1|Page

6.3. MEASUREMENT OF BLOOD FLOW AND CARDIAC OUTPUT

An adequate blood supply is necessary for all organs of the body; in fact, an impaired supply of
blood is the cause of various diseases. The ability to measure blood flow in the vessel that supplies
a particular organ would therefore be of great help in diagnosing such diseases. Unfortunately,
blood flow is a rather elusive variable that cannot be measured easily.
The rate of flow of a liquid or gas in a pipe is expressed as the volume of the substance that passes
through the pipe in a given unit of time. Flow rates are therefore usually expressed in liters per
minute or milliliters per minute (cmVmin).
Methods used in industry for flow measurements of other Hquids, like the turbine flowmeter and
the rotameter, are not very suitable for the measurement of blood flow because they require cutting
the blood vessel. These methods also expose the blood to sharp edges, which are conducive to
blood-clot formation.Practically all blood flow meters currently used in clinical and research
applications are based on one of the following physical principles:
1. Electromagnetic induction.
2. Ultrasound transmission or reflection.
3. Thermal convection.
4. Radiographic principles.
5. Indicator (dye or thermal) dilution.
Magnetic and ultrasonic blood flow meters actually measure the velocity of the bloodstream.
Because these techniques require that a transducer surround an excised blood vessel, they are
mainly used during surgery. Ultrasound, however, can be used transcutaneously to detect
obstructions of blood vessels where quantitative blood flow measurements are not required.
A plethysmography which actually indicates volume changes in body segments, can be used to
measure the flow of blood in the limbs.
6.3.1. Magnetic Blood Flow Meters.
Magnetic blood flow meters are based on the principle of magnetic induction. When an electrical
conductor is moved through a magnetic field, a voltage is induced in the conductor proportional
to the velocity of its motion. The same principle applies when the moving conductor is not a wire,
but rather a column of conductive fluid that flows through a tube located in the magnetic field.
Figure 6.29 shows how this principle is used in magnetic blood flow meters. A permanent magnet
or electromagnet positioned around the blood vessel generates a magnetic field perpendicular to
the direction of the blood flow. The voltage induced in the moving blood column is measured with
stationary electrodes located on opposite sides of the blood vessel and perpendicular to the
direction of the magnetic field.

Figure 6.29. Magnetic blood flow meter, principle.

The most commonly used types of implantable magnetic blood flow probes are shown in Figures
6.30 through 6.32. The slip-on or C type is applied by squeezing an excised blood vessel together
and slipping it through the slot of the probe. In some transducer models the slot is then closed by
inserting a keystone-shaped segment of plastic, as shown. Contact is provided
by two slightly protruding platinum disks that touch the wall of the blood vessel. For proper
operation, the orifice of the probe must fit tightly around the vessel. For this reason, probes of this
type are manufactured in sets, with diameters increasing in steps of 0.5 or 1 mm from about 2 to
20 mm. The probes shown in Figure 6.30 can be implanted for chronic use. In contrast. Figure
6.31 shows a model with a long handle for use during surgery.
2|Page

Figure 6.30. Samples of large and small lumen diameter blood flow probes.
Figure 6.31. Blood flow probe—clip-on type for use during surgery.
Figure 6.32. Extracorporeal blood flow probe.

In the cannula-type transducer^ the blood flows through a plastic cannula around which the magnet
is arranged. The contacts penetrate the walls of the cannula. This type of transducer requires that
the blood vessel be cut and its ends slipped over the cannula and secured with a suture. A similar
type of transducer (Figure 6.32) is also used to measure the blood flow in extracorporeal devices,
such as dialyzers. Magnetic blood flow meters actually measure the mean blood velocity. Because
the cross-sectional area at the place of velocity measurement is well defined with either type of
transducer, these transducers can be calibrated directly in units of flow.

