Carboxyhemoglobin – COHb

Physiological role and pathophysiology, reference intervals and the most likely causes of abnormalities

Carboxyhemoglobin – COHb

Reference interval COHb – examples
What is COHb ?
When should COHb be measured ?
Causes of increased COHb
Interpretation of COHb in cases of delayed measurement
Blood oxygenation during carbon monoxide poisoning

FCOHb is the fraction of total hemoglobin (ctHb) which is present as carboxyhemoglobin (COHb). By convention the fraction is expressed as a percentage (%). Thus [24]:

In the range of 0 – 60 % COHb in arterial (COHb(a)) and venous blood (COHb(v)) is similar, i.e. either venous or arterial blood may be analyzed [49]. In most medical texts FCOHb(a) is referred to as simply COHb, which also is used in the text below.

Reference interval COHb – examples

What is COHb?

Carboxyhemoglobin is the product of CO binding to hemoglobin. CO crosses the alveolar membrane easily and binds to hemoglobin with a higher affinity (∼250 times) than oxygen [50]. Since COHb is incapable of binding oxygen, it is categorized as a dyshemoglobin (see Hb).

The level of COHb in blood is determined by the amount of CO in blood. In healthy persons <2 % of total hemoglobin is present as COHb; this is the result of the small amount of CO produced endogenously during normal catabolism of heme to bilirubin [51] and the CO normally present in inspired air. The oxygen-carrying capacity of blood is reduced by the presence of COHb, and increased COHb is associated with risk of inadequate oxygen delivery and resulting tissue hypoxia.

When should COHb be measured?

The principal clinical utility of this test is in the diagnosis and monitoring of carbon monoxide poisoning [52]. Symptoms associated with carbon monoxide poisoning are indicated in Table II.

Cherry-red coloration of the skin is a well-known and more specific sign of carbon monoxide poisoning due to the color of COHb, but this sign is usually only evident post mortem [52].

Causes of increased COHb

Increased COHb is the result of increased CO in blood. The origins of this increased CO are either exogenous, endogenous or a combination of both; exogenous being more common than endogenous.

Exogenous causes of increased COHb, i.e. intentional or non-intentional carbon monoxide poisoning, can arise in a range of scenarios [52]; the most common include:

  • Exposure to vehicle exhaust fumes
  • Exposure to fumes produced during house fires/bonfires
  • Exposure to fumes from faulty domestic gas heating systems
  • Exposure to fumes from kerosene/paraffin heaters

 

The risk of carbon monoxide poisoning and raised COHb is increased if these exposures occur in a closed or poorly ventilated environment.

COHb levels in cases of carbon monoxide poisoning are in general much higher than those associated with endogenous causes and are typically in the range of 15 – 30 %, but can be as high as 50 – 70 % if the carbon monoxide concentration of inspired air is particularly high [54].

Endogenous causes of increased COHb are confined to those pathological conditions associated with increased heme catabolism [53]. They are:

  • Hemolytic anemias
  • Severe inflammatory disease, critical illness, e.g. sepsis

 

These pathologies may increase COHb levels around 3 – 10 % [53].

Combined exogenous and endogenous cause

Methylene chloride (dichloromethane) toxicity is a rare cause of clinically significant increase in COHb. The increased level arises because methylene chloride metabolism in the liver is associated with increased endogenous production of CO [55]. In this case increased COHb has, uniquely, a combined exogenous and endogenous cause.

Interpretation of COHb in cases of delayed measurement

COHb has a half-life of 3 – 4 hours when room air is inspired; this is reduced to 30 – 90 minutes if 100 % oxygen is inspired [52]. The relatively short half-life of COHb means that measured COHb may provide the false impression of low CO exposure if there is a delay between patient removal from exposure and blood sampling. For example, peak measured COHb of 30 % at the site of exposure could theoretically be reduced to 7 % 6 hours later, if room air is inspired. A similar reduction could occur over a period of only 2 hours if the patient is being administered with 100 % oxygen. It is important when interpreting measured COHb results that this physiological aspect is taken into account. Whilst a raised measured COHb (>10 %) almost invariably indicates carbon monoxide poisoning, a normal measured COHb might not be sufficient to exclude the diagnosis if there has been delay in blood sampling, particularly if oxygen has been administered.

