Non Invasive Blood Pressure

Alongside heart rate, Blood Pressure is one of the physiological parameters which has been
measured by clinicians for the longest period of time: it was known to be important in the
16th century. It remains one of the most important physiological indicators to date and is also
one of the more awkward parameters to measure. As has been discussed, blood is pumped
round the body by the heart. The blood makes its way around the body through the vascular
system which consists of (broadly) three phases:
1. The high pressure arterial tubes which carry the blood away form the heart. These tubes
are relatively thickwalled and stiff.
2. A microscopic capillary network is which the blood is brought into close proximity with
the cells in organs allowing transfer of oxygen, nutrients, enzymes and so on into the cell
and the removal of waste products and enzymes from the cell. The precise nature of what
is transferred depends on the nature of the cell.
3. The low pressure venous tubes which return the blood to the heart. These tubes are
relatively elastic and thin (but of greater cross sectional area than the arterial tubes).
By this means, blood can be brought to within a cell or two of every cell in the human body
(of which there are about 100000000000000, or 20000 times the world population).
However, not every cell receives blood all the time; the regulation of where the blood goes
at any point in time is a complex subject and beyond the scope of this course but a broad
approximation is that blood goes to where is its most needed mitigated by doing least long
term damage to the body (in terms of future survival4).
Blood pressure is generally quoted as two numbers: the systolic and diastolic arterial blood
pressures. A common misconception is that they are the pressure in the arterial and venous
systems respectively. In fact:
Systolic pressure is the arterial pressure when the heart is beating (ie during the systole5),
it is roughly the highest pressure present in the arterial (and indeed the whole vascular)
system and is a reflection of how hard the heart is pumping.

Diastolic pressure is the arterial pressure when the heart is not beating (ie during the
diastole5) and is roughly the lowest pressure present in the arterial (but not vascular)
system when the heart is resting between beats. It is a reflection of how hard the body (as
represented by the capillary system) is to pump blood into.

Both pressures are measured in millimetres of mercury (mmHg). When blood pressure is
quoted, both values are given in the form "systolic over diastolic": eg 120/70 is a systolic
pressure of 120 mmHg and a diastolic pressure of 70 mmHg. Doctors are interested in both
the absolute values and the difference between the two (known as the pulse pressure) as
these three factors help them diagnose conditions.
Invasive measures apart, a fourth measure of Blood Pressure is used: mean arterial pressure
or MAP. In the case where the systolic and diastolic pressures are known it provides a single
value summary of arterial pressure and is determined by the following formula:
MAP

Diastolic Pressure

Systolic Pressure Diastolic Pressure

3

It is possible to measure MAP noninvasively but clinician prefer to use systolic and
diastolic pressures. We will now consider three methods by which systolic and diastolic
blood pressure can be measured.
4 ie your brain, heart and lungs are much more important than your toes.
5 See the sections on heart function earlier on in these notes; Figure 8 in particular.

Method of Korotkoff
Also known as the ausculatory method, the method of Korotkoff was introduced by the
Russian army physician N. Korotkoff in 1905. Both this method and the next one we will
consider rely on blocking, or occluding, the flow of arterial blood for a short period of time.
To achieve this, compressive pressure is applied to a limb such that the pressure is
transmitted to the underlying blood vessels. Figure 45 shows a symbolic representation of a
limb to which compressive pressure, Pc is applied. This pressure is transmitted through the
flesh to the arteries as shown and the pressure applied to the wall of the artery is also Pc.
This means that the pressure difference between the inside of a blood vessel and the
surrounding tissue, the transmural pressure, is lowered.
Pc
Artery

Pc

Pc

Pa
Pc

Pc

Pc

Limb (bones not shown)

Pc

Pc
Pc

Figure 45: Compressive pressure applied to the outside of a limb is transmitted to the arteries in the limb.

Consequently, when the applied pressure is equal the arterial pressure then there is no radial
stress in the arterial wall. It is assumed that there is also no hoop stress in the wall at this
point and the vessel is said to be unloaded and any method which achieves this is said to
achieve vascular unloading. If the applied pressure is further increased such that Pc > Pa, the
vessel will collapse and flow will be completely occluded.
Occlusive cuffs
Vascular Unloading is achieved using an occlusive cuff, a flat bladder which can be wrapped
around the arm and inflated, thereby applying the internal pressure of the air in the bladder
uniformly around the limb as in Figure 45 in which we can now take Pc to refer to the cuff
pressure.
So, if Pc is greater than the pressure in an artery then blood flow will be blocked beyond the
point of occlusion. In medical terminology, if something is further away from the heart than
a reference point, it is said to be distal to that reference point and so we can say that flow is
stopped distal to an occluding cuff. (The opposite of distal is proximal.)
Korotkoff sounds
What Korotkoff discovered was that if a limb in partially occluded, a cardiac synchronous
sound is still present in the limb distal to the occlusion (ie further away from the heart than
the occlusion). These sounds are known as the Korotkoff sounds and are what clinicians
listen for using a stethoscope when they take Blood Pressure measurements They are only

present when the artery is partially occluded, if the blood vessel is fully occluded or not
occluded at all then they are not present.
To take a Blood Pressure reading, the clinician inflates the cuff to a sufficient pressure to
completely occlude the artery. The pressure is then reduced slowly (about 23 mmHg a
second) and 4 (or 5) different phases of Korotkoff sounds are by the clinician over
sequential pressure ranges:
I

Initial "tapping" sounds.

