Slide 1

VITAL SIGNS MEASUREMENTS

David Stell
david.stell@gstt.nhs.uk
Slide 2

WHAT ARE VITAL SIGNS?

‘Classic’ Vital Signs Other Monitored Parameters

Blood Pressure (BP) Oxygen Saturation

Heart Rate (HR)
Level of Consciousness
Respiratory Rate (RR)
Body Temperature (BT) End Tidal CO2

The four classic vital signs are Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR) and
Body Temperature (BT). These have historically been used to understand the state of the body, partly
because many disease states causes them to change and partly because they are easy to measure.

Nowadays we use a few other parameters in a similar way.

• A new technology called ‘pulse oximetry’ (which we will discuss later) has made it very easy (and
cheap) to measure blood oxygen saturation. In the UK oxygen saturation is measured at least as
regularly as the ‘classic’ vital signs and is sometimes thought of as a fifth vital sign.
• Changes in the ‘level of consciousness’ are often assessed along with the vital signs to get a more
complete picture of a patient’s current physiological state. This involves testing for things like
confusion (often by asking the patient where they are or what the date is), their response to stimuli
such as pain or verbal commands, and looking for other signs of consciousness such as eye
opening. A commonly used scale is the ‘Glasgow Coma Scale’ (GCS).
• This test is now quite often in used in severely ill patients who have been intubated (i.e. a tube has
been inserted into their trachea, often to allow a ventilator to breath for them). When used together
with oxygen saturation, end tidal CO2 measurements give a good picture of the amount of oxygen
being carried in the arterial blood.
Slide 3

DIAGNOSTIC TESTS

Vital signs measurements are types of physiological measurement

Diagnostic Tests
Imaging Pathological tests Endoscopy Physiological Measurements
Computed Tomography (CT)

Gastrointestinal Physiology
Magnetic Resonance (MR)

Anatomic Pathology

Cardiac Physiology

Respiratory / Sleep
Clinical Pathology
Nuclear Medicine

Neurophysiology
Ultrasound (US)

Bronchoscopy
Colonoscopy

Laparoscopy
Gastroscopy

Enteroscopy

Audiological
Arthroscopy
Colposcopy
Cystoscopy

Ophthalmic

Physiology
X-ray

I have included this to give an idea of where vital signs measurements fit in with the different
measurements and tests that we tend to perform in hospitals.

Most of the tests we perform in hospitals fall into one of these four categories:
• Imaging – these tests allow clinicians to view images depicting aspects of a patient’s anatomy.
• Pathological tests – these include a vast range of tests (which fall outside the remit of Clinical
Engineering) including many different blood, serum or swab tests (clinical pathology) and tests
performed using biopsies (these are tissue samples which preserve the original tissue structure) of
patient tissue (anatomical pathology).
• Endoscopy covers a range of investigations which involve using a rigid or a flexible tube to see
inside the body, I have given a small number of examples here, there are many more!
• Physiological measurements is a fairly general term which describes a broad range of tests, I have
given a few categories of physiological measurement here. Vital signs measurements are types of
physiological measurement. The only one of the tests we discussed on the previous slide which is
not a physiological measurements is the assessment of the level of consciousness.

(Note: Although most of the most commonly used hospital tests fall into one of these four categories
there are many tests which don’t. A few examples of tests which don’t fall into any of these categories
are the ‘Heaf test’ used to assess tuberculosis immunity, ‘patch tests’ used in the diagnosis of skin
contact allergies, and ‘tilt table testing’ used to distinguish between certain different types of vertigo.)
Slide 4

PHYSIOLOGICAL MEASUREMENTS

Organ system Understand

system

Understand
Physiological process
process

Signals Measure signal

We use ‘physiological measurements’ to produce quantitative description of processes within the

body.

It can be useful to think of it in terms of the hierarchical organisation of the body:

• The body contains a number of organ systems which perform the functions necessary for life.
One example is the cardiovascular system which includes the heart and all the blood vessels of
the body
• Within each organ system there will be many physiological processes. This animation shows the
cyclical contraction of the heart and the opening and closing of some of the heart valves; these are
a couple of examples of physiological processes.
• Many physiological processes produce signals. By “signal” here I mean “an observable change in
a quantity”.
• We aren’t able to measure organ systems or physiological processes directly, but we can try to
measure the signals that they produce.
• This can help us understand the process that produced the signal.
• And this can help us understand the state of the organ system as a whole.
When we talk about ‘physiological measurements’ this is the process that we are talking about. And
this is one way to understand vital signs – they are examples of physiological measurements.
Slide 5

DIAGNOSTIC PROCESS

List of possible
diagnoses

✓
• ------------------------------
• ------------------------------
Patient Clinical • ------------------------------
• ------------------------------ Investigations
History Examination •
•
------------------------------
------------------------------ Single
• ------------------------------
diagnosis

Another important aspect to understand about vital signs measurements is how they are used.
Before we talk about that I want to briefly talk about how diagnostic tests are used in the context of
the diagnostic process. This is a simplified view, in practice doctors wouldn’t always need to go
through all of these steps before making a diagnosis and when they do use all these steps it wouldn’t
necessarily be as linear as is shown here. But hopefully this will help you understand how tests are
usually used within the diagnostic process.

• The first thing a doctor will do when a patient presents in a healthcare setting is take a history this
involves asking a series of questions which will help the doctor narrow down the possible
diagnosis. Doctors usually see this as the most powerful part of the diagnostic process, in many
cases a diagnosis can be made solely on the basis of the information gathered from the patient
history.
• The next part of the process is clinical examination, this is when a doctor will physically examine
a patient. This could involve examining them for any visible abnormalities, listening to their internal
body sounds using a stethoscope or feeling for abnormalities.
• At this point the doctor may have identified the correct diagnosis. If not then they will have a list of
possible diagnosis (known in medic-speak as “differential diagnoses”), in this case the doctor
will use diagnostic tests to identify the correct diagnosis from this list (in medic-speak diagnostic
tests used in this way are called “investigations”). Each investigation requested by the doctor will
relate to one (or sometimes more than one) of the differential diagnoses on their list, and will be
used to either eliminate that diagnosis from the list or to confirm that it is the correct diagnosis
(tests with high specificity are good for eliminating diagnoses, tests with high sensitivity are good
for confirming diagnoses).
• In this idealised picture of the diagnostic process, once the doctor has the results from all the
investigations they requests they will know the correct diagnosis.