Blood oxygenation during carbon monoxide poisoning

The most significant effect of carbon monoxide poisoning and the resulting carboxyhemoglobinemia is reduced total oxygen (ctO2) in blood, and consequent tissue hypoxia. Despite this, oxygenation status, as assessed by pulse oximetry (SpO2) and blood gas parameters (pO2 and sO2), remains apparently normal. SpO2 is falsely normal in the context of carbon monoxide poisoning as (most) pulse oximeters are unable to distinguish COHb and O2Hb [57]. pO2 is unaffected by carbon monoxide poisoning.

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  328. Deutchman M, Tubay AT, Turok D. First trimester bleeding. Am Fam Physician 2009; 79: 985-94.
  329. Seeber BE. What serial hCG can tell you, and cannot tell you, about an early pregnancy. Fertil Steril 2012; 98: 1074-77.
  330. Barnhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med 2009; 361: 379-87.
  331. Yoo A Zacarro J. Falsely low serum hCG level in a patient with hydatidiform mole caused by the “High-Dose Hook Effect”. Laboratory Medicine 2000; 31: 431-35.
  332. Malin GL et al. Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis. BMJ 2010; 340:c1471.
  333. Olsen TG, Barnes AA, King JA. Elevated HCG outside of pregnancy – diagnostic considerations and laboratory evaluation. Obstet Gynecol Surv 2007; 62: 669-74.
Ref.: Acute care testing handbook. Radiometer Medical ApS, 2700 Brønshøj, Denmark, 2014.

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Effective April 18, 2018

This Online Privacy Notice (“Privacy Policy”) explains how we handle the Personal Data provided to us on websites, mobile sites, mobile applications, and other digital services and products controlled by Radiometer Medical ApS, Åkandevej 21, 2700 Brønshøj, Denmark, that link to this Privacy Policy (collectively, “Radiometer Sites”).  Radiometer is the data controller for the processing of Personal Data under applicable law.

This Privacy Notice does not apply to third-party websites to which Radiometer Sites may link.

Types of Information We Collect Online

The types of Personal Data that we may collect while you use the Radiometer Sites are described in this section and include both information that you provide to us and information that we collect automatically when you use the Radiometer Sites.
For purposes of this Privacy Policy, “Personal Data” means information that identifies you or that could reasonably be used to identify you. Examples of Personal Data include name, address, telephone number, and email address.

Information You Provide

You do not have to register for a service or program to receive much of the information available through Radiometer Sites. However, some of our content is available only to registered or identified users and will require you to set up a profile or provide specific information about yourself in order to provide you the service.

Personal Data You Provide When Visiting Radiometer Sites

Radiometer collects Personal Data that you provide on Radiometer Sites, for example, when purchasing a product, to receive marketing products and information, contact Radiometer customer service, or respond to Radiometer questionnaires or surveys. This could include:

  • Contact Information such as your name, address, phone number, or email address
  • Registration Information such as your username and password
  • Remuneration information when you provide a service to Radiometer in your capacity as a healthcare professional
  • Employment, education and other background information when you inquire about employment with Radiometer
  • Payment information (such as banking information, payment card number, expiration date, delivery address, and billing address)
  • Content you may provide (for example, when you complete our Online Contact Form or submit other information).

 

Personal Data You Share During Other Interactions with Radiometer

You may contact Radiometer to ask questions, discuss your concerns, or report issues regarding our products. If you communicate with or request information from Radiometer, you may be prompted to provide your contact information as well as any Personal Data that is relevant to your request.

