Comparative Study: Oscillometric And Auscultatory Blood Pressure Essay.

Discuss about the Oscillometric And Auscultatory Blood Pressure.

The essay focuses upon the concept of evidence based practices in nursing care. The evidence based practise methods helps in redesigning a safe, efficient and effective care. It helps the practitioners approach questions related to health care in an evaluative and qualitative manner. A study has been conducted in the assignment researching the benefits of using automated device for measuring the blood pressure of children in hospitals rather than manual devices. There are different school of thoughts both stating for and against the use of automated measurement devices over the manual ones. The question raised here has been supported through sufficient evidences and resources which have been further critically reviewed for reliability and validity. 

The blood pressure can be measured using both manual and automated measuring techniques. The manual device is also known as the auscularity device whereas the automated device is known as oscillometric device. As commented by Myers (2014), measuring accurate blood pressure helps in monitoring the proper functioning of different body systems and organs. The erroneous blood pressure measurement may result in wrong treatments being administered to the patients. Therefore, acute measurements procedures and techniques need to be developed. The focus of the assignment is use of automated blood pressure devices over manual devices for measuring the blood pressure of children within hospitals. A number of arguments have been placed in favour of use of the automated techniques over manual measurement processes. As commented by Mansoor  et al.(2016), the automated readings helps in representing the true blood pressure because of the built-in deflation rate of the device. However as argued by Daskalopoulou  et al.(2015), the clinicians suggest occasional checking of the automated blood pressure readings against the mercury sphygmomanometer. This is done to remove the chances of any errors which may have crept during the process of blood pressure measurement. However, finding the right size of cuff for accurate measurement of blood pressure in children often becomes difficult (Lin, Chang, Chou & Lin, 2014). Therefore, the emphasis is shifted upon the use of automated blood pressure measurement devices with a built-in deflation rate.

The research has been further substantiated with the help of developing a proper research question. The question has been developed in the PICO format where the P stands for Population, I stand for intervention, C stands for comparison and O stands for Outcome. Therefore, the question which can be raised over here is:  “Is using an automated blood pressure monitoring system (I) on children (P) more accurate in monitoring the level of blood pressure (O) compared to manual sphygmomanometers (C)?

Locating the evidence

A number of evidence bases have been referred to in order to retrieve adequate information regarding the benefits of choosing automated blood pressure measuring techniques over manual sphygmomanometers. In order to understand the differences one needs to develop sufficient idea regarding the different types of blood pressure measuring devices, their functioning and efficiencies. The blood pressure is divided into two components- systolic and diastolic pressure. The systolic pressure is when the heart is pumping and the diastolic pressure is recorded when the heart is at rest. In this respect, mercury sphygmomanometers are one of the old school manual methods of measuring blood pressure. The physician has to manually inflate or deflate the cuffs around the arm till the systolic and diastolic pressures are recorded (Benmira et al., 2016). However as argued by Chu  et al.(2017), there are a number of limitations of using the manual method of recording blood pressure such as  appropriate adjustment of the cuff  while measuring the blood pressure. Children have thin arms resulting in loose fitting of the cuff, which often results in erroneous recording of blood pressure.  Additionally, the children often become impatient during manual recording of the blood pressure which takes longer. The automatic recording of blood pressure takes lesser time comparatively. The inflatable part of the cuff needs to cover atleast 80% of the part of the patient’s arm (Neuhauser, Ellert, Thamm & Adler, 2015). A child’s cuff measures less than 24 cms in diameter. Therefore, using a large cuff may result in low blood pressure readings. However as argued by Benmira  et al.(2016) most of the hospitals lack different sized cuffs which affects accurate measurements.

As commented by Lin  et al. (2016), fraudulent marking of the lower meniscus of mercury can also result in inaccurate measurements being taken. Another variation which can be used over here is an aneroid sphygmomanometer. The features of the devices are similar to mercury sphygmomanometer excepting that here instated of using mercury for recording the blood pressure, a dial gauge is used, which is connected to the cuff. As argued by Neuhauser, Ellert, Thamm & Adler (2015), the dial gauge of the aneroid sphygmomanometers requires recalibration on a frequent basis further questioning the accuracy of the device. The automated blood pressure monitoring device measures the oscillations of the arteries using pressure sensors. The oscillations are processed using an algorithm to convert them into systolic and diastolic values which are displayed on a digital interface. The electronic sensors attached with the cuff can accurately sense the systole and diastole pressures which control the deflation rate tightly (Duncombe, Voss & Harris, 2017). Moreover, slight movement during the measurement of the blood pressure also affects the recording. Most of the times the children fail to sit quietly during the process of blood pressure monitoring resulting in false pressure data.

Appraising the evidence

Diagram:  Flowchart depicting the process of blood pressure monitoring in children

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There are contradictory opinions regarding the use of automated digital sphygmomanometer versus manual sphygmomanometers for measuring blood pressure. There are a number of limitations of the use of automatic digital sphygmomanometers such as faulty built-in –deflation rate. As commented by Rinfret  et al. (2017), the devices have to be checked against the manual sphygmomanometers in the initial stage to ascertain the accuracy of readings. The installation of the devices requires huge amount of expenditures such as investment behind battery replacements. As mentioned by Flynn  et al. (2017), for large arm cuffs the devices have to be connected to an AC adaptor.  The high cost associated with the devices does not restrict the purchasing ability of the same.  As argued by De Caen  et al. (2015), the blood pressure reading is also affected by the general health conditions of the patient. For example, the ones suffering from hypertension might depict elevated levels of mercuric pressure. The problem situation may be further analysed to find out the presence of some other health concerns such as presence of high cholesterol content in the blood. This results in narrowing of the blood vessels resulting in high pressure of blood within the arteries. As argued by Franssen  et al. (2017), the chances of   human errors in automatic digital sphygmomanometers is minimum as most of the critical operations are performed automatically.

