UNIT 3 CARDIOVASCULAR SYSTEM AND MEASUREMENTS:

The Heart and Cardiovascular System, Electro Cardiography, Blood Pressure Measurement,
Measurement of Blood Flow and Cardiac Output, Measurement of Heart Sound,
Plethysmography
MEASUREMENTS IN THE RESPIRATORY SYSTEM: The Physiology of the
Respiratory System, Tests and Instrumentation for The Mechanics of Breathing, Respiratory
Therapy Equipment

Part-A

a. Draw the ECG amplifier.

b. Write different clinical applications of ECG.
c. Write about the Physiology of Respiratory System
d. What is Plethysmography

Part-B

a. Draw the Cardiovascular System and discuss various characteristic features of ECG amplifiers
b. Draw different ECG lead configurations and explain recording of ECG.
c. Discuss in detail the blood pressure measurement by indirect method.
d. What is the importance of blood flow? Discuss the biomedical instruments that are used to
measure the blood flow.
e. Explain clearly the method of heart sound measurement.
f. Draw the Plethysmograph and explain how the blood volume is recorded.
g. Explain the ultrasonic method of blood flow measurement.
h. Explain the physiology of respiratory system.
i. Write in detail about the Respiratory therapy Equipment.
Cardiovascular System

The circulatory system, also called the cardiovascular system or the vascular system, is
an organ system that permits blood to circulate and transport nutrients (such as amino
acids and electrolytes), oxygen, carbon dioxide, hormones, and blood cells to and from
the cells in the body to provide nourishment and help in fighting diseases, stabilize
temperature and pH, and maintain homeostasis.
This system has three main components: the heart, the blood vessel and the blood itself. The
heart is the system’s pump and the blood vessels are like the delivery routes. Blood can be
thought of as a fluid which contains the oxygen and nutrients the body needs and carries the
wastes which need to be removed. The circulatory system of the blood is seen as having two
components, a systemic circulation and a pulmonary circulation.

The pulmonary circulation is a "loop" through the lungs where blood is oxygenated; and the
systemic circulation, a "loop" through the rest of the body to provide oxygenated blood.
Blood consists of plasma, red blood cells, white blood cells, and platelets. In contrast, oxygen
and nutrients diffuse across the blood vessel layers and enter interstitial fluid, which carries
oxygen and nutrients to the target cells, and carbon dioxide and wastes in the opposite
direction.
 Heart

Closed complex hydraulic system with a four chambered pump connected to flexible tubular
structures(blood vessels).

Main functions: Transportation / Blood purification

Structural details: Two parts (right & left)

Each part has two chambers – Atrium (Auricle), Ventricle

It has four valves:-

Tricuspid valve or right atrio-ventricular valve,
Bicuspid mitral valve or left atrio-ventricular valve,
Pulmonary valve or semilunar valve,
Aortic valve
All these valves are unidirectional and provides synchronous operation

Electrocardiography

Electrocardiography is a method of graphic tracing of the electric current generated by

the heart muscle during a heartbeat. Electrocardiograms are made by applying electrodes to
various parts of the body. Electrodes that record the electrical activity of the heart are placed
at 10 different locations: one on each of the four limbs and six at different locations on the
anterior surface of the chest. Atrial and ventricular depolarization and repolarization
are represented on the ECG as a series of waves: the P wave followed by the QRS complex
and the T wave. The first deflection is the P wave associated with right and left atrial
depolarization. The second wave is the QRS complex.
 Normal values

P wave duration 0.08 – 0.1 sec

QRS complex duration 0.06 – 0.1 sec
T wave duration 0.16 – 0.24 sec
P-R (P-Q) interval 0.12 – 0.20 sec
duration
Q-T interval duration 0.38 sec
Heart rate 75 bpm
To obtain an ECG, an examiner places electrodes (small round sensors that stick to the skin)
on the person's arms, legs, and chest. These electrodes measure the magnitude and direction
of electrical currents in the heart during each heartbeat. Each tracing shows the electrical
activity of the heart from different angles.

Introduction to ECG measurement system

The ECG system comprises four stages, each stage is as following:

(1) The first stage is a transducer—AgCl electrode, which convert ECG into electrical
voltage. The voltage is in the range of 1 mV ~ 5 mV.
(2) The second stage is an instrumentation amplifier (Analog Device, AD624), which has a
very high CMRR (90dB) and high gain (1000), with power supply +9V and -9V.

