Blood Pressure and Flow

Measurements

S-108.4010
Licentiate Course in Measurement
Science and Technology
 Contents
Blood Pressure Blood Flow

Palpatory Method Ultrasound Doppler

Non-Invasive

(Riva-Rocci Method) Laser Doppler Flowmetry

Auscultatory Method
Strain Gage Plethysmography
Ultrasonic Method
Electric-Impedance Plethysmogr.
Oscillometric Method
Photoelectric Plethysmography
Tonometry
Thermal Convection Probes

Extravascular
Dye Dilution Method
Sensor
Invasive

Intravascular Sensor Thermal Dilution Method

General on Radioisotopes
System Parameters
 Blood Pressure (1)
One of the oldest physiological measurements
Observation of blood pressure allows dynamic tracking of pathology and
physiology affecting to the cardiovascular system, which has profound
effects to all other organs of the body

Originates from the heart

Commonly refers to arterial blood pressure

Value depends on 3 factors:

cardiac output
diameter of arteries peripheral
the quantity of blood resistance

Values should be lower than 120 / 80 mmHg

(systolic pressure (SP) / diastolic pressure (DP))
 Blood Pressure (2)
High value increases the risk of heart attack and strokes
Low value increases the risk of lower oxygen perfusion e.g. in brains

However, the ’normal values’ differ from person to another

Pulse pressure (PP) = SP-DP

Mean pressure (MP)

average pressure during one cardiac cycle
driving force of the peripheral perfusion.
an estimate can be done by using an empirical formula:

MP = DP+PP/3

SP and DP may vary significantly throughout the arterial system but

MP is quite uniform (in normal situations)
Blood Pressure (3)
 Indirect Methods
in
Blood Pressure Measurements
 General Facts
Indirect measurement = non-invasive measurement

Brachial artery is the most common measurement site

Close to heart
Convenient measurement

Other sites are e.g.:

forearm / radial artery
wrist (tends to give much higher SP)

The most common indirect methods are auscultation

and oscillometry
 General Facts (cont.)
An occlusive cuff is placed on arm and inflated to P cuff > SP.
Then the cuff is deflated gradually and the measurement of
blood flow is done

The occlusive cuff should be of a correct size in order to

transmit the pressure to the artery evenly and thus to obtain
accurate results

A short cuff requires special attention in placement. Longer

cuff reduces this problem.

The cuff should be placed at the heart level in order to

minimize the hydrostatic effects
 Palpatory Method (Riva-Rocci Method)
When the cuff is deflated, there is a palpable
pulse in the wrist. Pcuff = BP

Several measurements should be done as the

respiration and vasomotor waves modulate the
blood pressure levels

ADVANTAGES
+) The blood pressure can be measured in noisy environment too
+) Technique does not require much equipment

DISADVANTAGES
-) Only the systolic pressure can be measured (not DP)
-) The technique does not give accurate results for infants and
hypotensive patients
 Auscultatory Method

Pulse waves that propagate

through the brachial artery,
generate Korotkoff sounds.

There are 5 distinct phases in the

Korotkoff sounds, which define SP
and DP

The Korotkoff sounds are

ausculted with a stethoscope or
microphone (automatic measurement)

The frequency range is 20-300 Hz

and the accuracy is +/- 2mmHg (SP)
Also with this method, several measurements and +/- 4mmHg (DP)
should be done.
Auscultatory Method (cont.)
ADVANTAGES
+) Auscultatory technique is simple and does not require much
equipment

DISADVANTAGES
-) Auscultatory tecnique cannot be used in noisy environment
-) The observations differ from observer to another
-) A mechanical error might be introduced into the system e.g. mercury
leakage, air leakage, obstruction in the cuff etc.
-) The observations do not always correspond with intra-arterial pressure

-) The technique does not give accurate results for infants and
hypotensive patients
 Ultrasonic Method
A transcutaneous (through the skin)
Doppler sensor is applied here.

The motion of blood-vessel walls

in various states of occlusion is
measured.

The vessel opens and closes with

each heartbeat when
DP < Pcuff < SP

The frequency difference between

transmitted (8 MHz) and received
signal is 40-500 Hz and it is
proportional to velocities of the wall motion and the blood.
 Ultrasonic Method (cont.)

As the cuff pressure is increased, the time between opening and closing
decreases until they coincide Systolic pressure

Again as the cuff pressure is decreased, the time between opening and
closing increases until they coincide Diastolic pressure

ADVANTAGES & DISADVANTAGES

+) Can be also used in noisy environment
+) Can be used with infants and hypotensive individuals
-) Subject’s movements change the path from sensor to vessel
 Oscillometric Method

The intra-arterial pulsation is

transmitted via cuff to transducer
(e.g. piezo-electric)
The cuff pressure is deflated
either linearly or stepwise

The arterial pressure oscillations

(which can be detected throughout the
measurement i.e. when Pcuff > SP and
Pcuff< DP) are superimposed on the
cuff pressure

http://colin-europe.com/docpdfdemos/oscillo0104.wmv

SP and DP are estimated from the amplitudes of the oscillation by using a

(proprietary) empirical algorithm.
Oscillometric Method (cont.)
ADVANTAGES
+) In the recent years,
oscillometric methods have
become popular for their
simplicity of use and
reliability.
+) MP can be measured
reliably even in the case of
hypotension

DISADVANTAGE
-) Many devices use fixed
algorithms leading to
large variance in blood
pressures
 Tonometry
Linear array of pressure sensors is pressed
against a superficial artery, which is
supported from below by a bone (radial artery).

