Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 87: Considerations of the Automatic Blood Pressure
It would be unfair of me to dismiss automatic blood pressure measurements as they are used in most settings, including the ICU. It’s important to understand their normal guestimate error range and when you should consider taking a manual BP. Similar to manual blood pressures, there are a number of steps you can take to help increase their accuracy. Instead of avoiding the inevitable, let’s empower the clinician to understand their equipment.
Website to check for validated BP machines:
https://www.validatebp.org/devices
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Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopulm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is brought to you by Jane, a clinic management software and EMR. We all know that choosing the right EMR can feel a bit overwhelming, especially when you're just starting out. You're trying to juggle both your practice needs and your budget, and that's not always the easiest combo. That's why Jane came up with a new balance plan. It includes essential features. You need to keep things running smoothly in your clinic without the extra stuff you don't. One-on-one telehealth, unlimited support, email reminders and more are included, no matter which plan you choose. So if you're looking for an EMR that helps you focus on your patients, not your costs, jane is here for you. Plans start as low as $39 a month. Visit janeapp backslash pricing to learn more and if you're ready to get started, use my code cardiopalm1mo at the time of signup for a one month grace period applied to your new account. Thanks again, jane.
Rachele Burriesci:All right, happy day after Thanksgiving is when you're listening to this and in real time we're the day before Thanksgiving. So this is my last all things cardiopulmon task before getting into full on Thanksgiving prep. The house is primarily cleaned, got to do a couple of loose ends in the kitchen and then, of course, the insane stuff that no one actually cares about. I don't know if you're this person that if you're having a holiday or hosting, you go deep on the cleaning, and that is definitely who I am. I need like a holiday every three months to force that deep clean sort of stuff, because you know the surface. The surface cleaning happens on the on the regular, but the deep cleaning, like the baseboard action and the windows, that must happen before the holidays, cause anyone cares about the shriek on the window. Well, windows are done, hoping to mop later today, and then, of course, food prep. So I did good this year.
Rachele Burriesci:Last year was a hot mess. We hosted my family for the first time and we had eight adults staying with us for four days. So, besides the regular holiday prep, we had to have the rooms ready and the bathrooms ready and all of that good stuff, and we were just finishing a huge reno this time last year. It seems like we're in the same sort of cycle all the time, but literally the day that my family arrived, we were drilling in a handrail to the basement before Nikki left for work. So today feels a little more chill in that kind of regard. It's just, you know, the regular, the regular cleaning, the regular food prep kind of stuff.
Rachele Burriesci:We keep trying to figure out how to make Thanksgiving more efficient, and my sister as well. We have these conversations back and forth what, what can you get done the day before? So Thanksgiving runs smoothly. So I think we're in a pretty good groove. This is going to be a very small Thanksgiving this year, just seven to eight adults, which definitely is easier than the 32 that we hosted the first year we were in this house. So it's funny to see how different years have different vibes, but it always kind of has that same get things done before the people come, even though it's the immediate right, like these are the people that are always in the house anyway.
Rachele Burriesci:So, anyway, happy day after Thanksgiving If you don't celebrate happy Black Friday. That is by far not what I'll be doing on Friday. I used to do the whole Black Friday thing back in the day we would go to like Woodbury Commons or there was another outlet mall in Long Island that I'm not pulling the name right now and we would shop like through the night. And then I would drive to my sister's house in Jersey and do like Black Friday with her as well. It's insanity, don't do that. They have made it a little bit easier with the extended sales and all that good stuff, but I went to Costco yesterday just to pick up like two items literally, and I have to tell you I could not get out of that place any faster. It was a zoo. The people were crazy. They couldn't like drive their carts. It felt like the sim was a little bit wild yesterday. So day after Thanksgiving for us is switching gears into Christmas season and we'll be putting up the tree and finishing the lights and all that good stuff. So I really enjoy the day after Thanksgiving. Now it's a good reset after the holiday, kind of switch chapters on seasons and kind of spend a little time with Nikki by myself, which is always fun, just a nice chill day with wifey, all right. So if you listened to last episode, if you haven't go back, take a listen, doesn't matter which order you listen to them in.
Rachele Burriesci:I was talking about improving accuracy with blood pressure, and when I was speaking about that, I was speaking specifically about osculatory technique, this typical blood pressure cuff with the manometer and stethoscope, and we talked about the obliteration technique being a little bit more precise. Today I wanted to flip gears a bit and talk about the automatic blood pressure cuff, and I think this is a question that I get asked quite a bit like which do you prefer? What's more accurate? The truth is, the osculatory with the stethoscope is more specific, it's more accurate, but technically, the gold standard for blood pressure measurement is actually intra-arterial, which is like an arterial line, which is very invasive, right. So on the list of accuracy, we have arterial line, which is going to give you real time, second to second, minute to minute update on that blood pressure. Then you have non-invasive techniques, osculatory technique being top of that list, but technically using a mercury sphygmomanometer say that fast is where that technique came from, and mercury is being phased out because of environmental concerns and things like that. So now they've moved to I believe it's called aneroid blood pressure, which is like that standard manometer and that has been proven to be as accurate as the mercury blood pressures, but those manometers need to be regularly calibrated and so if they're not regularly calibrated then the accuracy can, you know, vary.