Information That May Be Collected Automatically

When you use the Radiometer Sites, we also may collect certain usage and device information automatically as described below.

IP Address

We may record the Internet Protocol (“IP”) address of your computer or other electronic device when you visit the Radiometer Sites. An IP address identifies the electronic device you use to access the Sites, which allows us to maintain communication with your computer as you move about Radiometer Sites and to customise content.

Cookies and Other Tracking Technologies

We also collect information about your use of Radiometer Sites through tracking technologies such as cookies and web beacons. A “cookie” is a unique numeric code that is transferred to your computer to track your interests and preferences and to recognise you as a return visitor. A “Web beacon” is a transparent graphic image placed on a Web site, e-mail or advertisement that enables the monitoring of things such as user activity and site traffic. These technologies help remember your preferences and allow us to bring you the content and features that are likely to be of greatest interest to you on the basis of “clickstream” data that shows your previous activities on Radiometer Sites.

We utilise Google Display Advertising (such as Retargeting with Google Analytics, Google Display Network Impression Reporting, DoubleClick Campaign Manager integration, and Google Analytics Demographics and Interest Reporting) to (1) show you our ads on other websites based on your prior visits to Radiometer Sites, and (2) better understand our ad impressions and use of ad services. In connection with the Google Analytics Demographics and Interest Reporting service, we may use data from Google's interest-based advertising or third-party audience data (such as age, gender and interests) with Google Analytics to understand and improve our marketing campaigns and Site content. 

Some of our online advertising takes place through Google Display Advertising. As part of this program, we use Google Analytics features such as Retargeting. In connection with that feature and others offered by ad networks, we and the operators of ad networks, including Google, may use third-party cookies (such as the DoubleClick cookie) – and in some cases first-party cookies (such as the Google Analytics cookie) – to inform, optimise and serve ads across the Internet, based on a user's past visits to Radiometer Sites. We also may show you ads from some of our affiliated companies when you visit Radiometer Sites. 

You can opt out of Google Ads by visiting http://www.google.com/ads/preferences. If you do not want your data used by Google Analytics, you can install the Google Analytics opt-out browser add-on at the Google Analytics opt-out page.

This Radiometer Site is not designed to respond to "do not track" signals received from browsers.

To learn more about cookies and other tracking technologies, including how to disable them, please visit http://www.allaboutcookies.org/. Please note that some cookies are essential to the functioning of our Sites and deleting or disabling them will reduce the site’s functionality.

Mobile Tracking

Some Radiometer Sites are available either as mobile applications or mobile sites that you can use on your mobile device. If you use a mobile device to access and use the Radiometer Sites, we may collect the following mobile-specific information in addition to the other information described above: device or advertising ID, device type, hardware type, media access control (“MAC”) address, international mobile equipment identity (“IMEI”), the version of your mobile operating system, the platform used to access or download the Radiometer Site (e.g., Apple, Google, Amazon, Windows), location information and usage information about your device and your use of the Radiometer Sites.

Information Collected from Other Sources

We may combine information about you from a visit to one Radiometer Site with information about you from visits to other Radiometer Sites. We may also combine information about you that is collected through the Radiometer Sites with information that we have collected offline, as well as with information provided to us by third parties.

How We Use Your Information

We use your Personal Data to provide you the product and services you request, communicate with you, improve your experience on the Radiometer Sites, generally improve our products and services and for other internal business purposes. These uses may also include the recording, organisation, structuring, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, restriction, erasure or destruction of Personal Data. The Personal Data we collect about you may be stored for five years following the most recent interaction we have had with you, after which point it will be archived only for so long as reasonably necessary for the purposes set out above, in accordance with applicable laws.

Providing Product and Services You Request

If you choose to purchase a product or receive our services, we use the Personal Data that you provide through Radiometer Sites to manage your orders and invoices, to process payments, to respond to your questions, provide you the services you request and offer an optimal customer experience.