A sensor array is used here, because at

least one of the pressure sensors must lay
directly above the artery

When the blood vessel is partly collapsed,

the surrounding pressure equals the artery
pressure.

The pressure is increased continuously and

the measurements are made when the
artery is half collapsed

The hold-down pressure varies between

individuals and therefore a ’calibration’ must
be done
 Tonometry (cont.)
ADVANTAGES

+) Can be used for non-invasive, non-painful, continuous measurement

DISADVANTAGES
-) Relatively high cost
-) The wrist movement and tendons result
in measurement inaccuracies
 Direct Methods
in
Blood Pressure Measurements
 General Facts
Direct measurement = Invasive measurement

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

The most common sites are brachial and radial arteries

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

A division is made into extravascular and

intravascular sensor systems

This method is precise but it

is also a complex procedure
involving many risks….

Used only when essential to determine the blood pressure continuously

and accurately in dynamic circumstances
 Extravascular Sensor
The ’normal’ measuring system

The sensor is located behind the

catheter and the vascular pressure
is transmitted via this liquid-filled
catheter.

The actual pressure sensor can be

e.g. strain gage
variable inductance
variable capacitance
optoelectronic
piezoelectric, etc…
 Extravascular Sensor (cont.)
The hydraylic link is the major source of errors. The system’s natural
frequency may be damped and degraded due (e.g.):
.
too narrow catheter
too long tubing
various narrow connections
air bubbles in the catheter

The catheter-sensor system must be

flushed with saline-heparine solution
every few minutes in order to prevent
blood from clotting at the tip.
 Extravascular Sensor (cont.)

Normally the interesting frequency range is 0 – 100 Hz.

If only MP is measured the bandwidth is 20 Hz (harmonics > 10 are ignored)
 Intravascular Sensor
The sensor is located in the tip of the catheter. This way the hydraulic
connection is replaced with an electrical or optical connection

The dispacement of the diaphragm is

measured

+) The frequency response is not

limited by the hydraulic properties of
the system. No time delay.
+) Electrical safety and isolation when
using fiber optics

-) Breaks easily
-) More expensive
 Disposable Sensors
Disposable sensors decrease the risk of patient cross-contamination and
reduce the amount of handling by hospital personnel

Cheaper and more reliable than reusable pressure sensors

General on System Parameters

Even minute air bubbles in catheter have a dramatic effect on frequency
response
The natural frequency and the length of the catheter BETTER
have a following relationship: f  1 Teflon
n
L
Polyethylene
The catheter diameter has a linear relationship
to natural frequency Silicon rubber
WORSE
Stiffer catheters have a higher frequency response
 Indirect Methods
in
Blood Flow Measurements
Blood Flow
O2 and other nutrition concentration in the cells are
one of the primary measurements.

Blood flow helps to understand basic physiological

processes and e.g. the dissolution of a medicine into
the body.

It also helps to understand many pathological conditions,

since many diseases alter the blood flow. Also the blood
clots in the arterial system can be detected.

Usually the blood flow measurements are more

invasive than blood pressure measurements / ECG
 Blood Flow (2)

Normal blood flow velocity 0,5 m/s – 1 m/s (Systolic, large vessel)
 Doppler Measurements (1)
Ultrasound Doppler
The blood cells in the fluid scatter
the Doppler signal diffusively.

In the recent years ultrasound

contrast agents have been used in
order to increase the echoes.

The ultrasound beam is focused by

v a suitable transducer geometry and
fd  2 fc
c a lens

f c = 2 – 10 MHz
f d = 1,3 – 13 kHz
c = 1500 - 1600 m/s (1540 m/s)
 Doppler Measurements (2)
Ultrasound Doppler

In order to know where along the beam The flow velocity is obtained from
the blood flow data is colledted, a pulsed the spectral estimation of the
Doppler must be used received Doppler signal
 Doppler Measurements (3)
Ultrasound Doppler
The ultrasound Doppler device can be either a continuous wave or a pulsed
Doppler

CW DOPPLER PULSED DOPPLER

No minimum range Accuracy

Simpler hardware No minimum flow

Range ambiguity Minimum range

Low flow cannot be (Maximum flow) x (range)

detected = limited
 Doppler Measurements (4)
Ultrasound Doppler
GENERAL PARAMETERS

the power decays exponentially because of the heating of the tissue.

