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Oxygen management should rely on oxygenation targets, with minimal and maximal boundaries to avoid both hypoxemia and hyperoxemia. Oxygen titration using targets based on arterial saturation (SaO2) are not feasible due to discontinuous measurements of this parameter. The oxygen support must be titrated based on SpO2 that allows continuous measurements of patient oxygenation, even though this technology has limitations and needs improvement. We may hope for a major technological evolution as the main working principles of this technology, which are more than 50 years old, have not changed appreciably38. Waiting for this improvement in pulse oximetry technology, clinicians should tread carefully and apply algorithms to correct for these deficiencies. Whatever the clinician thinks is the appropriate oxygenation target, this "optimal SaO2" target needs to be corrected when utilizing the SpO2 for the titration based on skin pigmentation and oximeter brand. It has become increasingly apparent that the SpO2 target cannot simply be the SaO2 target!

To facilitate the quest of the optimal SpO2 targets and to promote a more homogeneous management of patients’ oxygenation regardless of skin pigmentation or monitoring device of oxygenation there are several potential solutions. We believe that one SpO2 target does not fit all patients and that further clinical trials and clinical guidelines should use corrected SpO2 targets rather than universal targets for all patients. Consequently, clinicians should first define a SaO2 target relative to the patient under respiratory support and then apply corrections for the mean bias related to the skin pigmentation and to the oximeter used to get the corrected SpO2 (Figure 3).

The COVID-19 pandemic has served to remind clinicians of the impact of skin pigment on oximeter accuracy. Old lessons learned anew. Device accuracy is both different and variable between brands. And while pulse oximetry is ubiquitous to virtually every healthcare delivery system, the simplicity of oximetry use belies a need for a more nuanced interpretation of SpO2 to avoid untoward consequences.

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