Marketing

You may also receive marketing information from Radiometer and related affiliates, such as offers regarding Radiometer related products or services, invitations to participate in surveys about our products, or notifications about special promotions. In such cases, we will use your contact and other Personal Data to send you marketing information.

Customised User Experiences

The Personal Data that you provide may be used to create customised offers, information, or services tailored to your interests and preferences. Also, we may use your IP address and the data that we obtain automatically through the use of cookies or similar tracking technologies to make our Radiometer Sites easier to use and navigate as well as to personalise the content provided on Radiometer Sites by anticipating the information and services that may be of interest to you.

Business and Product Improvement

In order to discover new facts that could help Radiometer better understand customer needs and help improve, develop, and evaluate product, services, materials, and programs. Radiometer analyses the information that you have provided. For these purposes Radiometer does not use information that can directly identify you.

Site Analytics and Improvement

We may use the information that you provide and the information we collect automatically about your use of the Radiometer Sites to monitor user traffic patterns and preferences for site improvement, analytics and optimisation.

Legal Basis for Processing

Under European data protection laws, Radiometer must have a legal basis to process your Personal Data. The legal basis that applies in a particular instance will depend on for which of the specific purposes described above Radiometer is processing your Personal Data:

  • In certain cases, Radiometer may ask for your consent to collect and process your Personal Data. Should you choose to provide your consent, you may later withdraw your consent by contacting us as described in the “Your Privacy Choices” section.  Please note that the withdrawal of consent will not affect processing which has already occurred.
  • In other instances, the processing of your Personal Data may be necessary in order to comply with an applicable law or regulation or for the performance of a contract to which you are subject. You may not be able to opt-out of this processing, or your choice to opt-out may impact our ability to perform a contractual obligation otherwise owed to you.
  • In still other instances, Radiometer may process your Personal Data based on Radiometer’s legitimate interests in communicating with you about our products and services, and about scientific research and educational opportunities.  You have the right to opt-out of all such processing of your Personal Data. You may do so by contacting us as described in the “Your Privacy Choices” section.  

 

Information We Share

We only share your Personal Data with third parties as described below. We do not sell or rent Personal Data to third parties for their own marketing purposes.

Third-Party Advertising and Online Behavioral Advertising

You may be provided with online advertisements of Radiometer products and services on third-party websites and mobile services that are tailored to you, for example, on the basis of information that you provide to Radiometer or a third-party website you are visiting, or of your browsing activity, purchases, or interests. These types of tailored online advertisements may come through several sources, such as the following:

  • We may share with our advertising service providers your non-identifying information that we have obtained from cookies and other tracking technologies on our Radiometer Web sites.
  • Some Radiometer Web sites participate in online behavioral advertising (this is also sometimes called re-target advertising or interest-based advertising). You can identify these sites by the “Advertising Choices” link in the footer. Our advertising network partners may place and use cookies on Radiometer Web sites and on other third-party Web sites to collect information about your activities in order to provide you with online advertisements that are based on your interests. When a Radiometer online behavioral advertisement is delivered to you, you will see an “Ad Choices” icon. Clicking on the icon or link will take you to a Web site where you can manage or opt out of the use of data about your browsing history that is used for the delivery of online behavioral advertisements. If you opt out, you may still see advertisements online, including advertisements from Radiometer that are based on other information (e.g., based on the content of the page being viewed rather than your prior clickstream activity). In some cases, data may still be collected about your browsing activity by these third-party advertisers, but they will not use this data to deliver advertisements that are based on your past online browsing behavior. You can also opt out now by clicking here.
  • Some Web browsers may transmit “do-not-track” signals to Web sites with which the browser communicates. As of the Effective Date of this Privacy Notice, an industry standard has not yet been established on how to respond to these signals. Therefore, Radiometer does not currently respond to these signals. As discussed above, you can opt-out from advertisers that use your browsing history to deliver online behavioral advertisements by visiting adchoices.