Magnetic blood flow transducers are also manufactured as cathetertip transducers. For this type,
the normal transducer design is essentially turned **inside out,'' with the electromagnet being
located inside the catheter, which has the electrodes at the outside. Catheter transducers cannot be
calibrated in flow units, however, because the cross section of the blood vessel at the place of
measurement is not defined.
The output voltage of a magnetic blood flow transducer is very small, typically in the order of a
few microvolts. In early blood flow meters, a constant magnetic field was used, which caused
difficulties with electrode polarization and amplifier drift. To overcome these problems, all
contemporary magnetic blood flow meters use electromagnets that are driven by alternating
currents. Doing this, however, creates another problem: the change of the magnetic field causes
the transducer to act like a transformer and induces error voltages that often exceed the signal
levels by several orders of magnitude. Thus, for recovering the signal in the presence of the
error voltage, amplifiers with large dynamic range and phase-sensitive or gated detectors have to
be used. To minimize the problem, several different waveforms have been advocated for the
magnet current, as shown in Figure 6.33. With a sinusoidal magnet current, the induced voltage is
also sinusoidal but is 90° out of phase with the flow signal.

Figure 6.33. Waveforms used in magnectic blood flow meters and error signals induced by the
current: (a) sine wave; (b) square wave; (c) trapezoidal wave.

With a suitable circuit, similar to a bridge, the induced voltage can be partially balanced out.
With the magnet current in the form of a square wave, the induced voltage should be zero once
the spikes from the polarity reversal have passed. In practice, however, these spikes are often of
extremely high amplitude, and the circuitry response tends to extend their effect. A compromise
is the use of a magnet current having a trapezoidal waveform. None of the three
waveforms used seems to have demonstrated a definite superiority.
3|Page

The block diagram of a magnetic blood flow meter is shown in Figure 6.34. The oscillator, which
drives the magnet and provides a control signal for the gate, operates at a frequency of between
60 and 400 Hz. The use of a gated detector makes the polarity of the output signal reverse when
the flow direction reverses. The frequency response of this type of system is usually high enough
to allow the recording of the flow pulses, while the mean or average flow can be derived by use
of a low-pass filter. Figure 6.35 shows a single-channel magnetic blood flow meter that can be
used with a variety of different transducers.

Figure 6.35. Magnetic blood flow meter.

6.3.2. Ultrasonic Blood Flow Meters.
In an ultrasonic blood flow meter, a beam of ultrasonic energy is used to measure the velocity of
flowing blood. This can be done in two different ways. In the transit time ultrasonic flow meter, a
pulsed beam is directed through a blood vessel at a shallow angle and its transit time is then
measured. When the blood flows in the direction of the energy transmission, the transit time is
shortened. If it flows in the opposite direction, the transit time is lengthened.

Figure 6.36. Ultrasonic blood flow meter, Doppler type.

More common are ultrasonic flow meters based on the Doppler principle (Figure 6.36). An
oscillator, operating at a frequency of several megahertz, excites a piezoelectric transducer
(usually made of barium titanate). This transducer is coupled to the wall of an exposed blood
vessel and sends an ultrasonic beam with a frequency F into the flowing blood. A small part of the
transmitted energy is scattered back and is received by a second transducer arranged opposite the
first one. Because the scattering occurs mainly as a result of the moving blood cells, the reflected
signal has a different frequency due to the Doppler effect. Its frequency is either F + F^) or F - Fp,
depending on the direction of the flow. The Doppler component Fjj is directly proportional to the
velocity of the flowing blood. A fraction of the transmitted ultrasonic energy, however, reaches
the second transducer directly, with the frequency being unchanged. After amplification of the
composite signal, the Doppler frequency can be obtained at the output of a detector as the
difference between the direct and the scattered signal components. With blood velocities in the
range normally encountered, the Doppler signal is typically in the low audio frequency range.
4|Page

Because of the velocity profile of the flowing blood, the Doppler signal is not a pure sine wave,
but has more the form of narrow-band noise. Therefore, from a loudspeaker or earphone, the
Doppler signal of the pulsating blood flow can be heard as a characteristic *' swish—swish—."

Figure 6.37. Percutaneous Doppler device with probe and earphones.