(3) We use an opto-coupler (NEC PS2506) to isolate the In-Amp and output.

(4) After the opto-coupler is a bandpass filter of 0.04 Hz to 150 Hz filter. It’s implemented
by cascading a low-pass filter and a high pass filter.

We measure the ECG by connecting two electrodes on the right and left chest respectively, as
shown on Figure 5. The body should be connected to ground of the circuits, so that we
connect the leg to the ground. If the body is not grounded, no signal would be obtained.

Simplified ECG recording system

Once the electrodes convert the ECG into electrical voltage, these voltages can be fed into an
instrumentation amplifier, and then be processed.

Instrumentation Amplifier

A very high CMRR is very essential for Instrumentation Amplifier. The small ac signal
voltage (less than 5 mV) detected by the sensor on the electrodes will be accompanied by a
large ac common-mode component (up to 1.5 V) and a large variable dc component (300
mV).

Supply Voltage +-9V Battery power

Programmable Gain 1, 100, 200, 500, 10 00, 2500
CMRR 130dB (Gain=500 to 1000)
Gain Bandwidth Product 25 MHz
Input offset 25 μV, max
 Important features of AD624 Instrumentation Amplifier

Characteristic features of ECG amplifiers

 Low internal noise (<2 mV)
 High Input Impedance (Z in > 10 MΩ)
 Bandwidth ranging from 0.16–250 Hz
 Bandwidth cut offs (>18 dB/octave).
 Notch filter (50 or 60 Hz, depending on country/region)
 Common mode rejection ratio (CMRR > 107 dB)
 Common mode input range (CMR ± 200 mV)
 Static electricity shock protection (>2000 V).

BLOOD PRESSURE
The determination of an individual's blood pressure is one of the most useful clinical
measurements that can be taken. By "blood pressure" we mean the pressure exerted
by the blood against the vessel walls, the arterial blood pressure being the most useful,
and hence the most frequently measured pressure.

Systolic blood pressure- The highest pressure in the artery, produced in the heart's
contraction (systolic) phase. The normal value for a 20-year-old man is 120 mm Hg.

Diastolic blood pressure- The lowest pressure in the artery, produced in the heart's
relaxation (diastolic) phase. The normal value for a 20-year-old man is 80 mm Hg.
MEASUREMENT OF BLOOD PRESSURE:

Blood pressure can be measured by several techniques. Basically they are categorized
into two methods,

1. Direct method

The direct method involves directly inserting a tube or catheter into a blood vessel. The
catheter is connected to a blood pressure transducer, which generates an electrical signal.

2. Indirect method

In this method, we measure the arterial blood pressure using two different methods:
1. The first method uses the sense of touch: it is thus called the palpatory method.
2. The second method uses the sense of hearing: it is thus called the auscultatory method.

A sphygmomanometer, an instrument that measures pressure, consists of a cuff which is

connected by lengths of tubing to an inflating bulb with a needle valve and to a mercury
manometer.

Auscultation method

This is the most accurate method and should take priority. You cannot determine a full MAP
(mean arterial pressure) without a diastolic reading. Ensure the cuff is fully deflated after
each measurement is complete as a prolonged inflated cuff can become painful for the
patient.

1. Place diaphragm of stethoscope over brachial pulse point.

2. Inflate cuff listening to heart beat – stop inflating after the heartbeat disappears.
3. Slowly deflate the cuff and identify the value of when the heart beat commences
again. This is the systolic pressure.
4. Keep slowly deflating the cuff until the heart beat disappears. This is the diastolic
pressure.
5. Deflate cuff completely and remove from patient’s arm. Leave cuff on if you will
need to take further BP measurements.
Measurement of Blood Flow and Cardiac Output

Cardiac output (known as ‘Q’) is a measure of the amount of blood that is pumped out of the
heart in one minute. ‘Q’ specifically refers to the amount of blood pumped out of the left
ventricle as this is the ventricle that supplies blood to the muscles and organs of the body.
Cardiac output is made up of two components, heart rate (HR) and stroke volume (SV).

