ABSTRACT

BASES AND OBJECTIVES:

This is a study on the

sphygmomanometer and its
calibration.
 BLOOD pressure levels have an important relationship to cardiovascular disease. Since
hypertensive disease has such a high prevalence in our population, identification of individuals
with high levels of blood pressure becomes critical for early management. Large differences
observed in blood pressure levels may often be caused by methodological differences
instrumentation, observer bias, or the excitement and anxiety of the client.

 This then calls for the use of the sphygmomanometer.

Sphygmomanometer is mainly related to the measurement of blood pressure and pulse rate.

The word comes from the Greek word ‘sphygmós’ (pulse), plus the scientific term manometer
(pressure meter) .

 The device was invented by Samuel Siegfried Karl Ritter von Basch. Scipione Riva-Rocci, an
Italian physician, introduced a more easily used version in 1896. Harvey Cushing discovered this
device in 1901 and popularised it.

 The sphygmomanometer is used in combination with the stethoscope.

(Stethoscope is an instrument used for auscultation—that is, to detect and study sounds arising
within organs such as the heart, lung, and stomach prior to treatment. )
 The sphygmomanometer is to check for the pressure whiles the stethoscope is to check for
the pulse rate.

A sphygmomanometer usually consists of an inflatable cuff, a measuring unit (the mercury

manometer), a tube to connect the two, and (in models that don't inflate automatically) an
inflation bulb also connected by a tube to the cuff. The inflation bulb contains a one-way valve
to prevent inadvertent leak of pressure while there is an adjustable screw valve for the
operator to allow the pressure in the system to drop in a controlled manner.

 A modified sphygmomanometer can also be used to check for muscle force.

A modified sphygmomanometer is made when a conventional sphygmomanometer is

adapted by removing the outer sleeve of the cuff, folding the remaining inflatable bladder in
thirds, and inserting the bladder into a cotton casing (12.5 X 9 X 1.5 cm).9 The modified
sphygmomanometer is then placed in a position to resist the movement caused by the muscle
group to be measured, and the force exerted by the patient is read from the dial.
 OPERATION OF THE SPHYGMOMANOMETER

The cuff is normally placed around the upper right arm, at roughly the same vertical height as
the heart while the subject seated with the arm supported. The cuff is inflated until the artery is
completely occluded. As a result, the vessel is squeezed closed, and its blood flow is stopped. At
this moment, if the diaphragm of the stethoscope is placed over the brachial artery at the distal
border of the cuff, no sounds can be heard from the vessel because blood flow is interrupted.
Listening with a stethoscope to the brachial artery at the elbow, the examiner slowly releases
the pressure in the cuff. As the pressure in the cuffs falls, a "whooshing" or pounding sound is
heard when bloodflow first starts again in the artery. This is due to the opening of the brachial
artery enough for small amount of blood to spurt through when the cuff pressure is
approximately equal to the systolic blood pressure. The pressure at which this sound began is
noted and recorded as the systolic blood pressure. The sound is known as Korotkoff’s sound. The
pressure in the cuff can be expressed in millimeters of mercury.

As the cuff pressure continues to drop, a series of increasingly louder sounds can be heard.
Then, when the cuff pressure is approximately equal to that within the opened artery the
sounds become abruptly muffled and disappears. The height of the mercury column when the
Sounds become abruptly muffled represents the arterial diastolic pressure. It measures the total
pressure (or the Bernoulli pressure), which in fact is the sum of the static pressure (which
usually is of main importance) in addition to dynamic pressure and hydrostatic pressure
difference.
However, dynamic pressure is usually of neglectable size, and the hydrostatic pressure difference
may be eliminated by holding the arm (or part being measured on) on the same height as the
heart.
The results are reported as a fraction, such as 120/80. In this notation, the upper number
indicates the systolic pressure in mm Hg, and the lower indicates the diastolic pressure in mm
Hg.
The difference between the systolic and the diastolic pressure, which is called the pulse
pressure is generally about 40 mm Hg.
The average pressure in the arterial system represents the force that is effective throughout the
cardiac cycle for driving blood to the tissues. This force is called the mean arterial pressure
(MAP) an is approximated by adding the diastolic pressure(DP) and one – third of the pulse
pressure(PP).
Hence

MAP=DP + 1/3PP
 Basically, there two main types

1. Manual
2. Digital

Digital
Digital non-portable with manual or automatic inflation. These are electronic, easy to operate
and practical in noisy environments. Many have not been validated for all patient groups, and
can give very inaccurate readings).They measure mean arterial pressure (MAP) and use
algorithms to calculate systolic and diastolic values. In this sense, they do not actually measure
the blood pressure, but derive the readings.
Digital portable wrist blood pressure monitors with automatic inflation. These are more
convenient for travel purposes.
Digital portable finger blood pressure monitors with automatic inflation. Again these too are
more portable and easy to operate. They are noted as being the smallest blood pressure
monitors around.
E.g.
Manual
Manual (older fashioned, though more precise). Must be operated by a trained person. Mercury
manometers are considered to be the "gold standard" of measurement because they do not go
out of calibration.
For this reason they are often required in clinical trials of pharmaceuticals and for clinical
evaluations of determining blood pressure for high risk patients including pregnant women.
Aneroid, mechanical, types are in common use, but should be checked against a mercury
manometer if they are suspected to be out of calibration.
E.g.
 CALIBRATION OF THE SPHYGMOMANOMETER

•Systematic errors in blood pressure measurements caused by inadequate

sphygmomanometer calibration are a common cause of over- and under –
identification of diseases such as hypertension. Good sphygmomanometer calibration
will contribute to reducing the burden of cardiovascular diseases.