Another concern which has been raised by experienced physicians regarding the manual sphygmomanometers usage has been termed as clinical inertia. As mentioned by Daskalopoulou  et al. (2015), a physician can heat the onset of the korotkoff sounds somewhere between 140 and 138. Therefore, in most cases the physician to choose upon a particular number. Therefore, the diagnosis often takes a hypothetical turn which may affect the quality of the care services. However, as argued by Neuhauser, Ellert, Thamm & Adler (2015), children have higher level of foetal haemoglobin which has less oxygen carrying capacity. In order to cope up with the deprivation the heart has to pump more blood which raises the normal blood pressure level. Therefore, along with the recording techniques in place certain degree of medical expertise is also required. As argued by Rinfret  et al. (2017), wrong interpretation of the results may affect the particular treatment methods being administered to the child.

Table: search criteria for evidence-based articles

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The manual sphygmomanometers are the most accepted old school method of monitoring and recording blood pressure. A loose end in the cuff of a blood pressure monitoring device may result in the recording of wrong results (Sheppard et al., 2014). On the other hand the automated blood pressure monitoring devices work with the help of electronic sensors and sense the systolic and diastolic pressure automatically at the same controlling the deflation rate. However, the automated devices require huge amount of investments making it difficult for maximum number of hospitals to purchase them (Benmira et al., 2016). Therefore, most of the hospitals are still using the manual methods of blood pressure recording. Thus, both the methods need a certain amount of medical expertise which will help in focussing upon the general health condition of the patient before arriving at a result.  Additionally, maintaining standard cuff sizes will help in measuring the blood pressure accurately across a wide age group (De Caen et al., 2015). The devices should be calibrated frequently to provide accurate results along with   controlling the cost of the medical equipments and devices. 

Conclusion

In this respect, a number of issues have been identified with both the manual and the automated methods of blood pressure recording. However, the accuracy is dependent upon the cuff sizes which are different depending upon the age and health of an individual. A healthy individual may require a wider cuff whereas a lean child may need a thinner cuff.  The automated blood pressure monitoring devices though easier to use specially with the children requires huge investments. Therefore, there are loopholes pertaining to the use of both the device and requires suitable policies and intervention strategies. 

References

Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179-189.

Chu, G., Zhang, Z., Xu, M., Huang, D., & Dai, Q. (2017). Validation of a smartphone auscultatory blood pressure kit Accutension XYZ-110 in adults according to the ANSI/AAMI/ISO 81060-2: 2013 standard. Blood pressure monitoring, 22(5), 290-294.

Daskalopoulou, S. S., Rabi, D. M., Zarnke, K. B., Dasgupta, K., Nerenberg, K., Cloutier, L., ... & McKay, D. W. (2015). The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Canadian Journal of Cardiology, 31(5), 549-568.

De Caen, A. R., Berg, M. D., Chameides, L., Gooden, C. K., Hickey, R. W., Scott, H. F., ... & Schexnayder, S. M. (2015). Part 12: pediatric advanced life support. Circulation, 132(18 suppl 2), S526-S542.

Duncombe, S. L., Voss, C., & Harris, K. C. (2017). Oscillometric and auscultatory blood pressure measurement methods in children: a systematic review and meta-analysis. Journal of hypertension, 35(2), 213-224.

Flynn, J. T., Kaelber, D. C., Baker-Smith, C. M., Blowey, D., Carroll, A. E., Daniels, S. R., ... & Gidding, S. S. (2017). Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics, p.1904.

Franssen, M., Farmer, A., Grant, S., Greenfield, S., Heneghan, C., Hobbs, R., ... & Milner, S. (2017). Telemonitoring and/or self-monitoring of blood pressure in hypertension (TASMINH4): protocol for a randomised controlled trial. BMC cardiovascular disorders, 17(1), 58.

Lin, Z. M., Chang, C. H., Chou, N. K., & Lin, Y. H. (2014, April). Bluetooth Low Energy (BLE) based blood pressure monitoring system. In Intelligent Green Building and Smart Grid (IGBSG), 2014 International Conference on (pp. 1-4). IEEE.

Myers, M. G. (2014). Replacing manual sphygmomanometers with automated blood pressure measurement in routine clinical practice. Clinical and Experimental Pharmacology and Physiology, 41(1), 46-53.

Neuhauser, H. K., Ellert, U., Thamm, M., & Adler, C. (2015). Calibration of blood pressure data after replacement of the standard mercury sphygmomanometer by an oscillometric device and concurrent change of cuffs. Blood pressure monitoring, 20(1), 39-42.

Rinfret, F., Cloutier, L., L'Archevêque, H., Gauthier, M., Laskine, M., Larochelle, P., ... & Van Nguyen, P. (2017). The gap between manual and automated office blood pressure measurements results at a hypertension clinic. Canadian Journal of Cardiology, 33(5), 653-657.

Sheppard, J. P., Holder, R., Nichols, L., Bray, E., Hobbs, F. R., Mant, J., ... & McManus, R. J. (2014). Predicting out-of-office blood pressure level using repeated measurements in the clinic: an observational cohort study. Journal of hypertension, 32(11), 2171.