Several BP measurement methods are now available. The main methods include catheterization, auscultation, oscillometry, volume clamping, and tonometry.
Catheterization is the gold standard method [6 (link)]. This method measures instantaneous BP by placing a strain gauge in fluid contact with blood at any arterial site (e.g., radial artery, aorta). However, the method is invasive.
Auscultation, oscillometry, and volume clamping are noninvasive methods. These methods employ an inflatable cuff.
Auscultation is the standard clinical method [7 (link)]. This method measures systolic and diastolic BP by occluding an artery with a cuff and detecting the Korotkoff sounds using a stethoscope and manometer during cuff deflation. The first sound indicates the initiation of turbulent flow and thus systolic BP, while the fifth sound is silent and indicates the renewal of laminar flow and thus diastolic BP.
Oscillometry is the most popular non-invasive, automatic method [8 (link), 9 (link)]. This method measures mean, diastolic, and systolic BP by also using a cuff but with a pressure sensor inside it. The measured cuff pressure not only rises and falls with cuff inflation and deflation but also shows tiny oscillations indicating the pulsatile blood volume in the artery. The amplitude of these oscillations varies with the applied cuff pressure, as the arterial elasticity is nonlinear. The BP values are estimated from the varying oscillation amplitudes using the empirical fixed-ratios principle. When evaluated against auscultation using an Association for the Advancement of Medical Instrumentation (AAMI) protocol, some oscillometric devices achieve BP errors within the AAMI limits of 5 mmHg bias and 8 mmHg precision [10 ]. However, oscillometry is unreliable in subjects with certain conditions such as atrial fibrillation, stiff arteries, and pre-eclampsia [11 ].
Volume clamping is a non-invasive, automatic method used in research [12 (link), 13 ]. This method measures instantaneous (finger) BP by using a cuff and a photoplethysmography (PPG) sensor to measure the blood volume (see Section V.A). The blood volume at zero transmural pressure is estimated via oscillometry. The cuff pressure is then continually varied to maintain this blood volume throughout the cardiac cycle via a fast servo-control system. The applied cuff pressure may thus equal BP. Volume clamping devices also achieve BP errors within AAMI limits when evaluated against auscultation and near AAMI limits when evaluated against radial artery catheterization [14 (link)].
However, cuff use has several drawbacks. In particular, cuffs are cumbersome and time consuming to use, disruptive during ambulatory monitoring, especially while sleeping, and do not readily extend to low resources settings.
Tonometry is another non-invasive method used in research that, in theory, does not require an inflatable cuff [15 , 16 ]. This method measures instantaneous BP by pressing a manometer-tipped probe on an artery. The probe must flatten or applanate the artery so that its wall tension is perpendicular to the probe. However, manual and automatic applanation have proven difficult. As a result, in practice, the measured waveform has been routinely calibrated with cuff BP whenever a BP change is anticipated [17 (link)].
In sum, the existing BP measurement methods are invasive, manual, or require a cuff. So, none are suitable for ubiquitous (i.e., ultra-convenient, unobtrusive, and low cost) monitoring.
Catheterization is the gold standard method [6 (link)]. This method measures instantaneous BP by placing a strain gauge in fluid contact with blood at any arterial site (e.g., radial artery, aorta). However, the method is invasive.
Auscultation, oscillometry, and volume clamping are noninvasive methods. These methods employ an inflatable cuff.
Auscultation is the standard clinical method [7 (link)]. This method measures systolic and diastolic BP by occluding an artery with a cuff and detecting the Korotkoff sounds using a stethoscope and manometer during cuff deflation. The first sound indicates the initiation of turbulent flow and thus systolic BP, while the fifth sound is silent and indicates the renewal of laminar flow and thus diastolic BP.
Oscillometry is the most popular non-invasive, automatic method [8 (link), 9 (link)]. This method measures mean, diastolic, and systolic BP by also using a cuff but with a pressure sensor inside it. The measured cuff pressure not only rises and falls with cuff inflation and deflation but also shows tiny oscillations indicating the pulsatile blood volume in the artery. The amplitude of these oscillations varies with the applied cuff pressure, as the arterial elasticity is nonlinear. The BP values are estimated from the varying oscillation amplitudes using the empirical fixed-ratios principle. When evaluated against auscultation using an Association for the Advancement of Medical Instrumentation (AAMI) protocol, some oscillometric devices achieve BP errors within the AAMI limits of 5 mmHg bias and 8 mmHg precision [10 ]. However, oscillometry is unreliable in subjects with certain conditions such as atrial fibrillation, stiff arteries, and pre-eclampsia [11 ].
Volume clamping is a non-invasive, automatic method used in research [12 (link), 13 ]. This method measures instantaneous (finger) BP by using a cuff and a photoplethysmography (PPG) sensor to measure the blood volume (see Section V.A). The blood volume at zero transmural pressure is estimated via oscillometry. The cuff pressure is then continually varied to maintain this blood volume throughout the cardiac cycle via a fast servo-control system. The applied cuff pressure may thus equal BP. Volume clamping devices also achieve BP errors within AAMI limits when evaluated against auscultation and near AAMI limits when evaluated against radial artery catheterization [14 (link)].
However, cuff use has several drawbacks. In particular, cuffs are cumbersome and time consuming to use, disruptive during ambulatory monitoring, especially while sleeping, and do not readily extend to low resources settings.
Tonometry is another non-invasive method used in research that, in theory, does not require an inflatable cuff [15 , 16 ]. This method measures instantaneous BP by pressing a manometer-tipped probe on an artery. The probe must flatten or applanate the artery so that its wall tension is perpendicular to the probe. However, manual and automatic applanation have proven difficult. As a result, in practice, the measured waveform has been routinely calibrated with cuff BP whenever a BP change is anticipated [17 (link)].
In sum, the existing BP measurement methods are invasive, manual, or require a cuff. So, none are suitable for ubiquitous (i.e., ultra-convenient, unobtrusive, and low cost) monitoring.