Dysphagia (2018) 33:282–292

https://doi.org/10.1007/s00455-017-9868-1 (0123456789().,-volV)(0123456789().,-volV)

REVIEW ARTICLE

Utility of Pulse Oximetry to Detect Aspiration: An Evidence-Based

Systematic Review
Deanna Britton1,2 • Amy Roeske3 • Stephanie K. Ennis4 • Joshua O. Benditt5 • Cassie Quinn1 •

Donna Graville2

Received: 11 August 2017 / Accepted: 22 November 2017 / Published online: 14 December 2017
Ó Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract
Pulse oximetry is a commonly used means to measure peripheral capillary oxyhemoglobin saturation (SpO2). Potential use
of pulse oximetry to detect aspiration is attractive to clinicians, as it is readily available, quick, and noninvasive. However,
research regarding validity has been mixed. This systematic review examining evidence on the use of pulse oximetry to
detect a decrease in SpO2 indicating aspiration during swallowing is undertaken to further inform clinical practice in
dysphagia assessment. A multi-engine electronic search was conducted on 8/25/16 and updated on 4/8/17 in accordance
with standards published by the Preferred Reporting for Items for Systematic Reviews and Meta-Analysis Protocols
(PRISMA). Inclusion criteria included use of pulse oximetry to detect aspiration with simultaneous confirmation of
aspiration via a gold standard instrumental study. Keywords included dysphagia or aspiration AND pulse oximetry.
Articles meeting criteria were reviewed by two blinded co-investigators. The search yielded 294 articles, from which 19
were judged pertinent and reviewed in full. Ten met the inclusion criteria and all were rated at Level III-2 on the Australian
Diagnostic Levels of Evidence. Study findings were mixed with sensitivity ranging from 10 to 87%. Potentially con-
founding variables were observed in all studies reviewed, and commonly involved defining ‘‘desaturation’’ within a
standard measurement error range (* 2%), mixed populations, mixed viscosities/textures observed during swallowing,
and lack of comparison group. The majority of studies failed to demonstrate an association between observed aspiration
and oxygen desaturation. Current evidence does not support the use of pulse oximetry to detect aspiration.

Keywords Pulse oximetry  Aspiration  Deglutition  Swallowing  Deglutition disorders

Introduction

Dysphagia is a common symptom of a wide variety of

underlying diseases, including neurologic and respiratory
& Deanna Britton conditions [1]. Secondary complications of dysphagia may
db23@pdx.edu
include aspiration pneumonia, respiratory failure, malnu-
1
Department of Speech & Hearing Sciences, Portland State trition, dehydration, and death [2, 3]. These complications
University (PSU), Portland, OR, USA frequently lead to increased hospital length of stay and
2
Northwest Clinic for Voice and Swallowing (NWCVS), higher medical costs [3]. For these reasons, early detection
Department of Otolaryngology - Head & Neck Surgery, and management of dysphagia is important to minimize or
Oregon Health & Sciences University (OHSU), Portland, OR, avoid the expensive and sometimes life-threatening con-
USA sequences of dysphagia.
3
Providence Sacred Heart Medical Center, Spokane, WA, Pulse oximetry has been advocated by some as a means
USA to detect aspiration [4, 5]. Pulse oximetry is a commonly
4
Auburn, AL, USA used noninvasive means of measuring peripheral capillary
5
Division of Pulmonary and Critical Care Medicine, oxygen saturation (SpO2), i.e., the percentage of oxy-
University of Washington Medical Center (UWMC), Seattle, genated hemoglobin in individuals at risk for hypoxemia
WA, USA