Most of the tests performed in hospitals are used as part of the diagnostic process, this includes
tests from all four of the categories that we discussed earlier (imaging, pathological tests, endoscopy
and physiological measurements). Vital signs measurements can be used in this way but this is not
the most common way they are used.
Slide 7

MONITORING VS DIAGNOSIS

Vital signs measurements are most commonly used for

monitoring, not diagnosis.

Diagnostic Measurements Monitoring Measurements

The main purpose is usually to either:
• Monitor changes in disease severity
The main purpose is to reach a
diagnosis. OR
• Predict / identify clinical
deterioration
The same measurements are used for
Each chosen measurement or test
patients with a wide range of different
relates to a specific possible diagnosis.
diagnoses.

The most common use for vital signs measurements is monitoring.

There are a couple of key differences between measurements made for diagnosis, and those made
for monitoring:
• The most important difference is the difference in terms of their purpose. Measurements made for
diagnosis are intended to help a doctor reach a final diagnosis. Measurements made for
monitoring are not usually intended to contribute to diagnosis, many patients who are being
monitored already have a diagnosis.
• Monitoring may be used to keep track of changes in disease severity, for instance medical
staff may give a patient some kind of treatment and then monitor them to see if the
treatment has been effective.
• The other main use of monitoring is to predict or identify clinical deterioration. If a
deterioration is predicted in advance then medical staff can sometimes intervene to
prevent the deterioration. If a deterioration can’t be detected in advance then if it is
detected as it is happening then that allows medical staff to treat it to try and reduce its
severity.
• Another key difference between diagnostic measurements and monitoring measurements is the
degree to which they are specific to a diagnosis. Diagnostic measurements are chosen with a
specific diagnosis in mind, many diagnostic tests will only be used in a very limited range of clinical
circumstances. Specific measurements are monitored in some circumstances but many of the
measurements used for monitoring are used for patients with all sorts of different diagnoses. Vital
signs measurements are a good example - virtually all hospital inpatients will have their vital signs
monitored.

In this lecture, for the most part, I will be talking about the way vital signs are measured in the context
of monitoring. The same technology is often used when they are measured diagnostically, but slightly
different technology is used in some circumstances.
Slide 8

TYPES OF MONITORING

Intermittent Monitoring Continuous Monitoring

Broadly speaking we use two types of monitoring in hospitals.

The first, and by far the most common, type of monitoring is intermittent monitoring, sometimes
known as “observations” or “obs”. Virtually all hospital inpatients have intermittent monitoring. This
usually involves a nurse or healthcare assistant coming round the ward at regular intervals with a
device on a wheeled stand. They use the device to make whichever measurements they need to
make. Historically those measurements would be recorded on a “chart” like this one. Whoever took
the measurements marks the point on the chart so that you can see the change over time. Some
hospitals are now moving towards having these measurements automatically uploaded to a digital
system.

A much smaller number of patients will have continuous monitoring. This is usually reserved for
patients in ‘intensive care units’, or patients who are having surgery or recovering from surgery.
Continuous monitoring involves making continuous real-time measurements which are often
displayed on a screen near the patient’s bed and often also on a separate screen near a “nurses’
station” for the nurses in the area to keep an eye on.

The technologies used for intermittent and continuous monitoring are often a bit different. We will be
talking about both so I thought it would be useful to introduce both types of monitoring at this stage.
Slide 9

SHOCK

“A life-threatening reduction of blood

flow to the tissues and vital organs”

There is one final piece of background I wanted to talk about before we talk about the different
technologies used to measure vital signs.

Earlier I said that one of the two purposes of monitoring is to predict clinical deterioration. Before we
move on to talk about the way vital signs are measured I wanted to explain one of the most important
types of clinical deterioration that we want to detect using vital signs monitoring. This type of clinical
deterioration is called “shock”. In general use the work “shock” is usually used to describe some kind
of nasty surprise (and you do even sometimes see people use it that way in medical dramas on TV!).
When the word “shock” is used in a medical context it means something completely different.

Shock is defined as “a life threatening reduction of blood flow to the tissues and vital organs” (Gaieski
et al. 2018).

Shock is not a disease, it is a physiological state that can be caused by a variety of different diseases.
Predicting shock is one of the most important purposes of monitoring so I thought it would be useful to
quickly talk about shock, and what causes shock, so you can understand how the measurements we
make can predict it.
Slide 10

SHOCK: CIRCULATORY SYSTEM

Shock is a state affecting the cardiovascular system. The cardiovascular system is complex but for
the purposes of understanding shock we can simplify it to a circuit with two pumps (the left heart and
right heart). The right heart pumps blood around the lungs and the left heart pumps blood around the
rest of the body.

To achieve controlled blood flow through all the body’s tissues the heart creates a pressure difference
between the arterial and venous sides of the circulation. You can think of the arterial vessels as
forming a high pressure reservoir, with the pressure maintained by the activity of the heart. The blood
flow through each tissue is controlled by controlling the resistance to flow. This resistance is
controlled in vessels known as arterioles. These lie between the arteries and the capillary beds, they
become narrower to increase resistance and reduce flow, and become wider to reduce resistance and
increase flow.
Slide 11

SHOCK: ELECTRICAL ANALOGUE

I find it helpful to conceptualise the cardiovascular system like an electrical circuit.

Under this analogy the heart is represented as two electrical cells which produce flow through the
lungs and the other tissues of the body. The arterioles and capillary beds are represented as
resistances arranged in parallel. The pressure difference between the arterial and venous circulations
is analogous to the potential difference (voltage) between the analogous arms of the circuit.

There are four different causes of shock. I will describe them all using both the schematic diagram
and the analogous electric circuit.
Slide 12

SHOCK: CARDIOGENIC

The first possible cause of shock is known as ‘cardiogenic’ shock. This is conceptually fairly easy to
understand.

If the heart stops pumping, or becomes much less effective at pumping, for instance because of an
arrhythmia, then it won’t be able to maintain the pressure difference between the arterial and venous
sides of the circulation. When this happens flow through the tissues and vital organs will stop or
become severely limited and the patient will enter a state of shock.

With the circuit analogue this is equivalent to the cells no longer producing a potential difference, or
only producing a very low potential difference. In this case there will only be very limited flow through
each of the resistances.
Slide 13

SHOCK: DISTRIBUTIVE

This next type of shock is slightly more conceptually difficult, but it is quite common.