 

Affiliates, Vendors and Suppliers

We have relationships with suppliers and affiliated companies, who help us operate our business and for whom it may be necessary to have access to your Personal Data in the course of providing services to Radiometer. We will not authorise these parties to use your Personal Data for any purpose that is not related to Radiometer and its related affiliates business operation, and we do not share Personal Data from countries that require consent, unless appropriate consent has been obtained in advance to sharing with related affiliates. We require them to handle your Personal Data collected in accordance with this Privacy Notice.

Co-branded Sites

We may partner with other companies to provide you with content or services on a joint or “co-branded” basis. At a cobranded site, you will see both the Radiometer logo and the logo of the co-branding partner displayed on your screen. You should read the individual privacy policies of our co-branding partners, as they may differ in some respects from ours. Reading these policies will help you to make an informed decision about whether to provide your information to a given site.

Product Reports

If you contact Radiometer regarding your experience in using one of our products, we may use the information that you provide in submitting reports to the designated government regulatory authority, as required of us by law.

Legal Rights and Obligations

In certain limited circumstances, Radiometer may need to disclose your Personal Data in order to comply with a legal obligation or demand, such as to comply with reporting obligations to our governing regulatory authorities regarding the safety of our products, or in connection with the sale or transfer of one of our product lines or divisions, which includes the services provided through one or more of the Radiometer Sites. In such instances, we will take measures to protect your Personal Data to the extent possible. We also reserve the right to use Personal Data to investigate and prosecute users who violate our rules or who engage in behavior that is illegal or harmful to others or to others’ property.

Change in Organisation

In the event Radiometer decides to reorganise or divest our business through sale, merger, or acquisition, Radiometer may share Personal Data about you with actual or prospective purchasers.  We will require any actual or prospective purchasers to treat this Personal Data in a manner consistent with this notice.

Children Privacy

Radiometer does not knowingly collect or use any Personal Data directly from children on Radiometer Sites (Radiometer defines as “children” as minors younger than 18). We do not knowingly allow children to order our products, to communicate with us, or to use any of our online services. If you are a parent and become aware that your child has provided us with information, please contact us using one of the methods specified below, and we will work with you to address this issue.

Your Privacy Choices

You have the right to see and get a copy of Personal Data about you that we maintain as well as to ask us to make corrections to inaccurate or incomplete Personal Data about you.  

You have the right to receive data you have provided to us in a machine-readable format and to transmit that data to another controller. 
You may also request the erasure of your Personal Data or the restriction of its processing, or object to the processing of Personal Data about you. 
To seek access to Personal Data about you, to file a concern, complaint, or request for correction, or to opt-out of particular programs, please:

  • contact our Legal & Compliance team by clicking on the “Contact Us” link on the Radiometer Site you are using (please add “Privacy” in the headline)
  • contact us by using the Radiometer contact information on the Radiometer mobile application you are using
  • contact us by emailing us at privacy@radiometer.dk.

 

You may also send a letter to the following address:
Radiometer Medical ApS Attn: Legal & Compliance (Privacy)
Åkandevej 21
2700 Brønshøj
Denmark

For more information about your privacy rights, or if you are not able to resolve a problem directly with us and wish to make a compliant, contact your local data protection authority, if applicable.

In all communications to Radiometer, please include your email address, the website address, mobile application, and/or the specific Radiometer product to which you provided Personal Data (e.g., www.radiometer.com), and a detailed explanation of your request. If you would like to delete, amend, or correct your Personal Data and are contacting us by email, please put “Deletion Request” or “Amendment/Correction Request” in the subject line of the email. We will respond to all reasonable requests in a timely manner and may need to further confirm your identity in order to process certain requests.

Data Security

Radiometer maintains reasonable technical, administrative and physical controls to secure any Personal Data collected through the Radiometer Sites. However, there is always some risk that an unauthorised third party could intercept an Internet transmission, or that someone will find a way to thwart our security systems. We urge you to exercise caution when transmitting Personal Data over the Internet, especially your financial-related information. Radiometer cannot guarantee that unauthorised third parties will not gain access to your Personal Data; therefore, when submitting Personal Data to Radiometer Sites, you must weigh both the benefits and the risks.