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D. Britton et al.: Utility of Pulse Oximetry to Detect Aspiration...
[6, 7]. This is accomplished by measuring the ratio of light
absorption of oxygenated (oxyhemoglobin) and deoxy-
genated (deoxyhemoglobin) blood. The underlying ratio-
nale posited for use of pulse oximetry to detect aspiration is
that aspiration may lead to bronchoconstriction and/or
airway obstruction leading to ventilation–perfusion mis-
match [8–10], which in turn results in a drop in oxygen
saturation [9]. Potential use of pulse oximetry to detect or
screen for aspiration risk is attractive to clinicians, as it is
readily available, quick, and noninvasive, and may be
easily incorporated into a clinical swallowing examination.
In fact, use of pulse oximetry to detect aspiration has been
advocated and adopted into clinical practice by many
clinicians. For instance, pulse oximetry has been incorpo-
rated into clinical swallowing assessment protocols, such
as the Volume–Viscosity Swallow Test [11, 12]. However,
research and expert opinions regarding the validity of pulse
oximetry to indicate aspiration has yielded mixed findings.
For instance, Zaidi et al. reported oxygen desaturation
during swallowing to be a potential marker of aspiration in
individuals following acute stroke [4]. However, others
have challenged the validity of using pulse oximetry to
detect aspiration [13]. Owing to the mixed conclusions of
research examining use of pulse oximetry to detect aspi-
ration, it remains a topic of debate and clinical confusion.
In this regard, a systematic review of the body of this lit-
erature will shed more light on the underlying factors
contributing to these discrepant findings and offer clinical
direction on the validity of using pulse oximetry to detect
prandial aspiration.
The purpose of this study is to systematically review
evidence on the use of pulse oximetry in individuals with
dysphagia to detect a decrease in SPO2 indicating aspira-
tion during swallowing, toward the goal of further
informing clinical practice in dysphagia assessment.
Methods
This systematic review was completed in accordance with
Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) standards [14, 15], an evidence-
based set of guidelines for reporting systematic reviews.
Peer-reviewed research studies directly investigating use of
pulse oximetry to detect aspiration with simultaneous
confirmation of aspiration via a gold standard instrumental
study, i.e., modified barium swallow study (MBSS) or
fiberoptic endoscopic evaluation of swallowing (FEES), in
adults were included. Articles that did not meet the inclu-
sion criteria or were published in a language other than
English were excluded (Fig. 1). Conference abstracts were
excluded owing to insufficient information to facilitate
review. Articles that studied pulse oximetry only in
283
combination with other aspects of the clinical swallowing
exam were excluded due to the difficulty in disentangling
the specific contribution of pulse oximetry to detection of
aspiration. Articles examining pediatric populations were
excluded due to the potential impact of differences in
swallowing and respiratory anatomy on findings. Because
of the inherent challenges in conducting large-scale studies
involving dysphagia rehabilitation research [16], we did
not exclude research based on study design or populations/
settings studied. Comprehensive literature search of
PubMed, CINAHL Plus, PsychINFO, AMED, and Embase
databases without date limits was conducted on 8/25/16
with an updated search covering the years 2016 forward on
4/8/17. Literature search strategies included use of medical
subject headings (MeSH) for the PubMed database, along
with text related to dysphagia, aspiration, and pulse
oximetry used with all targeted databases. See Table 1 for
keywords and search strategy. To ensure literature satura-
tion, additional hand searches of references from included
articles, relevant review articles, and other sources known
to the authors were completed.
The strength of the evidence for all of the articles fully
reviewed was rated via the Australian level of evidence
hierarchy for diagnostic accuracy (Table 2) [17], owing to
ease and reliability for characterizing quality of evidence
and risk for bias in diagnostic studies. Additional infor-
mation was extracted from each article to further determine
risk for bias at both outcome and study levels. Data
extracted from each article included demographic infor-
mation, parameters of measurement for pulse oximetry in
the context of swallowing, swallowing assessment meth-
ods, and study findings.
Results
Study Selection
Following removal of duplicate records, the search yielded
294 citations. Citations were screened in two stages. In
stage I, titles and abstracts were independently screened by
two co-investigators for relevance to the purpose of the
search. Two hundred ten articles without a specific focus
on both pulse oximetry and swallowing were excluded. In
stage II, abstracts were reviewed and articles skimmed.
Sixty-five articles that did not directly examine the use of
pulse oximetry to detect aspiration were excluded at this
stage, including review articles and abstracts. Blinded
inter-rater agreement for inclusion/exclusion of citations at
stage I and II screening was [ 80%. Discrepancies were
resolved via a third reviewer along with discussion and
consensus. The remaining 19 articles underwent full blin-
ded review by two co-investigators to determine relevance
123
284
Fig. 1 Preferred Reporting for
Items for Systematic Reviews
and Meta-Analysis (PRISMA)
flow chart
to the specific purpose, with exclusion of nine additional
articles due to lack of simultaneous examination of pulse
oximetry during swallowing with gold standard detection
of aspiration, i.e., via MBSS or FEES. Ultimately, ten
studies were qualitatively synthesized. With use of a
detailed form, the ten articles meeting criteria were
reviewed in full for details contained in Tables 3, 4, 5, and
6 by two co-investigators with blinded data extraction and
quality of evidence rating. Disagreements were resolved
through consensus discussion.
Study Characteristics
All ten citations reviewed examined SpO2 simultaneously
with a gold standard method of detecting aspiration, via
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D. Britton et al.: Utility of Pulse Oximetry to Detect Aspiration...
either MBSS [5, 18–22] or FEES [23–26]. All of these
articles were rated at Level III-2 on the Australian level of
evidence hierarchy for diagnostic accuracy (Table 2) [17].
Demographic information for the studies included is
outlined in Table 3. Most of the studies focused primarily
on the stroke population; others included individuals with
multiple underlying diagnoses. None of the studies inclu-
ded a statistical power analysis. Over half of the studies did
not include a comparison group; some of these studies
compared instances of aspiration versus no aspiration
within or between subjects. Exclusion criteria were vari-
able or, in some studies, unspecified.
D. Britton et al.: Utility of Pulse Oximetry to Detect Aspiration... 285

