Bloood Pressure Measurement Methods

• Blood-pressure values in the various chambers of the

heart and in the peripheral vascular system help the
physician determine the functional integrity of the
cardiovascular system.
• Fluctuations in pressure recorded over the frequency
range of hearing are called sounds. The sources of heart
sounds are the vibrations set up by the accelerations
and decelerations of blood.
• The function of the blood circulation is to transport
oxygen and other nutrients to the tissues of the body and
to carry metabolic waste products away from the cells.
 Blood pressure
• Blood is pumped around the body by the
heart.
• It makes its way around the body through
a network of tubes known as the
vascular system.
• Together with the heart they form the
cardiovascular system.
 The vascular system
• Three sub-systems:
• Arteries: high-pressure arterial tubes
which carry the blood away from the heart
• Capillary network: fine, thin-walled tubes
which allow transfer of nutrients & oxygen
into cells and the removal of waste
products from the cells
• Veins: low-pressure tubes which return the
blood to the heart
Typical values of
circulatory
pressures SP is the
systolic pressure,
DP the diastolic
pressure, and MP
the mean pressure.

Electrical impulse causes mechanical contraction of ventricular muscle

generates ventricular pressures that force blood through the pulmonary and
aortic valves into the pulmonary circulation and the systemic circulation, causing
pressures
• A single cycle of cardiac activity can be divided into two basic phases -
diastole and systole.
• During the contraction phase (systole), blood is ejected from both the left and
right ventricles and pumped into the systemic circulation and pulmonary
circulation, respectively.
• During the relaxation phase of the heart (diastole), the ventricles are filled with
blood in preparation for the next contraction phase.
•
Pressure measurements
The cycles of ventricular contraction and relaxation lead to
maximum (systolic) and minimum (diastolic) levels of blood
pressure in the major arteries in which blood is initially pumped.
• Blood pressure is generally recorded using two measurements (in
mmHg):
– Systolic Pressure
– Diastolic Pressure
• Blood pressure is usually reported as "Systolic over Diastolic“; e.g.
120/70 is a systolic pressure of 120 mmHg and a diastolic pressure
of 70 mmHg.
• Systolic and diastolic arterial blood pressure values are important measurements
and have tremendous diagnostic value as shown in table.
• The mean arterial pressure (MAP) that drives blood through the vasculature from
the arteries to arterioles, capillaries, venules, veins, and back to the heart
• The mean arterial pressure is a time-weighted average of pressure values in large
systemic arteries during the cardiac cycle.
• The ventricles spend approximately one-third (1/3) of their time in systole, and two-
thirds (2/3) in diastole.
MAP = (2/3) DBP + (1/3) SBP
• The mean arterial pressure is a function of
– (1) the rate at which the heart pumps blood into the large arteries,
– (2) the rate of blood flow out of the large arteries to enter smaller arteries and arterioles, and
– (3) arterial wall compliance.
• Pulse Pressure, the difference
between systolic and diastolic
pressures
 General Facts
Direct measurement = Invasive measurement

A vessel is punctured and a catheter (a flexible tube) is guided in

The most common sites are brachial and radial arteries

but also other sites can be used e.g. femoral artery

A division is made into extravascular and

intravascular sensor systems

This method is precise but it

is also a complex
procedure involving many
risks….

Used only when essential to determine the blood pressure continuously

and accurately in dynamic circumstances
Blood Pressure and Flow Measurements - S-108.4010 - Licentiate Course in Measurement Science and
Technology
 Direct Measurements
• Blood-pressure sensor systems can be divided into two
general categories according to the location of the sensor
element.
• Extravascular pressure sensor
– The most common clinical method for directly measuring
pressure is to couple the vascular pressure to an external
sensor element via a liquid-filled catheter.
• Intravascular pressure sensor
– The liquid coupling is eliminated by incorporating the
sensor into the tip of a catheter that is placed in the
vascular system.
 Extravascular pressure-sensor system
• Catheter insertion: surgical cut-down
or percutaneous insertion.
• A catheter couples a flush solution
(heparinized saline) through a
disposable pressure sensor with an
integral flush device to the sensing
port. The three-way stopcock is
used to take blood samples and
zero the pressure sensor.
 From John G. Webster (ed.),
Medical instrumentation
application and design, 4th
ed., John Wiley & Sons, 2010.
This material is reproduced
with permission of John Wiley
& Sons, Inc.

