The impact of pulse oximetry on diagnosis, management and outcomes of acute febrile illness in low-income and middle-income countries: a systematic review

Abstract

BackgroundAcute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such patients but is poorly detected by clinical examination. Therefore, including pulse oximetry in the assessment of acutely febrile patients may improve clinical outcomes in LMIC settings.MethodsWe systematically reviewed studies of any design comparing one group where pulse oximetry was used and at least one group where it was not. The target population was patients of any age presenting with acute febrile illness or associated syndromes in LMICs. Studies were obtained from searching PubMed, EMBASE, CABI Global Health, Global Index Medicus, CINAHL, Cochrane CENTRAL, Web of Science and DARE. Further studies were identified through searches of non-governmental organisation websites, snowballing and input from a Technical Advisory Panel. Outcomes of interest were diagnosis, management and patient outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 tool for Cluster Randomised Trials and Risk of Bias in Non-randomized Studies of Interventions tools, as appropriate.ResultsTen of 4898 studies were eligible for inclusion. Their small number and heterogeneity prevented formal meta-analysis. All studies were in children, eight only recruited patients with pneumonia, and nine were conducted in Africa or Australasia. Six were at serious risk of bias. There was moderately strong evidence for the utility of pulse oximetry in diagnosing pneumonia and identifying severe disease requiring hospital referral. Pulse oximetry used as part of a quality-assured facility-wide package of interventions may reduce pneumonia mortality, but studies assessing this endpoint were at serious risk of bias.ConclusionsVery few studies addressed this important question. In LMICs, pulse oximetry may assist clinicians in diagnosing and managing paediatric pneumonia, but for the greatest impact on patient outcomes should be implemented as part of a health systems approach. The evidence for these conclusions is not widely generalisable and is of poor quality.

Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries

“…Pulse oximetry was a core part of risk assessment in most included studies (although two of the earlier RCTs did not include oximetry), identifying severely ill children with hypoxaemia who otherwise may not have been appropriately referred or treated with oxygen. This finding concurs with other studies on pulse oximetry that have found pulse oximetry is an objective measure that improves hypoxaemia detection and risk stratification and provides health care workers and patients/families with greater confidence in treatment plans [ 40 , 44 - 49 ].…”

Modelling the cost‐effectiveness of pulse oximetry in primary care management of acute respiratory infection in rural northern Thailand

“…To our knowledge, this is the first study assessing the cost‐effectiveness of pulse oximetry in a LMIC rural primary care setting based on highly granular patient‐level data. We have also investigated the cost‐effectiveness of pulse oximetry in patients older than 5 years, who have not been the focus of previous comparative studies evaluating this intervention [ 17 ]. Additionally, we have factored in the cost of antimicrobial resistance in our analysis.…”

“…Second, because there is a paucity of data on the clinical impact of pulse oximetry in older children and adults in LMICs, we had to extrapolate findings from the literature pertaining to children <5 years old to these patient categories. Third, most data from the literature were derived principally from studies conducted in LMICs outside Southeast Asia, as an extensive systematic review failed to identify relevant studies carried out in this region [ 17 ]. To mitigate this, we have adapted, as far as possible, the potential impacts of pulse oximetry to the socio‐economic conditions in Thailand; for example, it is likely that most patients referred to hospital in Thailand will attend [ 22 ], unlike in many African countries [ 13 ].…”

“…It is unclear, however, whether supplementation of clinical assessment with pulse oximetry as a clinical decision support tool for the primary care management of ARIs other than community‐acquired pneumonia is cost‐effective, particularly in Southeast Asia where there is a paucity of data from clinical studies [ 17 ]. In this study, we aimed to model the cost‐effectiveness of pulse oximetry in the management of ARIs in children <5 years in a rural primary care setting in northern Thailand.…”

Pulse Oximetry Con: Stop Living in the Cave

“…Another review suggested trends toward fewer ICUs transfers with continuous Sp o 2 compared with spot checks but indicated that capnography may provide earlier warning of respiratory depression (12). Other reviews have highlighted the low level of evidence in support of the use of Sp o 2 and called for more research into optimizing its use, establishing patient-specific thresholds, and creating paradigms that positively improve outcomes across clinical settings (13, 14).…”