Non-invasive blood pressure (BP) measurements still rely on empirical interpretation of arterial oscillations recorded via cuff-based oscillometric methods. Extensive effort has dedicated to establishing a theoretical basis for oscillometry, aiming at more accurate BP estimations and measurement of additional hemodynamic parameters. However, oscillometry is still a heuristic method for BP inference. Goal: This study is focused on improving our understanding of the expression of arm volume pulsations in oscillometric signals. The aim is to identify main factors that determine the transfer function of arm volume to cuff pressure oscillations for existing cuff devices - this being an essential step in establishing a theoretical basis for oscillometry. Methods: The effects of air compression within the cuff and the influence of viscoelastic cuff material properties on the transfer function are studied by an experimental setup. Mechanical numerical modelling is used to interpret the results. Results: Air compression is found to be of adiabatic nature in the frequency range of interest. The cuff material exhibits viscous characteristics which is the cause of cuff response dependence on: inflation speed, tightness of wrapping, time passed since previous measurement, heart rate. Conclusion: It was found that typical cuffs used in clinical practice exhibit complex behavior. Cuff hardware needs to be improved to enable practical translation of pressure to arm volume oscillations. The presented characterisation method contributes to standardized development of new cuff prototypes and to identification of designs, techniques and materials with improved properties for enabling BP measurement accuracy and extraction of additional hemodynamic information.

Hemodynamic monitoring technologies are evolving continuously—a large number of bedside monitoring options are becoming available in the clinic. Methods such as echocardiography, electrical bioimpedance, and calibrated/uncalibrated analysis of pulse contours are becoming increasingly common. This is leading to a decline in the use of highly invasive monitoring and allowing for safer, more accurate, and continuous measurements. The new devices mainly aim to monitor the well-known hemodynamic variables (e.g., novel pulse contour, bioreactance methods are aimed at measuring widely-used variables such as blood pressure, cardiac output). Even though hemodynamic monitoring is now safer and more accurate, a number of issues remain due to the limited amount of information available for diagnosis and treatment. Extensive work is being carried out in order to allow for more hemodynamic parameters to be measured in the clinic. In this review, we identify and discuss the main sensing strategies aimed at obtaining a more complete picture of the hemodynamic status of a patient, namely: (i) measurement of the circulatory system response to a defined stimulus; (ii) measurement of the microcirculation; (iii) technologies for assessing dynamic vascular mechanisms; and (iv) machine learning methods. By analyzing these four main research strategies, we aim to convey the key aspects, challenges, and clinical value of measuring novel hemodynamic parameters in critical care.

In standard critical care practice, cuff sphygmomanometry is widely used for intermittent blood pressure (BP) measurements. However, cuff devices offer ample possibility of modulating blood flow and pulse propagation along the artery. We explore underutilized arrangements of sensors involving cuff devices which could be of use in critical care to reveal additional information on compensatory mechanisms. In our previous work, we analyzed the response of the vasculature to occlusion perturbations by means of observations obtained non-invasively. In this study, our aim is to (1) acquire additional insights by means of invasive measurements and (2) based on these insights, further develop cuff-based measurement strategies. Invasive BP experimental data is collected downstream from the cuff in two patients monitored in the OR. It is found that highly dynamic processes occur in the distal arm during cuff inflation. Mean arterial pressure increases in the distal artery by 20 mmHg, leading to a decrease in pulse transit time by 20 ms. Previous characterizations neglected such distal vasculature effects. A model is developed to reproduce the observed behaviors and to provide a possible explanation of the factors that influence the distal arm mechanisms. We apply the new findings to further develop measurement strategies aimed at acquiring information on pulse arrival time vs. BP calibration, artery compliance, peripheral resistance, artery-vein interaction.

Blood pressure (BP) surrogates, such as pulse transit time (PTT) or pulse arrival time (PAT), have been intensively explored with the goal of achieving cuffless, continuous, and accurate BP inference. In order to estimate BP, a one-point calibration strategy between PAT and BP is typically used. Recent research focuses on advanced calibration procedures exploiting the cuff inflation process to improve calibration robustness by active and controlled modulation of peripheral PAT, as measured via plethysmograph (PPG) and electrocardiogram (ECG) combination. Such methods require a detailed understanding of the mechanisms behind the vasculature’s response to cuff inflation; for this, a model has recently been developed to infer the PAT-BP calibration from measured cuff-induced vasculature changes. The model, while promising, is still preliminary and only partially validated; in-depth analysis and further developments are still needed. Therefore, this work aims to improve our understanding of the cuff-vasculature interaction in this model; we seek to define potential opportunities and to highlight which aspects may require further study. We compare model behaviors with clinical data samples based on a set of observable characteristics relevant for BP inference and calibration. It is found that the observed behaviors are qualitatively well represented with the current simulation model and complexity, with limitations regarding the prediction of the onset of the distal arm dynamics and behavior changes at high cuff pressures. Additionally, a sensitivity analysis of the model’s parameter space is conducted to show the factors that influence the characteristics of its observable outputs. It was revealed that easily controllable experimental variables, such as lateral cuff length and inflation rate, have a significant impact on cuff-induced vasculature changes. An interesting dependency between systemic BP and cuff-induced distal PTT change is also found, revealing opportunities for improved methods for BP surrogate calibration. However, validation via patient data shows that this relation does not hold for all patients, indicating required model improvements to be validated in follow up studies. These results provide promising directions to improve the calibration process featuring cuff inflation towards accurate and robust non-invasive blood pressure estimation.

In standard clinical practice, cuff devices are widely used for non-invasive blood pressure measurements (NIBP). However, cuff-based NIBP is prone to large errors especially in cases of hypo- and hypertension. In addition to this, the cuff measurement principle allows for estimation of a number of other hemodynamic parameters (e. g. cardiac output, arterial stiffness, augmentation index) by means of analysis of the pulse waveform and/or pulse amplitude recorded in the cuff pressure. However, in standard practice, the cuff is still only used for the measurement of BP.A key reason for the observed measurement errors and the limited set of extracted parameters lies in our poor understanding of the cuff device as a transducer; the cuff pressure response to arm volume pulsations (the cuff transfer function TF_cuff) depends on a large number of factors. It is not yet clear to what extent the cuff contributes to the NIBP error, or if the cuff in its current format is reliable for measurement of arterial pulse waveform/amplitude. In this study, we investigate the isolated cuff in order to gain a better understanding of the main sources of measurement errors. By using an experimental setup which measures the cuff response to mechanically simulated arm pulsations, we find that the cuff can explain part of the NIBP errors in cases of hypotension. Also, we find that pulse waveforms can be estimated using a standard cuff; however, measurement of the pulse volume amplitude is unfeasible. We demonstrate that the observed inaccuracies can be eliminated by usage of a calibrator device which obtains real-time information on TF_cuff. These findings will enable further investigation of the effects related to the pulse travel along the compressed limb and the interaction between cuff, arm tissue, distal arm hemodynamics and arterial walls for the development of improved occlusion-based measurement strategies.