Table 1 Search terms

Keywords related to Swallowing, Dysphagia, Aspiration
PubMed MeSH headings Free text search terms

Aspiration pneumonia, or ‘‘Aspiration,’’ or

Respiratory aspiration ‘‘Aspiration pneumonia’’
Deglutition, or ‘‘Deglutition,’’ or
Dysphagia, or ‘‘Dysphagia,’’ or
Swallowing, or ‘‘Swallowing,’’ or
Swallowing disorders, or ‘‘Fiberoptic endoscopic evaluation of swallowing,’’ or
Deglutition disorders ‘‘FEES,’’ or
‘‘Videofluoroscopic swallow study,’’ or
‘‘VFSS,’’ or
‘‘Modified barium swallow study,’’ or
‘‘MBSS’’
AND
Keywords related to Pulse Oximetry
PubMed MeSH headings Free text search terms

Pulse oximetry ‘‘Pulse oximetry,’’ or

‘‘Oxygen saturation,’’ or
‘‘Desaturation’’
NOT ‘‘children,’’ ‘‘pediatric,’’ ‘‘infant,’’ ‘‘meconium’’

Table 2 Australian levels of evidence. Reproduced with permission from Merlin et al. [17]
Level Diagnostic accuracy

I A systematic review of Level II studies

II A study of test accuracy with an independent, blinded comparison with a valid reference standard, among consecutive persons with a
defined clinical presentation
III-1 A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among non-consecutive persons with
a defined clinical presentation
III-2 A comparison with reference standard that does not meet the criteria required for Level II and III-1 evidence
III-3 Diagnostic case–control study
IV Study of diagnostic yield (no reference standard)

Pulse Oximetry Parameters populations, populations with underlying respiratory

Pulse oximetry measurement parameters and additional
factors indicating risk for bias are outlined in Table 3.
Criteria for ‘‘desaturation’’ in conjunction with swallowing
were variable between studies, either ranging from a 2 to
4% drop in oxygen saturation or unspecified with group
comparisons. Because the margin of error in most pulse
oximetry devices is approximately 2% [27–29], use of the
2% drop in SpO2 criteria for judging desaturation may lead
to bias. Study efforts to prevent measurement artifact were
variable and unspecified in half of the studies reviewed.
Nearly half of the included studies did not report efforts to
blind observations. Additional potentially confounding
variables were noted across all studies and included mixed
impairments, lack of control for viscosity or texture, and
lack of a comparison group (Tables 3 and 4).
Instrumental Swallow Study Parameters
Swallow study measurement parameters are outlined in
Table 5. The criteria for categorizing a participant as an
aspirator were not clearly specified in most of the reviewed
studies. Others indicated that participants would be cate-
gorized as ‘‘aspirators’’ if they were observed to aspirate at
least once on any food or liquid trial [22, 23]. Most of the
studies reported observations with a variety of textures and
amounts, but only one compared findings based on the
texture or viscosity aspirated [24].

