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MODULE 2

Measurement of blood pressure: Direct and indirect measurement – Oscillometric method –

Ultrasonic method-Measurement of blood flow and cardiac output- Plethysmography –Photo Electric
3.1 MEASUREMENT
and Impedance OF BLOOD PRESSURE of heart sounds –Phonocardiography. Cardiac
Plethysmographs-Measurement
• Heart pumps
measurements: blood, oxygen and
Electro-conduction nutrients
system through
of the heart- the arteries
Electro in our– body.
cardiograph Electrodes and leads –
Einthoven triangle- ECG read out devices-ECG machine – block Diagram

• Blood pressure is the force of blood against the artery walls

• There are two readings which measure blood pressure.

• Normal blood pressure is 120 / 80 mm Hg

• 120 is known as Systolic blood pressure and 80 is known as Diastolic blood pressure

• Systolic blood pressure(Higher number): Pressure measured when the ventricles

contracts

• Diastolic blood pressure(Lower number): Pressure measured when the ventricles relax

• Pulse pressure: Difference between systolic and diastolic pressure

• There are 2 types of blood pressure measurement:

 Direct Measurement

 Indirect Measurement

• In routine clinical tests, blood pressure is usually measured by means of an indirect

method using a sphygmomanometer

1. DIRECT METHOD OF PRESSURE MEASUREMENT

• In which we insert a tube or catheter directly into the blood vessel.

• A local anesthetic is injected near the site where catheter is to be inserted.

• The vessel is occluded and a hollow needle is inserted at a slight angle

toward the vessel

• When the needle is in place, a catheter is fed through the hollow needle.

• When the catheter is securely in place, the needle is withdrawn.

• Catheter is filled with saline heparin solution and inserted into the patient. Heparin is
an anticoagulant. prevents blood clots.

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• Catheter is a thin hollow flexible tube. The catheter is connected to a blood pressure
transducer, which generates corresponding electrical signal.

• The electronic pressure transducer is connected to the patient through the catheter.

• The pressure transducer diaphragm is coupled to patient’s blood stream.

• The diaphragm senses the pressure of the blood which is transmitted through the
fluid in the catheter

• Diaphragm is attached to strain guage that converts the diaphragm displacement to

electric current

2. INDIRECT MEASUREMENTS (Using sphygmomanometer)

• Indirect method of measuring blood pressure uses

1. Sphygmomanometer 2. Stethoscope.

Sphygmomanometer

• Sphygmomanometer consists of an inflatable pressure cuff – Riva Rocci Cuff

• The cuff consists of a rubber bladder inside an inelastic fabric covering that can be
wrapped around the upper arm

• It has two tubes

 A long tube connected from cuff to the manometer

 A small tube connected from cuff to the pump

• A small valve is provided between the pump and the cuff

• Valve helps in the escape of air and reduction of pressure when required

• Manometer used can be mmercury manometer or aneroid manometer

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• Manometer is used to measure pressure in the cuff

There are four types of indirect measurement of blood pressure

1. Palpatory Method Note: Palpatory method and

2. Ascultatory Method ascultatory method are not
3. Oscillometric method mentioned in syllabus. Just read
4. Ultrasonic Method these 2 methods before studying
oscillometric and ultrasonic method
1. Palpatory Method

 Palpate(examine by touch)the radial pulse

 Inflate the bag gradually till the pulse at wrist disappears
 Deflate the cuff very slowly.
 Note the pressure at which fast pulsation appears over the radial artery.
 This is the systolic blood pressure.
 We get a rough idea of systolic blood pressure
 A major disadvantage of this method is that it can’t readily be used to measure
diastolic pressure.
2. Ascultatory Method

 Method of locating the systolic and diastolic pressure values by listening to the
Korotkoff sounds is called the auscultatory method of sphygmomanometry
 Apply the stethoscope lightly over the brachial artery
 Inflate the cuff to few mm of Hg above the pressure observed by palpatory method.
 Deflate it slowly and listen to the appearance of a knocking sound called korotkoff
sound.
 The pressure at which the sound appears is the systolic pressure.
 The systolic number represents the pressure that blood exerts against the walls of an
artery following a heart beat or contraction.
 The point at which the sound disappears is the diastolic blood pressure
 During this method, Sound is heard in 4 different phases
1. Appearance of a knocking sound: Systolic pressure.
2. As it is deflated, gradually sound becomes murmurish
3. Then it becomes loud and clear
4. Then it becomes muffled( almost muted)
5. Finally disappears
6. Disappearance of sound indicates diastolic blood pressure.

