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UNIT II

NON ELECTRICAL PARAMETERS


MEASUREMENT AND DIAGNOSTIC
PROCEDURES
Syllabus
• Measurement of blood pressure - Cardiac
output - Heart rate - Heart sound - Pulmonary
function measurements – spirometer – Photo
Plethysmography, Body Plethysmography –
Blood Gas analysers, pH of blood –
measurement of blood pCO2, pO2, finger-tip
oxymeter - ESR, GSR measurements.
Measurement of blood pressure
• Blood pressure (BP) is the pressure exerted by
circulating blood upon the walls of blood vessels.
• When used without further specification, "blood
pressure" usually refers to the arterial pressure in
the systemic circulation.
• Blood pressure is usually expressed in terms of
the systolic (maximum) pressure
over diastolic (minimum) pressure and is measured in
millimeters of mercury (mm Hg).
• It is one of the vital signs along with respiratory
rate, heart rate, oxygen saturation, and body
temperature.
• Normal resting systolic (diastolic) blood pressure in an
adult is approximately 120 mm Hg (80 mm Hg),
abbreviated "120/80 mm Hg".
• Blood pressure varies depending on situation, activity,
and disease states.
• It is regulated by the nervous and endocrine systems.
• Blood pressure that is low due to a disease state is
called hypotension, and pressure that is consistently
high is hypertension.
• Both have many causes which can range from mild to
severe.
• Both may be of sudden onset or of long duration.
• Long term hypertension is a risk factor for many
diseases, including kidney failure, heart disease,
and stroke.
• Long term hypertension is more common than long
term hypotension in Western countries.
• Long term hypertension often goes undetected because
of infrequent monitoring and the absence of symptoms.
Classification
• Systemic arterial pressure
• Mean arterial pressure
• Pulse pressure
• Systemic venous pressure
• Pulmonary pressure
Systemic arterial pressure
• The table presented here shows the classification of
blood pressure adopted by the American Heart
Association for adults who are 18 years and older.
Classification of blood pressure for adults
Category systolic, mm Hg diastolic, mm Hg
Hypotension < 90 < 60
Desired 90–119 60–79
Prehypertension 120–139 80–89
Stage 1 hypertension 140–159 90–99
Stage 2 hypertension 160–179 100–109
Hypertensive urgency ≥ 180 ≥ 110

Isolated systolic hypertension ≥ 160 < 90


• In the UK, clinic blood pressures are usually
categorised into three groups; low (90/60 or lower),
normal (between 90/60 and 139/89), and high
(140/90 or higher).
• Blood pressure fluctuates from minute to minute
and normally shows a circadian rhythm over a 24-
hour period, with highest readings in the early
morning and evenings and lowest readings at night.
• Loss of the normal fall in blood pressure at night is
associated with a greater future risk of
cardiovascular disease and there is evidence that
night-time blood pressure is a stronger predictor of
cardiovascular events than day-time blood pressure.
• Various factors, such as age and sex, influence a person's
blood pressure and variations in it.
• In children, the normal ranges are lower than for adults
and depend on height.
• Reference blood pressure values have been developed for
children in different countries, based on the distribution of
blood pressure in children of these countries. (see table)
Reference ranges for blood pressure in children
Approximate
Stage Systolic Diastolic
age
Infants 1 to 12 months 75–100 50–70
Toddlers and
1 to 5 years 80–110 50–80
preschoolers
School age 6 to 12 years 85–120 50–80
Adolescents 13 to 18 years 95–140 60–90
• As adults age, systolic pressure tends to rise
and diastolic tends to fall.
• In the elderly, systolic blood pressure tends to
be above the normal adult range, thought to
be largely because of reduced flexibility of the
arteries.
• Also, an individual's blood pressure varies with
exercise, emotional reactions, sleep, digestion
and time of day (circadian rhythm).
• Differences between left and right arm blood pressure
measurements tend to be random and average to nearly
zero if enough measurements are taken.
• However, in a small percentage of cases there is a
consistent difference greater than 10 mm Hg which may
need further investigation, e.g. for obstructive arterial
disease.
• The risk of cardiovascular disease increases progressively
above 115/75 mm Hg.
• In the past, hypertension was only diagnosed if
secondary signs of high arterial pressure were present,
along with a prolonged high systolic pressure reading
over several visits.
• Regarding hypotension, in practice blood pressure is
considered too low only if noticeable symptoms are
present.
• Clinical trials demonstrate that people who
maintain arterial pressures at the low end of
these pressure ranges have much better long
term cardiovascular health.
• The principal medical debate concerns the
aggressiveness and relative value of methods
used to lower pressures into this range for those
who do not maintain such pressure on their own.
• Elevations, more commonly seen in older people,
though often considered normal, are associated
with increased morbidity and mortality.
Mean arterial pressure
• The mean arterial pressure (MAP) is the average over
a cardiac cycle and is determined by the cardiac
output (CO), systemic vascular resistance (SVR),
and central venous pressure (CVP).