Figure 2.5 Isolation in a disposable blood-pressure sensor. Disposable

blood pressure sensors are made of clear plastic so air bubbles are easily
seen.
Saline flows from an intravenous (IV) bag through the clear IV tubing and the
sensor to the patient. This flushes blood out of the tip of the indwelling
catheter to prevent clotting. A lever can open or close the flush valve. The
silicon chip has a silicon diaphragm with a four-resistor Wheatstone bridge
diffused into it. Its electrical connections are protected from the saline by a
compliant silicone elastomer gel, which also provides electrical isolation.
This prevents electric shock from the sensor to the patient and prevents
destructive currents during defibrillation from the patient to the silicon chip.
(a) Unbonded strain-gage pressure sensor. The diaphragm is directly coupled
by an armature to an unbonded strain-gage system. With increasing pressure,
the strain on gage pair B and C is increased, while that on gage pair A and D
is decreased,

(b) Wheatstone bridge with four active elements.

 INTRAVASCULAR SENSORS
• Catheter-tip sensors have the advantage that the hydraulic
connection via the catheter, between the source of pressure
and the sensor element, is eliminated.
• Detection of pressures at the tip of the catheter without the use
of a liquid-coupling system can thus enable the physician to
obtain a high frequency response and eliminate the time delay
encountered when the pressure pulse is transmitted in a
catheter–sensor system.
• The frequency response of the catheter–sensor system is
limited by the hydraulic properties of the system.
• For the detection of pressure in the catheter tip, straingage
systems is bonded onto a flexible diaphragm at the catheter tip
(1.67 mm outer diameter size).
• The fiber-optic
intravascular pressure
sensor can be made in
sizes comparable to
strain gages, but at a
lower cost.
• The fiber-optic device
measures the
displacement of the Schematic diagram of an intravascular
diaphragm optically by fiber-optic pressure sensor.
the varying reflection of
light from the back of the
deflecting diaphragm.
Characteristic curve
• Pressure causes
for the fiber-optic
deflection in a thin metal
pressure sensor.
membrane that
modulates the coupling
between the source and
detector fibers
Device is applied to the anterior fontanel. Pressure
is applied with the sensor such that the curvature
of the skin surface is flattened. When this
applanation occurs, equal pressure exists on both
sides of the membrane, which consists of soft
tissue between the scalp surface and the dura.
Monitoring of the probe pressure determines the
dura pressure. Pressure bends the membrane,
which moves a reflector. This varies the amount of
light coupling between the source and detector
fibers.

