, incorrect calibration or differences in the number and precision of wavelengths used[23]. Devices for non-medical use not conforming to this ISO standard may have larger deviations in SpO2 readings. There exist a limited number of studies comparing reasonably priced commercially available handheld devices to medical-standard-devices. These studies indicate that “low-cost” handheld devices provide sufficiently accurate SpO2 values in the range of about 90–100% compared to medical devices, however, below 90%, non-medical devices decrease in accuracy [16][24][25][26]. This property might be a drawback for measurements at high altitudes. Although, no explicit statement for the use of non-medical devices at high altitudes can be made based on these few studies. In general, there is a lack of data on the measurement accuracy of pulse oximeters at high altitudes comparing SpO2 to SaO2 obtained from ABG analysis. This complicates to identify devices that are appropriate for their usage at high altitudes without restrictions. However, certain parameters may require increased attention when the decision for a specific pulse oximeter has to be made: (1) accuracy, precision, and bias of the device [12]; (2) environmental conditions such as maximum operating altitude respectively minimum air pressure or the minimum operating temperature; (3) the availability of advanced algorithms to reduce motion artifacts or the detection of low perfusion; (4) the selection of the sensor location, typically using the finger[12][15][27][28]—however, other common positions such as the forehead may be considered, in particular if the measurement is conducted during motion[28][29][30]; (5) if required: the opportunity to sense carboxyhemoglobin and methemoglobin. In addition to the technical aspects, however, the measurement process itself becomes more error-prone with increasing altitude[6][12]Table 1 summarizes the most significant pitfalls that may lead to inaccurate SpO2 readings and possible countermeasures particularly for healthy people visiting high altitudes. The application of standardized procedure by trained users can prevent incorrect measurements and data interpretation[6][12]. Unfortunately, there exists no uniform standard for measuring protocols at high altitudes but there are some specific recommendations available to minimize measurement uncertainties which largely coincides with the countermeasures listed in Table 1: (1) The test person should remain in a sitting position for about 5 min, (2) the measuring site (normally the finger) should be kept as warm as possible, e.g., by wearing gloves, (3) motions of the sensor should be prevented, (4) the sensor should be shielded from ambient light, (5) a trained and experienced examiner should perform the measurements, and (6) SpO2 values should be monitored and averaged over a period of 2–3 min[12]. Additionally, if the device offers the ability to display the pulse wave graphically, it should be ensured that it remains as stable as possible[31]. In the following section, studies implementing a pulse oximeter to document the progress of acclimatization are illustrated.

Table 1. Most significant pitfalls and possible countermeasures for pulse oximetry particularly for healthy people at high altitudes.



  1. Li, R.T.; Kling, S.R.; Salata, M.J.; Cupp, S.A.; Sheehan, J.; Voos, J.E. Wearable Performance Devices in Sports Medicine. Sports Health Multidiscip. Approach 2016, 8, 74–78.
  2. Ma, C.Z.; Wong, D.W.; Lam, W.K.; Wan, A.H.; Lee, W.C. Balance Improvement Effects of Biofeedback Systems with State-of-the-Art Wearable Sensors: A Systematic Review. Sensors 2016, 16, 434.
  3. Altini, M.; Casale, P.; Penders, J.; Ten Velde, G.; Plasqui, G.; Amft, O. Cardiorespiratory fitness estimation using wearable sensors: Laboratory and free-living analysis of context-specific submaximal heart rates. J. Appl. Physiol. 2016, 120, 1082–1096.
  4. Welsh, E.J.; Carr, R. Pulse oximeters to self monitor oxygen saturation levels as part of a personalised asthma action plan for people with asthma. Cochrane Database Syst. Rev. 2015, 9, CD011584.
  5. Otani, S.; Miyaoka, Y.; Ikeda, A.; Ohno, G.; Imura, S.; Watanabe, K.; Kurozawa, Y. Evaluating Health Impact at High Altitude in Antarctica and Effectiveness of Monitoring Oxygen Saturation. Yonago Acta Med. 2020, 63, 163–172.