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Table 3 Study demographic information

Citation Population(s) Control group Exclusion Criteria

Collins Stroke (n = 54) None Diagnoses that might impact accurate SpO2
and readings, e.g., Raynaud’s or severe peripheral
Bakheit vascular disease
[5]
Sellars Multiple, including stroke, multiple sclerosis, Healthy (n = 5) without Not indicated
et al. cerebellar ataxia (n = 6) MBSS confirmation
[19]
Sherman Stroke and ‘‘other’’ (unspecified) (n = 46) None Receiving supplemental O2
et al. Compared groups with
[20] and without aspiration
Colodny Multiple, including stroke, dementia, Healthy (n = 77) Receiving supplemental O2
[24] cardiopulmonary (n = 104)
Leder ICU patients, currently NPO (diagnoses unknown) None Not indicated
[25] (n = 60) Compared four
groups, ± aspiration
with and without
supplemental O2
Smith Stroke (n = 53) None Cognitive or language impairment that precludes
et al. consent, inability to sit upright, respiratory
[21] infection, additional neurological or medical
impairment
Chong Stroke (n = 50), [ 65 years old None Excluded if difficulty obtaining accurate SpO2
et al. readings, e.g., due to respiratory or cardiac
[23] impairments
Higo Multiple, including cerebrovascular and Seen for esophageal Not indicated
et al. neuromuscular disease, head and neck tumor disease evaluation
[23] Dysphagic (n = 110) (n = 63)
Dysphagic with cuffed tracheostomy tube (n = 9) Laryngectomy (n = 22)
Wang Multiple, including stroke; nasopharyngeal cancer Healthy (n = 40) without Presence of PVD, chronic lung disease, smoking
et al. after radiation treatment; motor neuron disease; MBSS confirmation history and incomplete MBSS
[22] parkinsonism; brain tumor; MS; TBI; esophageal
cancer, vocal fold palsy; scleroderma (n = 60)
Marian Acute stroke (n = 50) None Pre-existing dysphagia or comorbidities that may
et al. Subjects used as own cause dysphagia, reduced level of
[26] controls consciousness, and/or need for supplemental
O2
COPD Chronic obstructive pulmonary disease; ICU intensive care unit; MBSS modified barium swallow study; MS multiple sclerosis; NPO nil
per os; O2 oxygen; PVD peripheral vascular disease; PO pulse oximetry; SpO2 peripheral capillary oxygen saturation; TBI traumatic brain injury

Study Findings aspiration concluded that there was no significant rela-

Study findings were mixed and highly variable (Table 6).
Reported measures of sensitivity and specificity for use of
pulse oximetry to detect aspiration ranged from 10 to 87%
and 39 to 100%, respectively. Reported measures of posi-
tive predictive value (PPV) and negative predictive value
(NPV) ranged from 35.5 to 100% and 52 to 88%, respec-
tively. Three of the four studies examining group com-
parisons reported a lack of change or relationship between
aspiration and oxygen desaturation. The majority of studies
(7/10) failed to demonstrate an association between aspi-
ration and O2 desaturation. Two of the ten studies that
examined O2 desaturation in relation to observed events of
tionship between events of aspiration and subsequent O2
desaturation.
Discussion
This systematic review has examined the use of pulse
oximetry to detect aspiration in studies with simultaneous
confirmation of aspiration via a gold standard instrumental
study, such as MBSS or FEES. Although the research
findings are mixed, the majority of the studies examined in
this systematic review do not support the use of pulse
oximetry for purposes of detecting aspiration (Table 6). In
addition, the strength of the evidence is weakened in many

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Table 4 Pulse oximetry parameters and risk for bias

Citation ‘‘Desaturation’’ Baseline Post-swallow Blinding? Artifact prevention Possible confounders—
defined time time observed examples
observed (min)