Figure 7.5 Fiber-optic pressure sensor for intracranial pressure measure-

ments in the newborn. The sensor membrane is placed in contact with the
anterior fontanel of the newborn.
 Heart Sounds and Murmurs
• Auscultation of the heart gives the clinician valuable
information about the functional integrity of the heart.
• Heart sounds are vibrations or sounds due to the acceleration or
deceleration of blood
• Murmurs are vibrations or sounds due to blood turbulence.
•The first heart sound is
associated with the movement of
blood during ventricular systole.
•The second heart sound is a
low-frequency vibration
associated with the deceleration
and reversal of flow in the aorta
and pulmonary artery and with
the closure of the semilunar
valves This second heart sound
is coincident with the completion
of the T wave of the ECG.
•The third heart sound is
attributed to the sudden
termination of the rapid-filling
phase of the ventricles from the
atria
•The fourth or atrial heart
sound is not audible but can be
recorded by the
phonocardiogram
•Occurs when the atria contract
and propel blood into the
ventricles.
• S1, S2
• S3
• S4
 Murmurs
• Most murmurs are developed by turbulence in rapidly moving
blood.
• Murmurs during the early systolic phase are common in children,
and they are normally heard in nearly all adults after exercise.
• Abnormal murmurs may be caused by stenoses and
insufficiencies (leaks) at the aortic, pulmonary, and mitral valves.
• They are detected by noting the time of their occurrence in the
cardiac cycle and their location at the time of measurement.
• Example: http://www.blaufuss.org/tutorial/index2.html
 Auscultation techniques
• Heart sounds travel through the body from the heart and major
blood vessels to the body surface.
• Because of the acoustical properties of the transmission path,
sound waves are attenuated and not reflected. The largest
attenuation of the wavelike motion occurs in the most
compressible tissues, such as the lungs and fat layers.
• There are optimal recording sites for the various heart sounds,
sites at which the intensity of sound is the highest because
the sound is being transmitted through solid tissues or
through a minimal thickness of inflated lung.
• There are four basic chest locations at which the intensity of
sound from the four valves is maximized.
Figure 7.16
Auscultatory areas
on the chest A,
aortic; P, pulmonary;
T, tricuspid; and M,
mitral areas. (From
A. C. Burton,
Physiology and
Biophysics of the
Circulation, 2nd ed.
Copyright © 1972 by
Year Book Medical
Publishers, Inc.,
Chicago. Used by
permission.)
 Frequency Response
• Heart sounds and murmurs have extremely small amplitudes, with
frequencies from 0.1 to 2000 Hz.
• Two difficulties may result.
– At the low end of the spectrum (below about 20 Hz), the
amplitude of heart sounds is below the threshold of audibility.
– The high-frequency end is normally quite perceptible to the
human ear, because this is the region of maximal sensitivity.
– However, if a phonocardiogram is desired, the recording
device must be carefully selected for high frequency-response
characteristics.
– That is, a light-beam, ink-jet, or digital-array recorder would be
adequate, whereas a standard pen strip-chart recorder would
not.
 Stethoscope
• Stethoscopes are used to transmit heart sounds from the chest
wall to the human ear.
• Some variability in interpretation of the sounds stems from the
user's auditory acuity and training.
• Stethoscope acoustics reflected the acoustics of the human
ear.
• Younger individuals have revealed slightly better responses
to a stethoscope than their elders.
• The mechanical stethoscope amplifies sound because of a
standing-wave phenomenon that occurs at quarter-
wavelengths of the sound.
 How does Stethoscope Work?
• The diaphragm is the bottom side pictured
in the image above. It basically is a plastic
sheet that transmits vibrations from your
skin and delivers them via the tubing to the
listener’s ears. It is this side you have to
use to hear medium to high-pitched
sounds.
• On the other hand the bell-side is just a
chamber that forms between the chestpiece
and your patient’s chest. The change in
volume of this chamber as a result of for
example heart beats causes sound waves to
travel via the tubing to the listener’s ear.
Use this side for low-pitched sounds.
•Mechanical stethoscope
has an uneven
frequency response,
with many resonance
peaks.
•These investigators
emphasized that the critical
area of the performance of a
stethoscope (the clinically
significant sounds near the
listener’s threshold of
hearing) may be totally lost if
the stethoscope attenuates
them as little 3 dB.