Rachele Burriesci:The simplest statement here is that there are pros and cons to each type of measurement. With that being said, automatic blood pressure machines, known as oscillometric blood pressure, is a mainstay way of assessing blood pressure. It's becoming more common in your typical primary care physician office. It's more common for patients to be able to purchase a home blood pressure unit to monitor at home more regularly at different hours of the day. And I think what people forget, especially if you're not in the setting it's the mainstay measurement in the hospital setting, including the ICU. So it would be wrong of me to say that manual blood pressure is the only way, because it's not, and I think we do a disservice with not maybe incorporating more automatic blood pressure discussion and or instruction in the sense of performing. Now, it doesn't take much instruction on how to actually use an automatic machine, but you want to know what. Each machine is a little bit different, especially if you're in the ICU setting. So having those conversations with students and new hires is an important piece From an accuracy perspective.
Rachele Burriesci:There are a number of articles. I went back as far as 2010, and essentially, the automatic blood pressure machines are not as accurate as the osculatory blood pressure technique and not as accurate as the IABP intra-arterial blood pressure readings as well. So the simplest answer is no, the automatic machines oscillatory oscillometric technique isn't as precise. Between 2010 and 2023, there are a number of different studies looking at different um different variables. So one one was a study this was actually a recent one, I think it was a 2022 or 2023 study was actually looking at atrial rhythm and the accuracy with automatic machines taking blood pressures with atrial rhythm versus sinus rhythm compared to an arterial line, and this was an interesting one because essentially, the answer is the automatic machines were still less accurate than the arterial line, but their point was there wasn't much difference between the atrial rhythms and the sinus rhythms, which is interesting because typically you have a harder time with automatic machines reading someone that has an atrial rhythm. So essentially, this article's conversation or discussion was that there wasn't much variability between the rhythms. With that being said, there was still statistically significant difference between the automatic machine and the arterial line.
Rachele Burriesci:And the primary thing that they talked about, which I have seen quite a bit in clinic is the extremes, the ends right, and so this is where I would say, as a clinician if you're getting, if you have someone who has really high blood pressure or you have someone who's really low blood pressure, or the machine keeps recycling, meaning it keeps starting over, keeps pumping back up, it comes down and it recycles back up. That's what I mean by recycle, restarting that's when I'm pulling out a manual blood pressure cuff, I want to use the osculatory technique to check myself and if it's similar, then proceed as normal. The 2023 study that compared it to the arterial blood pressure talked about the automatic machines underestimating high blood pressure and overestimating low blood pressure, and I think, from a clinical significant part, this is really important Because if you have someone who is running very low and their maps are already borderline and that machine is overestimating, then we might be putting that person at more harm in theory or at more at a higher risk for a syncopal episode. On the other end of the spectrum, if they're underestimating high blood pressures, we might be underestimating the risk of hypertensive urgency or risk of stroke. So I think the extremes is a good rationale as to hey, maybe let's check that with the osculatory technique with a manual blood pressure cuff.
Rachele Burriesci:I think this is part of the conversation just in general. But we use these machines regularly and I would be lying to you if I said I did not use an automatic cuff. That is the mainstay in the hospital. You almost rarely can find a manual blood pressure cuff unless it's part of the sometimes specific rooms have them like built into the wall and then there's a lot of limitation on how far you can pull that cuff to. How far you can pull that cuff to. But it is more difficult I have found to find a manual cuff in the hospital. The times that I would be looking for that cuff would be related to very low blood pressure, very high blood pressure and someone who has an arrhythmia, specifically AFib. That one article maybe counters that thought process. So something to keep in mind.
Rachele Burriesci:But from a how do you improve the accuracy of that automatic cuff? It follows the same rules that we talked about last episode. You want to have an appropriate size cuff episode. You want to have an appropriate size cuff. That's first and foremost. If your cuff is too small, you might have an erroneously high blood pressure. If your cuff is too big, you're going to have an erroneously low blood pressure. Arm position that brachial artery should be at the level of the heart, specifically right atrium. If your arm is too low, it can give you an erroneously high. If it's too high, give you an erroneously low. Same rules apply, trying to have your patient rest at least five minutes prior to taking that first blood pressure. If you know having a true resting number is important. Not speaking during that blood pressure, not crossing legs, not eating or having caffeine 30 minutes prior those are all things that can improve the accuracy of the blood pressure, despite the technique that is used.
Rachele Burriesci:One more thing that I want to kind of throw in here this is going to be a short episode today, but it is something that I want to kind of throw in here. This is going to be a short episode today, but it is something that I wanted to kind of broach the topic of If you have someone who has an erroneously or I shouldn't say erroneously a very high number, a very low number. I think a pet peeve of mine is taking a blood pressure until you get one that you like is where I have a bigger problem than if it's a osculatory technique or an automatic machine. There is a point where if you are going to use the equipment, then you have to trust the equipment. If you're going to trust the equipment when it's a number you like, then you have to trust the equipment when it's a number you don't like and instead of taking it until you find a number that you like or putting the cuff in a different location I actually had this happen recently because arms and legs are going to. It's comparing apples to oranges, right, it's not same. It's not same same. So if you, if you were concerned that wow, that's wildly low or wow, that's wildly high I don't know if that was accurate, besides the fact that maybe the person was moving or speaking or whatever, that would be a reason to check with osculatory technique.
