Does Ambient Light Affect the Accuracy of Pulse Oximetry?

Robert R Fluck Jr MSc RRT, Christine Schroeder RRT, Greg Frani CRT,
Brad Kropf CRT, Brenda Engbretson PhD

OBJECTIVE: Determine whether ambient light affects the accuracy of pulse oximetry readings.
DESIGN: Prospective, repeated-measures study. SETTING: A photographic darkroom. SUBJECTS:
Forty-five faculty and students at a university, none of whom had pale skin, dark skin, or evidence
of cardiopulmonary disease. Any nail polish was removed. METHODS: Five light sources were
individually tested: incandescent, quartz-halogen, infrared, fluorescent, and bilirubin light. A pulse
oximetry probe was placed on the subject’s finger, and the finger and probe were placed sideways
under each light source, on a predetermined mark. RESULTS: The greatest difference in pulse
oximetry reading between any of the light sources was 0.5%. Repeated-measures analysis of vari-
ance yielded a p value of 0.204. CONCLUSIONS: Ambient light has no statistically significant effect
on pulse oximetry readings. Even had the differences been statistically significant, the magnitude of
the differences was small and thus clinically unimportant. Key words: pulse oximetry, monitoring,
patient assessment, oxyhemoglobin saturation. [Respir Care 2003;48(7):677– 680. © 2003 Daedalus
Enterprises]

Introduction the device, spurious SpO2 readings could lead to inappro-

priate treatment.3
Pulse oximetry is widely used in clinical practice. Prior Early research showed that pulse oximeters produced
to the widespread use of pulse oximeters, arterial blood clinically acceptable results.4 Manufacturers claim a 68%
had to be drawn and analyzed with a co-oximeter every confidence limit (⫾ 1 standard deviation) of 2% for oxy-
time a clinician needed to know the oxygen saturation of gen saturations between 70% and 100% for adults or 3%
arterial blood. Pulse oximetry provides noninvasive, im- for neonates or adults with motion.5 However, according
mediate, and continuous arterial oxygen saturation read- to the American Association for Respiratory Care’s Clin-
ings (SpO2) and can be used in various settings.1 Although ical Practice Guidelines,1 several internal and external fac-
easy to perform, pulse oximetry requires clinician training tors can affect the accuracy of pulse oximetry. Readings
to ensure accurate readings. In one report 87% of nurses can be affected by patient motion,6 shivering,7 abnormal
claimed that they regularly use pulse oximetry to evaluate hemoglobins,6 intravascular dyes,8 low perfusion states,9,10
their patients, but only 37% thought they had adequate skin pigmentation,11 nail polish,12 and exposure of the mea-
training and knowledge of pulse oximetry.2 If pulse oxim- suring probe to ambient light during measurement.13 Many
etry is not properly performed or is performed by persons of these potentially confounding influences can be mini-
who are not aware of the limitations and applications of mized or eliminated, but ambient light is a factor in almost
all care environments. Numerous light sources have been
reported to interfere with the accuracy of pulse oximetry.
These largely anecdotal reports included interference from
Robert R Fluck Jr MSc RRT, Christine Schroeder RRT, Greg Frani CRT,
Brad Kropf CRT, and Brenda Engbretson PhD are affiliated with the
fluorescent,14 incandescent,15 quartz-halogen,16 and infra-
Department of Cardiorespiratory Sciences, State University of New York, red17 light sources.
Upstate Medical University, Syracuse, New York. There is a rationale for concern about the effects of
ambient light on pulse oximetry readings. Pulse oximetry
Correspondence: Robert R Fluck Jr MSc RRT, Department of Cardio-
respiratory Sciences, State University of New York, Upstate Medical
is based on the fact that light of 660 nm wavelength is
University, 750 East Adams Street, Syracuse NY 13210. E-mail: absorbed roughly 10 times more readily by deoxygenated
[email protected]. hemoglobin than by oxygenated hemoglobin, and light of

RESPIRATORY CARE • JULY 2003 VOL 48 NO 7 677

 DOES AMBIENT LIGHT AFFECT THE ACCURACY OF PULSE OXIMETRY?