II

The tapping sounds increase in intensity are less precise in time.

III The loudest phase, more akin to a thump than a tap.

IV A much more muffled sound.
V Silence no Korotkoff sounds
It is important for us, as engineers, to note that these are very empirical descriptions and
although the vast majority of clinicians use them to take very accurate Blood Pressure
measurements they describe the phenomenon in an imprecise manner. Searching the
literature will reveal a wide variety of slightly varying descriptions, particularly in relation to
the "murmurs" which can also be present.
However, the systolic and diastolic pressures are relatively well defined by this method: they
are the pressures at which the Korotkoff sounds start and the Phase IV sounds (ie when the
sounds become muffled) respectively. Figure 46 presents a summary of Korotkoff sounds.

Figure 46: A summary of the five Korotkoff sounds for a healthy patient. Source: Guydon

Traditionally, it has been assumed that Korotkoff sounds are caused by turbulence in the
artery when the blood is being pumped through an occluded section and many current text
books use this explanation. However, there are good arguments that this is not the case (for
example, the fact that they still occur when the artery is only marginally occluded near
diastolic pressure). The precise cause of Korotkoff sounds is a research area, but a recent
plausible suggestion is that they are caused by phase distortion of the pulse resulting from
complex pressure/cross sectional area interactions.

Automating the Method of Korotkoff

Figure 47 gives an overview of a system for automating the measuring of Blood Pressure
using the method of Korotkoff. A control systems receives a request for a reading to be
taken and it then follows a three phase process:
1. The cuff is inflated to slightly (2030 mmHg) above the systolic pressure. If a reading
has already been taken, the previous value can be used to determine the initial cuff
inflation pressure.
2. The cuff is deflated slowly (23 mmHg per second) and the audio signal from the
microphone is analysed to determine what phase of Korotkoff sounds are being observed.
The system makes a note of the pressure at which sounds start (the systolic pressure) and
the pressure at which phase IV sounds are present (the diastolic pressure).
3. Once Phase IV has been identified, both the systolic and diastolic pressures will have
been determined. The cuff is the deflated rapidly and the determined pressures are
reported.
Inflate
Deflate slowly

request for
reading

Cuff
Control

Deflate fast

Control
System

Cuff

Pressure
microphone

Korotkoff
Sounds
Detector

reading

Korotkoff
Phase
Figure 47: An overview of a system for automated Blood Pressure readings using the method of Korotkoff.
Note that thick lines represent piping.

The automated analysis of Korotkoff sounds is in fact a very complex task. First, it is
necessary to separate the Korotkoff sounds from the background noise (including the noise
of the heart beating). Second, assessing which phase a particular sound implies is a complex
signal processing task which requires a complex combination of hardware and software
processing and, probably, the implementation of either a nonlinear pattern matching system
of the use of rule based systems. These are beyond the scope of this course. However, it is
worth considering the cuff control system in more detail.
Cuff control
Figure 48 shows a cuff control system. The cuff is inflated (ie pressurised) by using a pump
to blow air into it and so when cuff inflation is requested the pump is turned on and that
valve is opened. When the cuff is sufficiently inflated, the control signal will be changed to
"defalte slowly" and the valve between the pump and the motor will be shut to present
unwanted air leakage. The second valve will be opened which allows a controlled slow
leakage of air from the cuff.
Finally, once the readings have been made, the cuff can be emptied of air and the final valve
is opened to achieve this.

Pump

Valve
1

Cuff

Inflate
Valve
2

Deflate slowly
Deflate fast
Pressure

Valve
3

Pressure
Sensor

Figure 48: A control system for an occlusive cuff. Note that the safety cutout devices which would be
present in a real system are not present. Thick lines represent tubing; the valves are "openshut" rather
than selecting one of two possible flow paths.

Safety aspects of cuffs

It is important that cuffs are not inflated to too high a pressure, or even held at moderately
high pressure for too long. There are two reasons for this: first, given that the purpose of the
pressure is to occlude blood flow down the limb it is necessary to ensure that the occlusion
does not occur for enough time to cause significant oxygen depletion for too long in the
occluded sections of the limb.

Figure 49: Bruising on an arm caused by a single use of an overzealous oscillometric Blood Pressure
device.

Secondly, in many people overaggressive measurement of Blood Pressure can result in

bruising of the arm as shown in Figure 49. Whilst this may seem a minor side effect, if
Blood Pressure readings are being taken every hour, the cumulative effects are quite painful
for the patient.

Therefore, it is necessary for the control system to stop the blood pressure reading if the
pressure is too high for too long.