Pan American Health Organization · 1st edition, 2020
Technical specifications, accuracy, and implementation guidance for pulse oximetry in COVID-19 patient monitoring, including home-based care.
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2020
- Audience
- Health professionals, health authorities, decision-makers responsible for health technologies
- Evidence
- Narrative review of clinical and laboratory studies, evidence synthesis from WHO and national guidelines
- Reviewed
- 20 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO technical document provides comprehensive guidance on using pulse oximeters as a critical tool for managing COVID-19 patients, addressing the phenomenon of ‘silent hypoxaemia’ where patients develop significant hypoxia without dyspnoea. More than 75% of hospitalised COVID-19 patients require supplemental oxygen, making oxygen saturation monitoring essential for staging severity and guiding treatment.
The document evaluates evidence on non-medical versus medical pulse oximeters, finding comparable efficacy for ruling out hypoxaemia (negative predictive value 99% for SpO₂ <90%), though accuracy decreases significantly below 90% saturation. It provides detailed technical specifications for three types of oximeters (finger, handheld, tabletop) and recommendations for implementation in health facilities, outpatient monitoring, nursing homes, and rural settings.
Specific clinical algorithms are provided linking oxygen saturation thresholds to management decisions: SpO₂ >96% requires isolation and monitoring; 94–96% warrants closer evaluation; 90–94% indicates need for second-level care; and <90% requires supplemental oxygen therapy. The guidance emphasises that pulse oximetry aids clinical decision-making but does not substitute for clinical evaluation.
Key points
For clinicians — doses and thresholds as stated in the guideline
- SpO₂ <90% is the threshold for initiating supplemental oxygen therapy in COVID-19 patients (88% in patients with COPD)
- SpO₂ 90–94% indicates need for referral to second-level care and consideration of oxygen therapy
- SpO₂ 94–96% warrants closer clinical evaluation; consider exertion oximetry (40-step walk or one-minute sit-to-stand test)
- A drop in SpO₂ ≥3% requires immediate clinical evaluation even if saturation remains within target range
- Non-medical pulse oximeters have 99% negative predictive value for ruling out hypoxaemia defined as SpO₂ <90%, but accuracy is inadequate below 90%
- Patients should measure saturation several times daily at rest after remaining silent for several minutes, recording values for 30–60 seconds
- Finger pulse oximeters require SpO₂ detection range 70–99% with accuracy within ±3%, pulse rate 30–240 bpm with accuracy within ±3 bpm
- All pulse oximeters must comply with ISO 80601-2-61 (specific requirements for pulse oximeter equipment) and ISO 14971 (risk management) standards
Interpretation of oxygen saturation results with pulse oximetry in outpatients with confirmed or suspected COVID-19
Table extracted from the guideline
| SpO₂ level | Clinical actions |
|---|---|
| SpO₂ >96% (RR <20, no emergency signs) | Normal value. Isolate at home, administer paracetamol 500 mg every 6–8 hours (maximum 4 g/day) for fever/pain, provide hydration/nutrition advice, identify emergency signs, do not administer antibiotics |
| SpO₂ 94–96% (RR <20, no emergency signs) | Consider closer evaluation or referral to health centre. May perform brief exercise (climb stairs, walk on site for one minute) to assess for desaturation during exertion |
| SpO₂ 90–94%* | Isolate in health care provider facilities, consider transfer to second-level care. Monitor vital and emergency signs. Consider oxygen intake and fluid administration. Analyse laboratory tests and imaging. Refer to second level and consider supplemental oxygen |
| SpO₂ <90% | Administer supplemental oxygen therapy to any patient with SpO₂ <90% |
| Drop in SpO₂ ≥3% | Consider referral to health centre for possible progressive clinical deterioration |
Source: Pan American Health Organization, Technical and Regulatory Aspects of the Use of Pulse Oximeters in Monitoring COVID-19 Patients. Reproduced in summary form.