  6. Tannheimer, M.; Lechner, R. The correct measurement of oxygen saturation at high altitude. Sleep Breath. 2019, 23, 1101–1106f
  7. Koehle, M.S.; Guenette, J.A.; Warburton, D.E. Oximetry, heart rate variability, and the diagnosis of mild-to-moderate acute mountain sickness. Eur. J. Emerg. Med. 2010, 17, 119–122.
  8. Burtscher, M.; Flatz, M.; Faulhaber, M. Prediction of susceptibility to acute mountain sickness by SaO2 values during short-term exposure to hypoxia. High Alt. Med. Biol. 2004, 5, 335–340.
  9. Tannheimer, M.; Thomas, A.; Gerngross, H. Oxygen saturation course and altitude symptomatology during an expedition to broad peak (8047 m). Int. J. Sports Med. 2002, 23, 329–335.
  10. Reuland, D.S.; Steinhoff, M.C.; Gilman, R.H.; Bara, M.; Olivares, E.G.; Jabra, A.; Finkelstein, D. Prevalence and prediction of hypoxemia in children with respiratory infections in the Peruvian Andes. J. Pediatr. 1991, 119, 900–906.
  11. Ottestad, W.; Kåsin, J.I.; Høiseth, L.Ø. Arterial Oxygen Saturation, Pulse Oximetry, and Cerebral and Tissue Oximetry in Hypobaric Hypoxia. Aerosp. Med. Hum. Perform. 2018, 89, 1045–1049.
  12. Luks, A.M.; Swenson, E.R. Pulse oximetry at high altitude. High Alt. Med. Biol. 2011, 12, 109–119.
  13. Chan, E.D.; Chan, M.M.; Chan, M.M. Pulse oximetry: Understanding its basic principles facilitates appreciation of its limitations. Respir. Med. 2013, 107, 789–799.
  14. Jubran, A. Pulse oximetry. Crit. Care 2015, 19, 272.
  15. Tamura, T. Current progress of photoplethysmography and SPO2 for health monitoring. Biomed. Eng. Lett. 2019, 9, 21–36.
  16. Lipnick, M.S.; Feiner, J.R.; Au, P.; Bernstein, M.; Bickler, P.E. The Accuracy of 6 Inexpensive Pulse Oximeters Not Cleared by the Food and Drug Administration: The Possible Global Public Health Implications. Anesth. Analg. 2016, 123, 338–345.
  17. Petterson, M.T.; Begnoche, V.L.; Graybeal, J.M. The effect of motion on pulse oximetry and its clinical significance. Anesth. Analg. 2007, 105, S78–S84.
  18. Zaouter, C.; Zavorsky, G.S. The measurement of carboxyhemoglobin and methemoglobin using a non-invasive pulse CO-oximeter. Respir. Physiol. Neurobiol. 2012, 182, 88–92.
  19. Feiner, J.R.; Rollins, M.D.; Sall, J.W.; Eilers, H.; Au, P.; Bickler, P.E. Accuracy of carboxyhemoglobin detection by pulse CO-oximetry during hypoxemia. Anesth. Analg. 2013, 117, 847–858.
  20. Prahl, S. Tabulated Molar Extinction Coefficient for Hemoglobin in Water; Oregon Medical Laser Center: Portland, OR, USA, 1998.
  21. Nitzan, M.; Romem, A.; Koppel, R. Pulse oximetry: Fundamentals and technology update. Med. Devices 2014, 7, 231–239.
  22. Center for Devices and Radiological Health. Pulse Oximeters—Premarket Notification Submissions [510 (k)s] Guidance for Industry and Food and Drug Administration Staff; U.S. Department of Health and Human Services: Washington, DC, USA, 2013.