Heart rate (HR) refers to the number of times the heart beats every minute (bpm). This can
be easily measured through the use of heart rate monitors or taking ones pulse (counting the
‘pulses’ at the radial artery for example over a one minute period).

Heart rates increase as the intensity of activity increases, as shown in the adjacent
picture. This is because the working muscles demand more energy, so the heart beats
increasingly faster in order to deliver the nutrients and O2 needed to meet these increased
energy demands. The normal resting heart rate range for an adult is between 60-100 bpm.

Stroke volume (SV) refers to the quantity of blood pumped out of the left ventricle with
every heart beat. The exact volumes are not easily measured, so they are often estimated
based on what we know about stroke volume and the factors that it affects such as blood
pressure which we can measure.

HR x SV = Q. Therefore to calculate Q we must first establish HR and SV.

HR (70BPM) x SV (70ml) = 4900ml/min or 4.9 litres per minute

An increase in HR, SV or both will increase Q. SV on the whole does not fluctuate too
much, with only relatively small increases with exercise. HR on the other hand increases
quite dramatically increasing Q.

ELECTROMAGNETIC BLOOD FLOWMETER

Works based on the principle of electromagnetic induction. The voltage induced in a

conductor moving in a magnetic field is proportional to the velocity of the conductor

A permanent magnet or electromagnet positioned around the blood vessel generates a

magnetic field perpendicular to the direction of the flow of the blood. 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. This method requires
that the blood vessel be exposed so that the flow head or the measuring probe can be put
across it.

The Induced emf

Where
B = magnetic flux density, T
L = length between electrodes, m
u = instantaneous velocity of blood, m/s

Ultrasonic blood flow meter

An ultrasonic flow meter is a type of flow meter that measures the velocity of a fluid with
ultrasound to calculate volume flow. Using ultrasonic transducers, the flow meter can
measure the average velocity along the path of an emitted beam of ultrasound. By averaging
the difference in measured transit time between the pulses of ultrasound propagating into and
against the direction of the flow or by measuring the frequency shift from the Doppler effect.

Ultra sonic flow meter

Doppler-shift flow-velocity meters

It is an non invasive method. It is based on the analysis of echo signals from erythrocytes
(RBCs) in blood. The incident ultrasound is scattered by the blood cells and scattered wave is
received by the second receiver. The frequency shift of the scattered wave gives idea about
velocity of scatterers. The Doppler frequency shift is a measure of size and direction of the
flow velocity.
Heart Sounds

Mechanical working processes of the heart produce sound which indicates health status of the
individual. The relationship between blood volumes, pressures and flows within the heart
determines the opening and closing of the heart valves. Normal heart sounds- lub and dub
occur during the closure of the valves.

First heart sound:

Occurs when the atrio ventricular (AV) valves close at the beginning of ventricular
contraction generated by the vibration of the blood and the ventricular wall is louder, longer,
more resonant than the second heart sound.

Second heart sound

Occurs when aortic and pulmonary semi lunar valves close at the beginning of ventricular
dilation generated by the vibration of the blood and the aorta, Aortic valve closes slightly
before pulmonary valve

Third heart sound

Connected with the diastolic filling period, the rapid filling phase starts with the opening of
the semi lunar valves. Attributes energy released with the sudden deceleration of blood that
enters the ventricle throughout this period

Fourth heart sound

Connected with the late diastolic filling period, occur during atrial systole where blood is
forced into the ventricles.
Measurement of Heart Sound

Early monaural stethoscope / Modern binaural Stethoscope / Modern Electronic Stethoscope

 Acoustic stethoscopes transmit sound mechanically from a chest-piece via air filled
hollow tubes to the listener's ears.
 The diaphragm and the bell work as two filters, transmitting higher frequency sounds
and lower frequency sounds, respectively.
 Electronic stethoscopes function in a similar way, but the sound is converted to an
electronic signal which is transmitted to the listener by wire.
 Functionalities often included in electronic stethoscopes are amplification of the
signal, filters imitating the function of the diaphragm and the bell and in some cases
recording abilities to allow storage of data.
 Even subtle changes in breath sounds can be picked up and magnified
 Electronic stethoscopes also allow the user to distinguish between body sounds of
high and low frequency.
 They now have wireless capabilities, which allow data to be transferred to a computer
or handheld device for storage and retrieval at a later time.