From the guideline
Verbatim
“It is important to note that while pulse oximetry can be a useful resource in clinical decision-making, it is not a substitute for clinical evaluation and is not in itself sufficient for diagnosis.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I consider this PAHO technical guidance particularly timely for Georgia's COVID-19 response infrastructure. The document's emphasis on home-based monitoring addresses a critical gap in our national system: early detection of silent hypoxaemia before patients deteriorate to require intensive care, which has been a challenge in our mountainous regions where transport to referral hospitals can take hours. The specific SpO₂ thresholds—particularly the <90% criterion for oxygen therapy and the ≥3% drop triggering re-evaluation—provide actionable decision points that our primary care physicians can implement immediately. However, Georgian clinicians must recognise that the 99% negative predictive value applies only to ruling out hypoxaemia, not quantifying its severity; below 90% saturation, these non-medical devices become unreliable, which is precisely when clinical decisions become most critical, so we cannot rely on home oximeters alone for managing deteriorating patients.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 20 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, this guidance is directly applicable for strengthening COVID-19 outpatient management capacity, particularly relevant given geographic challenges in rural mountainous regions where access to health facilities is limited. National programmes should consider procurement of finger pulse oximeters meeting ISO 80601-2-61 standards for distribution to primary care facilities and high-risk outpatients. The altitude correction factor mentioned for communities at higher elevations is particularly pertinent for highland areas of Georgia, Armenia, and Azerbaijan. Implementation would require training primary care physicians and community health workers in correct oximeter use, interpretation of results according to the SpO₂ thresholds specified (>96%, 94–96%, 90–94%, <90%), and clear referral pathways. The document's emphasis on monitoring in nursing homes aligns with the region's ageing population demographics and could inform protocols for long-term care facilities that expanded during the pandemic.
Questions this guideline answers
Quick answers
What is the accuracy of non-medical pulse oximeters compared to medical devices?
Non-medical pulse oximeters have comparable accuracy to medical oximeters in the 90–99% saturation range, with a negative predictive value of 99% for ruling out hypoxaemia (SpO₂ <90%). However, accuracy decreases significantly for saturations below 93%, and is inadequate at low oxygen saturation levels below 90%. The error level grows at actual oxygen saturation below 90% and is higher for lower-priced models.
What oxygen saturation level indicates need for supplemental oxygen in COVID-19 patients?
SpO₂ <90% is the threshold for initiating supplemental oxygen therapy in COVID-19 patients according to WHO and PAHO guidelines. For patients with chronic obstructive pulmonary disease (COPD), a threshold of 88% should be used. SpO₂ 90–94% indicates need for referral to second-level care and consideration of oxygen therapy.
How should patients use pulse oximeters for home monitoring of COVID-19?
Patients should rest and remain silent for several minutes before measurement. Take readings several times daily and record values. Observe device readings for 30–60 seconds and record the most frequently presented value. Only consider values associated with a strong pulse signal. Remove nail polish, warm cold limbs before measurement, and clean the device between users if shared.
What are the main limitations of pulse oximetry that can affect readings?
Nail polish, dirt, or artificial nails may cause lower values or prevent reading. Poor perfusion due to hypotension, shock, or cold can prevent proper pulse signal identification. Very bright light or sunlight can cause erroneous low values. For SpO₂ <90%, saturation may be overestimated particularly in patients with dark skin. Carbon monoxide poisoning, low-output heart failure, movements, trembling, and arrhythmias can cause unreliable readings.
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Other guidelines on this topic
- Assessment of infection prevention and control practices for COVID-19 isolation areas in healthcare facilities
- Initial care of persons with acute respiratory illness (ARI) in the context of coronavirus disease (COVID-19) in healthcare facilities: assess the risk, isolate, refer
- Flowchart for the Management of Suspected COVID-19 Patients at the First Level of Care and in Remote Areas in the Region of the Americas
- Ongoing Living Update of Potential COVID-19 Therapeutics: Summary of Rapid Systematic Reviews
- Ongoing Living Update of Potential COVID-19 Therapeutics: Summary of Rapid Systematic Reviews
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2020
- Status
- Current
- Published
- 2020-01-01
- Languages
- English, Spanish
- Scope
- Global, with focus on Region of the Americas
- Audience
- Health professionals, health authorities, decision-makers responsible for health technologies
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Narrative review of clinical and laboratory studies, evidence synthesis from WHO and national guidelines
- Record history
- Created 20 Oct 2026 · updated 20 Oct 2026 · next check Apr 2027
Pan American Health Organization. Technical and Regulatory Aspects of the Use of Pulse Oximeters in Monitoring COVID-19 Patients, 7 August 2020. Washington, D.C.: PAHO; 2020. (PAHO/HSS/MT/COVID-19/20-0029). Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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