Rachele Burriesci:I think technique is important and I also think that consistency is important. So if you're going to be using that automatic machine, then keep comparing that automatic machine and maybe do a side-by-side right to left arm versus, you know, either, you know completely pressing, you know, restart on your blood pressure until you get a number you like, versus making an appropriate clinical decision. I think you also have to look at the person, right? This is where a number can be just a number. I think looking at trends over time is helpful, especially if you're using the same type of machine. I think looking at time of day is helpful because that can play a big role in what type of number you're seeing, and I think that if there is concern then you can do a comparison type machine.
Rachele Burriesci:But you have to look at the person right. If your person's really symptomatic, I actually had an episode recently where a person was post-surgery. They were running pretty soft on their blood pressure. They were orthostatic with the nurse earlier in the day. They were more orthostatic with me after and one of the commentary was well, take the blood pressure on the leg to see if it's accurate. The blood pressure on the leg might be higher than the blood pressure on the arm. But if it's just because it's a number you prefer, then that's not helpful. The person was very symptomatic, the person was pale, the person was very dizzy, the person was more lethargic in standing than sitting.
Rachele Burriesci:Right, looking at the whole picture is always more important than just looking at one number. And try not to get into the situation where you use a number, because I see it happen in practice and I think that's where we falter as clinicians, right? I think if you're going to trust the machine, you have to trust the machine, and if you don't trust the machine, then you need to use an appropriate comparison, right? So if you're taking it on the right arm, well then assess the left arm with the same machine and see if it's wildly different on the right arm. We'll then assess the left arm with the same machine and see if it's wildly different. If it is wildly different, then maybe you need to try with the osculatory technique and see what that comparison is. And if it's same same, then you're trusting that number and that machine did its job. So I do think that we have to just be cautious with that stuff, knowing that there is differences, period and we have to, we have to understand that as well.
Rachele Burriesci:I think my follow-up episodes, I can really kind of dig into some of those research some more, because there's also, you know, differences between wrist, radial versus brachial, versus, like some of the more wearable type items. Now, like you can now take blood pressure with a finger on your phone and get that blood pressure right, like what's the comparison there? And I think those are conversations we have to have. The American Heart Association does still recommend a brachial artery over a wrist or finger oscillometric blood pressure technique period, and so I think knowing that is important.
Rachele Burriesci:I also think it's important to understand difference between a leg blood pressure and an arm blood pressure, because there are times that, for instance, like maybe you have a patient who had bilateral mastectomy and they're limb alert on both arms, or maybe they have a PICC line in one that failed and now they have a patient who had bilateral mastectomy and their limb alert on both arms, or maybe they have a PICC line in one that failed and now they have a new PICC in the other. So you don't have, you know, brachial artery to use and maybe you have to move to a leg femoral type blood pressure. Well then you need to know the difference in that measurement and how it compares. So I think there's still more to kind of dig in here and have a little bit more conversation, because I think it's important as a clinician that if you are asked to take, you know a leg blood pressure versus the arm, because your person's blood pressure is soft, what that actually means Is the number more important or is the whole picture more important? So I just think having these conversations and then actually having these conversations with providers.
Rachele Burriesci:Right, describing the actual symptoms versus just the number is equally important. I mean, I can't tell you how many patients I have that are severely orthostatic and are completely asymptomatic, right, so it's a caution, but it's not a hard stop, and you also have to play the game of understanding where they're trending and what that map is looking like and what are the implications for that as well. So I think you can really play both sides of the number game, but it's just a matter of how you're comparing it to your person and looking at the big picture as the primary point here, right, it's not just a number, it's trends. It's not just a number, it's a human, it's not just a number. There are symptoms or maybe no symptoms, right. I think that's really important. Also, looking at size of a person, right, height, weight plays a role in those numbers as well. And age for that matter. Five, you know 220, and their blood pressure is running 90 over 60, I'm going to be more concerned than my 82 year old female. That's 102 pounds soaking wet, right, it's important to not just look at the number but to look at the person in front of you, and so I'm going to leave you with that.
Rachele Burriesci:If you have any questions, if you have any commentary to this, please reach out to me, shoot me a DM. I am always interested in hearing your experience as well. So, if it is after Thanksgiving, happy belated Thanksgiving. If you don't celebrate and you are a Black Friday type of person, happy Black Friday. Cyber Monday is coming too, and I hope you had a wonderful holiday regardless, and had time to enjoy family and friends, because I do think that is the most important part of this next chapter in this next season. So I hope you all have a wonderful day, a wonderful week, enjoy your time and whatever you have to do, even if it's putting up the Christmas tree, get after it.