The absorption coefficient ~ proportional to frequency

the far field operation should be avoided due to beam divergence.

D2
d nf  D = Transducer diameter (e.g. 1 – 5 mm)
4

4
the backscattered power is proportional to f

the resolution and SNR are related to the pulse duration. Improving either
one of the parameters always affects inversely to the other
 Doppler Measurements (5)
Laser Doppler Flowmetry
The principle of measurement is the
same as with ultrasound Doppler

The laser parameter may have e.g.

the following properties:

5 mW
He-Ne-laser
632,8 nm wavelength

The moving red blood cells cause

Doppler frequency 30 – 12 000 Hz.

The method is used for capillary

(microvascular) blood flow
measurements
 Direct Methods
in
Blood Flow Measurements
 Indicator Dilution Methods (1)
Dye Dilution Method
A bolus of indicator, a colored dye (indocyanine green), is rapidly injected in
to the vessel. The concentration is measured in the downstream

The blood is drawn through a colorimetric cuvette

and the concentration is measured using the
principle of absorption photometry

amount of
dye

m
F
Avg. 1% peak C

 C t dt
flow t1

0
 Indicator Dilution Methods (2)
Thermal Dilution Method
A bolus of chilled saline solution is
injected into the blood circulation system
(right atrium). This causes decrease in the
pulmonary artery temperature.

heat content
of injectate
Q
F
 b cb  Tb t  dt
t1

density of blood specific heat of blood

(e.g. 1060 kg/m3) (e.g. 3640 J/(kg*K)

An artery puncture is not needed in this technique

Several measurements can be done in relatively short time

A standard technique for measuring cardiac output in critically ill patients

 Plethysmography
in
Blood Flow Measurements
 Plethysmography (1)
Strain Gage Method
Plethysmography means the methods for recording volume changes of an
organ or a body part (e.g. a leg)

Strain gage is made of silicone rubber

tubes, which are filled with conductive
liquid (e.g. mercury) whose impedance
changes with volume.

Venous occlusion cuff is inflated to 40

– 50 mmHg. In this way there will be
the arterial inflow into the limb but no
venous outflow.

If only a segment of limb is measured, there is a need for arterial occlusion

cuff also.
 Plethysmography (2)
Chamber Method
As the volume of the leg increases, the leg
squeezes some kind of bladder and decreases
its volume
Volume transducer can be e.g. water filled tube
(level) or air (pressure)

The speed of the return of the

venous blood is measured

Chamber plethysmograph is the only accurate non-invasive way to

measure changes in the blood volume
 Plethysmography (3)
Electric-Impedance Method
Different tissues in a body have a different resistivity. Blood is one of the best
conductors in a body (  = 1,5 Ωm)

A constant current is applied via skin

electrodes
I = 0,5 – 4 mA rms (SNR)
f = 50 – 100 kHz
(Zskin-electrode+shock)

The change in the impedance is

measured

L2
Vol  2 Z
Z0

The accuracy is often poor or unknown

 Plethysmography (4)
Photoelectric Method
A beam of IR-light is directed to the
part of the tissue which is to be
measured for blood flow (e.g. a finger
or ear lobe)

The blood flow modulates the attenuated

/ reflected light which is recorded.

The light that is transmitted / reflected is

collected with a photodetector

Method is simple Poor measure for changes in volume

Heart rate is clearly seen Very sensitive to motion artefacts
 Other Methods
in
Blood Flow Measurements
 Radioisotopes
A rapidly diffusing, inert radioisotope of lipid-soluble gas (133Xe or 85 Kr) is
injected into the tissue or passively diffused

The elimination of the radioisotope from microcirculatory bed is related to

the blood flow:
C (t )  C0 exp  kt
k  ln 2 / t1 / 2
 Thermal Convection Probe
This is one of the earliest techniques for blood flow measurements
The rate of heat removal from the tissue under probe is measured

The concentric rings are

isolated thermally & electrically
from each other

The central disk is heated

1 – 2 o C over the temperature
of tissue

A temperature difference of
2- 3 oC is established between
the disks

The method is not very common due extreme nonlinear properties and difficulties
in practical use (e.g. variable thermal characteristics of skin)
 Summary (1)
BLOOD PRESSURE

Describes the physiology and pathology of cardiocvascular system

”Normal” values are 120 / 80 mmHg
High values may lead to heart attack and strokes
Low values may lead to low oxygen perfusion

Almost all indirect methods rely on an occlusive

cuff which is placed on the bracial artery. The actual
measurement is done when the cuff is deflated

All direct methods require skin punctuation and a use

of catheter. Methods are used only when continuous and
accurate measurements are needed.
 Summary (2)
BLOOD FLOW
Usually more invasive methods are used than with blood
pressure measurements
Used for understanding physiological processes (e.g. medicine
dissolution). Also used for locating clots in arteries

Normal velocity is 0,5 - 1 m/s

Indirect measurements are done by using ultrasound or

plethysmographic method

Direct measurements are done by dilution methods (dye / thermal)