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Paper summary: Effect of lingual swab placement on pulse oximetery readings

Effect of lingual gauze swab placement on pulse oximeter readings in anaesthetised dogs and cats.
A. Mair, F. Martinez-Taboada, M. Nitzan (2016). Vet Rec,180(2): 49. doi: 10.1136/vr.103861

Introduction

The risk of peri-anaesthetic death for healthy American Society of Anaesthesiologists (ASA) physical status classification I-II dogs has been estimated to be 0.05% or 1:1849 and for ASA I-II cats 0.11% or 1:895 (Broadbelt et al, 2008) with cardiorespiratory factors partly responsible for these figures. In a study by Redondo et al (2017) the incidence of hypoxia in dogs under general anaesthesia was estimated to be 16.4% in the 1281 patients observed using pulse oximetry, a non-invasive, simple and readily available assessment of oxygen saturation of haemoglobin (SpO2).  However, interference by ambient light is a factor that can affect the accuracy of readings therefore, order to minimise the effects of ambient light, the placement of a gauze swab between the tongue and pulse oximeter probe is commonly used. 

This study was performed to investigate swab placement and offer an explanation for the improvement in SpO2 readings.  It also examined the perfusion index (PI) when different swab materials were used, and when the pulse oximeter probe was placed at different locations on the tongue.  PI is the ratio between the pulsatile and non-pulsatile component of peripheral tissues.

Methods

Client owned cats and dogs admitted for general anaesthesia were enrolled into the study provided their condition or procedure permitted the use of pulse oximetry without interference with the accuracy of the readings (e.g. severe hypovolaemia cases were excluded). 

Premedication and induction of anaesthesia was not standardised and was at the discretion of the attending anaesthetist, but all animals were maintained on isoflurane in 100% oxygen via endotracheal tube.  A pulse oximeter probe was placed on the tongue following induction and recordings of SpO2 and PI taken to form the control group.

Study part 1.

In this group of dogs (n = 17) and cats (n = 15) several swab configurations were randomly assessed: 10cm x 10cm 8-ply gauze swab between tongue and both sides of the probe; double thickness swab; half-thickness; quarter-thickness; red cotton fabric; 1 sheet of 0.1mm thick white paper; placing the swab on the emitter side of the probe; placing the swab on the detector side of the probe.  SpO2 and PI were recorded 15 seconds after placement of the test material. Following collection of the data the anaesthetic and procedure were completed as required.

Study part 2.

Dogs (n = 17) not included in part 1 of the study had a pulse oximetry probe placed on the lateral part of the tongue and also centrally to compare SpO2 and PI at each location.

Results

Animals were of mixed breed, sex and weight. Premedication in dogs was with medetomidine plus methadone (4/17 dogs), acepromazine plus methadone (7/17) or methadone alone (6/17) and induction of anaesthesia was with either alfaxalone (13/17) or propofol (4/17).  The procedures included neutering, dental treatment or endoscopy.  Cats were premedicated with medetomidine plus methadone (12/15 cats), acepromazine plus methadone (2/15) or methadone alone.  Induction of anaesthesia was with alfaxalone (12/15) or propofol (2/15).  Premedication and induction protocols were not recorded for one cat.

SpO2 in dogs

Compared to controls (no material) the SpO2 was significantly higher (p = < 0.05) when a standard gauze swab, half-thickness swab, double thickness swab or white paper was placed between the probe and tongue.  A double thickness swab also produced significantly higher SpO2 values (p = <0.05) than a quarter thickness swab.

SpO2 cats

A standard gauze swab, double thickness swab or red fabric produced SpO2 values significantly higher than controls (p = < 0.05).  Cats also had a significantly higher SpO2 value than dogs (97.8 ±2.0% v 95.5 ±2.6%; P = 0.012).

PI dogs

PI was significantly greater for the standard, double thickness and half-thickness swabs, the white paper & the red fabric when compared to controls in dogs (p = <0.05).  There was no significant difference compared to the control group when a ¼ thickness swab was placed in either probe position: the emitter or detector side.

PI cats

In cats only the double thickness swab and white paper groups demonstrated a significant difference in PI compared to the controls (P = <0.05).

Effects of premedication in dogs

The SpO2 in dogs was not significantly different between premedication protocols (p = 0.72). However, medetomidine/methadone premedication resulted in significantly lower PI values compared to acepromazine/methadone or methadone alone (p = 0.00178).