When the transducers are placed in a suitable mount (which defines the area of the blood vessel),
a frequency meter used to measure the Doppler frequency can be calibrated directly in
flow-rate units. Unfortunately, Doppler flow meters of this simple design cannot discriminate the
direction of flow. More complicated circuits, however, which use the insertion of two quadrature
components of the carrier, are capable of indicating the direction of flow.
Transducers for ultrasonic flow meters can be implanted for chronic use. Some commercially
available flow meters of this type incorporate a telemetry system to measure the blood flow in
unrestrained animals. Figure 6.37 is an illustration of a simple Doppler device, with the two
transducers mounted in a hand-held probe which is now widely used to trace blood vessels close
to the surface and to determine the location of vascular obstructions. In order to facilitate
transmission of ultrasonic energy, the probe must be coupled to the skin with an aqueous jelly.
Such devices can be used to detect the motion of internal structures in the body—for example, the
fetal heart. (See Chapter 9 for further discussion of ultrasonic diagnosis.)

6.3.3. Blood Flow Measurement by Thermal Convection

A hot object in a colder-flowing medium is cooled by thermal convection. The rate of cooling is
proportional to the rate of the flow of the medium. This principle, often used to measure gas flow,
has also been applied to the measurement of blood velocity. In one application, a thermistor in the
bloodstream is kept at a constant temperature by a servo system. The electrical
energy required to maintain this constant temperature is a measure of the flow rate. In another
method an electric heater is placed between two thermocouples or thermistors that are located
some distance apart along the axis of the vessel. The temperature difference between the upstream
and the downstream sensor is a measure of the blood velocity. A device of the latter
type is sometimes called a thermostromuhr (literally, from the German **heat current clock'').
Thermal convection methods for blood flow determination, although among the oldest ones used
for this purpose, have now been widely replaced by the other methods described in this chapter.

6.3.4. Blood Flow Determination by Radiographic Methods

Blood is not normally visible on an X-ray image because it has about the same radio density as
the surrounding tissue. By the injection of a contrast medium into a blood vessel (e.g., an iodated
organic compound), the circulation pattern can be made locally visible. On a sequential record of
the X-ray image (either photographic or on a videotape recording), the progress of the contrast
medium can be followed, obstructions can be detected, and the blood flow in certain blood vessels
can be estimated. This technique, known as cine (or video) angiography, can be used to assess the
extent of damage after a stroke or heart attack. Another method is the injection of a radioactive
isotope into the blood circulation, which allows the detection of vascular obstructions (e.g., in the
lung) with an imaging device for nuclear radiation, such as a scanner or gamma camera (see
Chapter 14).
5|Page

Vascular obstructions in the lower extremities can sometimes be detected by measuring

differences in the skin temperature caused by the reduced circulation. This can be accomplished
by one of the various methods of skin surface temperature measurement described in Chapter 9.

6.3.5. Measurement by Indicator Dilution Methods

The indicator or dye dilution methods are the only methods of blood flow measurement that really
measure the blood flow and not the blood velocity. In principle, any substance can be used as an
indicator if it mixes readily with blood and its concentration in the blood can be easily determined
after mixing. The substance must be stable but should not be retained by the
body. It must have no toxic side effects. An indocyanine dye, Cardiogreen, used in an isotonic
solution was long favored as a indicator. Its concentration was detemined by measuring the light
absorption with a densitometer (colorimeter). Radioactive isotopes (radioiodited serum albumen)
have also been employed for this purpose. The indicator most frequently used today, however, is
isotonic saline, which is injected at a temperature lower than the body temperature. The
concentration of the saline after mixing with the blood is determined with a sensitive
thermistor thermometer (see Chapter 9).
The principle of the dilution method is shown in Figure 6.38. The upper left drawing shows a
model of a part of the blood circulation under the (very simplified) assumption that the blood is
not recirculated. The indicator is injected into the flow continuously, beginning at time t, at a
constant infusion rate / (grams per minute). A detector measures the concentration downstream
from the injection point. Figure 6.38 (a) shows the output of a recorder that is connected to the
detector. At a certain time after the injection, the indicator begins to appear, the concentration
increases, and, finally, it reaches a constant value, Co (milligrams per liter). From the measured
concentration and the known injection rate, / (in milligrams per minute), the flow can be calculated
as