Collins [ 2% drop in Unspecified C2 ? Warm room, no nail polish, keep Underlying respiratory
and SpO2 Single- arm still impairments in some subjects
Bakheit blind Larger bolus sizes observed
[5] during MBSS versus during
clinical exam
Sellars [ 4% drop in 5 min 3 – Clean warm finger Mixed etiologies
et al. SpO2 Probes placed on non- Underlying respiratory
[19] hemiplegic hand impairments in some subjects
Varying MBSS protocols
Sherman Unspecified 1 min 3 Partially Unspecified Mixed etiologies
et al. Reported change Possibly underlying respiratory
[20] impairments in some subjects
Colodny Unspecified 10 min 10 ? Unspecified, except hand with Aspiration not measured in
[24] Group probe held steady control subjects
comparison
Leder [25] Unspecified 5 min 5 – Probe placed on finger on the Mixed etiologies
Group arm opposite of the blood
comparisons pressure probe
Smith [ 2% drop in Until 2 ? Probes were placed on non- Variable textures
et al. SpO2 ‘‘stable’’ hemiplegic hand Possibly underlying respiratory
[21] impairments in some subjects
Chong [ 2% drop in 5 min Up to 2 – Probe placed on non-hemiplegic Variable textures
et al. SpO2 hand Acutely ill elderly participants
[23] Exclude patients with capillary Combined aspirators and
issues penetrators in analysis
Higo et al. Compared [ 2 C1 min C1 – Unspecified Mixed etiologies
[18] and 3% drop
in SpO2
Wang [ 3% drop in C5 min C5 ? Clean warm finger Mixed etiologies
et al. SpO2 Keep arm still Variable textures
[22]
Marian [ 2% drop in Not stated 2 ? Unspecified Exclusion of non-aspirators
et al. SpO2 Lack of baseline SpO2 measures
[26]
COPD Chronic obstructive pulmonary disease; MBSS modified barium swallow study; PO pulse oximetry; SpO2 peripheral capillary oxygen
saturation

of these studies by study design flaws and potential for
bias, such as lack of a comparison group, blinding and
inter-rater reliability, as well as inadequate sample size
(Tables 4 and 5). Therefore, the evidence for use of pulse
oximetry as a means to detect prandial aspiration is inad-
equate and not convincing.
This discussion will reflect on the reviewed research
within the context of methodological factors, which may
have impacted the study findings, as well as other aspects
of medical knowledge critical to clinical decision making
[30] in this context, including consideration of physiologic
factors that could affect O2 saturation or desaturation in the
context of swallowing.
Variability in Comparison Methods for Prandial
Aspiration
Clinically, it is well known that individuals who aspirate do
not necessarily aspirate on every swallow [31]. Further,
risk for aspiration in individuals may vary depending upon
the texture or liquid viscosity [32] and the size of the bolus
[33, 34]. Theoretically, these same variables might impact
the degree of desaturation. For instance, aspiration of a
larger or solid bolus might be more likely to trigger airway
occlusion or bronchospasm. This may have been a factor in
the study published by Collins and Bakheit as their finding
of a positive correlation between prandial desaturation and

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Table 5 Swallow study parameters