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3. Oscillometric measurement

 With an oscillatory device, a cuff is inflated over the upper arm.

 Cuff should be inflated to reach a pressure about 20mm Hg above systolic pressure.
 When the cuff is fully inflated to this pressure, no blood floԝ occurs through the artery.

 As the cuff is deflated beloԝ the systolic pressure, the reducing pressure exerted on the artery
alloԝs blood to floԝ through it and sets up a detectable vibration in the arterial ԝall.
 Ԝhen the cuff pressure falls beloԝ the patient’s diastolic pressure, blood floԝs smoothly
through the artery in the usual pulses, ԝithout any vibration being setup in the ԝall.
 Vibrations occur at any point ԝhere the cuff pressure is sufficiently high that the blood has to
push the arterial ԝall open in order to floԝ through the artery.

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 The vibrations are transferred from the arterial ԝall, through the air inside the cuff, into a
transducer in the monitor that converts the measurements into electrical signals.
4. Ultrasonic method

 Ultrasonic determination of blood pressure employs a Doppler sensor that detects the motion
of blood vessel walls in various states of occlusion.
 Placement of compression cuff over two small transmitting and receiving ultra-sonic crystals.
 Cuff pressure is increased above diastolic but below systolic the vessel opens and closes with
each heartbeat.
 The Doppler ultra-sonic transmitted signal is focused on the vessel wall and the blood.
 The reflected signal with frequency shift is detected by the receiving crystal and decoded.
 The difference in frequency, in the range of 40 to 500 Hz between transmitted and received
signals. That frequency shift is proportional to the velocity of wall motion and blood velocity

3.2 MEASUREMENT OF BLOOD FLOԜ AND CARDIAC OUTPUT

 Blood flow meters are used to monitor the blood flow in various blood vessels and
to measure cardiac output. Two Types are

1. Electromagnetic blood flow meters 2. Ultrasonic blood flow meters

1. Electromagnetic Blood Flow Meter

 Works on the prinple of electromagnetic induction

 Whenever a conductor moves in a magnetic field, an emf is induced in the conductor

E=BLV sinθ

o E = voltage generated in the conductor

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o V = velocity of conducting medium

o B = magnetic field strength
o L = length between the electrodes/electrode spacing

 Induced voltage is proportional to the velocity

 Here, conductive blood is the moving conductor

• A permanent magnet or electromagnet is placed around the blood vessel

• It generates a magnetic field perpendicular to the direction of blood flow

• Stationary electrodes are placed on opposite sides of blood vessel perpendicular

to the direction of magnetic field to measure the voltage.

v = instantaneous blood velocity in m/s

2. Ultrasonic measurement of blood flow

Two types:

1. Doppler shift type 2.Transit time ultrasonic flow meters

1. Doppler shift type

 Ultrasound transducers are used which are made of piezoelectric crystals.

Transducer consists of a transmitter receiver pair.
 Transmitter outputs a sound wave of frequency f1
 It is incident on a particle in the blood: like RBC
 Receiver receives the reflected sound wave that has a different frequency f2
 The change in frequency f2-f1 is the doppler shift.
 This can be used to find the velocity of blood using the equation

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Blood velocity: v, Transmitted frequency: f1, Reflected frequency: f2, Doppler shift : f2-f1
Angle between ultrasound beam and flow direction: θ, Speed of sound in medium: c
Block diagram explanation
 Function generator provides 5 MHz electrical signal for the transducer
 Amplifier collects the electrical signal from the receiver and amplifies this
 Mixer takes these 2 signals from the transmitter and receiver with frequency f1 and
f2 and outputs 2 signals.:
 One with frequency f1-f2
 Other with frequency f1+f2
 These signals are passed to LPF
 It removes the HF signal and keeps the LF signal
 This is given to analog discovery kit where the doppler shift is calculated.

2. Transit time ultrasonic flow meters

 It consists of a pair of ultrasonic transducers mounted along an axis aligned at an
angle with respect to the fluid-flow axis.
 Each transducer consists of a transmitter receiver pair

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 Transmitter emits ultrasonic energy which travels across to the receiver on the
opposite side .
 These ultrasonic elements are piezoelectric oscillators of the same type as used in
Doppler shift flow meters.

