PY 5.

16 : Record Arterial Pulse Tracing using Finger

Plethysmography in a volunteer or simulated environment
At the end of this practical, Phase 1 MBBS student should be able to:

5.16.1 List the different methods of Plethysmography

5.16.2 Explain the principle and procedure of recording Finger Plethysmography

5.16.3 Understand the physiological basis of various waves in a normal arterial pulse waveform

5.16.4 Enumerate various abnormal pulse waveforms

PLETHYSMOGRAPHY
The word plethysmography is derived from the Greek "plethysmos" (increasing, enlarging, becoming full),
and "graphos" (to write).

Plethysmography measures changes in volume in different areas of your body.It is especially effective in
detecting changes caused by blood flow. It measures these changes with blood pressure cuffs or other
sensors. These are attached to a machine called a plethysmograph. Plethysmograph is an instrument
which determines the change in blood flow in the artery with each cardiac cycle, by acquiring the
voluminous changes of the tissue
Plethysmography is not as accurate as an arteriogram, which is more commonly used to identify blood
clots. But it’s less invasive and less expensive.

The gold standard method of arterial pulse pressure waveform acquisition is the Intra-Arterial Probe
method, which is limited by its invasiveness, apart from being complicated and a risky procedure.
Therefore, arterial pulsatile variations acquisition by noninvasive techniques employing either applanation
tonometry or plethysmography is vital.

In the past, Dungeon’s sphygmograph was used to record the pulse tracing.

Various plethysmography techniques have been employed to measure the change in blood volume with
specific transduction techniques which cater to specific applications.
FINGER PLETHYSMOGRAPHY
Finger plethysmography is a well-known technique for the acquisition of arterial pulse waveforms. The
technique involves the acquisition of the volumetric variation of the finger due to pulsatile flow of blood in
the artery, to obtain the arterial pulse waveform of the subject. The fingertip Photoelectric
plethysmography (PPG) signal reflects the blood movement in the vessel, which goes from the centre
(heart) to the end (fingertips) in a wave-like motion. It is affected by the heartbeat, the haemodynamics
and the physiological condition caused by the change in the properties of an arteriole. The effects can be
observed as distortions in the wave profiles.

Different Configurations
IR Plethysmograph – Finger Clip

The Plethysmograph (Finger Clip) is an infrared photoelectric sensor used to record changes in pulsatile
blood flow from a finger or toe. Uses reflected light and works best where the light can reflect from the
bone beneath the tissue.

IR Plethysmograph – Velcro Strap

The Plethysmograph (Velcro Strap) is an infrared photoelectric sensor used to record changes in pulsatile
blood flow from the finger, toe or forehead
PRINCIPLE and PROCEDURE of Photoelectric plethysmography, also known as
photoplethysmography

PPG is easy to set up, convenient, simple and economically efficient compared to the other types of
plethysmograph.
A photoplethysmogram (PPG) is an optically obtained plethysmogram that can be used to detect blood
volume changes in the microvascular bed of tissue. A PPG is often obtained by using a pulse
oximeter which illuminates the skin and measures changes in light absorption. A conventional pulse
oximeter monitors the perfusion of blood to the dermis and subcutaneous tissue of the skin. With
each cardiac cycle the heart pumps blood to the periphery. Even though this pressure pulse is somewhat
damped by the time it reaches the skin, it is enough to distend the arteries and arterioles in the
subcutaneous tissue.  

The photoplethysmogram probe consist of an infrared light source (typically a photodiode emitting light at
a wavelength of around 900 nm) and a photodetector (phototransistor). The light source to illuminate the
tissue (e.g. skin), and a photodetector to measure the small variations in light intensity associated with
changes in the blood vessels volume. The increase in blood volume indicates decrease in light intensity
and vice versa.
Photoplethysmogram

The appearance of the PPG pulse is commonly divided into two phases: the anacrotic phase is the rising
edge of the pulse, whereas the catacrotic phase is the falling edge of the pulse. The first phase is
primarily concerned with systole, and the second phase with diastole and wave reflections from the
periphery. A dicrotic notch is usually seen in the catacrotic phase of subjects with healthy compliant
arteries.
The arterial pulse waveform/ NORMAL PULSE WAVE

The normal pulse wave shows the following components:

a. Percussion Wave or the Anacrotic Limb. This is the sharp upstroke. It is due to expansion of the
artery due to ventricular systole and corresponds to the maximum ejection phase. The leisurely down
stroke is called the catacrotic limb.

b. Tidal Wave. This predicrotic wave is due to elasticity of aorta. It is sometimes recorded soon after
the peak of the tracing.

c. Dicrotic Notch and Wave. These are seen on the descending limb. The notch , the negative wave,
is due to recoil of the elastic aorta that causes the blood column to momentarily sweep back towards
the heart. The reverse flow closes the aortic valve and rebounds from it to cause the positive dicrotic
wave. The systolic and diastolic phases of the ventricle can be indicated on the arterial pulse tracing.
The maximum ejection phase lasts from the upstroke to the peak of percussion wave, while the
reduced ejection phase lasts from the peak to dicrotic notch. Thus, systole is from the upstroke to the
dicrotic notch. The arterial pulse waveform can be separated into three distinct components

A: Normal pulse tracing- P: percussion wave; t: tidal wave; d: dicrotic notch; n: dicrotic wave, t: tidal wave; VS: period of
ventricular systole (aortic valve open); B: Water-hammer (corrigan’s) pulse-showing rapid upstroke and descent. C: Pulse tracing
in aortic stenosis showing a gradual upstroke and slow descent.

Types of Abnormal Arterial Pulse waves

a. Dicrotic Pulse. There are two palpable waves, one in systole, and the other in diastole. It is seen
most commonly in low stroke volume.

b. Corrigan’s, Water-hammer, or Collapsing Pulse. It is characterized by an abrupt rise, and a

sudden fall of the pulse wave in early diastole. It is seen most commonly in aortic regurgitation in which
the incompetent valve cannot close properly to prevent backflow of blood from the aorta back into the
ventricle. The rapid upstroke is due to greatly increased and vigorous stroke volume while the
collapsing is caused by two factors: the diastolic ‘run-off’ of blood back into the left ventricle and the
rapid ‘run-off’ of blood towards the periphery due to low peripheral resistance resulting from arteriolar
dilatation. This type of pulse is also found in patent ductus arteriosus, or a large arterio-venous fistula.
 c. Pulsus Parvus or Slow-rising Pulse. It is a small (parvus = small), weak, pulse which rises slowly
and has a late systolic phase. The weak upstroke is due to decreased stroke volume and a narrow
pulse pressure. It is seen especially in aortic stenosis, left ventricular failure and hypovolemia.

d. Alternating Pulse (Pulsus Alternans). The pulse beats are regular but alternately large and small
in amplitude, i.e. large and small systolic peaks. It is seen in left ventricular failure when the ventricle is
severely diseased. The variation in strength should not be confused with an arrhythmia. The
mechanism, however, is not known.

e. Pulsus Paradoxus. The term describes the marked decrease in pulse volume (and blood pressure)
which occurs on deep inspiration. It is an accentuation of normal physiological fall in systolic pressure
by 8–10 mm Hg. The paradox is that while the pulse may not be felt at the wrist, heart sounds may still
be heard at the precordium. It occurs in patients with large pericardial effusion.

f. Thready Pulse. Thin, thready pulse is a feature of shock and due to decrease in stroke volume.

USES
 Monitoring heart rate and rhythm
 Blood flow monitoring in peripheral vascular disorders
 Angiogenesis
 Sympathetic and parasympathetic nervous system research