Citation ‘‘Aspiration’’ categorized Textures/amounts observed

Collins and Not directly indicated 150 ml liquid; 3 oz mousse and half of a 200
Bakheit barium-impregnated shortbread biscuit
[5]
Sellars et al. Not directly indicated Liquid and paste barium, and biscuit coated with
[19] barium in 5, 10 ml, or self-regulated volumes
Sherman Not directly indicated Liquid and paste barium and crackers coated with
et al. [20] barium in 5 and 15 ml volumes
Colodny Aspiration was categorized by at least one event on any bolus during FEES Dysphagic group: 5–50 ml liquid and/or puree as
[24] exam for dysphagics. Comparison groups were penetrators, liquid tolerated until aspiration
aspirators, solid aspirators and normal Non-dysphagic group: 150 ml of a liquid, puree,
and a chewable solid
Leder [25] Not directly indicated Custard, milk, and cracker boluses dyed with blue
food in 5 ml volumes
Smith et al. Not clearly indicated. ‘‘Aspiration on one or more occasion’’ was compared. Thin and thick liquid barium in 3, 5, 10, and 20 ml
[21] Additionally, combined analysis with aspirators and penetrators volumes; Yogurt and bread with barium in 5 ml
volumes
Chong et al. ‘‘Aspiration was considered to be present on FEES if there was any Water swallow: 50 ml water in 10-ml aliquots—
[23] aspiration or penetration on any food consistency’’ prior to FEES
Four blue dyed textures observed with FEES: (1)
honey thick; (2) nectar thick; (3) thin; and (4)
paste
Amounts: 3–5 large spoonfuls (approx 8 ml each)
Higo et al. Not directly indicated ‘‘Thin liquid, thick liquid or paste barium in 3 and
[18] 5 ml and self-regulated volumes
Wang et al. Observed by case (at least 1 event of aspiration on any food consistency or Thin liquid, thick liquid and paste barium in two
[22] amount), and also per aspiration and desaturation events 5-ml boluses
Marian et al. Per swallow, for each participant one swallow with aspiration (PAS C 6) Not specified. Discussion suggests multiple
[26] and one without were compared viscosities
ml milliliters; PAS penetration–aspiration scale

aspiration was observed in the context of much larger bolus
volumes [5]. For these reasons, group and case compar-
isons (Table 6) that seek to classify each individual as an
aspirator or non-aspirator may cloud the issue of whether
or not pulse oximetry can detect aspiration for specific
swallow events. Only two of the ten reviewed studies
(Wang et al. [22]; Marian et al. [26]) examined a drop in
SpO2 in association with specific swallows [22, 26]
(Table 6). Both of these studies concluded no relationship
between O2 desaturation and instances of aspiration. In
addition, two of the ten studies (Chong et al. [21]; Smith
et al. [23]) also categorized individuals with observed
penetration (no aspiration) in the group of individuals with
observed aspiration [21, 23] (Table 5). However, theoreti-
cally, it does not make sense that SpO2 would decrease due
to the presence of food or liquid in the laryngeal vestibule,
as bronchospasm or interference with respiration would
typically occur at the level of the lower respiratory system
or lungs.
Definition of ‘‘Desaturation’’ in the Context
of Swallowing
One issue of variability lies in the definition of ‘‘desatu-
ration’’ in the context of using pulse oximetry to identify
instances of aspiration. Of the studies examining sensitiv-
ity/specificity of pulse oximetry to detect aspiration in this
review, the majority specified a C 2% drop in O2 satura-
tion during eating as ‘‘desaturation’’ (Table 4). The stated
rationale for this criterion is unclear and may have con-
tinued over time through precedent. The problem with this
criterion is that the standard error of measurement for pulse
oximeters is generally about 2% [6]. More specifically, for
SaO2 values of 90% or higher, the precision of SpO2
measures to estimate the actual percent saturation of oxy-
gen bound to hemoglobin in arterial blood (SaO2), i.e., the
standard deviation of differences between the 2 measures,
is \ 3%, and the bias of SpO2 measures, i.e., the mean
difference, is \ 2% [27–29]. Other researchers have com-
mented on this issue as well. For instance, Colodny stated
that ‘‘controversy exists over the use of the 2% desaturation

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D. Britton et al.: Utility of Pulse Oximetry to Detect Aspiration... 289

Table 6 Study findings—prediction of aspiration from pulse oximetry

Citation Comparisons Sensitivity Specificity Positive Negative Conclusion
predictive predictive PRO or CON to detect aspiration from PO
value value
(PPV) (NPV)