It is caused when the resistance to flow between the arterial and venous sides of the circulation
becomes very low. This can be caused by serious allergic reactions (known as “anaphylactic shock”)
or by the body’s response to infection (known as “septic shock”). In both of these cases the body
dramatically reduces the resistance to flow through capillary networks, the purpose is to increase the
supply of nutrients and white blood cells to the affected tissues. If the body’s response is too slow
then the resistance to flow can fall so low that heart is no longer able to maintain the required
pressure difference between arterial and venous vessels. The relatively high resistance of the blood
vessels in other tissues means that their blood supply falls dramatically and it is not longer possible
for the body to regulate blood supply.

Using the electrical analogy this is equivalent to a short circuit in one of the parallel arms of the circuit.
In this case virtually all of the current will flow through this arm of the circuit, the others will receive
hardly any flow.
Slide 14

SHOCK: HYPOVOLAEMIC

The electrical circuit analogy doesn’t work for this type of shock.

Hypovolaemic shock is caused when there isn’t enough blood volume to supply all the tissues, for
example after serious bleeding. The arterial vessels maintain blood pressure through the elastic recoil
of their walls. If there isn’t a high enough volume of blood in the arterial vessels then they won’t be
able to maintain the blood pressure and the body won’t be able to control the blood supply to different
tissues in the usual way.
Slide 15

SHOCK: OBSTRUCTIVE

Obstructive shock is caused by a high pressure in the chest. This is not as common as cardiogenic or
distributive shock but can be caused by conditions such as tension pneumothorax and cardiac
tamponade. This creates a large resistance to blood flow in the thorax increasing the resistance to
flow both in the arteries leaving the heart and the veins returning to the heart.

In the electrical analogy this is a bite like large resistances on the conductors leading to and from the
heart batteries, although not exactly equivalent.
Slide 16

BP (BLOOD PRESSURE)

Description Clinical Use

• Refers to the pressure in the • Raised BP

peripheral systemic arteries
• Measured at roughly the
height of the heart
• Upper arm for seated patients
• More flexibility for patients lying
in bed
• Risk factor for multiple diseases
• Not usually a feature / predictor
of acute deteriorations
• Reduced BP
• All types of shock are associated
with low blood pressure
• Can predict shock in some cases

The first vital sign I wanted to look at in a bit more detail is Blood Pressure (BP).

Clinical use
A lot of people are familiar with high blood pressure, and the idea that high blood pressure is bad for
you. Having a high blood pressure for a long period of time (many years or decades) is a risk factor
for a number of different diseases but, in the context of monitoring, clinical staff are more interested in
low blood pressure – it is a particularly useful parameter to monitor to predict / identify shock. All types
of shock are associated with a fall in blood pressure. For some types of shock the blood pressure will
begin falling before the patient enters shock so acts as a good predictor of shock. Blood pressure is a
key vital sign to monitor to identify shock early.

Characteristics
When we talk about BP in a medical context we are talking about the pressure of the blood in the
systemic arteries (i.e. the pressure in the arteries that supply the body, not the pressure in the heart
itself, and not the pressure in the arteries of the lungs).

BP is measured at a point in the body that is at the same level as the heart, to negate hydrostatic
effects. For patients who are sitting down it is usually measured in the upper arm, which is at
approximately the same height as the heart. For patients who are lying in a bed the whole body is
taken to be at approximately the same height as the heart.
Slide 17

BP (BLOOD PRESSURE)

140

120 Systolic Blood Pressure

Pressure (mmHg)

100

80 Diastolic Blood Pressure

60
120
40 Quoted as:
80
20

0
0.0 0.5 1.0 1.5 2.0
Time (s)

BP is measured at a point in the body that is at the same level as the heart, to negate hydrostatic
effects. For patients who are sitting down it is usually measured in the upper arm, which is at
approximately the same height as the heart. For patients who are lying in a bed the whole body is
taken to be at approximately the same height as the heart.

The pressure in the arteries fluctuations with the heartbeat. This plot shows two cycles. The profile
has this characteristic saw-tooth shape with a rapid increase in pressure associated with the pumping
action of the heart which fills the elastic arteries with blood. This is followed by a slower decrease in
pressure as blood flows out of the arteries into tissue capillary beds, and the tension in the arterial
wall gradually relaxes. (The little ‘bump’ in the declining pressure is known as the ‘dicrotic’ notch, it is
a transient increase in pressure associated with the closure of the aortic valve.)

The peak pressure is known as the ‘systolic blood pressure’, the lowest pressure is known as the
‘diastolic blood pressure’. Blood pressure is always quoted in units of mmHg often quoted as
“[systolic] over [diastolic]”. In this example the blood pressure is 120/80.
Slide 18

BP: UNITS

BP is always quoted in millimetres of mercury (mmHg)

Where:
From hydrostatics: • = pressure
• = fluid density
• = the specific force of gravity
• = the height of a fluid column

Pressures quoted in mmHg refer to in mm,

where is the density of mercury (~13,594 kg.m-3)
Slide 19

BP: THE KOROTKOFF METHOD

Method 1:

The Korotkoff
Method

Used for
intermittent
monitoring

So on to the measurement technologies for intermittent monitoring measurement technology for BP.

The oldest technology used to measure BP makes use of the Korotkoff method:
• An inflatable cuff is wrapped around the upper arm (at approximately the same vertical height as
the heart)
• The pressure in the cuff can be varied using a hand pump and is displayed on a dial (historically a
mercury manometer was used)
• A stethoscope is used to listen to the sound of blood flow near the elbow
There is an artery in the upper arm called the brachial artery, which continues until just below the
elbow. When the cuff is inflated it is assumed that the pressure applied to this artery is the same as
the air pressure within the cuff, the blood flow produces characteristic sounds at different pressures.
Slide 20

BP: THE KOROTKOFF METHOD

Cuff pressure
No blood flow,
greater than
no flow sounds
systolic pressure

Intermittent
Cuff pressure
turbulent flow
between systolic
produces
and diastolic
characteristic
pressures
sounds

Cuff pressure Constant laminar

less than diastolic flow produces no
pressure flow sounds

The clinician will begin by pumping up the cuff until they can hear no flow sounds through the
stethoscope. They will then gradually release the pressure while listening for flow sounds:
• When the cuff pressure is greater than the systolic blood pressure this causes the artery to
collapse so there is no blood flow and no sounds can be heard through the stethoscope.
• When the cuff pressure is between the systolic and diastolic pressures the artery will open and
close with each heartbeat, this intermittent flow and the shape of the arterial walls when the artery
is partially open produces turbulent flow. This produces flow sounds which can be heard through
the stethoscope.
• When the cuff pressure is below the systolic pressure the artery remains open and undeformed by
the pressure in the cuff. Flow is laminar and silent.

