Impact of COVID-19 on the association between pulse oximetry and arterial oxygenation in patients with acute respiratory distress syndrome

Managing patients with acute respiratory distress syndrome (ARDS) requires frequent changes in mechanical ventilator respiratory settings to optimize arterial oxygenation assessed by arterial oxygen partial pressure (PaO(2)) and saturation (SaO(2)). Pulse oxymetry (SpO(2)) has been suggested as a non-invasive surrogate for arterial oxygenation however its accuracy in COVID-19 patients is unknown. In this study, we aimed to investigate the influence of COVID-19 status on the association between SpO(2) and arterial oxygenation. We prospectively included patients with ARDS and compared COVID-19 to non-COVID-19 patients, regarding SpO(2) and concomitant arterial oxygenation (SaO(2) and PaO(2)) measurements, and their association. Bias was defined as mean difference between SpO(2) and SaO(2) measurements. Occult hypoxemia was defined as a SpO(2) ≥ 92% while concomitant SaO(2) < 88%. Multiple linear regression models were built to account for confounders. We also assessed concordance between positive end-expiratory pressure (PEEP) trial-induced changes in SpO(2) and in arterial oxygenation. We included 55 patients, among them 26 (47%) with COVID-19. Overall, SpO(2) and SaO(2) measurements were correlated (r = 0.70; p < 0.0001), however less so in COVID-19 than in non-COVID-19 patients (r = 0.55, p < 0.0001 vs. r = 0.84, p < 0.0001, p = 0.002 for intergroup comparison). Bias was + 1.1%, greater in COVID-19 than in non-COVID-19 patients (2.0 vs. 0.3%; p = 0.02). In multivariate analysis, bias was associated with COVID-19 status (unstandardized β = 1.77, 95%CI = 0.38–3.15, p = 0.01), ethnic group and ARDS severity. Occult hypoxemia occurred in 5.5% of measurements (7.7% in COVID-19 patients vs. 3.4% in non-COVID-19 patients, p = 0.42). Concordance rate between PEEP trial-induced changes in SpO(2) and SaO(2) was 84%, however less so in COVID-19 than in non-COVID-19 patients (69% vs. 97%, respectively). Similar results were observed for PaO(2) regarding correlations, bias, and concordance with SpO(2) changes. In patients with ARDS, SpO(2) was associated with arterial oxygenation, but COVID-19 status significantly altered this association.