The earliest method for determining cardiac output, the Fick method, is based on this simple
model. The indicator is the oxygen of the inhaled air that is * 'injected*' into the blood in the lungs.
The ''infusion rate" is determined by measuring the oxygen content of the exhaled air and
subtracting it from the known oxygen content of the inhaled room air. The oxygen metabolism
only approximately resembles the model of the open circulation, because only part of the oxygen
is consumed in the systemic circulation and the returning venous blood still contains some oxygen.
Therefore, the oxygen concentration in the returning venous blood has to be determined and
subtracted from the oxygen concentration in the arterial blood leaving
the lungs. The measurements are averaged over several minutes to reduce the influence of short-
term fluctuations. An automated system is available that measures the oxygen concentration (by
colorimetry) and the oxygen consumption, and continuously calculates the cardiac output from
these measurements. When a dye or isotope is used as an indicator, the concentration does not
assume a steady-state value but increases in steps whenever the recirculated indicator again passes
the detector [points R in Figure 6.38 (b)].
The recirculation often occurs before the concentration has reached a plateau. Consequently, a
slightly different method is usually used, and the indicator is injected as a bolus instead of being
infused at a constant rate.
Figure 6.38(c) shows the concentration for this case, again under the assumption that it is an open
system. The concentration increases at first, reaches a peak, P, and then decays as an exponential
function. This "washout curve'* is mainly a result of the velocity profile of the blood, which causes
a "spread" of the bolus. To calculate the flow, the area under the concentration curve has to be
determined. This is given by the integral:

From the value of this integral, and from the amount B of the injected indicator (in milligrams),
the flow can be calculated:
6|Page

Because of the recirculation, the concentration does not show a monotonous decay as in Figure
6.38(b); instead, after some time, a "hump" (R in the figure) occurs. Normally, the portion of the
curve preceding the recirculation hump is exponential, and the decay curve can be determined,
despite the recirculation, by exponential extrapolation (Hamilton method). This was originally
done by manually replotting the curve on semilogarithmic paper, which resulted in a straight line
for the exponential part of the curve. This line was then extended, the extended part Replotte on
the original plot, and the extrapolated curve integrated with a planimeter.
To simplify this complicated and time-consuming operation, various special-purpose analog
computers were used which employed several different algorithms or determining the area under
the curve despite the recirculation distortion. The use of cold saline as an indicator avoids these
problems.
Because the volume injected is normally only 10 ml, the circulating blood is rewarmed rapidly
and no measurable recirculation occurs. Injection of the cool saline and measurement of the blood
temperature are frequently performed with a single catheter of special design. This device is called
the Swan-Ganz catheter, the principle of which is shown in Figure 6.39. It is a special adaptation
of the pulmonary artery floatation catheter described in Section 6.2.4.3. This catheter contains four
separate lumens. One lumen terminates about 30 cm (12 in.) from the tip and is used to inject the
cooled saline.

Figure 6.39. Swan-Ganz catheter for the measurement of cardiac output by the thermal
dilution method. (Not drawn to scale.) The opening for saline injection is actually
7|Page

located 30 cm distal from the catheter tip and the lumens vary in diameter.
The second lumen contains two thin wires that lead to a tiny electrical temperature sensor close to
the top of the catheter. The third lumen ends at the catheter tip and can be used to measure the
blood pressure at this point with one of the pressure transducers described in Section 6.2.
The fourth lumen is used to inflate a small rubber ballon at the tip of the catheter. Once the catheter
has been inserted into a vein, the ballon is inflated and the returning venous blood carries the
catheter until its tip is positioned in the pulmonary artery. The position of the catheter can be
checked by measuring the pressure at its tip. Thus, the catheter can, if necessary, be inserted
without fluoroscopic control. The thermistor is connected into a bridge circuit which permits
measurement and recording of the blood temperature during injection. A
relatively simple analog computer, which consists essentially of an electronic integrator and
necessary controls, permits direct reading of the cardiac output. The complete thermodilution
catheter and the cardiac output computer are illustrated in Figure 6.40.
8|Page

