Final practical revision

physiology 2
prof.Dr.Heba Shawky
Arterial Blood Pressure (ABP)
Prof. Dr.Heba Shawky
 Measurement of Arterial Blood Pressure (ABP)
Definition of ABP:
It is the lateral pressure of the blood on the arterial wall.
Systolic Blood Pressure:
It is the maximum pressure reached in the arteries
during ventricular ejection. It equals 120 mmHg.
Average (90-140) mmHg
Diastolic Blood Pressure:
It is the minimum pressure reached in the arteries just
before ventricular ejection begins. It equals 80 mmHg.
Average (60-90) mmHg
Pulse pressure:
It is the difference between systolic pressure and
diastolic pressure. It equals 40 mmHg.
Mean arterial blood pressure:
It is the average pressure throughout the cardiac cycle.
It equals diastolic pressure + 1/3 pulse pressure.
It is 90 mmHg in average and it provides the driving
force for the blood into the tissues.
ABP = Cardiac output x total peripheral resistance
= (HR x SV) x TPR
-Measurement of blood pressure provides us with
information about the heart's pumping ability and
the condition of the systemic blood vessels.
- In general, systolic blood pressure indicates the
force contraction of the heart, whereas the diastolic
blood pressure indicates the state of the peripheral
resistance.
Principle:
-Normally the flow of blood in the vessels is
streamline or laminar .If a stethoscope is put on
a vessel with laminar flow, no sound is heard.
-When the flow of blood in vessel is turbulent,
sounds can be heard with stethoscope.
The sounds heard during the auscultatory
method of measurement of ABP are known as
korotkoff sounds
Apparatus:
Blood pressure is measured indirectly by the use of
sphygmomanometer.
Principle:
-Human blood pressure is most commonly
measured in the brachial artery of the upper arm.
-In addition to being a convenient place for
measurement it has the added advantage of being
at approximately the same level of the heart, so
that the pressure which is obtained closely
approximates the pressure in the aorta leaving the
heart.
-This allows us to correlate blood pressure with
heart activity.
• General instructions:
1-Ask patient if he/she has ingested caffeine or used
nicotine within the past 60 minutes or exercised within the past
30 minutes. Also note if the patient is in pain or very emotionally
upset.
2-Patient should sit quietly for at least 5 minutes prior to
measurement.
3-Measurement done on bare arm ‐ remove a sleeve that
cannot be rolled up without causing restriction.
4-Patient is seated in chair with back supported.
5-Feet flat on the floor, legs uncrossed.
6-Patient must evacuate his bladder from urine before measurement.

7-Patient is seated comfortably and the arm extended on the table.

8-The cuff is completely deflated by rolling it into a tight cylinder with the
valve open.

9-The cuff is then opened and wrapped around the bare upper arm, making
certain that the inflatable bag within the cuff is placed over the medial aspect
of the upper arm, i.e. over the brachial artery. The cuff should not be too tight
or too loose. The lower edge of the cuff should be one or two inches above the
antecubital fossa. If the inflation causes the bag to bulge unevenly, the whole
bag should be re-applied more evenly.

10. Place the manometer on a table at the level of the heart

Methods: Two methods are used for
determining blood pressure:
1-Palpatory method
2-Auscultatory method.
Both methods are essential because
occasionally the auscultatory method; though
generally more accurate, may give inaccurate
results.
Palpatory method
 Palpatory method
Increase the pressure about 20mmhg
Then deflate the cuff untill pulsation reappear
This is reading (2)

Inflate the cuff untill the Palpate the radial puls

pulsation disappear ,
this is reading (1)

Systolic pressure =reading(1)+reading(2)

2
• The palpatory method measures only the
systolic pressure and is inaccurate
• Auscultatory Method:
Auscultatory method

Place the cone on the Brachial artery

When the sound 1st appear
Is systolic pressure

Raise the pressure in the cuff

above systolic pressure measured by
palpatory method by about (20 mmHg)
You hear nothing , then deflate the cuff slowly.
The point
at which
the sound
Disappears Deflate the cuff slowly
Is the diastolic
pressure
Korotkoff sounds.
Phase 1: Sharp and clear sound. The pressure
where the sound first appears is the systolic pressure.
Phase 2: The sounds become softer murmur
Phase 3: The sounds become louder and clear
again
Phase 4: The sounds suddenly become muffled and
reduced in intensity. After which all sounds disappear.
Diastolic pressure is the pressure at which the sounds
disappear.
Why palpatory before auscultatory?

