Clinical paper| Volume 169, P189-197, December 2021

Pulse oximetry waveform: A non-invasive physiological predictor for the return of spontaneous circulation in cardiac arrest patients ---- A multicenter, prospective observational study



      This study aimed to investigate the predictive value of pulse oximetry plethysmography (POP) for the return of spontaneous circulation (ROSC) in cardiac arrest (CA) patients.


      This was a multicenter, observational, prospective cohort study of patients hospitalized with cardiac arrest at 14 teaching hospitals cross China from December 2013 through November 2014. The study endpoint was ROSC, defined as the restoration of a palpable pulse and an autonomous cardiac rhythm lasting for at least 20 minutes after the completion or cessation of CPR.


      150 out-of-hospital cardiac arrest (OHCA) patients and 291 in-hospital cardiac arrest (IHCA) patients were enrolled prospectively. ROSC was achieved in 20 (13.3%) and 64 (22.0%) patients in these cohorts, respectively. In patients with complete end-tidal carbon dioxide (ETCO2) and POP data, patients with ROSC had significantly higher levels of POP area under the curve (AUCp), wave amplitude (Amp) and ETCO2 level during CPR than those without ROSC (all p < 0.05). Pairwise comparison of receiver operating characteristic (ROC) curve analysis indicated no significant difference was observed between ETCO2 and Amp (p = 0.204) or AUCp (p = 0.588) during the first two minutes of resuscitation.


      POP may be a novel and effective method for predicting ROSC during resuscitation, with a prognostic value similar to ETCO2 at early stage.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Soar J.
        • Maconochie I.
        • Wyckoff M.H.
        • Olasveengen T.M.
        • Singletary E.M.
        • Greif R.
        • et al.
        2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.
        Circulation. 2019; 140
        • Soar J.
        • Maconochie I.
        • Wyckoff M.H.
        • Olasveengen T.M.
        • Singletary E.M.
        • Greif R.
        • et al.
        International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
        Resuscitation. 2019; 145: 95-150
        • Damluji A.A.
        • Al-Damluji M.S.
        • Pomenti S.
        • Zhang T.J.
        • Cohen M.G.
        • Mitrani R.D.
        • et al.
        Health Care Costs After Cardiac Arrest in the United States.
        Circ Arrhythm Electrophysiol. 2018; 11
      1. Bateman RM, Sharpe MD, Jagger JE, Ellis CG, Solé-Violán J, López-Rodríguez M, et al. 36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016. vol. 20. BioMed Central; 2016.

        • Levine R.L.
        • Wayne M.A.
        • Miller C.C.
        End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.
        N Engl J Med. 1997; 337: 301-306
        • Sanders A.B.
        • Ewy G.A.
        • Taft T.V.
        Prognostic and therapeutic importance of the aortic diastolic pressure in resuscitation from cardiac arrest.
        Critical Care Medicine. 1984; 12: 871-873
        • Paradis N.A.
        • Martin G.B.
        • Rivers E.P.
        • Goetting M.G.
        • Appleton T.J.
        • Feingold M.
        • et al.
        Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation.
        Jama. 1990; 263: 1106-1113
        • Paiva E.F.
        • Paxton J.H.
        • O’Neil B.J.
        The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review.
        Resuscitation. 2017; 123: 1-7
        • Tat L.C.
        • Ming P.K.
        • Leung T.K.
        Abrupt rise of end tidal carbon dioxide level was a specific but non-sensitive marker of return of spontaneous circulation in patient with out-of-hospital cardiac arrest.
        Resuscitation. 2016; 104: 1-6
        • Naim M.Y.
        • Sutton R.M.
        • Friess S.H.
        • Bratinov G.
        • Bhalala U.
        • Kilbaugh T.J.
        • et al.
        Blood Pressure– and Coronary Perfusion Pressure-Targeted Cardiopulmonary Resuscitation Improves 24-Hour Survival From Ventricular Fibrillation Cardiac Arrest.
        Critical Care Medicine. 2016; 44: e1111-e1117
        • Morgan R.W.
        • French B.
        • Kilbaugh T.J.
        • Naim M.Y.
        • Wolfe H.
        • Bratinov G.
        • et al.
        A quantitative comparison of physiologic indicators of cardiopulmonary resuscitation quality: Diastolic blood pressure versus end-tidal carbon dioxide.
        Resuscitation. 2016; 104: 6-11
      2. Yagi T, Nagao K, Kawamorita T, Soga T, Ishii M, Chiba N, et al. Detection of ROSC in Patients with Cardiac Arrest During Chest Compression Using NIRS: A Pilot Study. Oxygen Transport to Tissue XXXVII, vol. 876, New York, NY: Springer New York; 2016, pp. 151–7.

        • Allen J.
        Photoplethysmography and its application in clinical physiological measurement.
        Physiol Meas. 2007; 28: R1-R39
      3. Reisner A, Shaltis PA, McCombie D, Asada HH. Utility of the photoplethysmogram in circulatory monitoring. Anesthesiology 2008;108:950–8.