The clinician can identify the systolic pressure as the cuff pressure when the sounds first appear and
the diastolic pressure as the cuff pressure when the sounds disappear.
Slide 21

BP: MERCURY & ANEROID MANOMETERS

Clarence, E. G. & Grim, C. M., 2007. Office Blood Pressure

Measurement. In: Black, H. R. & Elliot, W. J., Hypertension. Elsevier.

This schematic shows a typical working principle of an aneroid sphygmomanometer used to measure
BP using the Korotkoff method. The pressurised air causes a set of elastic bellows to deform by an
amount that is related to the magnitude of the pressure. This is translated into movement of the
needle by a series of gears.
Slide 22

BP: THE OSCILLOMETRIC METHOD

Figure showing the true arterial

blood pressure and the cuff
pressure

Figure showing the high-pass

filtered cuff pressure

Babbs, C.F., 2012. Oscillometric measurement of systolic and diastolic blood pressures validated in a physiologic
mathematical model. BioMed Eng OnLine 11(56) doi:10.1186/1475-925X-11-56

The pulsatile pressure in the brachial artery causes pressure oscillations in the cuff. The magnitude of
these oscillations can be measured electronically and used to infer the arterial blood pressure.

Different manufacturers of oscillometric devices have designed different (proprietary) algorithms to

estimate the arterial blood pressure, based on empirical testing.

This method is not considered to be as accurate as the Korotkoff method for estimating the systolic
and diastolic blood pressures, although there is a smaller degree of operator dependence. It does
give a more reliable estimate of the ‘mean arterial pressure’ (MAP). This is the average arterial blood
pressure over a single cardiac cycle, it can be estimated from the systolic pressure (SP) and diastolic
pressures (DP) by assuming a true sawtooth (triangular) pressure profile, as below:
1
𝑀𝐴𝑃 ≈ 𝐷𝑃 + (𝑆𝑃 − 𝐷𝑃)
3
See also Ogedegbe, G., Pickering, T., 2010. Principles and techniques of blood pressure
measurement. Cardiology Clinics 28(4) doi:10.1016/j.ccl.2010.07.006
Slide 23

BP: THE OSCILLOMETRIC METHOD

Different devices look different internally but this schematic shows a shows broadly how an
oscillometric BP machine works.

The cuff is inflated using a pressure source, typically some kind of electric pump which pumps air into
the cuff via an ‘inflate valve’. The ‘deflate valve’ is used to gradually reduce the pressure in the cuff, in
a controlled manner, to get the oscillometric reading. The ‘dump valve’ is a safety feature which will
automatically release all the pressure in the cuff in the event of a fault. Some designs may also
include ‘bleed valves’ which release air when a particular maximum pressure is reached – used to
ensure that the cuff is not inflated to a pressure greater than a safe maximum.

The pressure transducer can only measure the pressure difference between two gases so must be
connected both to the cuff and to ambient pressure. The processor will contain the data processing
electronics necessary to filter the signal from the pressure transducer and infer the diastolic, systolic
and mean blood pressures.
Slide 24

BP: CONTINUOUS MONITORING

Example of a pressure transducer Clinical Arrangement

This space must be Strain gauges usually arranged

vented to atmosphere in a Wheatstone bridge

Adapted from figure in:

Mendelson, Y., 2012. Biomedical Sensors. In: Enderle J. D. & Miller, K., Scanlan, L.,2015. Vascular pressure monitoring. url
Bronzino J. D. Introduction to Biomedical Engineering. Elsevier. clinicalgate.com/vascular-pressure-monitoring [Accessed 30/12/2019]

Blood pressure can be measured pseudo-continuously using a device which performs an oscillometric
measurement at regular intervals. However, given that blood pressure is such an important vital sign
clinicians often wish to monitor it continuously. Doctors often decsribe ‘beat-to-beat’ monitoring –
meaning that the pressure profile associated with each beat of the heart beat is monitored. The most
common technique is intra-arterial blood pressure (IABP) monitoring, this involves gaining physical
access to the pressurised arterial blood. IABP does carry risks so in practice it is only used in a limited
number of areas in hospital, usually only intensive care units (ICUs) and operating theatres.

Pressure transducers can only measure the pressure difference between two points, they cannot
measure absolute pressure at a single point; in this sense pressure transducers are a bit like
voltmeters, which can only measure a potential difference between two points, not an absolute
potential (note that apparent exceptions to this rule do exist – e.g. mercury manometers, in this case a
vacuum can be seen as the reference pressure). IABP transducers therefore need to measure the
pressure difference between arterial blood pressure and another pressure. Atmospheric pressure is
usually used – so IABP transducers need to be vented to the atmosphere. For this reason it is usually
easier for the transducer to be situated outside the body.

There are various different designs of pressure transducer, this figure (left) shows one example. The
space here, behind the diaphragm is vented to the atmosphere, and these strain gauges are usually
arranged in a Wheastone bridge.

This figure shows a typical arrangement. The transducer is placed at roughly the same vertical height
as the heart, usually taped to the patient’s arm, it is connected to a continuous monitor with an
electrical wire. A pressurised bag of saline is used to provide a continuous, slow, flow of saline into
the artery, this prevents blood flow into the catheter, which could lead to blocking of the catheter with
blood clots.

See also Walton, T., Wilson, M., 2017. Principles of pressure transducer function and sources of error
in clinical use. Anaesthesia & Intensive Care Medicine 18(11) doi:10.1016/j.mpaic.2017.07.010
Slide 25

BP: CONTINUOUS MONITORING

One problem when measuring a continuously varying pressure with a transducer at the end
of a catheter is resonance.
The natural frequency ( ) of a fluid filled catheter is given by:

Where = diameter of catheter, = volume elasticity of the system (i.e. the pressure exerted on the fluid in the catheter per unit
volume deformation) = the density of the fluid in the catheter, = the length of the catheter

I.e. is proportional to and , and inversely proportional to . To maximise we need

to use catheters which are as short, fat and stiff as possible.

Damping (𝐷) is also a consideration for IABP monitoring. Over-damping tends to introduce
a time lag so changes in BP aren’t detected immediately. Under-damping causes overshoot
(so diastolic BP is underestimated and systolic BP is overestimated). Damping is increased
by air bubbles or clots in the catheter, and by reducing (𝐷 ).

