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Cited by 96Non-Invasive Vital Sign MonitoringHemodynamic Monitoring and TherapyHealthcare Technology and Patient Monitoring

Pulse Oximeter Performance, Racial Inequity, and the Work Ahead

Open access
Okunlola, Olubunmi E, Lipnick, Michael S, Batchelder, Paul B, Bernstein, Michael, Feiner, John R, Bickler, Philip E·2022·Respiratory Care
DOI 10.4187/respcare.09795
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Abstract

It has long been known that many pulse oximeters function less accurately in patients with darker skin. Reasons for this observation are incompletely characterized and potentially enabled by limitations in existing regulatory oversight. Based on decades of experience and unpublished data, we believe it is feasible to fully characterize, in the public domain, the factors that contribute to missing clinically important hypoxemia in patients with darkly pigmented skin. Here we propose 5 priority areas of inquiry for the research community and actionable changes to current regulations that will help improve oximeter accuracy. We propose that leading regulatory agencies should immediately modify standards for measuring accuracy and precision of oximeter performance, analyzing and reporting performance outliers, diversifying study subject pools, thoughtfully defining skin pigmentation, reporting data transparently, and accounting for performance during low-perfusion states. These changes will help reduce bias in pulse oximeter performance and improve access to safe oximeters.

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  • Overestimated SpO2 readings in patients with darker skin pigmentation lead to lower hospital admission, higher occult hypoxemia, delayed or no access to dexamethasone, therapeutic oxygen, and COVID-19 therapies, resulting in increased hospital readmission, organ dysfunction, and mortality.

    “leading to lower hospital admission; higher occult hypoxemia; and delayed or no access to dexamethasone, therapeutic oxygen, and COVID-19 therapies, resulting in increased hospital readmission, organ dysfunction, and mortality [11-18].”

    From Impact of skin pigmentation on pulse oximetry blood oxygenation and wearable pulse rate accuracy: systematic review and meta-analysis (2024) · cites this paper as [14]

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

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  • Patients with darker skin pigmentation are more likely than patients with lighter skin color to have overestimated SpO2 readings.

    “Patients with darker skin pigmentation are more likely than patients with lighter skin color to have overestimated SpO2 readings”

    From Impact of skin pigmentation on pulse oximetry blood oxygenation and wearable pulse rate accuracy: systematic review and meta-analysis (2024) · cites this paper as [14]

  • Recent studies have shown a positive bias in oxygen saturation measurements in patients with darkly pigmented skin, particularly under low saturation conditions.

    “Recent studies have shown a positive bias in oxygen saturation measurements in patients with darkly pigmented skin, particularly under low saturation conditions.”

    From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [52]

  • More recent studies have revealed that dark skin pigmentation influences the accuracy and performance of pulse oximeter devices, resulting in overestimations, with increased incidence in the risk for occult hypoxemia (SO2<88% despite normal SpO2>92%).

    “More recent studies have also revealed that dark skin pigmentation influences the accuracy and performance of pulse oximeters devices, resulting in overestimations [17,49,50,51,52,53] with increased incidence in the risk for occult hypoxemia (SO2<88% despite normal SpO2>92%) [54,55].”

    From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [52]

  • Other subjective scales were employed in 13 studies (35.14%).

    “and other subjective scales were employed in 13 studies (35.14%) [30,42,43,44,45,50,52,56,72,78,80,87,88].”

    From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [52]

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Authors
Okunlola, O. E., Lipnick, M. S., Batchelder, P. B., Bernstein, M., Feiner, J. R., & Bickler, P. E.
Affiliations
  • University of California, San Francisco (US)
  • Clinimark, Louisville, Colorado.
ORCID
Venue
Respiratory Care
Publisher
SAGE Publications
Published
2021-11-12
Volume
67
Issue
2
Pages
252-257
ISSN
0020-1324 (ISSN-L)
DOI
10.4187/respcare.09795
OpenAlex
W3214554178
Cited by
96
References
13
Citations by year
2026: 8 · 2025: 21 · 2024: 20 · 2023: 31 · 2022: 16
FWCI
5.09
Type
journal article
Language
en
Open access
Licence
Locations
  • Respiratory Care (publishedVersion, public-domain)
  • PubMed (publishedVersion)
Topics
  • Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
  • Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
  • Health Sciences › Medicine › Surgery › Healthcare Technology and Patient Monitoring
Keywords
pulse oximetry, skin pigmentation, racial disparities in health, hypoxemia detection, regulatory oversight, reporting transparency, dark skin
MeSH terms
Hypoxia, Humans, Oximetry, Oxygen, Skin Pigmentation

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