  23. Pretto, J.J.; Roebuck, T.; Beckert, L.; Hamilton, G. Clinical use of pulse oximetry: Official guidelines from the Thoracic Society of Australia and New Zealand. Respirology 2014, 19, 38–46.
  24. Hudson, A.J.; Benjamin, J.; Jardeleza, T.; Bergstrom, C.; Cronin, W.; Mendoza, M.; Schultheis, L. Clinical Interpretation of Peripheral Pulse Oximeters Labeled “Not for Medical Use”. Ann. Fam. Med. 2018, 16, 552–554.
  25. Luks, A.M.; Swenson, E.R. Pulse Oximetry for Monitoring Patients with COVID-19 at Home. Potential Pitfalls and Practical Guidance. Ann. Am. Thorac. Soc. 2020, 17, 1040–1046.
  26. Smith, R.N.; Hofmeyr, R. Perioperative comparison of the agreement between a portable fingertip pulse oximeter v. a conventional bedside pulse oximeter in adult patients (COMFORT trial). S. Afr. Med. J. 2019, 109, 154–158.
  27. Ross, E.M.; Matteucci, M.J.; Shepherd, M.; Barker, M.; Orr, L. Measuring arterial oxygenation in a high altitude field environment: Comparing portable pulse oximetry with blood gas analysis. Wilderness Environ. Med. 2013, 24, 112–117.
  28. Bradke, B.; Everman, B. Investigation of Photoplethysmography Behind the Ear for Pulse Oximetry in Hypoxic Conditions with a Novel Device (SPYDR). Biosensors 2020, 10, 34.
  29. Longmore, S.K.; Lui, G.Y.; Naik, G.; Breen, P.P.; Jalaludin, B.; Gargiulo, G.D. A Comparison of Reflective Photoplethysmography for Detection of Heart Rate, Blood Oxygen Saturation, and Respiration Rate at Various Anatomical Locations. Sensors 2019, 19, 1874.
  30. Yamaya, Y.; Bogaard, H.J.; Wagner, P.D.; Niizeki, K.; Hopkins, S.R. Validity of pulse oximetry during maximal exercise in normoxia, hypoxia, and hyperoxia. J. Appl. Physiol. 2002, 92, 162–168.
  31. Lorente-Aznar, T.; Perez-Aguilar, G.; García-Espot, A.; Benabarre-Ciria, S.; Mendia-Gorostidi, J.L.; Dols-Alonso, D.; Blasco-Romero, J. Estimation of arterial oxygen saturation in relation to altitude. Med. Clin. 2016, 147, 435–440.
  32. Barker, S.J. “Motion-resistant” pulse oximetry: A comparison of new and old models. Anesth. Analg. 2002, 95, 967–972.
  33. Clarke, G.W.J.; Chan, A.D.C.; Adler, A. Effects of motion artifact on the blood oxygen saturation estimate in pulse oximetry. In Proceedings of the 2014 IEEE International Symposium on Medical Measurements and Applications, Lisabon, Portugal, 11–12 June 2014; pp. 1–4.
  34. Giuliano, K.K.; Higgins, T.L. New-generation pulse oximetry in the care of critically ill patients. Am. J. Crit. Care 2005, 14, 26–37.
  35. Louie, A.; Feiner, J.R.; Bickler, P.E.; Rhodes, L.; Bernstein, M.; Lucero, J. Four Types of Pulse Oximeters Accurately Detect Hypoxia during Low Perfusion and Motion. Anesthesiology 2018, 128, 520–530.
  36. Cannesson, M.; Talke, P. Recent advances in pulse oximetry. F1000 Med. Rep. 2009, 1, 66.
  37. Fluck, R.R.; Schroeder, C.; Frani, G.; Kropf, B.; Engbretson, B. Does ambient light affect the accuracy of pulse oximetry? Respir. Care 2003, 48, 677–680.
