Supplement oxygen impairs detection of hypoventilation by pulse oximetry

Study objective: This two-part study was designed to determine the effect of supplemental oxygen on the detection of hypoventilation, evidenced by a decline in oxygen saturation (SpO₂) with pulse oximetry. Design: Phase 1 was a prospective, patient-controlled, clinical trial. Phase 2 was a prospective, randomized, clinical trial. Setting: Phase 1 took place in the operating room. Phase 2 took place in the postanesthesia care unit (PACU). Patients: In phase 1, 45 patients underwent abdominal, gynecologic, urologie, and lower-extremity vascular operations. In phase 2, 288 patients were recovering from anesthesia. Intervention: In phase 1, modeling of deliberate hypoventilation entailed decreasing by 50% the minute ventilation of patients receiving general anesthesia. Patients breathing a fraction of inspired oxygen (FIO₂) of 0.21 (n = 25) underwent hypoventilation for up to 5 min. Patients with an FIO₂ of 0.25 (n = 10) or 0.30 (n = 10) underwent hypoventilation for 10 min. In phase 2, spontaneously breathing patients were randomized to breathe room air (n = 155) or to receive supplemental oxygen (n = 133) on arrival in the PACU. Measurements and results: In phase 1, end-tidal carbon dioxide and SpO₂ were measured during deliberate hypoventilation. A decrease in SpO₂ occurred only in patients who breathed room air. No decline occurred in patients with FIO₂ levels of 0.25 and 0.30. In phase 2, SpO₂ was recorded every min for up to 40 min in the PACU. Arterial desataration (SpO₂ < 90%) was fourfold higher in patients who breathed room air than in patients who breathed supplemental oxygen (9.0% vs 2.3%, p = 0.02). Conclusion: Hypoventilation can be detected reliably by pulse oximetry only when patients breathe room air. In patients with spontaneous ventilation, supplemental oxygen often masked the ability to detect abnormalities in respiratory function in the PACU. Without the need for capnograpliy and arterial blood gas analysis, pulse oximetry is a useful tool to assess ventilatory abnormalities, but only in the absence of supplemental inspired oxygen.