6.4. PLETHYSMOGRAPHY
Related to the measurement of blood flow is the measurement of volume changes in any part of
the body that result from the pulsations of blood occuring with each heartbeat. Such measurements
are useful in the diagnosis of arterial obstructions as well as for pulse-wave velocity
measurements. Instruments measuring volume changes or providing outputs that can be related to
them are called plethysmographs, and the measurement of these volume changes, or phenomena
related thereto, is called plethysmography.
A "true** plethysmograph is one that actually responds to changes in volume. Such an instrument
consists of a rigid cup or chamber placed over the limb or digit in which the volume changes are
to be measured, as shown in Figure 6.41. The cup is tightly sealed to the member to be measured
so that any changes of volume in the limb or digit reflect as pressure changes
inside the chamber. Either fluid or air can be used to fill the chamber.

Figure 6.41. Plethysmograph.

Plethysmographs may be designed for constant pressure or constant volume within the chamber.
In either case, some form of pressure or displacement transducer must be included to respond to
pressure changes within the chamber and to provide a signal that can be calibrated to represent the
volume of the limb or digit. (See the description of the pressure transducers in Section 6.2.2. and
displacement transducers in Chapter 2.)
The baseline pressure can be calibrated by use of a calibrating syringe. This type of
plethysmograph can be used in two ways (see Figure 6.41).If the cuff, placed upstream from the
seal, is not inflated, the output signal is simply a sequence of pulsations proportional to the
individual volume changes with each heartbeat.
The plethysmograph illustrated in Figure 6.41 can also be used to measure the total amount of
blood flowing into the limb or digit being measured. By inflating the cuff (placed slightly upstream
from the seal) to a pressure just above venous pressure, arterial blood can flow past the cuff,but
venous blood cannot leave. The result is that the limb or digit increases its volume with each
heartbeat by the volume of the blood entering during that beat. The output tracing for this
measurement is shown in Figure 6.42.The slope of a line along the peaks of these pulsations
represents the overall rate at which blood enters the limb or digit. Note, however, that after a few
seconds the slope tends to level off. This is caused by a back pressure that builds up in the limb or
digit from the accumulation of blood that cannot escape.

Figure 6.42. Blood volume record from plethysmograph.

Another device that quite closely approximates a **true" plethysmograph is the capacitance
plethysmograph shown in Figure 6.43. In this device, which is generally used on either the arm or
leg, the limb in which the volume is being measured becomes one plate of a capacitor. The
other plate is formed by a fixed screen held at a small distance from the limb by an insulating
layer. Often a second screen surrounds the outside plate at a fixed distance to act as a shield for
greater electrical stability. Pulsations of the blood in the arm or leg cause variations in the
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capacitance, because the distance between the limb and the fixed screen varies with these
pulsations. Some form of capacitance-measuring device is then used to obtain a continuous
measure of these variations. Since the length of the cuff is fixed, the variations in capacitance can
be calibrated as volume variations. The device can be calibrated by using a special cone of known
volume on which the diameter can be adjusted to provide the same capacitance reading as the limb
on which measurements are made. Since the capacitance plethysmograph essentially integrates
the diameter changes over a segment of the limb, its readings are reasonably close to those of a
*True" plethysmograph. Also, as with the *'true'' plethysmograph, estimates of the total volume
of blood entering an arm or leg over a given period of time can be made by placing an occluding
cuff just upstream from the capacitance device and by pressurizing the cuff to a pressure greater
than venous pressure but below
arterial pressure.

Figure 6.43. Capacitance plethysmograph.

Several devices, called plethysmographs, actually measure some variable related to volume rather
than volume itself. One class of these **pseudo-plethysmographs" measures changes in diameter
at a certain cross section of a finger, toe, arm, leg, or other segment of the body. Since
volume is related to diameter, this type of device is sufficiently accurate for many purposes.
A common method of sensing diameter changes is through the use of a mercury strain gage, which
consists of a segment of small-diameter elastic tubing, just long enough to wrap around the limb
or digit being measured.
When the tube is filled with mercury, it provides a highly compliant strain gage that changes its
resistance with changes in diameter. With each pulsation of blood that increases the diameter of
the limb or digit, the strain gage elongates and, in stretching, becomes thinner, thus increasing its
resistance. The major difficulty in using the mercury strain gage is its extremely low impedance.
This drawback necessitates the use of a low-impedance bridge to measure small resistance
variations and convert them into voltage changes that can be recorded. A mercury strain gage
plethysmograph is shown in Figure 6.44. A difficulty that is common to all diameter-measuring
Pseudo-plethysmographs is that of interpreting single-point diameter changes as volume changes.