Collins Case 73% 87% – – PRO: pulse oximetry can reliably detect aspiration
and in most dysphagic patients
Bakheit
[5]
Sellars Group – – – – CON: patients showed drops of C 4% and a
et al. significantly greater drop in SpO2 than the healthy
[19] group (t test, p \ 0.05), but associated with
aspiration in only 2 of 6 cases
Sherman Group – – – – PRO: data show ‘‘an association between oxygen
et al. desaturation and swallowing abnormalities.’’
[20] Patients who aspirated had a significantly greater
decline than patients who did not (p 0.002)
Colodny Group – – – – CON: ‘‘No relation was found between SpO2 levels
[24] and aspiration’’
Leder Group – – – – CON: ‘‘No significant differences in SpO2 levels
[25] based on aspiration status or O2 requirements for
any of the 4 groups’’
Smith Case 87% 39% 36% 88% CON: inadequate PPV for detection of aspiration.
et al. Use of pulse oximetry to detect both aspiration and
[21] penetration improved to a PPV of 69%
Chong Case 55.9% 100% 100% 51.6% PRO: the combination of a 50 ml water swallow test
et al. and pulse oximetry is a sensitive screening for
[23] silent aspiration in acutely ill elderly
Higo Case C 2% C 2% – – CON: ‘‘No matter what cut-off point is adopted,
et al. SpO2 SpO2 sensitivity and specificity are insufficient to use
[18] drop drop (pulse oximetry) as a diagnostic tool to predict or
84.6% 82.5% identify aspiration’’
C 3%
SpO2
drop
61.5%
Wang Case 39.1% 59.4% 35.5% 61.1% CON: No significant correlation between
et al. And, per swallow desaturation and aspiration on VFSS (Chi Squared
[22] (i.e., aspiration and test, p = 0.87)
desaturation Only 11/37 (29.7%) aspiration events occurred with
events) desaturation, and 12/39 desaturation events
occurred with an aspiration event
Marian Per swallow 10% 100% – – CON: No correlation between aspiration/dysphagia
et al. severity (k = 0.007) or the amount of aspirated
[26] material and SpO2 levels (k = 0.1101)
SpO2 Peripheral capillary oxygen saturation
Comparison types: By case between-subject comparisons, i.e., aspirators versus non-aspirators; By swallow within-subject comparisons per
swallow, i.e., instances of aspiration versus no aspiration; By group between-group comparisons, i.e., group averages of SpO2 for aspirators
versus non-aspirators

criterion as indicative of aspiration’’ [13]. In addition, both
Leder and Colodny critiqued the 2% criterion as being
arbitrary and at the margin of error for the pulse oximetry
equipment [24, 25].
In addition to considering the standard error of mea-
surement in pulse oximetry devices, it is important to note
that the bias and precision of SpO2 measures tend to
worsen when SaO2 is lower than 90% [27, 28]. This is not
surprising considering the characteristics of the oxyhe-
moglobin dissociation curve (Fig. 2), a sigmoid-shaped
curve that demonstrates the complex relationship between
the amount of oxygen available and dissolved in plasma,
i.e., partial pressure of O2 dissolved in arterial blood
(PaO2), and the amount (percent) saturation of oxygen
bound to hemoglobin in arterial blood (SaO2). Owing to the
sigmoidal shape of the oxyhemoglobin disassociation curve