920 nm wavelength is absorbed by oxygenated hemoglo- Prior to the acquisition of data we measured the relative
bin more readily than by deoxygenated hemoglobin. The output from each of the 5 light sources, using narrow band
ratio of those 2 light absorptions is the basis for the algo- pass filters at the 2 wavelengths used by pulse oximeters.
rithm to calculate SpO2. The photoplethysmography con- The light sources included a 23-watt fluorescent lamp, a
tribution (the “pulse” aspect of pulse oximetry) permits 100-watt incandescent lamp, 125-watt infrared heat lamp,
isolation of the pulsatile flow of arterial blood (which can a 10-watt quartz-halogen lamp, and portable infant biliru-
be referred to as the “alternating current” signal) from bin lamp. The light intensity at each of the wavelengths
tissue, venous blood, and nonpulsatile arterial blood (which was measured with a photometer (Graseby S370, UDT
collectively make up the static or “direct current” signal).7 Instruments, Baltimore, Maryland). Measurements were
By comparing the ratio of the “alternating current” and taken using 2 interference band pass filters (Edmund In-
“direct current” red light signal (660 nm) to the ratio of dustrial Optics, Barrington, New Jersey): one with a peak
that of the infrared light signal (920 nm) the pulse oxime- at 660 nm, the other at 905 nm (a band pass filter specif-
ter cancels out the components of the static signal and ically for 920 nm was not available). The filters have a full
calculates arterial blood oxygen saturation.7 half width maximum of 12.8 nm, which means that trans-
The 2 wavelengths sensed by the oximeter probe (660 mission through the filter falls to 50% of peak value at ⫾
nm and 920 nm) can be generated (in various proportions) 6.4 nm. The measurements were done in a photographic
by several ambient light sources commonly used in clin- darkroom to exclude other sources of ambient light. Table
ical settings. For example, the spectrum of energy pro- 1 lists the ratio of the intensity at 660 nm to the intensity
duced by both quartz-halogen and incandescent bulbs be- at 905 nm from each light source.
gins in the visible range, at 650 nm, and peaks around Quartz-halogen, infrared, and incandescent bulbs have
1,000 nm. An infrared heat lamp, with spectral output fairly similar energy output ratios, and those ratios are
beginning at approximately 700 nm, generates little energy close to 1. Because these ratios are ⬍ 1, the energy inten-
in the visible (red) range. In contrast, bilirubin and fluo- sity is slightly higher around 905 nm.
rescent light sources emit more energy at shorter wave- The fluorescent and bilirubin bulbs have similar energy
lengths and minimal energy in the infrared range. Bilirubin output ratios (about 112 and 132), and because those ratios
light peaks around 200 – 400 nm. Fluorescent light pro- are ⬎ 100, their intensity is higher around 660 nm.
duces most of its energy in the visible range: 405–579 nm. The environmental conditions of our study were con-
Since pulse oximetry depends on accurate measurement trolled. The subjects participated one at a time, and the
of the 660 –920 nm range and quartz-halogen, incandes- tests were conducted in complete darkness in a photo-
cent, infrared, fluorescent, and bilirubin bulbs produce graphic darkroom that excluded all ambient light. Each
wavelengths in that range, those light sources could, the- light source was applied at the same intensity, which was
oretically, affect pulse oximetry readings. While practitio- confirmed with the photometer, in the spectral range of
ners and manufacturers commonly believe that those light 200 –1,000 nm; the distance of the light source from the
sources do affect pulse oximetry readings,5 there have been subject’s finger was adjusted so that the overall intensity
no randomized, prospective, controlled studies addressing was the same. The probe was placed on the subject’s right
this topic.16 Therefore, the purpose of this study was to index finger, and the finger was positioned sideways under
determine whether the ambient light sources commonly each light source to maximize the potential for interfer-
used in clinical settings affect SpO2 readings. Our hypoth- ence from the ambient light being tested. The subject’s
esis was that ambient light does affect SpO2 readings. finger was placed on the same predetermined mark under
each light source. Once the reading was stable, SpO2 was
recorded from a pulse oximeter (Nellcor N-200, Nellcor
Methods
Puritan Bennett, Pleasanton, California). The pulse oxim-