Figure 6.44. Mercury strain gage plethysmograph.

Figure 6.45. Photoelectric plethysmograph.
Another step away from the true plethysmograph is the photoelectric plethysmograph. This device
operates on the principle that volume changes in a limb or digit result in changes in the optical
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density through and just beneath the skin over a vascular region. A photoelectric plethysmograph
is shown in Figure 6.45. A light source in an opaque chamber illuminates a
small area of the fingertip or other region to which the transducer is applied.
Light scattered and transmitted through the capillaries of the region is picked up by the photocell,
which is shielded from all other light. As the capillaries fill with blood (with each pulse), the blood
density increases, thereby reducing the amount of light reaching the photocell. The result causes
resistance changes in the photocell that can be measured on a Wheatstone bridge and recorded.
Pulsations recorded in this manner are somewhat similar to those obtained by a true
plethysmograph, but the photocell device cannot be calibrated to reflect absolute or even relative
volumes. As a result, this type of measurement is primarily limited to detecting
the fact that there are pulsations into the finger, indicating heart rate and determining the arrival
time of the pulses. One serious difficulty experienced with this type of device is the fact that even
the slightest movement of the finger with respect to the photocell or light source results in a severe
amount of movement artifact. Furthermore, if the light source produces heat, the effect of the heat
may change local circulation beneath the light source and photocell.
A more reliable device is the impedance plethysomgraph, in which volume changes in a segment
of a limb or digit are reflected as impedance changes. These impedance changes are due primarily
to changes in the conductivity of the current path with each pulsation of blood. Impedance
plethysmographic measurements can be made using a two-electrode or a four-electrode system.
The electrodes are either conductive bands wrapped around the limb or digit to be measured or
simple conductive strips of tape attached to the skin. In either case, the electrodes contact the skin
through a suitable electrolyte jelly or paste to form an electrode interface and to remove the effect
of skin resistance. In a two-electrode system, a constant current is forced through the tissue
between the two electrodes, and the resulting voltage changes are measured. In the four-electrode
system, the constant current is forced through two outer, or current electrodes, and the voltage
between the two inner, or measurement, electrodes is measured. The internal body resistances
between the electrodes form a physiological voltage divider. The advantage of the four-electrode
system is a much smaller amount of current through the measuring electrodes, thus reducing the
possibility of error due to changes in electrode resistance. Currents used for impedance
plethysmography are commonly limited to the lowmicroampere range. The driving current is ac,
sometimes a square wave, and usually of a high-enough frequency (around 10 kHz or higher) to
reduce the effect of skin resistance. At these frequencies the capacitive component of the skin
electrode interface becomes a significant factor.
Several theories attempt to explain the actual cause of the measured impedance changes. One is
that the mere presence of additional blood filling a segment of the body lowers the impedance of
that segment. Tests reported by critics of this method, however, claim that the actual impedance
difference between the blood-filled state and more **empty" state is not significant.
A second theory is that the increase in diameter due to additional blood in a segment of the body
increases the cross-sectional area of the segment's conductive path and thereby lowers the
resistance of the path. This may be true to some extent, but again the percentage of area change is
very small.
Critics of impedance plethysmography argue that the measured impedance changes are actually
changes in the impedance of the skin-electrode interface, caused by pressure changes on the
electrodes that occur with each blood pulsation.
Whatever the reason, however, impedance plethysmography does produce a measure that closely
approximates the output of a true plethysmograph. Its main difficulty is the problem of relating
the output resistance to any absolute volume measurement. As with the photocell
plethysmograph, detection of the presence of arterial pulsations, measurement of pulse rate, and
determination of time of arrival of a pulse at any given point in the peripheral circulation can all
be satisfactorily handled by impedance plethysmography. Also, the impedance plethysmograph
can measure time-variant changes in blood volume. A special form of impedance
plethysmography is rheoencephalography, the measurement of impedance changes between
electrodes positioned on the scalp. Although primarily limited to research applications, this
technique provides information related to cerebral blood flow and is sometimes used to detect
circulatory differences between the two sides of the head. Theoretically, such information might
help in locating blockages in the internal carotid system, which supplies blood to the brain.
11 | P a g e