A common problem with IABP monitoring using this method is resonance. This occurs where one of
the frequencies present in the IABP signal is close to the natural frequency of the system comprising
the fluid filled catheter and the transducer. In practice the natural frequency of this system is typically
higher than the fundamental frequency of the IABP signal (typically ~60 Hz). To avoid problems with
resonance, as a rule of thumb, the natural frequency should be at least ten times higher than this. The
natural frequency can be increased by using short, fat, stiff catheters.

Damping is also a consideration when measuring IABP, it can be increased by reducing the diameter
of the catheter, and the presence of air bubbles or clots in the tubing.
Slide 26

HR (HEART RATE)

Raised Heart Rate Reduced Heart Rate

• Can be caused by
• Shock – part of the body’s • Less common sign than raised
compensatory response HR
• Infection • May be due to arrhythmia
• Lung disease • Other possible causes include
• Fluid loss head injury and hypothermia

The next vital sign is heart rate (HR).

A high HR is a more common than a low HR. If a patient goes into shock then often the body will try to
compensate by increasing the HR, so a rapid increase in heart rate can be suggestive of shock,
particularly if there is a simultaneous fall in BP. Raised HR can also be suggestive of infection, lung
disease or fluid loss. A fall in HR is less common but can be suggestive of an arrhythmia and various
other problems.
Slide 27

HR: TECHNOLOGIES

Intermittent Monitoring Continuous Monitoring

Manual Palpation Pulse oximetry – to be discussed later

Pulse oximetry – to be discussed later Electrocardiogram (ECG) – to be discussed later

Intermittent monitoring
Historically the easiest way to measure HR was by manual palpation – by feeling for the pulsation of
one of the more superficial arteries in the body. Now, use of a pulse oximeter is probably the most
common way to measure HR. We will discuss pulse oximetry a bit later.

Continuous monitoring
Pulse oximetry can be used for continuous HR measurement as well as for intermittent monitoring,
however ECG is considered to be more reliable. ECG is covered in the next lecture.
Slide 28

RR (RESPIRATORY RATE)

Raised Respiratory Rate Reduced Respiratory Rate

• Less common sign than raised

Usually suggestive of a lung RR
disease such as asthma or • May be caused by:
pneumonia • Head injury
• Morphine overdose

The next vital sign is respiratory rate (RR).

Clinical use
RR is not usually as clinical useful as BP and HR but it is still routinely monitored. As with HR,
abnormally raised RR is more common than abnormally low RR. Raised RR is usually a response to
difficulty oxygenating the blood – i.e. it is usually suggestive of a disease affecting the respiratory
system, such as pneumonia or asthma. It can decrease in some cases, for example following a head
injury or as a result of a morphine overdose (heroine overdoses can kill by over-suppression of
breathing).
Slide 29

RR: TECHNOLOGIES

Intermittent Monitoring Continuous Monitoring

Electrocardiogram (ECG) – to be discussed later

Manual counting

Gas flow measurements

Inductance pneumography

Intermittent monitoring
Manual counting is still the main way that RR is measured for intermittent monitoring. All the
alternative technologies for measuring it take too long to set-up. One of the problems with intermittent
monitoring of RR is that if patients are aware that their RR is being measured it becomes difficult for
them to breath naturally. For this reason, many clinicians will pretend to be taking the patient’s pulse,
when in fact they are counting breaths.

Continuous monitoring
ECG can be used to measure respiratory rate for continuous monitoring. There are a few other
technologies that we are not going to discuss in depth. For patients who have been intubated or are
wearing a face mask it is possible to measure RR by monitoring the gas flow in and out of the lungs.
A technology called ‘inductance pneumography’ is also sometimes used, particularly for a type of test
called a ‘sleep study’ – this involves the patient wearing an elastic strap with an attached conductive
wire following a zig-zag route along its whole length. As the patient’s chest expands and contracts the
inductance of the wire changes, this change in inductance can be used to calculate RR.
Slide 30

BT (BODY TEMPERATURE)

Clinical Use Monitoring

• Raised BT
• Strongly associated with
infection
• Can be used to monitor whether
treatment is successfully
reducing infection
• Reduced BT
• Usually a serious clinical sign
• Can be indicative of shock
• Intermittent monitoring
• Very common
• Used particularly for patients
with infection or at risk of
infection
• Continuous monitoring
• Rarely necessary due to the
body’s large thermal mass – BT
only changes slowly
• Necessary where clinicians are
trying to artificially control BT

The last of the classic vital signs is body temperature (BT).

Clinical use
BT is the vital sign that is relied upon least in a clinical context. The body raises its temperature in
response to infection, this thought to be because human cells cope better with slightly higher
temperatures than many infectious agents do, so high BT (fever) is usually a sign of infection.
Monitoring BT can help clinicians determine when an infection has cleared following treatment – i.e.
clinicians may give a patient a treatment against infection (e.g. antibiotics) and then monitor their body
temperature to see if it returns to normal, indicating that the infection has resolved. Raised BT is also
(obviously) a feature of heat stroke, but this is much more rare.

Low BT is usually a serious clinical sign, indicating that the body is unable to maintain sufficient
cardiac output (i.e. that the body is in shock).

Intermittent monitoring
Intermittent monitoring of temperature is traditionally done using a mercury thermometer. This has two
disadvantages: mercury is toxic so breakages can harm the patients, and this requires contact
between the patient and the thermometer – most patients who are being monitored have an infection
or are at risk of infection, so minimising the risk of transmission of infection between patients is
particularly important for temperature measurement devices. The two most common types of devices
used for intermittent temperature monitoring now are thermistor-based contact devices with single use
disposable caps, and tympanic devices which measure IR emissions.

Continuous monitoring
The body has a large thermal mass, its temperature therefore changes very slowly, this means that
intermittent monitoring is usually sufficient for most clinical purposes and continuous monitoring is
rarely necessary. Continuous monitoring is used where a patient’s body temperature is being
artificially controlled, in these cases a thermistor based temperature transducer is typically placed in
the patient’s rectum as this gives a better indicator of core body temperature than any other easily
accessible body site.
Slide 31

BT: BACKGROUND
Countercurrent Heat Exchange

Before we talk about temperature measurement I want to discuss the concept of countercurrent heat
exchange.