Approval was obtained from the Upstate Medical Uni- Table 1. Energy Output Ratios
versity’s Institutional Review Board for the Protection of
Human Subjects. We recruited 45 Upstate Medical Uni- Light Source
Energy Output
versity faculty and student volunteers between the ages of Ratio*
20 and 59. Subjects gave written informed consent. A brief Quartz-halogen 0.70
medical history was obtained from each subject, to ex- Infrared 0.55
clude individuals with cardiopulmonary disease. A visual Incandescent 0.81
inspection was done to exclude individuals with peripheral Fluorescent 112.10
edema. Subjects who were extremely pale or had dark skin Bilirubin light 132.08
pigmentation were also excluded. Any nail polish was *Ratio of the intensity at 660 nm in mw to the intensity at 905 nm in mw
removed.

678 RESPIRATORY CARE • JULY 2003 VOL 48 NO 7

 DOES AMBIENT LIGHT AFFECT THE ACCURACY OF PULSE OXIMETRY?

Table 2. Pulse Oximetry Readings Under 5 Light Sources and Control

Control Quartz-Halogen Infrared Incandescent Fluorescent Bilirubin

Mean SpO2 98 97.5 97.6 97.7 97.6 97.8

SEM 0.182 0.158 0.150 0.165 0.160 0.163
Difference NA ⫺0.467 ⫺0.311 ⫺0.289 ⫺0.356 ⫺0.200
SEM NA 0.133 0.130 0.141 0.128 0.137

SpO2 ⫽ pulse oximetry reading

SEM ⫽ standard error of the mean
NA ⫽ not applicable

etry probe was cleaned with an alcohol pad between sub- light sources would not be expected to interfere with each
jects. The light sources were applied in a random order other.
determined by the Latin square design. Our results do not support the belief that ambient
The fluorescent light source was allowed to warm up for light affects pulse oximetry readings. Ambient light is
3 min, to ensure that it was providing a stable intensity listed as an interfering factor in the American Associ-
output. Each individual’s SpO2 was also measured in com- ation for Respiratory Care’s Clinical Practice Guide-
plete darkness, to serve as a control reading. lines for Pulse Oximetry,1 and several published reports
suggest that ambient light causes interference. Brooks
Statistical Analysis et al17 found that an infrared heat lamp caused false low
SpO2 readings. Block16 found that a quartz-halogen light
Statistical analysis was performed with statistics soft-
placed next to the pulse oximetry probe on the subject’s
ware (Minitab, State College, Pennsylvania). All values
finger caused false low readings. Amar and Neidzwski14
are expressed as mean ⫾ standard error of the mean. Dif-
reported that fluorescent light caused a pulse oximeter
ferences were considered statistically significant when
to give a reading when it was not attached to a patient.
p ⬍ 0.05 (2-sided). A one-way analysis of variance, with
repeated measures, was used to analyze the effects of the However, those reports were anecdotal, not prospective,
5 sources on SpO2 readings. randomized, controlled studies.
Our results may be explained by considering the prin-
ciple of photoplethysmography. A pulse oximeter uses pho-
Results toplethysmography to detect arterial pulsations and mea-
sure the saturation of arterial blood. Therefore, both the
A sample of convenience included 45 subjects (29 volume of arterial blood in tissue and the light absorption
women, 16 men). The mean age of the women was 35.5 ⫾ of blood change during the pulsatile phase. The photode-
2.1 years, and that of the men was 35.4 ⫾ 2.9 years. All
tector, sampling the light at 480 times per second, is also
the subjects had good cardiopulmonary function.
measuring ambient light during both static and pulsatile
The SpO2 for each light source for each subject was
phases. Therefore, the pulse oximeter nulls not only tissue
subtracted from the control value for that subject. The
and venous blood but also incident energy from any am-
differences were then averaged for all subjects for each
light source. Table 2 shows the results. No difference bient energy source.1
⬎ 0.5% was measured between any light source and the We used only healthy white subjects, to minimize con-
control. Measurements were all higher than the control, founding variables. Future research should include testing
with little variability among measurements. subjects with darker skin and subjects whose oxygen sat-
uration is below normal (⬍ 95%).