• MAP can be approximately determined from


measurements of the systolic pressure and the
diastolic pressure
Pulse pressure
• The pulse pressure is the difference between the measured
systolic and diastolic pressures,

• The up and down fluctuation of the arterial pressure results


from the pulsatile nature of the cardiac output, i.e. the
heartbeat.
• Pulse pressure is determined by the interaction of the stroke
volume of the heart, the compliance (ability to expand) of the
arterial system—largely attributable to the aorta and large
elastic arteries—and the resistance to flow in the arterial tree.
• By expanding under pressure, the aorta absorbs some of the
force of the blood surge from the heart during a heartbeat.
• In this way, the pulse pressure is reduced from what it would
be if the aorta were not compliant.[
• The loss of arterial compliance that occurs with aging explains
the elevated pulse pressures found in elderly patients.
Systemic venous pressure
• Blood pressure generally refers to the arterial
pressure in the systemic circulation.
• However, measurement of pressures in the
venous system and the pulmonary vessels plays
an important role in intensive care medicine but
requires invasive measurement of pressure using
a catheter.
• Venous pressure is the vascular pressure in
a vein or in the atria of the heart.
• It is much less than arterial pressure, with
common values of 5 mm Hg in the right
atrium and 8 mm Hg in the left atrium.
• Variants of venous pressure include:
• Central venous pressure, which is a good approximation of right atrial
pressure, which is a major determinant of right ventricular end diastolic volume.
(However, there can be exceptions in some cases.)
• The jugular venous pressure (JVP) is the indirectly observed pressure over the
venous system. It can be useful in the differentiation of different forms of
heart and lung disease.
• The portal venous pressure is the blood pressure in the portal vein. It is normally
5–10 mm Hg
Normal pressure range
Site
(in mmHg)
Central venous pressure 3–8
Right ventricular systolic 15–30
pressure diastolic 3–8
Pulmonary artery systolic 15–30
pressure diastolic 4–12
Pulmonary vein/
2–15
Pulmonary capillary wedge pressure
systolic 100–140
Left ventricular pressure
diastolic 3-12
Pulmonary pressure

• Normally, the pressure in the pulmonary


artery is about 15 mm Hg at rest.
• Increased blood pressure in the capillaries of
the lung cause pulmonary hypertension,
leading to interstitial edema if the pressure
increases to above 20 mm Hg, and to
pulmonary edema at pressures above 25 mm
Hg.
Measurement
• For survey blood pressure
measurements the following
equipment is required
– simple mercury
sphygmomanometer,
– stethoscope,
– cuffs,
– non-elastic measuring tape.