Countercurrent heat exchange can be used when fluid flows from a warm place to a cool place (or
vice versa) and there is a need to limit heat flow between the two areas (i.e. we want to maintain a
temperature difference between the warm and cool areas). Countercurrent heat exchangers work by
putting the inflow and outflow channels close to one another; there is heat transfer from the warm fluid
to the cool fluid so the warm fluid is cooled before it reaches the cool area and the cool fluid is
warmed before it reaches the warm area.
Slide 32

BT: BACKGROUND
Countercurrent Heat Exchange
Left: Light micrograph (A) and scanning electron
micrograph (B) showing the network of rete
arteries (ra) and rete veins (rv) forming a
countercurrent heat exchange system in a seal’s
flipper.

Right: schematic showing the vascular

architecture of the flipper as a whole.

Seals can use their flippers as radiators by

diverting blood supply through the brachial artery
(ba) and outflow through the large veins shown in
the top left of the schematic. Or they can
conserve heat by diverting both inflow and
outflow through the countercurrent heat
exchanger.

Taken from: Blix, A.S., Walløe, L., Messelt, E.B., Folkow,

L.P., 2010. Selective brain cooling and its vascular basis
in diving seals. Journal of Experimental Biology.
Doi:10/1242/jeb.040345

I have only included this slide because I think it is interesting, and it illustrates the use of
countercurrent heat exchangers in nature really well. You don’t need to know this for your exam!

The best example of a countercurrent heat exchanger that I can find is in a seal’s flipper:
• When seals dive in freezing seas in the winter, they don’t want to lose a lot of heat through their
flippers so they use a countercurrent heat exchanger made up of ‘rete arteries’ and ‘rete veins’
which form a network so there is plenty of surface area for heat exchange. This way they are able
to maintain a large temperature difference between their flippers and their core.
• In the summer seals may want to lose heat through their flippers to cool the rest of their body, so
they can divert blood away from the countercurrent heat exchanger and instead use their main
brachial artery and large superficial veins
Slide 33

BT: BACKGROUND
Countercurrent Heat Exchange

Humans don’t need to maintain as big a temperature difference between their extremities and their
core as diving seals do, but we do still have a (slightly simpler) countercurrent heat exchange
mechanism which allows us to maintain a significant temperature difference between our core and our
limbs: our deep veins tend to create a tortuous network of venae comitans – deep veins which form a
network right next to main arteries to allow heat exchange between arterial blood entering the limb
and venous blood returning to the core.

When humans get cold we can divert blood to these deep venae comitans rather than more
superficial veins to reduce heat loss from the limbs, we also tend to reduce blood supply to the limbs
to reduce the amount of heat we can lose still further.

The reason I am telling you all this is just to make you aware that when we measure BT it really
matters where we measure it – because the body is good at maintaining a temperature difference
between the core and the extremities. In hospitals we are usually interested in the core temperature –
the temperature of the vital organs – so when we measure temperature we have to measure it in an
area which doesn’t receive its blood supply via a countercurrent heat exchanger.
Slide 39

BT: MEASUREMENT SITES

Site Comments
Tends to be ~1 C lower than core body temperature. Gives inaccurate readings if the arm is not
Armpit
held tightly to the body or if the thermometer is not in place long enough (~30 seconds).
Mouth (under
Tends to be ~1 C lower than code body temperature.
the tongue)
Considered to give the most accurate estimate of core body temperature but poorly tolerated by
Rectum
patients
The tympanic membrane shares its blood supply with the hypothalamus (the area of the brain
Tympanic
responsible for regulating temperature). Accurate measurement of tympanic membrane
membrane
temperature accurately reflects core body temperature however, in practice only IR
(eardrum)
measurements are possible, these are less accurate than contact measurements.
Forehead (over The temporal artery is a superficial artery. IR temperature readings at this site can be reasonably
the temporal accurate, however accuracy requires good technique (the operator must accurately target the
artery) correct site).
Slide 41

BT: MEASUREMENT TECHNOLOGIES

Mercury Thermometer
Operating principle
Thermal expansion of mercury
metal.
Advantages
High accuracy, no calibration
required.
Disadvantages
Mercury toxicity, infection risk

Mercury thermometers are a very accurate way of measuring temperature however they are no longer
used in the NHS for two main reasons:
• Mercury is toxic, its use in medical equipment creates a hazard if the thermometer were to break
• Many patients whose temperature is being monitored have an infection or are at risk of infection so
it is very important that the risk of cross-infection from equipment used to measure temperature is
particularly low; mercury thermometers require direct contact with the patient so do carry a cross-
infection risk.

Mercury thermometers are only suitable for intermittent monitoring.

Slide 42

BT: MEASUREMENT TECHNOLOGIES

Operating principle Electronic Contact Thermometer
Thermistor – temperature
dependent electrical resistance
Thermocouple – thermoelectric
effect
Advantages
Good accuracy, capable of
continuous monitoring
Disadvantages
Require calibration

These devices use a temperature sensitive electrical circuit. They are very widely used in hospitals.
Thermistors are the most common sensors. These sensors are the most accurate technology that is
currently in widespread use in hospitals and are the only sensors in widespread use that are capable
of continuous monitoring, however they are more commonly used for intermittent monitoring.
Slide 43

BT: MEASUREMENT TECHNOLOGIES

Operating principle
Discussed on next slide
Advantages
Can access tympanic
Infrared Thermometer
membrane, quick to use, works
well for paediatric patients
Disadvantages
Accuracy is limited and is
operator dependent

We will discuss the operating principle behind these devices on the next few slides.

Infrared thermometers are mainly used to measure the temperature of the tympanic membrane (the
eardrum), this is a very useful site to measure temperature as it shares a blood supply with the region
of the brain involved in temperature control, so its temperature should accurately reflect core
temperature. More recently it has also been used to take the temperature over the temporal artery
on the forehead.

Infrared thermometry is not considered to be as accurate as other technologies, and temporal artery
measurements in particular can be operator dependent (i.e. poor operator technique can lead to
inaccurate measurements). This technique does have the advantage that it is very quick to use, this is
particularly important for paediatric patients who often find it difficult to stay still for procedures that
take longer than a few seconds.

This technology is currently only used for intermittent monitoring.

Slide 44

BT: BLACK-BODY RADIATION

Black-Body Radiation

To understand infrared thermometry it is first necessary to understand the concept of ‘black-body

radiation’.