Figure 7.17 The typical frequency-response curve for a stethoscope

can be found by applying a known audiofrequency signal to the bell of a
stethoscope by means of a headphone-coupler arrangement. The audio
output of the stethoscope earpiece was monitored by means of a coupler
microphone system. (From P. Y. Ertel, M. Lawrence, R. K. Brown, and A. M.
Stern, Stethoscope Acoustics I, "The Doctor and his Stethoscope."
Circulation 34, 1966; by permission of American Heart Association.)
 Issues with stethoscopes
• When the stethoscope chest piece is firmly applied, low
frequencies are attenuated more than high frequencies. The
diaphragm becomes taut with pressure, thereby causing an
attenuation of low frequencies.
• Loose-fitting earpieces cause additional problems, because the
leak that develops reduces the coupling between the chest
wall and the ear, with a consequent decrease in the listener's
perception of heart sounds and murmurs.
• Stethoscopes are also useful for listening to the sounds caused
by air flow obstruction or lung collapse
• Electronic stethoscopes have selectable frequency-response
characteristics ranging from the ‘‘ideal’’ flat-response case and
selected bandpasses to typical mechanical stethoscope
responses. Physicians, however, have not generally accepted
these electronic stethoscopes, mainly because they are
unfamiliar with the sounds heard with them.
 Indirect Measurement of blood pressure
• Indirect measurement of blood pressure is an attempt to measure
intra-arterial pressures noninvasively.
• The most standard manual techniques employ either the palpation
or the auditory detection of the pulse distal to an occlusive cuff.
• Sphygmomanometer consisting of an inflatable cuff for occlusion of
the blood vessel, a rubber bulb for inflation of the cuff, and either a
mercury or an aneroid manometer for detection of pressure
• The occlusive cuff is inflated until the pressure is above systolic
pressure and then is slowly bled off (2 to 3 mm Hg/s) (0.3 to
0.4 kPa/s).
• When the systolic peaks are higher than the occlusive pressure,
the blood spurts under the cuff and causes a palpable pulse in the
wrist (Riva–Rocci method).
Figure 7.20 Typical indirect blood-pressure measurement system The
sphygmomanometer cuff is inflated by a hand bulb to pressure above the
systolic level. Pressure is then slowly released, and blood flow under the
cuff is monitored by a microphone or stethoscope placed over a
downstream artery. The first Korotkoff sound detected indicated systolic
pressure, whereas the transition from muffling to silence brackets diastolic
pressure. (From R.F. Rushmer, Cardiovascular Dynamics, 3rd ed., 1970.
Philadelphia:
W.B. Saunders Co. Used with permission.)
• The pressure in the cuff (blue line in top panel) is initially raised to a value above the
expected arterial systolic pressure (red line in top panel). This will ensure complete
obstruction of flow in the brachial artery.
• The cuff pressure is then
gradually reduced at a rate
of 2-3 mm Hg per second.
At all cuff pressures above
the systolic pressure, flow in
the brachial artery remains
obstructed. However, as
soon as the cuff pressure
falls below that of the peak
systolic pressure, a small
volume of blood is forced
through the obstruction. The
vessel constriction caused
by the pressure cuff causes
flow of this volume of blood
to be turbulent. The
turbulent flow causes a
tapping sound known as the
Korotkoff’s sound, which
can be heard by the
stethoscope.
• Laminar flow refers to streamline movement of blood. In laminar flow, blood flows in
layers which move parallel to the long axis of the blood vessel (straight arrows
parallel with the vessel long axis). Close to the vessel wall, an infinitely thin layer of
blood in contact with the wall is stationary (i.e., does not flow). The next layer in
contact with this layer has a low velocity. As the layers extend toward the vessel
interior, their velocity increases.
• Despite the pulsatile nature of flow
in arteries, laminar blood flow is
silent.
• Constriction of the vessel, or
obstruction of the vessel lumen,
disrupts laminar flow and leads to
turbulent blood flow. At the point of
constriction, blood flow velocity
increases, but small eddies lead to
flow in directions other than parallel
to the long axis of the vessel.
Such current eddies lead to
turbulence.
• Turbulent blood flow is noisy and
can be heard by using a
stethoscope placed over the artery
at or distal to the point of
constriction or obstruction.
 Korotkoff Sounds
Auscultatory
• The manometer pressure at Systolic Auscultatory
the first detection of the Cuff Pressure 141 Korotkoff Diastolic
Sounds 78
pulse indicates the systolic
pressure.
• As the pressure in the cuff is
decreased, the audible
Korotkoff sounds pass

Pressure
through five phases.
– I Initial “tapping” sounds
(systolic pressure). Cuff
– II The tapping sounds increase
in intensity but are less well
defined in time
Relative Intensity