sphygmomanometer
• The simple mercury sphygmomanometer is
recommended because there are no reliable automated
devices on the market.
• This may change when the accuracy of future
automated devices is found to be sufficient in validation
against the simple mercury sphygmomanometer.
• The bell of the stethoscope should be used because it
gives clearer sounds than the diaphragm.
• A set of 3-4 cuffs with different size should be available
and special attention should be paid to the use of
proper cuff width in relation to the size of the arm.
• A measuring tape is used to measure arm circumference
before selecting the proper cuff width.
Measurement procedures
Preparation for measurement
• Before the blood pressure measurement begins the following conditions
should be met:
1. Subjects should abstain from eating, drinking (anything else than water),
smoking and taking drugs that affect the blood pressure one hour before
measurement.
2. Because a full bladder affects the blood pressure it should have been
emptied.
3.Painful procedures and exercise should not have occurred within one hour.
4.Subject should have been sitting quietly for about 5 minutes.
5.Subject should have removed outer garments and all other tight clothes. The
sleeve of shirts, blouses, etc. should have been rolled up so that the upper
right arm is bare. The remaining garments should not be constrictive and the
blood pressure cuff should not be placed over the garment.
6.Blood pressure should be measured in a quiet room with comfortable
temperature. The room temperature should have been recorded.
7. The time of day should have been recorded.
8.The blood pressure measure should be identified on the blood pressure data
recording form.
Position of the subject
• Measurements should be taken in sitting
position so that the arm and back are
supported.
• Subject's feet should be resting firmly on the
floor, not dangling.
• If the subject's feet do not reach the floor, a
platform should be used to support them.
Position of the arm
• The measurements should be
made on the right arm
whenever possible.
• The subject's arm should be
resting on the desk so that the
antecubital fossa (a triangular
cavity of the elbow joint that
contains a tendon of the
biceps, the median nerve, and
the brachial artery) is at the
level of the heart and palm is
facing up.
• To achieve this position, either
the chair should be adjusted or
the arm on the desk should be
raised, e.g. by using a pillow
(see Picture ). The subject
must always feel comfortable.
Selection of the cuff
• The greatest circumference of the
upper arm is measured, with the
arm relaxed and in the normal
blood pressure measurement
position (antecubital fossa at the
level of the heart), using a non-
elastic tape (see Picture ).
• The measurement should be read
to the nearest centimeter.
• This reading should be recorded in
the data form.
• Select the correct cuff for the arm
circumference and record the size
of the selected cuff in the blood
pressure recording data form.
• The cuff should be placed on the
right arm so that its bottom edge is
2-3 cm above the antecubital fossa,
allowing sufficient room for the bell
of the stethoscope. The top edge of
the cuff should not be restricted by
clothing.
Number of measurements
• Three measurements should be taken one
minute apart.
• If three measurements are not feasible, two
will suffice with a certain loss in data stability.
Procedure of the pulse rate and blood
pressure measurement
1. The radial pulse is
palpated and the
pulse rate is counted
for 30 seconds,
measured by a
digital wrist watch or
one with second
hand. (See Picture )

Measurement of the pulse rate


2. Record 30-second pulse count and whether pulse was
regular.
3. The manometer should be placed so that the scale is at
eye level, and the column perfectly vertical. The
subject should not be able to see the column of the
manometer. (See Picture)

Placement of the manometer


4. Determining the peak inflation level:
– The mercury column has to be at 0 level.
– The subject's radial pulse is again palpated.
– The cuff is inflated and the level of the top of the
meniscus of the mercury column is noted at the point
when the radial pulse disappears. The cuff is
immediately deflated by completely opening the
valve.
– The peak inflation level is determined by adding 30
mm to the pressure where the radial pulse
disappeared.
5. Venous blood pool in the forearm is normalized
by waiting at least 30 seconds or by raising the
arm for 5-6 seconds.
6.The brachial pulse is
located and the bell of
the stethoscope is
placed immediately
below the cuff at the
point of maximal
pulsation.
If it is not possible to feel
the brachial pulse, the
bell of the stethoscope
should be placed over
the area of the upper
arm immediately inside
the biceps muscle Placement of the bell
tendon.
The bell should not touch
the cuff, rubber or
clothing. (See Picture )
7. The cuff is rapidly inflated to the peak inflation level and then deflated at a
rate of 2 mmHg per second.
8. The pressure should be reduced steadily at this rate until the occurrence
of the systolic level at the first appearance of a clear, repetitive tapping
sound (Korotkoff Phase 1) and diastolic level at disappearance of
repetitive sounds (Phase 5) have been observed. Then the cuff should be
rapidly deflated by fully opening the valve of the inflation bulb. Note:
There may be a brief period (auscultatory gap) between systolic and
diastolic pressure, when no Korotkoff sounds are heard. Therefore, the
2mmHg/second deflation should be continued until the diastolic blood
pressure is definitely established. If Korotkoff sounds persist until the cuff
is completely deflated, a diastolic blood pressure of 0 should be recorded.
9. The measurements should be recorded to the nearest 2 mmHg. If the top
of the meniscus falls half way between two markings, the marking
immediately above is chosen. The subject is not told the blood pressure
values at this point.
10. After one minute of wait to allow redistribution of blood in the forearm a
second measurement is made by repeating steps 7 to 9. The subject
should not change position during the wait.
11. After another one minute a third measurement is made by repeating
steps 7 to 9.
12. The subject may now be told the measurement values.
Measurement Methods