        • Narang V.P.
        Utility of the pulse oximeter during cardiopulmonary resuscitation.
        Anesthesiology. 1986; 65: 239-240
        • Wijshoff R.W.C.G.R.
        • van der Sar T.
        • Peeters W.H.
        • Bezemer R.
        • Aelen P.
        • Paulussen I.W.F.
        • et al.
        Detection of a spontaneous pulse in photoplethysmograms during automated cardiopulmonary resuscitation in a porcine model.
        Resuscitation. 2013; 84: 1625-1632
        • Xu J.
        • Li C.
        • Zheng L.
        • Han F.
        • Li Y.
        • Walline J.
        • et al.
        Pulse Oximetry: A Non-Invasive, Novel Marker for the Quality of Chest Compressions in Porcine Models of Cardiac Arrest.
        PLoS ONE. 2015; 10: e0139707
        • Xu J.
        • Zhu H.
        • Wang Z.
        • Yu X.
        • Walline J.
        Why do not we use finger pulse oximeter plethysmograph waveform to monitor the effectiveness of cardiopulmonary resuscitation?.
        Resuscitation. 2011; 82: 959
      4. Fu Y, Yin L, Seery S, Dai J, Zhu H, Jin K, et al. Pulse rate as an alternative, real-time feedback indicator for chest compression rate: a porcine model of cardiac arrest. Journal of Clinical Monitoring and Computing 2020:1–9.

        • Meaney P.A.
        • Bobrow B.J.
        • Mancini M.E.
        • Christenson J.
        • de Caen A.R.
        • Bhanji F.
        • et al.
        Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association.
        Circulation. 2013; 128: 417-435
        • Wilson B.J.
        • Cowan H.J.
        • Lord J.A.
        • Zuege D.J.
        • Zygun D.A.
        The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock: a retrospective cohort study.
        BMC Emerg Med. 2010; 10: 1606-1616
        • Louw A.
        • Cracco C.
        • Cerf C.
        • Harf A.
        • Duvaldestin P.
        • Lemaire F.
        • et al.
        Accuracy of pulse oximetry in the intensive care unit.
        Intensive Care Medicine. 2001; 27: 1606-1613
        • SPITTAL M.J.
        Evaluation of pulse oximetry during cardiopulmonary resuscitation.
        Anaesthesia. 1993; 48: 701-703
        • Reuss J.L.
        Factors influencing fetal pulse oximetry performance.
        J Clin Monitor Comput. 2003; 18: 13-24
        • Talke P.
        • Stapelfeldt C.
        Effect of peripheral vasoconstriction on pulse oximetry.
        J Clin Monitor Comput. 2006; 20: 305-309
        • Li C.
        • Xu J.
        • Han F.
        • Walline J.
        • Zheng L.
        • Fu Y.
        • Zhu H.
        • Chai Y.
        • Yu X.
        Identification of return of spontaneous circulation during cardiopulmonary resuscitation via pulse oximetry in a porcine animal cardiac arrest model.
        J Clin Monitor Comput. 2019; 33: 843-851
        • Jubran A.
        Pulse oximetry.
        Intensive Care Medicine. 2004; 30: 2017-2020
        • Monnet X.
        • Lamia B.
        • Teboul J.-L.
        Pulse oximeter as a sensor of fluid responsiveness: do we have our finger on the best solution?.
        Crit Care. 2005; 9: 429-430
        • Shamir M.
        • Eidelman L.A.
        • Floman Y.
        • Kaplan L.
        • Pizov R.
        Pulse oximetry plethysmographic waveform during changes in blood volume.
        Br J Anaesth. 1999; 82: 178-181
        • Cannesson M.
        • Besnard C.
        • Durand P.G.
        • Bohé J.
        • Jacques D.
        Relation between respiratory variations in pulse oximetry plethysmographic waveform amplitude and arterial pulse pressure in ventilated patients.
        Crit Care. 2005; 9: R562-R568
        • Hartmann S.M.
        • Farris R.W.D.
        • Di Gennaro J.L.
        • Roberts J.S.
        Systematic Review and Meta-Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.
        J Intensive Care Med. 2015; 30: 426-435
        • Sheak K.R.
        • Wiebe D.J.
        • Leary M.
        • Babaeizadeh S.
        • Yuen T.C.
        • Zive D.
        • Owens P.C.
        • Edelson D.P.
        • Daya M.R.
        • Idris A.H.
        • Abella B.S.
        Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest.
        Resuscitation. 2015; 89: 149-154
        • Touma O.
        • Davies M.
        The prognostic value of end tidal carbon dioxide during cardiac arrest: a systematic review.
        Resuscitation. 2013; 84: 1470-1479
        • Sanders A.B.
        • Kern K.B.
        • Otto C.W.
        • Milander M.M.
        • Ewy G.A.
        End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. A prognostic indicator for survival.
        Jama. 1989; 262: 1347-1351
        • Hassan M.A.
        • Weber C.
        • Waitz M.
        • Huang L.
        • Hummler H.D.
        • Mendler M.R.
        Reliability of Pulse Oximetry during Progressive Hypoxia, Cardiopulmonary Resuscitation, and Recovery in a Piglet Model of Neonatal Hypoxic Cardiac Arrest.
        Neonatology. 2017; 112: 40-46

      Linked Article

      • Pulse oximetry plethysmography: A new approach for physiology-directed CPR?
        ResuscitationVol. 169
        • Preview
          The overarching aim of cardiopulmonary resuscitation (CPR) is to generate sufficient myocardial and cerebral blood flow to allow for survival with favorable neurologic outcome.1 The adequacy of myocardial and cerebral blood flow during CPR depends, in part, on force of chest compressions, rate of compressions, chest compression fraction, and allowing full chest recoil for sufficient venous return.2–6 Therefore, the core tenets of CPR are to push hard and push fast, minimize interruptions, and allow full chest recoil.
        • Full-Text
        • PDF