Variations in Physician Interpretation of Overnight Pulse Oximetry Monitoring

doi:10.1378/chest.07-0312

Chest

Volume 132, Issue 3, September 2007, Pages 852-859

https://doi.org/10.1378/chest.07-0312 Get rights and content

Background

Overnight pulse oximetry is commonly used for hypoxemia evaluation in patients with COPD and sleep-disordered breathing. There is little information regarding its impact on physician decision making, and therefore an important measure of its clinical utility is untested and unknown. The aim of this study was to describe physician interpretation, use, and opinions regarding overnight pulse oximetry.

Methods

Forty-one pulmonary physicians and fellows participated in structured interviews consisting of three oximetry record interpretations, oral responses to a standard question set, and a questionnaire. Qualitative data were analyzed using an open coding process. Quantitative data were assessed for distributions.

Results

Four measures were consistently used by the majority of physicians in record interpretation: background information, arterial oxygen saturation measured by pulse oximetry (Spo₂) waveform and pattern, and time spent with Spo₂ < 90%. An additional 10 measures were consistently used by 5 to 46% of physicians. No interpretation generated a recommendation with > 60% consensus. There was a wide range of opinions on important matters related to this test, including test utility, indications, variables considered most important for interpretation, and criteria for nocturnal oxygen prescription. Forty-one physicians provided 35 different opinions on when nocturnal supplemental oxygen should be initiated.

Conclusions

The variation in physician interpretation, use, and opinions regarding overnight pulse oximetry calls into question its clinical utility and underscores a need for standardization of presentation, training, and interpretation.

Section snippets

Participants

A total of 24 board-certified pulmonary physicians and 17 pulmonary fellows in three academic medical centers in Cleveland participated in the study. The division chief from each participating institution granted permission to approach their physicians for enrollment into this study. Requests were made to keep the subject matter of the interview confidential to avoid priming subsequent subjects. Interviews were conducted in physician offices or at a conveniently located conference room. The

Results

A total of 24 board-certified pulmonary physicians and 17 pulmonary and critical care fellows participated in the study. This represented 65% of all potential subjects in the three academic centers. Reasons for not participating included the following: co-author, busy schedule, failure to return contact, and absence (eg, vacation). All participants completed the interview process.

Discussion

We found a wide variation in physician interpretation and use of overnight pulse oximetry. When presented with three separate oximetry records, physicians weighed different information and generated substantially different recommendations. They also had varying opinions regarding test indications, test utility, the “most important” information, and criteria for nocturnal supplemental oxygen prescription.

These findings have important implications for the clinical utility of overnight oximetry.

References (20)

CA Lewis et al.
Home overnight pulse oximetry in patients with COPD: more than one recording may be needed
Chest
(2003)
A Chaouat et al.
A randomized trial of nocturnal oxygen therapy in chronic obstructive pulmonary disease patients
Eur Respir J
(1999)
WA Whitelaw et al.
Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea
Am J Respir Crit Care Med
(2005)
N Netzer et al.
Overnight pulse oximetry for sleep-disordered breathing in adults: a review
Chest
(2001)
E Chiner et al.
Nocturnal oximetry for the diagnosis of the sleep apnoea hypopnoea syndrome: a method to reduce the number of polysomnographies?
Thorax
(1999)
DG Fryback et al.
The efficacy of diagnostic imaging
Med Decis Making
(1991)
DG Davila et al.
Oximeter's acquisition parameter influences the profile of respiratory disturbances
Sleep
(2003)
VG Kirk et al.
Comparison of home oximetry monitoring with laboratory polysomnography in children
Chest
(2003)
UJ Magalang et al.
Prediction of the apnea-hypopnea index from overnight pulse oximetry
Chest
(2003)
JC Vazquez et al.
Automated analysis of digital oximetry in the diagnosis of obstructive sleep apnoea
Thorax
(2000)

There are more references available in the full text version of this article.