• Direct Blood Pressure Measurement


• Indirect Blood Pressure Measurement
Direct Blood Pressure Measurement
• The direct method of pressure measurement is used when the highest
degree of absolute accuracy, dynamic response and continuous
monitoring is required.
• For direct measurement, a catheter or a needle type probe is inserted
through a vein or artery to the area of interest.
• Two types of probes can be used.
• One type is the catheter tip probe in which the sensor is mounted on
the tip of the probe and the pressure exerted on it are converted to the
proportional electrical signals.
• The other is the fluid-filled catheter type, which transmits the pressure
exerted on its fluid-filled column to an external transducer.
• This transducer converts the exerted pressure to electrical signals.
• The electrical signals can then be amplified and displayed or recorded.
• Catheter tip probes provide the maximum dynamic response and avoid
acceleration artefacts whereas the fluid-filled catheter type systems
require careful adjustment of the catheter dimensions to obtain an
optimum dynamic response.
• Measurement of blood pressure by the direct method,
through an invasive technique, gives not only the systolic,
diastolic and mean pressures, but also a visualization of the
pulse contour and such information as stroke volume,
duration of systole, ejection time and other variables.
• Once an arterial catheter is in place, it is also convenient for
drawing blood samples to determine the cardiac output,
blood gases and other chemistries.
• Problems of catheter insertion have largely been eliminated
and complications have been minimized.
• This has been due to the development of a simple
percutaneous cannulation technique; a continuous flush
system that causes minimal signal distortion and simple,
stable electronics which the paramedical staff can easily
operate.
BP Measurement – Direct method
A typical setup of a fluid-filled system for measurement blood pressure shown in fig.
• Figure shows a simplified circuit diagram commonly used for
processing the electrical signals received from the pressure
transducer for the measurement of arterial pressure.
• The transducer is excited with a 5V dc excitation.
• The electrical signals corresponding to the arterial pressure
are amplified in an operational amplifier or a carrier
amplifier.
• The modern preamplifier for processing pressure signals are
of the isolated type and therefore comprise of floating and
grounded circuits similar to ECG amplifiers.
• The excitation for the transducer comes from an amplitude
controlled bridge oscillator through an isolating transformer,
which provides an interconnection between the floating and
grounded circuits.
• An additional secondary winding in the transformer is used
to obtain isolated power supply for the floating circuits.
• The input stage is a differential circuit, which
amplifies pressure change, which is sensed in the
patient connected circuit.
• The gain of the amplifier can be adjusted
depending upon the sensitivity of the transducer.
• After RF filtering, the signal is transformer-
coupled to a synchronized demodulator for
removing the carrier frequency from the pressure
signal.
• For the measurement of systolic pressure, a
conventional peak reading type voltmeter is used.
• When a positive going pressure pulse appears at
A, diode D3 conducts and charges C3 to the peak
value of the input signal, which corresponds to
the systolic value.
• Time constant R3C3 is chosen in such a way that it gives a
steady output to the indicating meter.
• The value of diastolic pressure derived in an indirect way.
• A clamping circuit consisting of C1 and D1 is used to
develop a voltage equal to the peak-to-peak value of the
pulse pressure.
• This voltage appears across R1.
• Diode D2 would then conduct and charge capacitor C2 to
the peak value of the pulse signal.
• The diastolic pressure is indicated by a second meter M2
which shows the difference between the peak systolic
minus the peak-to-peak pulse pressure signal.
• The mean arterial pressure can also be read by using a
smoothing circuit when required.
The Rheographic Method
• A fully automatic apparatus for measuring systolic and diastolic blood
pressures has been developed using the ordinary Riva-Rocci cuff and the
principle of rheographic detection of an arterial pulse.
• Here, the change in impedance at two points under the occluding cuff
forms the basis of detection of the diastolic pressure.
• In this method, a set of three electrodes (Fig.), which are attached to the
cuff are placed in contact with the skin. A good contact is essential to
reduce the skin electrode contact impedance.
• Electrode B which acts as a common electrode is positioned slightly
distal from the mid-line of the cuff.
• Electrodes A and C are placed at a certain distance from the electrode B,
one distally and the other proximity.