Another special type of plethysmograph is the oculo pneumo plethysmograph, shown in Figure
6.46. As the name implies, this instrument measures every minute volume changes that occur in

the eye with each

Figure 6.46. Oculo pneumo plethysmograph.
arterial blood pulsation. A small eye cup is placed over the sclera of each eye and is connected to
a transducer positioned over the patient's head by a short section of flexible tubing. A vacuum,
which can be varied from zero to - 300 mm Hg, is applied to hold the eye cups in place. Pulsations
are recorded on two channels of a three-channel pen recorder, one for each eye. The third channel
is used to record the vacuum. By periodically allowing the vacuum to build up to - 300 mm Hg
and deplete to zero, the instrument can also be used as a recording suction ophthalmo
dynamometer, an instrument for measuring arterial blood pressure within the eye. Ocular
plethysmography and blood pressure measurements are of particular interest
because the eye provides a site for non-invasive access to the cerebral circulation system.
Occlusion of one of the internal carotid arteries or other interference in the blood supply to one
hemisphere of the brain can be detected by nonsymmetric pressures and pulsations at the eyes.
In certain rodents the tail is a convenient region for measurement of circulatory factors. For these
measurements, a caudal plethysmograph is used. Caudal plethysmographs can utilize any of the
previously described methods of sensing volume changes or the presence of blood pulsations. The
same limitations encountered in human plethysmographic procedures are also found in caudal
plethysmography. In addition, a special physiological factor must be considered in measuring
blood pulsations from the tail of a rodent. Many animals use their tails as radiators in the control
of body temperature. At low temperatures, very little blood actually flows through the vessels of
the tail, and plethysmographic measurements become very difficult. If the animal is heated to a
temperature at which the tail is used for cooling, however, sufficient blood flow for good
plethysmographic measurements is usually found. Sometimes the necessary temperature for good
caudal measurements is so near the point of overheating that traumatic effects are encountered