Cited by (36)

Polysomnography
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition
Polysomnography is for studying sleep and its effect on various organ functions. Sleep stages are constructed by monitoring electroencephalogram, chin electromyogram, and eye movements by electrooculogram. Sleep architecture is comprised of the wakefulness stage, Stage W, and NREM and REM sleep stages. Continuous monitoring of respiratory effort, nasal and oral airflow during inspiration and expiration, arterial oxygen saturation, electrocardiogram, and limb electromyogram will assess cardiorespiratory function and movement disorders during sleep. Continuous and simultaneous audiovisual recording enhances the diagnostic utility of polysomnography. Polysomnography is used to diagnose sleep-disordered breathing, movement disorders, and abnormal behavior during sleep, such as REM sleep behavior disorder and arousal disorders.
WRISTOX<inf>2</inf> is a reliable tool to diagnose obstructive sleep apnoea syndrome
2021, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Use of pulse oximetry at home has not shown a similar success as when done in hospital [19], hence these results will likely differ if the WristOx2 is used at home. The pulse oximetry monitoring is scored manually by a doctor and therefore the result is operator dependent and may lack consistency, especially if not trained properly [23] although the interobserver variability in this study was low. Pulse oximetry measures the oxygen saturation change and does not monitor nasal flow and respiratory effort as per polysomnography, thus it is not able to distinguish obstructive events from central events and hence, may give inaccurate results in children with mixed sleep-disordered breathing.
Overnight pulse oximetry is an alternative to polysomnography (PSG) in diagnosing obstructive sleep apnoea syndrome, but its sensitivity is reported to be low.
To determine the (a) diagnostic accuracy, interobserver reliability and reliable oxygen desaturation index of 4% (ODI₄) score at diagnosing obstructive sleep apnoea syndrome in children and (b) correlation between the apnoea hypopnoea index (AHI) with ODI₄ and oxygen nadir between both PSG and oximetry.
This cross-sectional study included children aged 1–18 years old, undergoing a fully attended overnight PSG for suspected obstructive sleep apnoea syndrome. The Nonin 3150 WristOx₂ ™ [Fig. 2] was worn simultaneously during the PSG. Poor oximetry recordings were excluded. Pulse oximetry was scored using the McGill Oximetry Score (MOS) whereby a score of 2–4 was positive for OSAS. Specificity, sensitivity, positive predictive values (PPV), negative predictive values (NPV) and interobserver reliability of the WristOx₂ were calculated.
One hundred and sixty-two children with a mean (SD) age of 9.3 (±3.5) years (range 2 years 6 months old - 17 years old) were included after excluding 18 children (poor oximetry data [n = 16] and incomplete PSG [n = 2]). Interobserver agreement of the WristOx₂ was 0.8763 (95% CI:0.80, 0.95). WristOx₂ had a sensitivity 50%, specificity 96.7%, PPV 96% and NPV 53% at diagnosing OSAS. ODI₄ ≥ 2 events/hour in oximetry had a sensitivity of 97.6% and negative predictive value of 85.7% at diagnosing OSA.
Overnight pulse oximetry with the Nonin 3150 WristOx₂ ™ is an accurate and reliable tool in diagnosing significant OSAS in children.
Indications of overnight oximetry in clinical practice
2015, Medecine du Sommeil
L’oxymétrie nocturne est un outil simple et peu coûteux, très utilisé en pratique courante dans la prise en charge des troubles respiratoires nocturnes (TRN). Cependant, cette méthode a des indications et des limites qu’il faut connaître et que cette fiche technique a pour objectif de préciser. L’oxymétrie nocturne a un intérêt indiscutable pour le dépistage d’un TRN, la surveillance simplifiée et rapide du traitement d’un TRN par pression positive continue ou ventilation non invasive, pour aider à la titration de l’avancée mandibulaire en cas de traitement par orthèse et enfin pour évaluer le degré d’urgence des examens diagnostiques lors d’une suspicion clinique de TRN. En revanche, l’oxymétrie nocturne ne permet pas de confirmer un diagnostic de trouble respiratoire nocturne, de prédire la nature obstructive ou centrale d’un SAS ni de dépister les TRN sans désaturation.
Overnight oximetry is a simple and inexpensive tool which is widely used in the management of sleep-disordered breathing (SDB). However, the method has indications and limitations outlined in this report. Overnight oximetry is undeniably useful for SDB screening, for simple and rapid evaluation of SDB treatment with continuous positive airway pressure or non-invasive ventilation, for the titration of mandibular advancement in oral appliance treatment and lastly, to prioritize patients for diagnostic evaluation when SDB is suspected. However, overnight oximetry cannot ascertain a diagnosis of SDB, cannot predict the obstructive or central nature of the respiratory disorder and cannot detect SDB without desaturation.
Polysomnography
2013, Encyclopedia of Sleep
Polysomnography is an essential tool for diagnosis and treatment of sleep disorders. This refers to the recording and interpretation of physiologic data collected simultaneously. Understanding the principles of this technology including basic rules is necessary for sleep physicians and technologists for both scoring and interpretation. The American Academy of Sleep Medicine published a new manual for the scoring of sleep in 2007 which includes modifications to the visual scoring, the scoring of sleep-disordered breathing, and movement disorders during sleep. Early studies that evaluated these changes in scoring rules has created some controversy in the respiratory scoring events, which will need further investigation.
Polysomnography
2013, Encyclopedia of Sleep
Polysomnography is an essential tool for diagnosis and treatment of sleep disorders. This refers to the recording and interpretation of physiologic data collected simultaneously. Understanding the principles of this technology including basic rules is necessary for sleep physicians and technologists for both scoring and interpretation. The American Academy of Sleep Medicine published a new manual for the scoring of sleep in 2007 which includes modifications to the visual scoring, the scoring of sleep-disordered breathing, and movement disorders during sleep. Early studies that evaluated these changes in scoring rules has created some controversy in the respiratory scoring events, which will need further investigation.
Sleep medicine training across the spectrum
2011, Chest
Citation Excerpt :
We take for granted that clinical assessment and testing are rational and lead to optimal outcome, when in reality there is variance in each area.57 One example found in pulmonary medicine is the difference in physician interpretation in oximetry over time, where it appears that there are no standards.58 Are there such standards across laboratories or within each center?
There is now a new pathway and examination for sleep medicine, sponsored by the American Board of Internal Medicine, and a number of accredited sleep medicine fellowship programs through the Accreditation Council for Graduate Medical Education. This review takes an historical approach to discuss the process of education for sleep physiology and disorders not only in the postgraduate period but also at all levels of instruction. In reality, there is a continuum of knowledge that needs to be reinforced up and down the educational system, of which Sleep Medicine subspecialty training is just one part. Although progress has been made at all educational levels up to this point, the future of training and education will depend on a sustained effort at several levels from undergraduate to postgraduate continuing medical education and will be facilitated by professional societies and other specialties who will collectively promote the value of and outcomes for clinical sleep medicine.