All bodies whose temperature is greater than absolute zero radiate electromagnetic radiation whose
spectrum is characteristic of their temperature. Bodies at higher temperature emit higher frequency
radiation. Objects hotter than about 470°C emit visible light – we are familiar with objects which emit
red light when they get hot, like charcoal, electric oven hobs and iron in a blacksmith. Incandescent
light bulb filaments reach a temperature of about 3000°C so emit light which is close to white in
colour. The surface of the sun is approximately 5778°C and emits true white light (i.e. light that
contains all the frequencies of the visible spectrum).

The ‘black-body’ spectrum for a body at a given temperature is determined by Planck’s law.
Slide 45

BT: BLACK BODY SPECTRA

Ultraviolet
Visible

Infrared
Normalised spectral radiance

37°C
Red Hot
The Sun

0 5000 10000 15000 20000

Wavelength (nm)

These are the black-body spectra for the surface of the Sun (5778 C), ‘red hot’ (855 C), and body
temperature (37°C), you can see that the sun emits light at all the frequencies in the visible range.
‘Red hot’ items emit mostly infrared light but do emit a small amount of low frequency visible light,
which makes them appear to glow red to our eyes. Bodies at body temperature emit no light in the
visible range, their emissions are entirely within the infrared range.
Slide 46

BT: INFRARED MEASUREMENT TECHNOLOGIES

Thermopile Pyroelectric Sensor

• Consists of several thermocouple junctions connected

in series
• Temperature difference exists between the surface
exposed to IR light and a surface hidden from this light
– creates a potential difference across thermopile
• Potential difference can be analysed to give
temperature difference between the exposed and
hidden surface
• Thermistor required to give temperature of hidden
surface
• Uses pyroelectric effect – property of some crystals to
produce potential difference when their temperature
changes
• Requires shutter to obscure crystal and then expose it
to IR light
• The potential difference created gives the temperature
change
• Thermistor required to give initial temperature

See Beeta, V., Cascetta, F., Sepe, D., 1997. An assessment of infrared tympanic thermometers for body temperature measurement. Physiological Measurement 18(215)

See Beeta, V., Cascetta, F., Sepe, D., 1997. An assessment of infrared tympanic thermometers for
body temperature measurement. Physiological Measurement 18(215) for more details.
Slide 47

BT: MEASUREMENT TECHNOLOGIES

Operating principle
Temperature dependent
chemical reaction
Advantages
No cross-infection risk Phase-Change Thermometer
Disadvantages
Limited temperature range,
single-use

The final temperature measurement technology is these phase-change thermometers. These devices
can come mounted on sticks to be inserted into the armpit or the mouth to take a temperature then, or
they can come as stickers which can be stuck onto the forehead. Each of the dots contains a mixture
of organic chemicals which changes colour at a specific temperature. The highest temperature is
given by the last dot to have changed colour, this example shows a temperature of 37.0°C.

The big advantage of these thermometers is that they are for single patient use so they eliminate the
risk of cross-infection on temperature monitoring equipment. They are only suitable for intermittent
monitoring.
Slide 48

OXYGEN SATURATION

• Oxygen saturation is the proportion of haemoglobin binding sites

which have a bound oxygen molecule
• Oxygen delivery to the body is given by the equation:

• Cardiac Output (CO) can only be measured with difficulty

• Oxygen saturation alone can give some useful information
• In healthy people oxygen saturation is ≥96% (it can’t be too high in healthy
people)
• Low oxygen saturation may be caused by:
• Hypoventilation – patient not breathing enough
• Shunt – part of the lung not being ventilated
• Diffusion impairment – oxygen in the airways isn’t effectively diffusing into the blood

The final ‘vital sign’ I want to discuss is oxygen saturation. This is not one of the classic ‘vital signs’
but is now at least as widely measure as the original four. This is a good example of a measurement
that is taken because it is easy. Pulse oximetry, the technology usually used to measure oxygen
saturation has been around since the 1980s, and because it is so easy to use, is now used extremely
widely. Before that oxygen saturation could only be measured using an invasive test so was
measured much more rarely.

Oxygen is poorly soluble in water, so, in the blood it is carried bound to a specialised molecule called
haemoglobin. Oxygen saturation is the proportion of haemoglobin oxygen binding sites in a blood
sample which have a bound oxygen molecule. It is usually quoted as a percentage.

Oxygen saturation is an important physiological measurement because it can be used to calculate the
oxygen content in blood, which makes up half of the equation which determines how much oxygen is
delivered to the body. (The arterial O2 content is given by the product of Oxygen Saturation and the
concentration of haemoglobin in the blood.)

As an aside, the other half of this equation, cardiac output (CO), is also a very useful physiological
measurement. It is possible to measure CO but it is a difficult measurement to make which involves
an invasive procedure. For this reason we only measure it in a small group of patients where it is
particularly valuable. If we could measure cardiac output as easily as oxygen saturation then it would
definitely be used for routine monitoring.

Back to oxygen saturation. In healthy people the oxygen saturation of the arterial blood is close to
100%, above 96% is considered normal and (in healthy people) there is no such thing as a an oxygen
saturation which is ‘too high’ (a reading of 100% is fine). Low oxygen saturation is indicative of lung
disease, i.e. it tells us about the health of the respiratory system, not of any other physiological
system (it is like respiratory rate in this respect).
Slide 49

OXYGEN SATURATION: TECHNOLOGIES

Arterial Blood Gas (ABG) Pulse Oximetry

• Gold standard measurement technique • Blood’s optical characteristics change

• Involves taking blood from an artery
• Unpleasant for patients
• Risk of infection / embolism
• Unreliable if blood is exposed to air
• Historically analysis was done in a
laboratory, increasingly now done by a
machine near the point-of-care (a blood
gas analyser)
• Suitable for intermittent monitoring only
• We won’t be discussing this technology
depending on oxygen saturation – pulse
oximetry uses this change
• Quick and easy to use
• Suitable for both intermittent and
continuous monitoring
• Also routinely used to measure heart rate
(HR)

The gold standard method of measuring oxygen saturation is to take an arterial blood gas (ABG). This
involves sticking a needle into one of the patient’s arteries (usually the radial artery of the arm)
extracting some blood and then analysing it. This is an unpleasant procedure for patients (more
unpleasant than taking normal, venous, blood) and does carry some risks, including the risk of
infection or embolism.

ABGs can give very accurate measurements but it is important that the analysis is performed quickly
once the blood has been taken, and that the arterial blood isn’t exposed to ambient air, if it is exposed
to ambient air then it will absorb oxygen and immediately become 100% saturated giving an
inaccurate measurement. Historically the analysis was performed in a lab, now it is increasingly done
using a machine, called a blood gas analyser, in the patient environment, this allows the analysis to
be done more quickly which has a number of advantages including potentially reducing the risk of
exposure to air.