• A high frequency current source operating at 100 kHz is connected to
the electrodes A and C.
• When we measure the impedance between any two electrodes before
pressurizing the cuffs, it shows modulation in accordance with the blood
flow pulsations in the artery.
• Therefore, arterial pulse can be detected by the demodulation and
amplification of this modulation.
Automated Blood Pressure Measurement
• When the cuff is inflated above the systolic value, no pulse is developed
by the electrode A.
• The pulse appears when the cuff pressure is just below the systolic level.
• The appearance of the first distal arterial pulse results in an electrical
signal, which operates a valve to fix a manometer pointer on the systolic
value.
• As long as the pressure in the cuff is between the systolic and diastolic
values, differential signal exists between the electrodes A and C.
• This is because the blood flow is impeded underneath the occluding cuff
and the pulse appearing at the electrode A is time delayed from the
pulse appearing at C.
• when the cuff pressure reaches diastolic pressure, the arterial blood flow
is no longer impeded and the differential signal disappears.
• A command signal is then initiated and the diastolic pressure is indicated
on the manometer.
• In the rheographic method of measuring blood pressure, the cuff need
not be precisely positioned as in the case with the Korotkoff microphone,
which is to be fixed exactly above an artery.
• Also the readings are not affected by ambient sounds.
Oscillometric Measurement Method
• The oscillometric technique operates on the principle that
as an occluding cuff deflates from a level above the systolic
pressure, the artery walls begin to vibrate or oscillate as the
blood flows turbulently through the partially occluded
artery and these vibrations will be sensed in the transducer
system monitoring cuff pressure.
• As the pressure in the cuff further decreases, the
oscillations increase to a maximum amplitude and then
decreases until the cuff fully deflates and blood flow returns
to normal.
• The cuff pressure at the point of maximum oscillations
usually corresponds to the mean arterial pressure.
• The point above the mean pressure at which the oscillations
begin to rapidly increase in amplitude correlates with the
diastolic pressure (fig.)
• The oscillometric method is based on oscillometric
pulses (pressure pulses) generated in the cuff during
inflation of deflation.
• Blood pressure values are usually determined by the
application of mathematical criteria to the locus or
envelope formed by plotting a certain characteristic
called the oscillometric pulse index of the oscillometric
pulses against the baseline cuff pressure (Fig.)
• The baseline-to-peak amplitude, peak-to-peak
amplitude, or a quantity based on the partial or
full time-integral of the oscillometric pulse can be
used as the oscillometric pulse index.
• The baseline cuff pressure at which the envelope
peaks (maximum height) is generally regarded as
the MAP (Mean Arterial Pressure).
• Height-based and slope-based criteria have been
used to determine systolic and diastolic
pressures.
Ultrasonic Doppler Shift Method
• Automatic blood pressure monitors have also
been designed based on the ultrasonic
detection of arterial wall motion.
• The control logic incorporated in the
instrument analyzes the wall motion signals to
detect the systolic and diastolic pressures and
displays the corresponding values.
• In principle, the instrument consists of four major subsystems (Fig.).
• The power supply block converts incoming ac line voltage to several
filtered and regulated dc voltages required for the pneumatic
subsystem in order to inflate the occlusive cuff around the patient’s
arm.
• At the same time, control subsystem signals gate-on the transmitter
in the RF and audio subsystem, thereby generating a 2 MHz carrier,
which is given to the transducer located in the cuff.
• The transducer converts the RF energy into ultrasonic vibrations,
which pass into the patient’s arm.
• The cuff pressure is monitored by the control subsystem and when
the pressure reaches the preset level, further cuff inflation stops.
• At this time, audio circuits in the RF and audio subsystems are
enabled by control subsystem signals and the audio signals
representative of any Doppler frequency shift are thus able to enter
the control subsystem logic.
• The control subsystem signals the pneumatic subsystem to bleed off
the cuff pressure at a rate determined by the preset bleed rate.
• As air bleeds from the cuff the frequency of the returned RF is not
appreciably different from the transmitted frequency as long as the
brachial artery remains occluded.
• Till then, there are no audio signals entering the control subsystem.
Ultrasonic based BP Measurement
Blood Pressure, ECG and Heart Sound

K S R College of Engineering

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