Plethysmography
A plethysmograph is an instrument for measuring changes in volume within an organ or
whole body (usually resulting from fluctuations in the amount of blood or air it contains).
It is the determination of blood flow (or other physiological parameters) by measurement of
volume changes of the limb. The advantages include non-invasive nature of measuring blood
volume and flow relatively easily.

The chamber has a rigid cylindrical container that houses a bladder filled with liquid (water)
or air. As the volume of the limb increases due to arterial flow, the volume / pressure of the
bladder changes which can be measured using a pressure transducer or simply by the water
rising on a calibrated tube.

After cuff pressure is turned on, the initial volume-versus-time slope is caused by arterial
inflow. After the cuff is released, segment volume rapidly returns to normal.

RESPIRATORY PHYSIOLOGY
Respiration is defined as the movement of oxygen from the outside environment to the cells
within tissues, and the transport of carbon dioxide in the opposite direction.
The process of respiration is divided into four categories:
1- Pulmonary ventilation.
2- Diffusion of oxygen and CO2 between alveoli and tissues.
3- Transport of oxygen and CO2 in body fluids to and from cells.
4- Regulation of respiration
Anatomy of the Respiratory System

The respiratory system includes the lungs, the conducting airways that direct air to the gas
exchange sites (alveoli), certain parts of the central nervous system, and the muscles of the
chest wall and the diaphragm that are responsible for inflation and deflation of the lungs

The normal adult human lung weighs about 1000g and consists of about 50% blood and 50%
tissue by weight. About 10% of the total lung volume is composed of various types of
conducting airways and some connective tissue. The remaining 90% is the respiratory or gas
exchange portion of the lung, composed of alveoli and supporting capillaries.

Respiration involves respiratory cycles of inhaled and exhaled breaths. The contraction of the
diaphragm muscle causes a pressure variation, which is equal to the pressures caused by
elastic, resistive and inertial components of the respiratory system. In contrast, exhalation
(breathing out) is usually a passive process. Breathing in, brings air into the lungs where the
process of gas exchange takes place between the air in the alveoli and the blood in
the pulmonary capillaries

Respiratory Therapy Equipment

When a patient is incapable of adequate ventilation (breath) naturally, mechanical assistance
must be provided to save his/her life. So the process of providing mechanical assistance in
respiration and in supplying patients with higher than the normal concentration of oxygen or
other therapeutic gases or medications constitute Respiratory therapy

Main Instruments for Respiratory Therapy

1. Inhalators
2. Ventilators & Respirators
3. Humidifiers
4. Nebulizers

Inhalators - This is used to supply oxygen or some other therapeutic gases to patient who is
able to breathe spontaneously(naturally) without assistance for eg: oxygen supply to the
mother after or during the labor.

It is mainly used when the concentration of oxygen required is more than that of air required.
It consists of: gas, equipment for reducing the pressure & controlling the gas and a device for
administering the gas.
Ventilator - is a machine that is used to move breathable air in and out of the lungs in
patients who are unable to breathe or have a difficulty in breathing. Ventilator does not
improve the quality of air. It performs the process of respiration in the patients with
respiratory difficulties to sustain their life.

Modes of Mechanical Ventilation

Volume-cycled Mode - In this mode, the inhalation proceeds till an optimum tidal volume are
achieved and then the expiration begins. A constant volume of air is supplied throughout the
process.
Pressure-cycled Mode - A set peak aspiratory pressure is applied and the air moves into the
lungs along a changing pressure gradient. When the maximum pressure is attained, passive
expiration begins.

Humidifiers - In order to prevent damage the patient’s lungs (walls), the air or oxygen
applied during therapy should be humidified. Thus, virtually all inhalators, ventilators and
respirators include equipment to humidify the air either by heat vaporization (steam) or by
bubbling an air stream through a jar of water.
Nebulizers - When therapy requires that water or some type of medication be suspended in
the inspired air as an aerosol, a device called a nebulizer is used. Ultrasonic nebulizers
produce high intensity sound energy well above the audible range, this when applied to water
or medication, this energy vibrates the substance with such intensity that high volume minute
particles is produced.