Third Party Sites and Social Media Plug-ins

This Privacy Notice does not apply to third-party websites to which Radiometer Sites may link. Radiometer Sites may use social media plug-ins (e.g., the Facebook “Like” button, “Share to Twitter” button) to enable you to easily share information with others. When you visit Radiometer Sites, the operator of the social plug-in can place a cookie on your computer or other electronic device that enables that operator to recognise individuals who have previously visited our Site. If you are logged into the social media website (e.g., Facebook, Twitter) while browsing on our Radiometer Site, the social media plug-in allows that social media website to receive information that you have visited our Radiometer Site. The social media plug-in also allows the social media website to share information about your activities on our Radiometer Site with other users of their social media website. These sharing settings are managed by the social media website and governed by its privacy policy.

Accessing Our Sites Globally

This site is owned and operated by Radiometer in Denmark, but the information you provide will be accessible to our affiliates, vendors, and suppliers in other countries in accordance with this policy. Furthermore, if you are visiting this site from a country other than Denmark, your communication with us will necessarily result in the transfer of information across international borders. The level of legal protection for Personal Data is not the same in all countries; however, we will take the security measures described in this Privacy Notice in an effort to keep your information secure. By using this site, you understand that your Personal Data may be stored and processed in the United States and in any country to which we may transfer your information in the course of our business operations.

Notice to California Residents 

Subject to certain limits under California Civil Code § 1798.83, California residents may ask us to provide them with (i) a list of certain categories of Personal Data that we have disclosed to third parties for their direct marketing purposes during the immediately preceding calendar year, and (ii) the identity of those third parties. To make this request, California residents may contact us at privacy@radiometer.dk.

Changes to Our Privacy Policy

We will only use Personal Data in the manner described in this Privacy Policy in effect when the information was collected from you or as authorised by you. However, and subject to any applicable consent requirements, we reserve the right to change the terms of this Privacy Policy at any time. Any changes to this Privacy Policy will be reflected on this page with a new effective date. Radiometer encourages you to review this Privacy Policy regularly for any changes. Any Personal Data collected upon your continued use of Radiometer Sites will be handled in accordance with the currently-posted Privacy Policy.

Privacy and Security

Radiometer Medical ApS (“Radiometer”), along with its affiliates and subsidiaries respect your privacy, value our relationship, and are committed to safeguarding your privacy. We understand the importance of privacy to our customers and visitors to the Radiometer websites. Our use of Personal Data is governed by our Privacy Policy and by accessing and using the Radiometer websites, you agree to be bound by that Privacy Policy.

You recognise and agree that when submitting your personally identifiable information to Radiometer websites, while Radiometer has safeguards in place to prevent unauthorised access or interception, there is no absolute guarantee of security. IN THE UNLIKELY EVENT OF AN INTERCEPTION OR UNAUTHORISED ACCESS DESPITE OUR EFFORTS, RADIOMETER SHALL NOT BE RESPONSIBLE FOR SUCH INTERCEPTIONS OR UNAUTHORISED ACCESS, OR ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES (INCLUDING LOST PROFITS) SUFFERED BY A CUSTOMER OR USER, EVEN IF RADIOMETER HAS PREVIOUSLY BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, RADIOMETER DOES NOT WARRANT, EITHER EXPRESSLY OR IMPLIED, THAT THE INFORMATION PROVIDED BY ANY CUSTOMER SHALL BE FREE FROM INTERCEPTION OR UNAUTHORISED ACCESS, AND DOES NOT PROVIDE ANY IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. EACH CUSTOMER IS RESPONSIBLE FOR MAINTAINING THE CONFIDENTIALITY OF HIS OR HER OWN PASSWORD.

 

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