6.5. MEASUREMENT OF HEART SOUNDS

In the early days of auscultation a physician listened to heart sounds by placing his ear on the chest
of the patient, directly over the heart. It was probably during the process of treating a well-
endowed, but bashful young lady that someone developed the idea of transmitting heart sounds
from the patient's chest to the physician's ear via a section of cardboard tubing. This
was the forerunner of the stethoscope, which has become a symbol of the medical profession.
The stethoscope (from the Greek word, stethos, meaning chest, and skopein, meaning **to
examine") is simply a device that carries sound energy from the chest of the patient to the ear of
the physician via a column of air. There are many forms of stethoscopes, but the famiUar
configuration has two earpieces connected to a common bell or chest piece. Since the system is
strictly acoustical, there is no amplification of sound, except for any that might occur through
resonance and other acoustical characteristics.
Unfortunately, only a small portion of the energy in heart sounds is in the audible frequency range.
Thus, since the dawning of the age of electronics, countless attempts have been made to convince
the medical profession of the advantage of amplifying heart sounds, with the idea that if the sound
level could be increased, a greater portion of the sound spectrum could be heard and greater
diagnostic capability might be achieved. In addition, high-fidelity equipment would be able to
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reproduce the entire frequency range, much of which is missed by the stethoscope. In spite of these
apparent advantages, the electronic stethoscope has never found favor with
the physician. The principal argument is that doctors are trained to recognize heart defects by the
way they sound through an ordinary stethoscope, and any variations therefrom are foreign and
confusing.
Nevertheless, a number of electronic stethoscopes are available commercially. Instruments for
graphically recording heart sounds have been more successful. As stated in Chapter 5, a graphic
record of heart sounds is called a phonocardiogram. The instrument for producing this recording
is called a phonocardiograph. Although instruments specifically designed for phonocardiography
are rare, components suitable for this purpose are readily available.
The basic transducer for the phonocardiogram is a microphone having the necessary frequency
response, generally ranging from below 5 Hz to above 1000 Hz. An ampUfier with similar
response characteristics is required, which may offer a selective lowpass filter to allow the high
frequency cutoff to be adjusted for noise and other considerations. In one instance, where the
associated pen recorder is inadequate to reproduce higher frequencies, an integrator is employed
and the envelope of frequencies over 80 Hz is recorded along with actual signals below 80 Hz.
The readout of a phonocardiograph is either a high-frequency chart recorder or an oscilloscope.
Because most pen galvanometer recorders have an upper-frequency limitation of around 100 or
200 Hz, photographic or light-galvanometer recorders are required for faithful recording of heart
sounds. Although normal heart sounds fall well within the frequency range of pen recorders, the
high-frequency murmurs that are often important in diagnosis require the greater response of the
photographic device.
Some manufacturers of multiple-channel physiological recording systems claim the
phonocardiogram as one of the measurements they offer. They have available as part of their
system a microphone and amplifier suitable for the heart sounds, the amplifier often being the
same one used for EMG (see Chapter 10). Some of these systems, however, have only a pen
recorder output, which Hmits the high-frequency response of the recorded signal to about 100 or
200 Hz. The presence of higher frequencies (murmurs) in the phonocardiogram indicates a
possible heart disorder. For this reason, a spectral analysis of heart sounds can provide a useful
diagnostic tool for discriminating between normal and abnormal hearts. This type of analysis,
however, requires a digital computer with a high-speed analog-to-digital conversion capability and
some form of Fourier-transform software. A typical spectrum of heart sounds is shown in Figure
6.47. Microphones for phonocardiograms are designed to be placed on the chest, over the heart.
However, heart sounds are sometimes measured from other vantage points. For this purpose,
special microphone transducers are placed at the tips of catheters to pick up heart sounds from
within the chambers of the heart or from the major blood vessels near the heart.
Frequency-response requirements for these microphones are about the same as for
phonocardiograph microphones. However, special requirements dictated by the size and
configuration of the catheter must be considered in their construction. As might be expected, the
difference in acoustical paths makes these heart-sound patterns appear somewhat different from
the usual phonocardiogram patterns.
The vibrocardiograph and the apex cardiograph, which measure the vibrocardiogram and apex
cardiogram, respectively, also use microphones as transducers. However, since these
measurements involve the lowfrequency vibrations of the heart against the chest wall, the
measurement is normally one of displacement or force rather than sound. Thus, the microphone
must be a good force transducer, with suitable low-frequency coupling from the chest wall to the
microphone element. For the apex cardiogram, the microphone must be coupled to a point between
the ribs. A soft rubber or plastic cone attached to the element of the microphone gives
good results for this purpose. Because the vibrocardiogram and the apex cardiogram do not contain
the high-frequency components of the heart sounds, these signals can be handled by the same type
of amplifiers and recorders as the electrocardiogram (see Section 6.1). Often, these signals are
recorded along with a channel of ECG data to maintain time reference. In this case, one channel
of a multichannel ECG recorder is devoted to the heart vibration signal.
For recording the Korotkoff sounds from a partially occluded artery (see Chapter 5 and Section
6.2), a microphone is usually placed beneath the occluding cuff or over the artery immediately
downstream from the cuff.
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Figure 6.47. Frequency spectrum of heart sounds.

The waveform and frequency content of these sounds are not as important as the simple
identification of their presence, so these sounds generally do not require the high-frequency
response specified for the phonocardiogram. Circuitry for identification of these sounds is
included in certain automated, indirect blood pressure measuring devices (see Section 6.2.2).
Measurement of the ballistocardiogram requires a platform mounted on a set of extremely flexible
springs. When a person lies on the platform, the movement of his body in response to the beating
of his heart and the ejection of blood causes similar movement of the platform. The amount of
movement can be measured by any of the displacement or velocity transducers or accelerometers
described in Chapter 2.