  38. World Health Organization. Pulse Oximetry Training Manual; WHO Press: Geneva, Switzerland, 2011.
  39. Hafen, B.B.; Sharma, S. Oxygen Saturation. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2020.
  40. Peacock, A.J. ABC of oxygen: Oxygen at high altitude. BMJ 1998, 317, 1063–1066.
  41. West, J.B. High-altitude medicine. Am. J. Respir. Crit. Care Med. 2012, 186, 1229–1237.
  42. Severinghaus, J.W.; Naifeh, K.H.; Koh, S.O. Errors in 14 pulse oximeters during profound hypoxia. J. Clin. Monit. 1989, 5, 72–81.
  43. Jeong, I.C.; Yoon, H.; Kang, H.; Yeom, H. Effects of skin surface temperature on photoplethysmograph. J. Healthc. Eng. 2014, 5, 429–438.
  44. Khan, M.; Pretty, C.G.; Amies, A.C.; Elliott, R.; Shaw, G.M.; Chase, J.G. Investigating the Effects of Temperature on Photoplethysmography. IFAC PapersOnLine 2015, 48, 360–365.
  45. Khan, M.; Pretty, C.G.; Amies, A.C.; Elliott, R.; Chiew, Y.S.; Shaw, G.M.; Chase, J.G. Analysing the effects of cold, normal, and warm digits on transmittance pulse oximetry. Biomed. Signal Process. Control 2016, 26, 34–41.
  46. Feiner, J.R.; Severinghaus, J.W.; Bickler, P.E. Dark skin decreases the accuracy of pulse oximeters at low oxygen saturation: The effects of oximeter probe type and gender. Anesth. Analg. 2007, 105, S18–S23.
  47. Bickler, P.E.; Feiner, J.R.; Severinghaus, J.W. Effects of skin pigmentation on pulse oximeter accuracy at low saturation. Anesthesiology 2005, 102, 715–719.
  48. Ralston, A.C.; Webb, R.K.; Runciman, W.B. Potential errors in pulse oximetry. III: Effects of interferences, dyes, dyshaemoglobins and other pigments. Anaesthesia 1991, 46, 291–295.
  49. Sjoding, M.W.; Dickson, R.P.; Iwashyna, T.J.; Gay, S.E.; Valley, T.S. Racial Bias in Pulse Oximetry Measurement. N. Engl. J. Med. 2020, 383, 2477–2478.
  50. Tannheimer, M. The Use of Pulse Oximetry at High Altitude. Res. Investig. Sports Med. 2020, 6, 10–13.
  51. Rodden, A.M.; Spicer, L.; Diaz, V.A.; Steyer, T.E. Does fingernail polish affect pulse oximeter readings? Intensive Crit. Care Nurs. 2007, 23, 51–55.
  52. Chan, M.M.; Chan, M.M.; Chan, E.D. What is the effect of fingernail polish on pulse oximetry? Chest 2003, 123, 2163–2164.
  53. Yeganehkhah, M.; Dadkhahtehrani, T.; Bagheri, A.; Kachoie, A. Effect of Glittered Nail Polish on Pulse Oximetry Measurements in Healthy Subjects. Iran. J. Nurs. Midwifery Res. 2019, 24, 25–29.
  54. Ballesteros-Pena, S.; Fernandez-Aedo, I.; Picon, A.; Lorrio-Palomino, S. Influence of nail polish on pulse oximeter readings of oxygen saturation: A systematic review. Emergencias 2015, 27, 325–331.
  55. Foutch, R.G.; Henrichs, W. Carbon monoxide poisoning at high altitudes. Am. J. Emerg. Med. 1988, 6, 596–598.
  56. Buchheit, M.; Simpson, B.M.; Garvican-Lewis, L.A.; Hammond, K.; Kley, M.; Schmidt, W.F.; Aughey, R.J.; Soria, R.; Sargent, C.; Roach, G.D.; et al. Wellness, fatigue and physical performance acclimatisation to a 2-week soccer camp at 3600 m (ISA3600). Br. J. Sports Med. 2013, 47, i100–i106.
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