Probe position on the tongue in dogs

When the pulse oximeter probe was placed centrally on the canine tongue both SpO2 and PI readings were higher than when placed on the lateral side (p = 0.02 and p = 0.00612 respectively).

Discussion

The authors of the study suggest that the significantly higher SpO2 values, compared to no swab controls, when a double thickness gauze swab is placed between the probe and tongue in dogs and cats may be due to the increase in external pressure due to the presence of the swab. This may be due to the material between both sides of the probe and the tongue affecting the ratio of pulsatile to non-pulsatile tissue.  Using a reflectance probe Teng and Zhang (2004) reported that the plethysmograph signal from a fingertip sensor increased and was then followed by a decrease, as contact pressure increased. A plethysmograph signal i.e. PI, is proportional to the product of pulse pressure and arterial compliance.  Arterial compliance is the ability of the artery wall to passively expand and contract in response to changes in transmural pressure. Transmural pressure is the difference in pressure between the interior and exterior of a blood vessel.  If transmural pressure is low the blood vessel can passively expand and contract more than if the transmural pressure is high e.g. when external pressure is applied.  Therefore, when external pressure is applied to the tongue, as was the case when applying a gauze swab, the PI increases.

Multiple arteriovenous anastomoses have been described in the canine tongue and can result in pulsatile venous blood flow. If external pressure compresses the arteriovenous anastomoses the pulsatile flow in the venules is reduced and SpO2 increases.  This may also be one explanation for the higher SpO2 values observed when the probe was placed centrally on the tongue where a there are a greater number of anastomoses compared to the periphery. Cats have no or few lingual arteriovenous anastomoses and this may explain the higher SpO2 observed in this species when compared to dogs (Jasiński and Miodoński 1979).  However, it does not explain why SpO2 increased following swab placement in the cat, therefore other mechanisms must be involved.  Another explanation for higher central SpO2 may be the placement of the probe close to the large central lingual artery: during systole arterial diameter increases which in turn increases the amount of oxygenated haemoglobin available – causing an increase in SpO2 measurements compared to the periphery. 

Although medetomidine can result in peripheral vasoconstriction, and other studies have demonstrated low lingual SpO2 readings following alpha-2 agonist administration, this was not observed in this study. However, arterial blood-gas analysis was not performed to monitor alterations to arterial partial pressure of oxygen.  PI values were, however, lower in dogs that received medetomidine as part of their premedication protocol suggesting the peripheral hypoperfusion had reduced the ratio between pulsatile and non-pulsatile flow. Hypothermia can also produce a similar effect and although temperature was not recorded in this study hypothermia is more likely in the smaller body size of the cat compared to the dog and may be another explanation for the lower PI in this species.

Other factors that may have affected SpO2 values include light scattering: the white paper group had significantly higher SpO2 compared to the controls and red fabric had no effect. 

Why is this important?

Increased contact pressure following the use of gauze swabs between the tongue and pulse oximeter probe may result in higher SpO2 readings.  Probes placed centrally on the tongue produce higher SpO2 measurements than those placed peripherally. However, as this study made no comparison to the partial pressure of arterial oxygen (SaO2) it is unclear whether the SpO2 readings obtained are a reflection of true arterial oxygenation status.

Article by
Dr. Karen Heskin
BVSc CertSAO MRCVS

Veterinary Technical Manager, Jurox UK

Originally published: Thursday, 9th January 2020

References

Broadbelt D.C., Blissett K.J., Hammond R.A., Neath P.J., Young L.E., Pfeiffer D.U. & Wood J.L. (2008) The risk of death: the Confidential Enquiry into Perioperative Small Animal Fatalities. Vet Anaesth & Analg 35: 365–373

Jasinski A. & Miodonski A. (1979) Blood vessels in the tongue of the kitten: Scanning electron microscopy of microcorrosion casts. Anatomy and Embryology. 155: 347–353

Redondo, J.I., Rubio M., Soler G., Serra I., Soler C. & Gomez-Villamandos, R.J. (2007) Normal values and incidence of cardiorespiratory complications in dogs during general anaesthesia. A review of 1281 cases. J Vet Med 54: 470–477

Teng X.F. & Zhang Y.T. (2004) The effect of contacting force on photoplethysmographic signals. Physiological Measurement 25: 1323–1335

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