All measurements are contaminated by errors that may be divided into two types:
• random errors are different on every occasion and can be reduced by averaging a
number of measurements (random variation caused by biological variability is usually
indistinguishable from random measurement error and is also reduced by averaging),
and
• systematic errors, which have approximately the same value on every occasion and
are not reduced by averaging.
Inadequate sphygmomanometer calibration is a common cause of systematic error in
BP measurements. Systematic errors are difficult to detect and correct. The only way
to reduce systematic errors is to use the correct measurement technique and well
calibrated instruments.
•Talking about manual sphygmomanometers, specifically mercury and aneroid ;
Several studies indicate that substantial proportions of sphygmomanometers in
general practices and hospitals exhibit clinically significant (>3 mmHg) systematic
pressure errors and other faults. Some guidelines implicitly assume that mercury
sphygmomanometers never require calibration. While aneroid sphygmomanometers
fare worse than mercury instruments, many studies have found significant errors in
mercury sphygmomanometers.
Mercury sphygmomanometers
The mercury sphygmomanometer is a simple and accurate device that can be
serviced easily, but concerns rightly exist about the toxicity of mercury for people
who use mercury sphygmomanometers and those who service them. The greatest
concern about mercury, however, is its toxic effect on the environment, and mercury
increasingly is being banned from use in medicine.
Aneroid sphygmomanometers
Aneroid sphygmomanometers register pressure through a bellows and lever system
that is more intricate mechanically than the mercury reservoir and column. The jolts
and bumps of everyday use affect accuracy over time, which usually leads to falsely
low readings and thus underestimations of blood pressure. They are therefore less
accurate in use than mercury sphygmomanometers. Moreover, aneroid
sphygmomanometry is also prone to all the problems of the auscultatory technique.
As mercury sphygmomanometers are removed from clinical practice, people tend to replace
them with aneroid devices on the false assumption that they are equally accurate.

Features and weaknesses common to mercury and aneroid sphygmomanometers

Features
• Inflation-deflation system
• Occluding bladder encased in a cuff
• Auscultation of Korotkoff sounds with stethoscope
• Connecting rubber tubing

Weaknesses
• Defective control valve—leakage:
—Underestimation of systolic blood pressure
—Overestimation of diastolic blood pressure
• Leaks as a result of cracked or perished rubber:
—Mercury fall cannot be controlled
• Inadequate tubing:
—Minimum length of 70 cm between cuff and manometer
—Minimum length of 30 cm between pump and cuff
• Connections not airtight
 Criteria to consider when selecting a calibration interval:

• the probability that the sphygmomanometer will go out of calibration to a clinically

significant extent between calibrations.

• the consequences of discovering that a sphygmomanometer has a clinically

significant calibration error.

• the cost of calibration.

•The calibration interval also depends on the robustness of the instrument and the conditions
under which it is used. If an instrument proves to be stable after several calibration cycles it is
possible to increase the calibration interval with caution and due consideration of the risks of
erroneous measurements. Conversely, if large calibration errors are found, the interval should be
reduced or the instrument replaced.
Sphygmomanometers should be checked for the following:
• air leakage
• rapid exhaust time
• the condition of cuff, tubes, bulb and fittings
• scale visibility
• contamination of the glass tube or mercury
• cuff inflation and deflation control
• security of mercury containment.

ALL SPHYGMOMANOMETERS ARE CHECKED AT TWO PRESSURES. E.G. ( 0 and 100 mm Hg)

In practice, checking ‘sphygs’ include the following:

• if the sphygmomanometer is electronic set it to a mode in which pressure is continuously
displayed
• using Y-connectors and leak free tubing connect the reference manometer to the
sphygmomanometer pressure inlet and a sphygmomanometer bulb.
• with the valve open check that the reference manometer displays zero and record the
pressure indicated by the sphygmomanometer
• increase the pressure to approximately 200 mmHg and deflate slowly, stopping when the
reference manometer indicates approximately 100 mmHg
• record and compare the pressures indicated on the reference manometer and on the
sphygmomanometer
• open the valve so the pressure decreases to zero over 2–3 seconds and check that the
reference manometer displays zero pressure
• record the pressure indicated by the sphygmomanometer.

Error of the pressure indicator should be 1 mmHg or less. Good quality mercury and electronic
pressure indicators should be capable of achieving this performance.

Recommended calibration and check intervals for mercury, aneroid and electronic
sphygmomanometers
Type of instrument Calibration Check interval(months)

•Mercury sphygmomanometers that 36 6

are permanently fixed to an immovable
object

•Portable mercury sphygmomanometers 12 6

•Aneroid sphygmomanometers used 6 1

in a consulting room 6 1

•Aneroid sphygmomanometers 6 0.5

carried around daily 6 0.5

•Electronic oscillometric sphygmomanometers 12 6

•Electronic manual sphygmomanometers 12 6
Stroke and cardiovascular disease are devastating for the patient and contribute substantially to
the burden of diseases all over the world. Inappropriate antihypertensive treatment increases
the cost of health care, decreases the quality of life of patients, and exposes patients to
potential adverse effects of treatment.
Inadequate sphygmomanometer calibration results in untreated hypertension in some patients,
and in some patients, receiving antihypertensive treatment they would not otherwise receive.
Traceable calibration of sphygmomanometers will increase the direct costs of running a clinical
practice but the resulting reduction in over- and under - detection of hypertension has been
shown to be equivalent to the reduction that would be obtained from additional visits of every
patient to their doctors.