– III The loudest phase, more

akin to a thump than a tap
of sounds

– IV A much more muffled sound

– V Silence – no Korotkoff
sounds (diastolic pressure).
 Issues
• Take several measurements, because normal respiration and
vasomotor waves modulate the normal blood-pressure
levels.
• No accurate pressures for infants and hypotensive patients.
• Using an occlusive cuff of the correct size is important if the clinician
is to obtain accurate results. The pressure applied to the artery wall
is assumed to be equal to that of the external cuff. However, the
cuff pressure is transmitted via interposed tissue. With a cuff of
sufficient width and length, the cuff pressure is evenly transmitted to
the underlying artery.
• The cuff should be placed at heart level to avoid hydrostatic effects.
• Auscultatory technique is simple and requires minimum equipment.
• Cannot be used in a noisy environment, whereas the palpation
technique can.
• The hearing acuity of the user must be good for low frequencies
from 20 to 300 Hz, the bandwidth required for these measurements.
• Bellville and Weaver (1969) have determined the energy distribution of the Korotkoff
sounds for normal patients and for patients in shock. When there is a fall in blood
pressure, the sound spectrum shifts to lower frequencies. The failure of the
auscultation technique for hypotensive patients may be due to low sensitivity of the
human ear to these low-frequency vibrations (Geddes,1970).
• There is a common misconception that normal human blood pressure is 120/80,
meaning that the systolic value is 120 mm Hg (16 kPa) and that the diastolic value is
80 mm Hg (10.7 kPa). This is not the case. A careful study (by Master et al., 1952)
showed that the age and sex of an individual determine the ‘‘normal value’’ of blood
pressure.
 Design Of An Automatic Indirect Blood
Pressure Measurement System.
• The basic technique involves an automatic
sphygmomanometer that inflates and deflates
an occlusive cuff at a predetermined rate. A
sensitive detector is used to measure the distal
pulse or cuff pressure.
• ultrasonic, piezoelectric, photoelectric,
electroacoustic, thermometric,
electrocardiographic, rheographic, and tissue-
impedance devices.
•
First Method
The first technique employs an automated auscultatory device wherein a microphone replaces
the stethoscope.
• The cycle of events that takes place begins with a rapid (20 to 30mmHg/s) (2.7 to 4 kPa/s)
inflation of the occlusive cuff to a preset pressure about 30 mm Hg higher than the suspected
systolic level. The flow of blood beneath the cuff is stopped by the collapse of the vessel.
• Cuff pressure is then reduced slowly (2 to 3 mm Hg/s) (0.3 to 0.4 kPa/s).
• The first Korotkoff sound is detected by the microphone, at which time the level of the cuff
pressure is stored.
• The muffling and silent period of the Korotkoff sounds is detected, and the value of the diastolic
pressure is also stored. After a few minutes, the instrument displays the systolic and diastolic
pressures and recycles the operation.
• The presence of other sounds (e.g. the noise of the heart beating) confuses the analysis.
 Ultrasonic determination of blood pressure
• Figure shows the placement of the compression cuff over two small transmitting and receiving
ultrasound crystals (8 MHz) on the arm.
• The Doppler ultrasonic transmitted signal is focused on the vessel wall and the blood. The
reflected signal (shifted in frequency) is detected by the receiving crystal and decoded.
• The difference in frequency, in the range of 40 to 500 Hz, between the transmitted and received
signals is proportional to the velocity of the wall motion and the blood velocity.
• As the cuff pressure is increased above
diastolic but below systolic, the vessel opens
and closes with each heartbeat, because the
pressure in the artery oscillates above and
below the applied external pressure in the cuff.
• The opening and closing of the vessel are
detected by the ultrasonic system.
• As the applied pressure is further increased,
the time between the opening and closing
decreases until they coincide. The reading at
this point is the systolic pressure.
• Conversely, when the pressure in the cuff is
reduced, the time between opening and closing
increases until the closing signal from one
pulse coincides with the opening signal from
the next. The reading at this point is the
diastolic pressure, which prevails when the
vessel is open for the complete pulse.
 Advantages/Disadvantages
• Advantages - can be used with infants and hypotensive
individuals and in high-noise environments.
• Disadvantage - movements of the subject's body cause changes
in the ultrasonic path between the sensor and the blood vessel.
• Complete reconstruction of the arterial-pulse waveform is also
possible via the ultrasonic method.
• A timing pulse from the ECG signal is used as a reference.
• The clinician uses the pressure in the cuff when the artery opens
versus the time from the ECG R wave to plot the rising portion
of the arterial pulse.
• Conversely, the clinician uses the cuff pressure when the artery
closes versus the time from the ECG R wave to plot the falling
