Racial Disparity in Oxygen Saturation Measurements by Pulse Oximetry: Evidence and Implications
The pulse oximeter is a ubiquitous clinical tool used to estimate blood oxygen concentrations. However, decreased accuracy of pulse oximetry in patients with dark skin tones has been demonstrated since as early as 1985.
Most commonly, pulse oximeters may overestimate the true oxygen saturation in individuals with dark skin tones, leading to higher rates of occult hypoxemia (i.e., clinically unrecognized low blood oxygen saturation). Overestimation of oxygen saturation in patients with dark skin tones has serious clinical implications, as these patients may receive insufficiently rigorous medical care when pulse oximeter measurements suggest that their oxygen saturation is higher than the true value.
Recent studies have linked pulse oximeter inaccuracy to worse clinical outcomes, suggesting that pulse oximeter inaccuracy contributes to known racial health disparities. The magnitude of device inaccuracy varies by pulse oximeter manufacturer, sensor type, and arterial oxygen saturation. The underlying reasons for decreased pulse oximeter accuracy for individuals with dark skin tones may be related to failure to control for increased absorption of red light by melanin during device development and insufficient inclusion of individuals with dark skin tones during device calibration.
Inadequate regulatory standards for device approval may also play a role in decreased accuracy. Awareness of potential pulse oximeter limitations is an important step for providers and may encourage the consideration of additional clinical information for management decisions. Ultimately, stricter regulatory requirements for oximeter approval and increased manufacturer transparency regarding device performance are required to mitigate this racial bias.
Pulmonologists, critical care specialists, translational researchers, and clinicians
After reading this journal article, learners will be able to:
- Recognize that race may be inadequate as a proxy for skin tone in pulse oximetry validation studies.
- List types of validation data that are important for demonstrating the accuracy of pulse oximeters.
- Obtain additional data when caring for a patient with dark skin whose SpO2 is close to a cutoff point that changes management according to clinical guidelines.
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Article Authorship Disclosures (as submitted to the ATS prior to article publication date)
Haya Jamali, M.D., Ph.D. (Massachusetts General Hospital, Boston, MA, USA) reported no relevant financial relationships.
Lauren T. Castillo, B.S.N., R.N. (VA Puget Sound Health Care System, Seattle, WA, USA) reported no relevant financial relationships.
Chelsea Cosby Morgan, M.D. (Veterans Affairs Bay Pines Health Care System, Bay Pines, FL, USA) reported no relevant financial relationships.
Jason Coult, Ph.D. (University of Washington, Seattle, WA, USA) reported no relevant financial relationships.
Janice L. Muhammad, M.S., B.S.N., R.N., C.N.M. (VA Puget Sound Health Care System, Seattle, WA, USA) reported no relevant financial relationships.
Oyinkansola O. Osobamiro, M.D. (University of Washington, Seattle, WA, USA) reported no relevant financial relationships.
Elizabeth C. Parsons, M.D. (VA Puget Sound Health Care System, Seattle, WA, USA) reported no relevant financial relationships.
Rosemary Adamson, M.B., B.S. (VA Puget Sound Health Care System, Seattle, WA, USA) reported no relevant financial relationships.
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