Palpatory method Auscultatory method

Record systolic only Record both systolic and diastolic
Not accurate accurate

Why palpatory before auscultatory? 

To avoid auscultatory gap
Physiologic variations in ABP
Age: Infants : 80/40 mm Hg
Children: 100/65 mm Hg
Adults: 120/80 mm Hg
Sex: Women < men before menopause
Circadian rhythm:
peak value early in the morning due to sympathetic activity
lowest level at midnight
Race: people belonging to some races may have higher ABP and
higher incidence of hypertension than people belonging to other
races.
Emotions: strong emotional stress elevates ABP .
The effects of exercise on the systolic and diastolic pressures:
Changes in ABP during exercise depend on the type of exercise .
-If exercise is dynamic ,systolic pressure is moderately increased
due to increase SV , while diastolic pressure either falls or not
changed due to vasodilator metabolites .
-If the exercise is static ,both systolic and diastolic pressures are
markedly increased due to compression of blood vessels and
increase resistance.
Effect of gravity on ABP:
The MAP in all major arteries is about 100 mm Hg in
average when they are at the level of the left
ventricle as when the subject is lying down.
However, in standing position,
-pressure in arteries above the level of left ventricle
decreases by 0.77 mmHg for each 1 cm above the
level of the ventricle.
- Pressure in arteries below the level of left ventricle
increases by 0.77 mmHg for each 1 cm below the level
of the ventricle.
.If the mean blood pressure at the level of the heart in lying
position is 140 mmHg, in an artery 26 cm above the heart, the
mean pressure will be in average :
a.120 mmHg
b.160 mmHg
c.149 mmHg
d.140 mmHg
60 years old male visits primary health care
unit for headache. His blood pressure was
180/90 mmHg.
Mean arterial blood pressure in above patient
on 30 cm above level of the heart is
a. 135.4 mmHg
b. 143.1 mmHg
c. 96.9 mmHg
d. 87 mmHg
 ECG
By
Prof. Dr.Heba Shawky
 Electrocardiogram ECG

- Depolarization & repolarization of cardiac

myocytes results in electrical currents.
- These currents can be recorded by
electrodes on the body surface(good conductor).
- Each wave of ECG has characteristic
shape, direction, duration and amplitude.
ECG machine
• The paper is divided into small squares 1 × 1
mm. Each 5 small squares are bounded by a
heavier line. Each small square = 0.04
second. The horizontal calibration gives the
amplitude of the waves in mV. 1 mV = 10
mm.
 Description of the Normal ECG :
1. The P wave: represents atrial depolarization.
2. The QRS complex: represents ventricular depolarization.
It is formed of:
a. Q wave which represents the depolarization of the interventricular
septum.
b. R wave which represents the depolarization of the 2 ventricles
simultaneously.
c. S wave which represents the depolarization of the thick posterobasal
part of the left ventricle.
3.The T wave: represents ventricular repolarization.
4.U wave( which is usually absent ) represents repolarization of the papillary
muscles
N.B. Atrial repolarization is masked by ventricular depolarization.
Durations of different ECG segments &
intervals
Segment/ interval representation Duration
Depolarization wave from
P-R interval SA node to atria, AV node 0.12-0.2 sec (3-5 ss)
to ventricles
Time of conduction
P-R segment 0.06- 0.1 sec
through the AV node.
Correspondes to plateau of
S-T segment isoelectric
ventricular myocyte AP.
Duration of both
0.2 – 0.4 sec (according to
Q-T interval depolarization &
HR)
repolarization of ventricles

NB: segment is a staight line, while interval is segment + wave

Durations & amplitudes of different
ECG waves
Waves Representation Duration amplitude
Atrial
P wave < 0.1 sec (2.5 ss) < 0.25 mV (2.5 ss)
depolarization
Ventricular 1 mv in limb leads
QRS complex < 0.08 (2ss)
depolarization 3 mv in chest leads
< 0.5 mv in limb
Ventricular
T wave 0.16 (4 ss) leads
repolarization
<1mv in chest leads
Repolarization of
Small positive wave
±U wave the papillary
after T wave
muscles

NB: Atrial repolarization is masked by ventricular depolarization

 ST segment is iso-electric
coincide with plateau of myocyte action
potential
 Important of PR interval:
It is the interval from beginning of P wave to
beginning of QRS complex.
It represents the atrial depolarization and the
duration of the atrioventricular conduction.
Important of ST Segment:
From the end of the S wave to the beginning of
the T wave. During this time the heart is
completely depolarized, and therefore the record
is isoelectric.
ECG Recording Analysis

1- Determination of the heart rate:

HR = 300 / number of large squares in between

each consecutive R wave.