portion of the arterial pulse
 Oscillometry
• This method predates the method of Korotkoff but was not
originally as popular. However, it is now the standard method for
automated Blood Pressure measurement.
• In 1885 the French physiologist Marey observed that, if he placed
a patient’s arm in a pressure chamber then the pressure of the
chamber would fluctuate with the pulse and the magnitude of the
fluctuation would vary with the pressure of the chamber.
• It is now known that these fluctuations correspond to the occluding
effect on the artery of pressure applied uniformly to the arm and
that the same effect can be observed in the pressure of an
occluding cuff.
• Measures the amplitude of oscillations that appear in the cuff
pressure signal which are created by expansion of the arterial
wall each time blood is forced through the artery.
 Oscillometric method
• Using this method, it is therefore possible to design a device for
measuring Blood Pressure non−invasively in which it is not
necessary to analyse the Korotkoff sounds and only a cuff needs
to be attached to the patient.
• A pressure slightly above systolic pressure is detected by
determining the shift from small-amplitude oscillations at cuff
pressure slightly above systolic pressure and when the cuff
pressure begins to increase amplitude (Point 1).
• As the cuff continues to deflate, the amplitude of the oscillations
increases reaching a maximum, and then decreases as the
cuff pressure is decreased to zero.
• Point 2 is the maximum cuff-pressure oscillation which is
essentially true mean arterial pressure. Since there is no apparent
transition in the oscillation amplitude as cuff pressure passes
diastolic pressure, algorithmic methods are used to predict diastolic
pressure.
Figure 7.22 The oscillometric method A compression cuff is
inflated above systolic pressure and slowly deflated. Systolic pressure is
detected (Point 1) where there is a transition from small amplitude
oscillations (above systolic pressure) to increasing cuff-pressure
amplitude. The cuff-pressure oscillations increase to a maximum (Point 2)
at the mean arterial pressure.
• The pressure at which the oscillations have their maximum amplitude is
the Mean Arterial Pressure (MAP).
• Systolic pressure and diastolic pressure are estimated.
 Empirical determination of
systolic and diastolic pressures
• Systolic pressure = cuff pressure when the oscillation amplitude is 55% of
the maximum amplitude
• Diastolic pressure = cuff pressure when the oscillation amplitude is 85% of
the maximum amplitude
 Overview of a system for
Oscillometric Blood
• It is possible to design a system for measuring blood pressure non-
Pressure
invasively using oscillometry.
• The cuff control system developed for the method of Korotkoff sounds
can be used and combined with a pressure measurement system.
•
Cuff Control System
The cuff is inflated (ie pressurised) by using a pump to blow air into it and so when cuff
inflation is requested the pump is turned on and that valve is opened.
• When the cuff is sufficiently inflated, the control signal will be changed to "deflate slowly"
and the valve between the pump and the motor will be shut to present unwanted air
leakage.
• The second valve will be opened which allows a controlled slow leakage of air from
the cuff.
• Finally, once the readings have been made, the cuff can be emptied of air and the final
valve is opened to achieve this.
 Pressure sensor
• Pressure sensors typically employ the piezo−resistive
principle to convert pressure to an electrical signal.
• A silicon chip is micro−machined to give a diaphragm
around which four resistors are diffused in a bridge
configuration. Application of pressure to the diaphragm
results in a change in the value of these resistors which
creates a differential voltage output proportional to the
applied pressure.
•
Pressure sensor
There are two pieces of information in the pressure signal: the underlying pressure to
which the cuff has been inflated (or deflated) and the fluctuations present on the
signal.
• The underlying signal is a low frequency signal and can be extracted by passing the
signal through a low−pass filter.
• The fluctuations, which are cardiac synchronous, can be extracted using a
band−pass filter.
• Given that the outputs from the sensor are differential, differential amplifiers and
filters are required here.
• it is essential that the circuit used has a near infinite input impedance because the
sensors have a finite output impedance (approximately 5kW) which varies with
the applied pressure.
• It is also inappropriate to drive two amplifiers directly from the sensor and so the
sensor itself must be connected to a high input−impedance differential buffering
amplifier from which two filters can be driven.
Figure 7.23 Block diagram of the major components and subsystems of
an oscillometric blood-pressure monitoring device, based on the Dinamap
unit, I/O = input/output; MAP = mean arterial pressure; HR = heart rate; SYS
= systolic pressure; DYS = diastolic pressure. From Ramsey M III. Blood
pressure monitoring: automated oscillometric devices, J. Clin. Monit. 1991, 7,
56–67.