ABGs do give other useful information besides oxygen saturation so are used fairly frequently, but if
only oxygen saturation is required then we wouldn’t usually measure it by this method, instead we use
Pulse Oximetry.

You probably already know that blood changes colour depending on its oxygen saturation – fully
oxygenated blood is bright red in colour (i.e. it does not absorb red light – red light is fully reflected)
and deoxygenated blood is a darker red colour (i.e. it does absorb a bit more red light). It turns out
that blood’s optical characteristics change both for red light and for near infrared light. Pulse oximetry
takes advantage of these optical characteristics to measure oxygen saturation.

The technology relies on the fact that arterial blood flow is pulsatile to function. The fact that it detects
pulsatile blood flow means that pulse oximetry equipment can be used to measure heart rate. It is
now the most common way to measure heart rate in a hospital environment. This technology is widely
used for both intermittent and continuous monitoring.
Slide 50

PULSE OXIMETRY: BEER-LAMBERT LAW

𝐴
Where:
𝐴 = optical attenuation
= optical path length
= absorptivity of the attenuating substance
= concentration of the attenuating substance

Where light passes through a mixture containing multiple attenuating substances:

Pulse oximetry is the most conceptually complicated of the physiological measurements that we have
discussed before. I am now going to briefly go through some of the mathematics behind it.

The key physical principle behind pulse oximetry is the Beer-Lambert law, given here. This law states
that the attenuation of a light signal is proportional to the length of the light path through an
attenuating substance, the absorptivity of the attenuating substance, and the concentration of the
attenuating substance.

If the light passes through a mixture containing different substances then the attenuation is the sum of
the products of the substances’ absorptivities and concentrations, multiplied by the path length.
Slide 51

PULSE OXIMETRY: OPERATING PRINCIPLE

𝐴
Absorption

Arterial blood
Other tissues
Total

Time

Pulse oximetry involves measuring the light absorption for a body part (such as a finger). We can
calculate absorption from the amount of light transmitted through the body part when we place a light
source on one side and a detector on the other.

When the absorption over time is measured for red or infrared light there is a small cyclical change in
total absorption like that shown in the plot. This change is caused by the changing volume of arterial
blood present in the body part with each heart beat. Most of the absorption is by tissues other than
arterial blood but some of the absorption, including the entirety of the cyclical element, is by arterial
blood. The effect of the other tissues can be eliminated by considering only the cyclical element of the
absorption (𝛥𝐴).

I go through how this is used to derive oxygen saturation in the next slides. For further detail see this
paper: Mannheimer, P.D., 2007, The light-tissue interaction of pulse oximetry. Anesthesia and
Analgesia 105(6) doi:10.1213/01.ane.0000269522.84942.54
Slide 52

PULSE OXIMETRY: OPERATING PRINCIPLE

The amount of arterial blood in the body part is equivalent to the

concentration term in the Beer-Lambert law.
Let be the arterial blood ‘concentration’; the Beer-Lambert
law can be rewritten as:
𝐴

PULSE OXIMETRY: OPERATING PRINCIPLE

We assume that the only element in blood that absorbs red and
infrared light is haemoglobin.
Haemoglobin has oxygenated and deoxygenated forms, let
their absorptivites be and respectively.

Let the proportion of oxygenated haemoglobin be , the overall

absorptivity can therefore be rewritten as:

+ 1−

PULSE OXIMETRY: OPERATING PRINCIPLE

Substitute this back into the expression derived earlier:

+ −

• is known (calculated from the amount of light transmitted

through the body part)
• and are known (from lab studies)
• is oxygen saturation, the desired parameter
• and are unknown
Slide 55

PULSE OXIMETRY: OPERATING PRINCIPLE

We can eliminate the unknown terms by measuring the absorption of

two light wavelengths, and , and taking a ratio:
+ −
+ −
and are the same for both wavelengths so are eliminated:
+ −
+ −
The equation can now be solved (numerically) for .

PULSE OXIMETRY: OPERATING PRINCIPLE

In practice light scattering within tissues is wavelength

dependent so the path length ( ) is slightly different for each
wavelength. This is accommodated using an empirical
constant, :
+ −
+ −

The Beer-Lambert law assumes a single straight path from the emitter to the detector. In practice light
is scattered by particles in the body tissues. This means that some of the light that reaches the detector
will not have travelled in a straight line between the emitter and the detector but will have followed a
longer, more tortuous route. The effective path length is therefore longer.

The amount of scattering is not the same for both wavelengths of light. An empirical constant (i.e. a
constant whose value is determined using experiments) is used to account for this effect.
Slide 57

PULSE OXIMETRY: SITES

Finger Ear lobe Nasal Ala Pulse oximetry can be
used as a number of
different body sites but
the empirical constant
is different at different
sites.
It is not uncommon for
clinical staff to use a
finger probe on other
Toe Foot (babies) Finger (exclusive) sites when they can’t get
a finger reading. This
gives unreliable
measurements. With
more recent designs
(bottom right) it is not
possible to attach the
device to the wrong site.

Pulse oximetry can be used in a number of different body sites but the empirical value k that we
discussed on the previous slide is different for different sites (it is also different for patients in different
size ranges – usually quoted as weight ranges by the manufacturer).

It is physically possible to attach the most common finger probe (top left) to a number of different body
sites. In cases when it is not possible to get a reading from the finger (for example when the patient is
in shock, or they are cold, so they have low peripheral blood flow) nurses sometimes use this finger
probe at other body sites. This does give a reading, but not an accurate one. There has recently been
a nation-wide alert about the risk of getting the wrong reading this way.

New designs eliminate this risk (see bottom right) as they cannot be attached to other body sites. It is
very important to consider ‘foreseeable misuse’ at the design stage!

Slide 58

PULSE OXIMETRY: KEY POINTS

• The absorptivity of arterial blood for red and infrared light changes with
oxygen saturation
• The amount of arterial blood in tissues fluctuates with each cardiac cycle
• We can isolate the absorption by arterial blood by considering only the
change in absorption (not the absolute absorption)
• We can derive a relationship between oxygen saturation and light
absorption from the Beer-Lambert law
• The derived equation includes parameters whose values are not known in practice:
• We can eliminate these unknown terms by using two wavelengths of light and
taking a ratio
• In practice an empirical constant is required to accommodate
wavelength dependent light scattering, it’s value varies with body site