Pulse oximetry is a non-invasive optical technique used to measure arterial oxygen saturation (SpO2) in a variety of clinical settings and scenarios. Despite being one the most significant technological advances in health monitoring over the last few decades, there have been reports on its various limitations. Recently due to the Covid-19 pandemic, questions about pulse oximeter technology and its accuracy when used in people with different skin pigmentation have resurfaced. This review presents an introduction to the technique of pulse oximetry including its basic principle of operation, technology, and limitations, with a more in depth focus on skin pigmentation. Relevant literature relating to the performance and accuracy of pulse oximeters in populations with different skin pigmentation are evaluated. The majority of the evidence suggests that the accuracy of pulse oximetry differs in subjects of different skin pigmentations to a level that requires particular attention, with decreased accuracy in patients with dark skin. Some recommendations, both from the literature and contributions from the authors, suggest how future work could address these inaccuracies to potentially improve clinical outcomes. These include the objective quantification of skin pigmentation to replace currently used qualitative methods, and computational modelling for predicting calibration algorithms based on skin colour.
Recent reports have highlighted the potential challenges skin pigmentation can have in the accurate estimation of arterial oxygen saturation when using a pulse oximeter. Pulse oximeters work on the principle of photoplethysmography (PPG), an optical technique used for the assessment of volumetric changes in vascular tissue. The primary aim of this research is to investigate the effect of melanin on tissue when utilising the technique of PPG. To address this, a Monte Carlo (MC) light-tissue interaction model is presented to explore the behaviour of melanin in the visible range in the epidermis. A key novelty in this paper is the ability to model the Modified Beer Lambert Law (MBLL) through a fully functional three-dimensional (3D) model in reflective optical geometry. Maximum photon penetration depth was achieved by red light, however limited bio-optical information was retrieved by moderately and darkly pigmented skin at source-detector separations of less than 3 mm. The current MC model can be modified to provide a more realistic representation of skin by assessing the impact of scatter in the dermis, as well as absorption of light by blood, water, and lipids.
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