Principles and Techniques of Blood Pressure Measurement

Introduction
Blood pressure assessment is an integral part of clinical practice. Routinely, a
patients blood pressure is obtained at every physical examination, including outpatient
visits, at least daily when patients are hospitalized before and during most medical
procedures. Blood pressure, sometimes referred as arterial blood pressure, is the
pressure exerted by circulating blood upon the walls of blood vessels, and is one of the
principal vital signs. During each heartbeat, blood pressure varies between a maximum
systolic and a minimum diastolic pressure. The blood pressure in the circulation is
principally due to the pumping action of the heart. Blood pressure is recorded as two
numbers, such as 120/80. The larger number indicates the pressure in the arteries as
the heart pumps out blood during each beat. This is called the systolic blood pressure.
The lower number indicates the pressure as the heart relaxes before the next beat. This
is called the diastolic blood pressure.

Blood Pressure Measurement

Two methods for measuring a blood pressure exist, the direct ( invasive ) and
indirect (noninvasive) method. The direct method is the criterion standard and consists
of using an intra-arterial catheter to obtain a measurement. This method, however, is
not practical due to its invasiveness and its inability to be applied to large groups of
asymptomatic individuals for hypertension screening.
Therefore, the indirect (noninvasive) method is typically used. The indirect method
involves collapsing the artery with an external cuff, providing an inexpensive and easily
reproducible way to measure blood pressure. The indirect method can be performed
using a manual cuff and sphygmomanometer or with an automated oscillometric device.
The manual method requires auscultation of the blood pressure, whereas the
automated system depends on oscillometric devices. Usually the auscultatoric
measurement is preferred by doctors, the oscillometric method is mainly used in home
blood pressure measurement devices.
1

Auscultatoric Measurement Devices

Auscultatoric measurement devices determine blood pressure by using the

sphygmomanometer . A sphygmomanometer, an instrument that measures pressure,
is needed in both methods. Each sphygmomanometer consists of a cuff (containing a
"bladder") which is connected by lengths of tubing to an inflating bulb with a needle
valve and to an aneroid pressure gauge as showed in figure 1.

Figure 1: Sphygmomanometer with aneroid pressure gauge

1.1 Positioning of The Cuff

The center of the sphygmomanometer bladder should be placed over the brachial
artery. Many cuffs have some sort of marking scheme so that placement over the
brachial artery is under, or just medial to the biceps tendon is facilitated[2]. The lower
border of the cuff should be about 2cm proximal to the antecubital fossa and the cuff
should be firmly wrapped around the arm. Figure 2 show the position of checking the
brachial artery.

Figure 2: Checking the position of brachial artery

The subject will be asked to relax and sits on a chair with the lower arm supported
as in Figure 3. The blood pressure cuff is placed on the subject's right arm, allowing 1
inch between the bottom of the cuff and the crease of the elbow as show in figure 3.
The brachial pulse is palpated just above the angle of the elbow (the "antecubital
fossa").

Figure 3: The blood pressure cuff is placed on the subjects right arm

Figure 4 show the diaphragm is placed over the brachial artery in the space between
the bottom of the cuff and the crease of the elbow. At this point no sounds should be
heard. The cuff pressure is inflated quickly to a pressure about 30 mm Hg higher than
the systolic pressure determined by the method of palpation[3]. Then the air is let out of
the cuff at a rate such that cuff pressure falls at a rate of about 5 mm Hg/sec.

Figure 4: The diaphragm is placed over the brachial artery in the space between the bottom of the
cuff and the crease of the elbow

At some point the person listening with the stethoscope will begin to hear sounds with
each heartbeat. Then the pressure in the cuff is slowly released. When blood starts to
flow in to the artery, the turbulent flow creates a pulse synchronic pounding (first
Korotkoff sound). Korotkoff sound is the arterial sounds heard through a stethoscope
applied to the brachial artery distal to the cuff of a sphygmomanometer that change with
varying cuff pressure and that are used to determine systolic and diastolic blood
pressure. The pressure at which this sound is first detected is the systolic blood
pressure. The cuff pressure is further released until no more sound can be detected at
the diastolic arterial pressure. The laminar flow that normally occurs in arteries produces
little vibration of the arterial wall and therefore no sounds. However, when an artery is
partially constricted, blood flow becomes turbulent, causing the artery to vibrate and
produce sounds. The figure 5 show between two different blood flow : laminar flow and
turbulent flow,

Figure 5:Laminar flow and turbulent flow

When measuring blood pressure using the auscultation method, turbulent blood flow will
occur when the cuff pressure is greater than the diastolic pressure and less than the
systolic pressure. The "tapping" sounds associated with the turbulent flow are known
as Korotkoff sounds. These sounds are not same with the heart sounds produced by
the opening and closing of the heart valves.

Oscillometric Measurement Devices

Blood pressure monitor operation is based on the oscillometric method. This
method takes advantage of the pressure pulsations taken during measurements.
Oscillometric measurement devices use an electronic pressure sensor with a numerical
read out of blood pressure[3]. In most cases the cuff is inflated and released by an
electrically operated pump and valve, which may be fitted on the wrist (elevated to heart
height), although the upper arm is preferred. Initially the cuff is inflated to a pressure in
excess of the systolic arterial pressure, and then the pressure reduces to below diastolic
pressure. Once the blood flow is present, but restricted, the cuff pressure will vary
periodically in synchrony with the cyclic expansion and contraction of the brachial artery.
The values of systolic and diastolic pressure are computed from the raw data, using an
algorithm.

Conclusion
Initially the cuff is inflated to a level higher than the systolic pressure. Thus
the artery is completely compressed, there is no blood flow, and no sounds are heard.
The cuff pressure is slowly decreased. At the point where the systolic pressure
exceeds the cuff pressure, the Korotkoff sounds are first heard and blood passes in
turbulent flow through the partially constricted artery. Korotkoff sounds will continue to
be heard as the cuff pressure is further lowered. However, when the cuff pressure
reaches diastolic pressure, the sounds disappear. Now at all points in time during the

cardiac cycle, the blood pressure is greater than the cuff pressure, and the artery
remains open.

Prepared by,
Wee Soo Lee
CMET
Date: 23 October 2013

REFERENCE
[1]Caro, Colin G. (1978). The Mechanics of The Circulation. Oxford [Oxfordshire]:
Oxford University Press. ISBN 0-19-263323-6.
[2]Jump up ^ Klabunde, Richard (2005). Cardiovascular Physiology Concepts.
Lippincott Williams & Wilkins. pp. 934. ISBN 978-0-7817-5030-1.
[3]Jump up to: a b "Understanding blood pressure readings". American Heart
Association. 11 January 2011. Retrieved 30 March 2011.