• 60–100 beats/min (Normal)

• >100 beats/min (Tachycardia)
• <60 beats/min (Bradycardia)
 2-Rhythmcity:
Measure successive R-R intervals: If the intervals are equal in duration
this means regular heart rate. If not, this means irregular heart rate.

3-P-R interval:
Measured from beginning of P-wave to beginning of R wave
P-R interval duration = 0.12-0.2 sec
It represents: …………………………………………….

4-QRS Complex:
QRS duration = …< 0.08 sec………………………………………
It represent ……………………………………………...
5-S-T segment:
Measured from the end of the S wave to beginning of T wave
S-T segment = ………………………………….……….
If it is not isoelectrical what is the significance?………..
Some Abnormal ECG
Recordings
Sinus tachycardia
 Sinus tachycardia
• Elevated heart rate of impulses greater than 100
beats/min in an average adult.
• Causes:
• 1-Sympathetic stimulation
• 2-Noradrenaline
• 3-Thyroxine
• 4-Fever
 Sinus tachycardia
Symptoms:
• Sinus tachycardia is often asymptomatic unless
very rapid it may cause Heart palpitations — a
racing, uncomfortable heartbeat or a sensation
of "flopping" in the chest.
Treatment:
• Treatment of the cause.
• Beta blockers are useful if the cause is
sympathetic over activity.
Sinus bradycardia
 Sinus bradycardia
• Bradycardia can be a serious problem if the heart
doesn't pump enough oxygen-rich blood to the body,
brain and other organs might not get enough oxygen,
possibly causing these
• Symptoms:
• Near-fainting or fainting (syncope)
• Fatigue
• Chest pains
• Easily tiring during physical activity
Causes of sinus bradycardia:

• 1-Vagal stimulation
• 2-Acetylcholine
• 3-Digitalis
• When a slow heart rate is normal
• A resting heart rate slower than 60 beats a
minute is normal for some people, particularly
healthy young adults and trained athletes.
Sinus bradycardia in athletes is due to heart
adapting to the physical stresses.
 Atrial fibrillation
• Irregular and rapid heart rate.
• Causes: unknown but may be due to:
– Hypertention
– Atherosclerosis
– Heart valve disease.
– Hyperthyroidism
• Symptoms:
– Heart palpitation.
– Fatigue
– Shortness of breath
– Chest pain
 Atrial fibrillation
• Complications:
– Stroke.
– Heart failure.
• Treatment:
– Treatment of the cause (hyperthyroidism).
– Anti-arrythmic drugs
– B-blockers to control heart rate.
– Anti-coagulant (to prevent blood clots and stroke).
– Electric shock to restore normal heart rate.
– Pacemaker implantation (in persistent cases).
ECG Findings:

• Atrial rate: 400-600 b/min

• Ventricular rate: 75- 175 b/min
• Rhythm: irregular
• Origin: atria (not SA node)
• P wave: absent
• QRS: normal
 Ventricular fibrillation
Ventricular fibrillation is life-threatening.
It is the most serious cardiac rhythm disturbance resulting in failure of
the heart to pump blood.
Symptoms:
Loss of consciousness is the most common sign of ventricular
fibrillation.
Cause:
Most commonly it occurs as a complication of
-myocardial infarction
-ischemic heart disease.
 Ventricular fibrillation
ECG Findings
• Irregular deflections of varying amplitude
• No identifiable P waves, QRS complexes, or T waves
• Rate 150 to 500 per minute

• Emergency treatments
• -Cardiopulmonary resuscitation (CPR). This treatment can help
maintain blood flow through the body.
• -Electrical shock
Ventricular fibrillation
 Acute myocardial infarction

Definition:
• Death of part of the myocardium due to sudden
persistent cessation of its blood supply.
Causes:
• Coronary artery disease
• Atherosclerosis
• Hypertension
 Myocardial infarction
Symptoms:
• Chest pain: Severe not relieved by rest
• Diffuse, retrosternal radiating to: Shoulders, arms, forearms, (usually
the left), Neck, lower jaw, back or epigastrium.