Discussion
Conclusions
Our findings suggest that ambient light has no statisti-
cally significant effect on SpO2 readings and that ambient
light’s effect on SpO2 is clinically unimportant. We believe Pulse oximeter readings are not significantly affected
the results would be similar in the clinical setting. by 5 light sources commonly found in the clinical set-
In the clinical setting patients are often exposed to sev- ting. Therefore, our data suggest that ambient light in
eral light sources simultaneously, rather than individually the clinical setting has no clinically important effect on
as in our experimental design. However, different ambient pulse oximetry readings.

RESPIRATORY CARE • JULY 2003 VOL 48 NO 7 679

 DOES AMBIENT LIGHT AFFECT THE ACCURACY OF PULSE OXIMETRY?

REFERENCES 9. Brown M, Vender JS. Noninvasive oxygen monitoring. Crit Care

Clin 1988;4(3):493–509.
1. American Association for Respiratory Care. AARC Clinical Practice 10. Welch JP, DeCesare R, Hess D. Pulse oximetry: instrumentation and
Guideline: Pulse oximetry. Respir Care 1991;36(12):1406–1409. clinical applications. Respir Care 1990;35(6):584–597; discussion
2. Bowes WA 3rd, Corke BC, Hulka J. Pulse oximetry: a review of the 597–601.
theory, accuracy, and clinical applications. Obstet Gynecol 1989; 11. Ries AL, Prewitt LM, Johnson JJ. Skin color and ear oximetry. Chest
74(3 Pt 2):541–546. 1989;96(2):287–290.
3. Scanlan CL. Analysis and monitoring of gas exchange. In: Scanlan 12. Cote CJ, Goldstein EA, Fuschman WH, Hoaglin DC. The effect
CL, Wilkins RL, Stoller JK. Egan’s fundamentals of respiratory care, of nail polish on pulse oximetry. Anesth Analog 1988;67(7):
7th edition. St Louis: Mosby; 1999:337–369. 683–686.
4. Ralston AC, Webb RK, Runciman WB. Potential errors in pulse 13. Trivedi NS, Ghouri AF, Shah NK, Lai E, Barker SJ. Effects of
oximetry. III: Effects of interferences, dyes, dyshaemoglobins and motion, ambient light, and hypoperfusion on pulse oximeter func-
other pigments. Anaesthesia 1991;46(4):291–295. tion. J Clin Anesth 1997;9(3):179–183.
5. Mallinckrodt Inc. Operator’s manual- N-395 pulse oximeter. St Louis 14. Amar D, Neidzwski J, Wald A, Finck AD. Fluorescent light inter-
2000:25, 73. feres with pulse oximetry. J Clin Monit 1989;5(2):135–136.
6. Huch A, Huch R, Konig V, Neuman MR, Parker D, Yount J, Lubbers D. 15. Siegel MN, Gravenstein N. Preventing ambient light from affecting
Limitations of pulse oximetry (letter). Lancet 1988;1(8581):357–358. pulse oximetry (letter). Anesthesiology 1998;67(2):280.
7. Sinex JE. Pulse oximetry: principles and limitations. Am J Emerg 16. Block FE Jr. Interference in a pulse oximeter from a fiberoptic light
Med 1999;17(1):59–67. source. J Clin Monit 1987;3(3):210–211.
8. Vokach-Brodsky L, Jeffrey SS, Lemmens HJ, Brock-Utne JG. Isosulfan 17. Brooks TD, Paulus DA, Winkle WE. Infrared heat lamps interfere
blue affects pulse oximetry. Anesthesiology 2000;93(4):1002–1003. with pulse oximeters (letter). Anesthesiology 1984;61(5):630.

680 RESPIRATORY CARE • JULY 2003 VOL 48 NO 7