Specialist commentator comments

Comments on this technology were invited from clinical experts working in the field and relevant patient organisations. The comments received are individual opinions and do not represent NICE's view.

Eight specialist commentator responses were received. Four of the specialist commentators had used the Nasal Alar SpO2 sensor in clinical practice.

Level of innovation

Most commentators thought the Nasal Alar SpO2 sensor was thoroughly novel, or was a significant modification of an existing technology with potential for different outcomes and impact. Three commentators thought it was a minor variation on existing technology but they had no experience of using it directly; 1 stated it was a potentially useful variation.

Commentators were not aware of similar products, apart from the nasal bridge sensor. One commentator stated that finger probes can be used on the nose, but this was not ideal. Similarly, other commentators highlighted that earlobe probes can also be used on the nose, which may yield acceptable signals. It should be noted that these applications are off-label use against manufacturers' instructions. One commentator had used paediatric probes to achieve the same aim as the Nasal Alar SpO2 sensor, but stated that these are not designed for this purpose and do not work as well.

Potential patient impact

Some commentators thought the Nasal Alar SpO2 sensor would improve the accuracy and reliability of continuous SpO2 monitoring, especially in poorly perfused patients. Two commentators thought it may provide earlier detection of hypoxia, which may be beneficial: one stated it may provide an extra level of safety from earlier identification and subsequent treatment. One commentator highlighted that the ability to measure SpO2 continuously would be a major factor in improving the safety of healthcare. This commentator described caring for critically ill patients without a functioning pulse oximeter is extremely risky. Another highlighted that the ability to monitor SpO2 in low output states is important because of the well-established harm from hypoxaemia and hyperoxia. Another user of the device stated that they could obtain accurate readings with the Nasal Alar SpO2 sensor, so care for their patients is based on good clinical data. One commentator had found forehead sensors to be less accurate than this device.

Most commentators said the device would be most likely to be used in patients with poor peripheral perfusion or low output, when digit or ear readings have not worked. Other suggested situations where the device would be useful included: for very sick or shocked patients; when fingers are not accessible to check saturation (such as during surgery); patients who need their hands to be free; patients with burns or amputated limbs; older or confused patients who fidget; those who cannot tolerate finger probes or patients in the head-down position during surgery. Commentators identified that the sensor may not be able to be used in patients with nasal problems or with facial trauma.

Two commentators stated the device could be used in any scenario where pulse oximetry is used to monitor SpO2. These included operating theatres, intensive care and high dependency units, emergency departments, wards and out of hospital critical care areas where procedural sedation is used.

Two commentators highlighted the Nasal Alar SpO2 sensor is non-invasive, and one thought there would be less need for invasive arterial blood sampling to ensure enough oxygenation. In 1 setting, commentators used the device instead of monitoring oxygen saturation with invasive arterial lines. This commentator stated that the risks associated with invasive arterial monitoring may be removed, such as bleeding, pain and ischaemia to the hand.

Two commentators thought benefits to patients were minimal. One thought it simply increases the increases the range of options from which to obtain oximetry readings. Another thought it may be less likely to be displaced than finger probes, but it may well be in a patient's visual field and be distracting.

One commentator highlighted that there have been pressure injuries reported from long-term use of conventional sensors.

Potential system impact

Some commentators thought the Nasal Alar SpO2 sensor would make it easier to monitor SpO2. One commentator with experience of the device stated that sensor placement is easy and does not need the constant repositioning experiences with ear probes, which tend to fall off because of head movement. This commentator thought there would be less wasted nursing time when there is difficulty obtaining a reading, because the device works every time. Another commentator stated that an SpO2 monitor which provides continuous accurate information under a wide range of conditions with minimal intervention from healthcare professionals would be a significant advantage.

One commentator thought there may be benefits relating to fewer critical hypoxic incidents (where SpO2 is less than 90%), possibly fewer cardiac arrests because of hypoxia and decreased morbidity leading to reduced hospital stay.

Commentators highlighted that the Nasal Alar SpO2 sensor was more expensive than other devices. Two commentators stated that as a single patient use sensor, it would be more expensive than the conventional reusable finger and ear probes. One commentator said this device would need to be provided in addition to existing technology, but additional costs could be minimised by acquiring a small number of these new devices for patients in particular need.

Two commentators thought the Nasal Alar SpO2 sensor would lead to cost savings. Two commentators considered that it would not be necessary to order and stock other types of device for when digit probes do not work if this device were used. One of the commentators stated they have stopped using forehead sensors, nasal bridge and earlobe probes after adopting the Nasal Alar SpO2 sensor, resulting in cost savings. Another commentator stated that it was not necessary to apply a new Nasal Alar SpO2 sensor if it needed temporary removal, as is the case with the stick-on forehead sensors or the nasal bridge probes, thus saving costs. They added that in the setting where the Nasal Alar SpO2 sensor is being used instead of arterial lines, the device is cheaper. Arterial lines may cost between £50 and £80, including the cost of the line and its corresponding transducer.

Most commentators did not identify any obstacles to adopting the device. One commentator stated that it offered more choice for clinicians and patients. Another user of the device had experienced no problems in changing healthcare professional working practices, as benefits were easily seen.

One commentator thought there may be infection control advantages with this device because it is single patient use.

Most commentators thought that special training to use the device was not needed. One stated the training would only take a few minutes and could be cascaded to other users very easily. Another stated that only adequate knowledge of duration of use and change of position was needed.

General comments

Most commentators stated that conventional pulse oximeters may not work in patients with poor peripheral perfusion. However, one commentator stated that in severe shock with very poor circulation the blood flow to the nasal ala will also be reduced, but not as much as in the peripheries. Another stated that it was rare not to be able to get any oximetry in patients using existing devices.

Most commentators thought the device was robust, with little or no maintenance needed. One user of the device reported no reliability problems.

One commentator thought there could be a potential disadvantage in critical care settings with nasal intubated patients or those with nasogastric tubes, and thought readings could be affected by face mask ventilation.

One commentator stated that they were currently doing a clinical evaluation of the device in patients having robotic-assisted laparoscopic prostatectomy. This type of surgery needs the patient to be in a head-down position for prolonged periods, where access to the hands maybe restricted and venous congestion in the head makes it difficult to detect a standard reading with current ear probes. Their preliminary experience of the Nasal Alar SpOsensor was that they can reliably get a reading which correlates with arterial blood gas sampling, allowing an earlier response to hypoxia. This commentator said that they may reconsider their practice of routinely inserting invasive arterial lines as a result.