123
290
Fig. 2 Oxyhemoglobin dissociation curve. The sigmoidal shape
demonstrates the varying affinity of hemoglobin for O2 [35]. Note
that once PaO2 is below 60 mmHg, the curve becomes steep and
smaller changes in PaO2 will reduce SaO2. The affinity of hemoglobin
for O2 will vary with a number of factors. For instance, the curve will
shift left (increasing oxygen affinity for hemoglobin) with increased
pH, reduced PaCO2, reduced 2,3-diphosphoglycerate (DPG), and
reduced temperature. Conversely, the curve will shift right (reducing
oxygen affinity for hemoglobin) with decreased pH, increased PaCO2,
increased DPG, and increased temperature. PaO2 partial pressure of
O2 dissolved in arterial blood; SaO2 saturation of oxygen bound to
hemoglobin in arterial blood Image source Wikimedia Commons
contributors, ’File:Oxyhaemoglobin dissociation curve.png’, Wiki-
media Commons, the free media repository, 19 February 2017, 01:04
UTC, (https://commons.wikimedia.org/w/index.php?title=File:Oxy
haemoglobin_dissociation_curve.png&oldid=234162700) [accessed
26 November 2017]
[35], pulse oximetry may not detect hypoxemia as easily in
individuals with higher PaO2 levels [27]. Conversely,
individuals with lower SpO2 values (e.g., in the lower 90s)
at baseline may show larger drops with smaller changes. It
is therefore plausible that an individual’s underlying res-
piratory function could impact the accuracy of pulse
oximetry in detecting aspiration.
Control for Artifact in Pulse Oximetry Measures
In addition to considering the limits of pulse oximetry
devices and the impact of the oxyhemoglobin dissociation
curve, other factors may lead to erroneous pulse oximetry
measures. Measurement artifact may occur for a variety of
reasons, including motion artifact, nail polish, skin pig-
mentation, low perfusion state (e.g., low cardiac output,
vasoconstriction, or hypothermia), use of intravenous dyes,
and anemia [27, 36]. Elevated levels of dyshemoglobins,
such as carboxyhemoglobin (associated with exposure to
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D. Britton et al.: Utility of Pulse Oximetry to Detect Aspiration...
carbon monoxide) and methemoglobin, may also lead to
inaccurate SpO2 readings [27]. Use of a waveform display,
available on many pulse oximeters, can help distinguish a
normal signal from a signal with various forms of artifact
[27]. Many of the studies included in this review docu-
mented efforts to minimize artifact, but at least four did not
specify these efforts (Table 4). The time it takes for a pulse
oximeter to detect a change in SpO2 is also a consideration
with attempts to use pulse oximetry to detect aspiration.
Jubran reported that the length of time to detect a decrease
in SpO2 was [ 1 min [27]. All articles included in this
review specified the duration of time for observation after
each swallow (Table 4).
Possible Impact of Breathing Swallowing
Coordination
Alteration of breathing–swallowing coordination might
potentially explain desaturation in the context of swal-
lowing for some individuals. The upper airway serves
multiple purposes in humans, including breathing, swal-
lowing, and speech. Swallowing must therefore be coor-
dinated with respiration. The key indices of breathing–
swallowing coordination include the respiratory phase
pattern (observation of inspiration or expiration before and
after each swallow) and the swallow apnea duration [37].
The swallow apnea duration refers to the duration of time
of a centrally controlled cessation of breathing that occurs
during each swallow. Swallow apnea duration may change
in the context of underlying disease. For instance, longer
swallow apnea durations have been observed in the elderly
[37] and in individuals with neurologic disease [38]. In
addition, in individuals with underlying respiratory or
pulmonary disease, such as those with an elevated respi-
ratory rate, the time needed for the swallow apnea (ap-
proximately 1 s) could compete with the individual’s
ventilatory needs. For instance, oxygen desaturation asso-
ciated with eating and swallowing—without aspiration—
was observed in some of the reviewed studies. Theoreti-
cally, the time needed for the swallow apnea in individuals
with underlying respiratory impairments and/or prolonged
swallow apnea duration owing to underlying neurologic
disease might lead to the fluctuation of O2 saturation.
Further research would be needed to confirm this
possibility.
Conclusion
Current evidence does not support the use of pulse
oximetry to detect aspiration. This may be partially related
to methodological factors in existing studies, including
variability in comparison methods for measuring prandial
D. Britton et al.: Utility of Pulse Oximetry to Detect Aspiration...
aspiration, defining ‘desaturation’ in the context of swal-
lowing within the standard error of measurement, and lack
of control for artifact in pulse oximetry measures. It is
possible that factors other than aspiration might explain
desaturation in the context of swallowing in some indi-
viduals, such as alterations to swallow apnea duration.
Although utility for detection of aspiration is not con-
firmed, pulse oximetry may aid generalized judgments of
patient homeostasis during swallowing assessment.
Acknowledgements The authors would like to thank Breanna Sch-
warz, B.S., for her assistance with literature searches and data
organization.
Compliance with Ethical Standards
Conflict of interest Deanna Britton continues to receive royalties from
Plural Publishing, Pro-Ed, Inc., and Medbridge Education. She is
additionally affiliated (Affiliate Assistant Professor) with the
Department of Rehabilitation Medicine at the University of Wash-
ington, Seattle, WA. Joshua O. Benditt owns stock in Ventec. The
remaining authors indicate no conflicts of interest.
Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.
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