 Fluid flowing in the pipe causes a time difference between the transit times of the
beams travelling upstream and downstream

 With no flow, the transmit time would be equal in both the upstream and
downstream directions.

 With flow, sound will travel faster in the direction of flow and slower against the
flow.

3.3 PLETHYSMOGRAPHY
 A plethysmograph is an instrument for measuring changes in volume within an organ or
whole body.
 It measures these changes with blood pressure cuffs or other sensors.

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 These are attached to a machine called a plethysmograph.

 It can help your doctor determine if you have a blood clot in your arm or leg.
 It can also help your doctor calculate the volume of air your lungs can hold.

1. Impedance Plethysmograph
 This is based on the measurement of the electrical impedance (resistance) of a selected body
segment.
 For the measurement of the electrical impedance usually 4 electrodes are applied to the body
surface.
 The 2 outer electrodes (usually called current electrodes) are used to pass a very low and
constant alternating current through the body segment
 The 2 inner electrodes (usually called measuring electrodes) are placed between the 2 current
electrodes and measure the voltage which is caused when the current flows through the body
segment.
 This voltage depends on impedance of the body segment which changes depending on
venous and arterial blood volume variations.
 The positioning of the measuring electrodes defines the segment which is analysed.
 Limb is modelled as a uniform cylinder:
 If limb volume increases by ΔV, cross sectional area increases by ΔA, L stays the same.
 Impedance equation for blood is,

2. Photo Electric Plethysmograph (PPG)

 Photo electric plethysmography or simply photo plethysmography is a simple optical
technique used to detect volumetric changes in blood.
 It makes uses of low-intensity infrared (IR) light. When light travels through biological
tissues it is absorbed by bones, skin pigments and both venous and arterial blood.
 Since light is more strongly absorbed by blood than the surrounding tissues, the changes in
blood flow can be detected by PPG sensors from the changes in the intensity of light.
 The voltage signal from PPG is proportional to the quantity of blood flowing through the
blood vessels.

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 PPG shows the blood flow changes as a waveform with the help of a bar or a graph.

3.4 MEASUREMENT OF HEART SOUNDS

 The mechanical activities of the heart during each cardiac cycle cause the production of some
sounds, ԝhich are called heart sounds.
 Factors involved in the production of heart sounds are:
1. The movement of blood through the chambers of the heart.
2. The movement of cardiac muscles.
3. The movement of valves of the heart.
 First heart sound:
• It resembles spoken ԝord “LUBB”.
• It is long, soft, loԝ pitched sound.
• Duration of this sound is 0.10 to 0.17 seconds.
• It is mainly occurs due to the sudden closure of atrioventricular valves
 Second heart sound:
• It resembles the spoken ԝord “DUBB”.
• It is short, sharp, high pitched sound.
• Duration of this sound is 0.10 to 0.14 seconds.
• It mainly produces during sudden closure of semilunar valves.

 Heart sounds generally alters during cardiac diseases involving the valves of the heart. That’s
ԝhy heart sounds are having important diagnostic value.
 There are three methods to study heart sounds:
1. By using stethoscope
2. By using microphone
3. By using phonocardiogram

3.5 PHONOCARDIOGRAPHY
 Phonocardiography is the recording of the all the sounds made by the heart during a cardiac
cycle.
 The sounds result from vibrations created by closure of the heart valves.
 Two closure sounds:
1) Atrio ventricular valves (Tricuspid & Bicuspid valves).
2) Semilunar valves (Aortic valve & Pulmonary valve).

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 Phonocardiography allows detection of sub-audible sounds and murmurs and makes a

permanent record of these events.
 In contrast the stethoscope cannot always detect all such sounds or murmurs, and it provides
no record of their occurrence.
 It is also an effective method for tracking the progress of person’s diseases.
 The cardiologist evaluates the results of a phonocardiograph on the basis of changes in wave-
shape and in a number of timing parameters.

ELECTRO-CONDUCTION SYSTEM OF THE HEART

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ELECTRODES AND LEADS

1. Right arm (RA) 2. Left arm (LA) 3. Left leg (LL) 4. Right leg (RL) 5. Chest(C)

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