View all citing articles on Scopus

Funding was provided by the American Heart Association National Scientist Development Award (0530188N), CHEST Foundation of the American College of Chest Physicians T. Franklin Williams Geriatric Development Research Award, and National Institutes of Health/National Heart, Lung, and Blood Institute grant K23 HL079114–01A2.

The authors have no conflicts of interest to disclose.

View full text

Chest

ORIGINAL RESEARCHSLEEP MEDICINEVariations in Physician Interpretation of Overnight Pulse Oximetry Monitoring

Background

Methods

Results

Conclusions

Section snippets

Participants

Results

Discussion

Home overnight pulse oximetry in patients with COPD: more than one recording may be needed

Chest

A randomized trial of nocturnal oxygen therapy in chronic obstructive pulmonary disease patients

Eur Respir J

Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea

Am J Respir Crit Care Med

Overnight pulse oximetry for sleep-disordered breathing in adults: a review

Chest

Nocturnal oximetry for the diagnosis of the sleep apnoea hypopnoea syndrome: a method to reduce the number of polysomnographies?

Thorax

The efficacy of diagnostic imaging

Med Decis Making

Oximeter's acquisition parameter influences the profile of respiratory disturbances

Sleep

Comparison of home oximetry monitoring with laboratory polysomnography in children

Chest

Prediction of the apnea-hypopnea index from overnight pulse oximetry

Chest

Automated analysis of digital oximetry in the diagnosis of obstructive sleep apnoea

Thorax

ORIGINAL RESEARCH
SLEEP MEDICINE
Variations in Physician Interpretation of Overnight Pulse Oximetry Monitoring