• ECG Findings
• Elevated ST segment over infarced area.
Myocardial infarction
 RESPIRATION
Prof. Dr.Heba Shawky
Lung volumes & capacities using
spirometer
 Lung volumes
1-Pulmonary ventilation = minute respiratory volume
- It the total volume of air that flows into and out of the
respiratory system in one minute.
- Minute ventilation = TV × respiratory rate
= 500 ml/breath × 12 breath/min
= 6000 ml/min.

2. Tidal volume (TV):

It is the volume of air inspired or expired in one
respiratory cycle at rest . Equals 500 ml of air.
3. Inspiratory reserve volume (IRV):
It is the maximum volume of air that can be inspired by
forced inspiration after normal inspiration.
It equal 3000 ml.
4. Expiratory reserve volume (ERV):
It is the maximum volume of air that can
be expired by forced expiration at the end
of normal expiration.
It equals 1100 ml
It decreases in lung diseases.
 Lung volumes
5. Residual volume (RV):
it is the volume of air that remain in the lung after a
maximal forced expiration.
It equals: 1200 ml.
• Importance:
– It aerates blood between breaths and hence prevents
marked changes in blood PO2, PCO2.
– It prevents lung collapse.
– It only can be expelled by opening the chest wall
• It increases when the resistance of air passages is
increased (bronchial asthma).
• It also increases when lung elasticity decreases
(emphysema).
• It cant be measured by spirometry.
 Minimal air
• It is a very small volume of air (few ccs) that
remains in the lungs even after opening of the
chest wall and complete collapse of the lung.

• It has a medicolegal importance as it indicates that

an infant was born alive and has taken his first
breath.

• If a piece of lung tissue is placed in water, it floats

while in case of an infant born dead (still birth) the
lung tissue sinks in water.
 Lung capacities
• Lung capacities are sums of more than one lung volume.

• Inspiratory capacity (IC):

– It is the maximum volume of air that can be inspired at the end of
a normal expiration.
– IC = TV + IRV = 500+ 3000= 3500 ml.

• Functional residual capacity (FRC):

– It is the volume of air remaining in the lung after normal
expiration.
– FRC = ERV + RV =1200+ 1100 = 2300 ml.
– FRC is the volume of air in the lungs between breaths when the
respiratory muscles are relaxed.
– It cant be measured by spirometry.
 Lung capacities
• Vital capacity (VC):
– It is the maximum volume of air that can be
expired following a maximum inspiration.
– VC = TV+ IRV+ ERV = 500+ 3000+ 1100=
4600ml.

• Total lung capacity (TLC):

– It is the volume of air in the lung at the end of
maximum inspiration.
– TLC = TV+ IRV+ ERV+ RV = 5800 ml.
– It cant be measured by spirometry.
 Volumes and capacities that can’t be
measured by spirometry:
1. Residual capacity.
2. Functional residual capacity.
3. Total lung capacity.

• They are measured by Helium dilution

method.
 Clinical significance of the vital
capacity:
• VC is measured clinically as an index of
pulmonary function.
• It gives useful information about the health of
lungs and the strength of respiratory muscles.
• It is larger in:
1. Males (more than females).
2. Athletes ( more than sedentary people).
3. Standing position, where gravity pulls the
viscera down, allowing more free descent of the
diaphragm.
 Clinical significance of the vital
capacity:
• It is smaller in:
1. Females.
2. Recumbent position, pregnancy, abdominal
tumors, where the abdominal viscera prevent
free descent of the diaphragm.
3. Paralysis and weakness of respiratory muscles.
4. Bone deformities of chest wall, e.g. kyphosis or
scoliosis.
5. Loss of lung elasticity, e.g. emphysema.
6. Obstructive lung disease, e.g., bronchial
asthma.
7. Restrictive lung disease, e.g., lung fibrosis.
 Timed vital capacity
• It is a very simple test of pulmonary function.

• It is obtained by spirometry when a subject

inspires maximally and then expires as hard and
as completely as he can.
• The total volume exhaled is the forced vital
capacity or FVC
• The volume exhaled in the first second is called
forced expiratory volume 1 (FEV1).

• Normally, FEV1 is about 80% of the FVC.

Lung volumes & capacities using
spirometer
 Obstructive And Restrictive Lung
Diseases
OBSTRUCTIVE LUNG RESTRICTIVE LUNG
DISEASE DISEASE
Bronchial asthma Lung fibrosis

FEV 1 IS REDUSED more than FVC Both FEV1 & FVC are reduced

Ratio FEV1/FVC % is normal or

Ratio FEV1/ FVC % is low
increased

Residual volume is increased. Residual volume is decreased.

Thank You