Journal of Clinical Monitoring and Computing

, Volume 21, Issue 5, pp 277–282 | Cite as

Impact of Withdrawal of 450 ml of Blood on Respiration-Induced Oscillations of the Ear Plethysmographic Waveform

  • Michael J. Gesquiere
  • Aymen A. Awad
  • David G. Silverman
  • Robert G. Stout
  • Denis H. Jablonka
  • Tyler J. Silverman
  • Kirk H. Shelley



It has been widely appreciated that ventilation-induced variations in systolic blood pressure during mechanical ventilation correlate with changes in intravascular volume. The present study assessed whether alterations in volume status likewise can be detected with noninvasive monitoring (ear plethysmograph) in non-intubated subjects (awake volunteers).


Eight healthy adults were monitored with EKG, noninvasive blood pressure, an unfiltered ear plethysmograph, and a respiratory force transduction belt before (PRE) and after (POST) withdrawal of 450 ml of blood from an antecubital vein. Spectral-domain analysis was used to determine the peak ventilatory frequency and the power of the associated variation in the ear plethysmographic tracing; Interphase differences in the respiration-induced plethysmographic variations were assessed by Wilcoxon signed rank test. In addition, the changes in the ear plethysmographic tracing were compared to changes in heart rate and blood pressure.


There was a significant increase in respiratory-associated oscillations at the respiratory frequency between the PRE and POST phases (p = 0.012). These changes were detected despite lack of changes in heart rate or blood pressure.


Respiration-induced changes of the ear plethysmographic waveform during spontaneous ventilation increase significantly as a consequence of withdrawal of approximately one unit of blood in healthy volunteers.


photoplethysmograph hemodynamic monitoring non-invasive monitoring 


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  1. 1.
    Bilchick KC, Wise RA. Paradoxical physical findings described by kussmaul: pulsus paradoxus, kussmaul’s sign. Lancet 2002; 359: 1940–2PubMedCrossRefGoogle Scholar
  2. 2.
    Jardin F, Farcot J, Gueret P, Prost J, Ozier Y, Bourdarias J. Cyclic changes in arterial pulse during respiratory support. Circulation 1983; 68: 266–74PubMedGoogle Scholar
  3. 3.
    Khan F, Davidson NC, Littleford RC, Litchfield SJ, Struthers AD, Belch JJ. Cutaneous vascular responses to acetylcholine are mediated by a prostanoid-dependent mechanism in man. Vasc Med 1997; 2: 82–6Google Scholar
  4. 4.
    Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology 2005; 103: 419–28PubMedCrossRefGoogle Scholar
  5. 5.
    Morgan B, Crawford W, Guntheroth W. The hemodynamic effects of changes in blood volume during intermittent positive-pressure ventilation. Anesthesiology 1969; 30: 297–305PubMedCrossRefGoogle Scholar
  6. 6.
    Perel A, Pizov R, Cotev S. Systolic blood pressure variation is a sensitive indicator of hypovolemia in ventilated dogs subjected to graded hemorrhage. Anesthesiology 1987; 67: 498–502PubMedCrossRefGoogle Scholar
  7. 7.
    Pizov R, Ya’ari Y, Perel A. Systolic pressure variation is greater during hemorrhage than during sodium nitroprusside-induced hypotension in ventilated dogs. Anesth Analg 1988; 67: 170–4PubMedCrossRefGoogle Scholar
  8. 8.
    Szold A, Pizov R, Segal E, Perel A. The effect of tidal volume and intravascular volume state on systolic pressure variation in ventilated dogs. Intensive Care Med 1989; 15: 368–71PubMedCrossRefGoogle Scholar
  9. 9.
    Pizov R, Segal E, Kaplan L, Floman Y, Perel A. The use of systolic pressure variation in hemodynamic monitoring during deliberate hypotension in spine surgery. J Clin Anesth 1990; 2: 96–100PubMedCrossRefGoogle Scholar
  10. 10.
    Connors A, Speroff T, Dawson N. The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996; 276: 889–97PubMedCrossRefGoogle Scholar
  11. 11.
    Marik PE. The systolic blood pressure variation as an indicator of pulmonary capillary wedge pressure in ventilated patients. Anaesth Intensive Care 1993; 21: 405–8PubMedGoogle Scholar
  12. 12.
    Ornstein E, Eidelman LA, Drenger B, Elami A, Pizov R. Systolic pressure variation predicts the response to acute blood loss. J Clin Anesth 1998; 10: 137–40PubMedCrossRefGoogle Scholar
  13. 13.
    Perel A. Cardiovascular assessment by pressure waveform analysis. ASA Annual Refresher Course Lecture 1991:264Google Scholar
  14. 14.
    Preisman S, Kogan S, Berkenstadt H, Perel A. Predicting fluid responsiveness in patients undergoing cardiac surgery: functional haemodynamic parameters including the respiratory systolic variation test and static preload indicators. Br J Anaesth 2005; 95: 746–55PubMedCrossRefGoogle Scholar
  15. 15.
    Rooke GA, Schwid HA, Shapira Y. The effect of graded hemorrhage and intravascular volume replacement on systolic pressure variation in humans during mechanical and spontaneous ventilation. Anesth Analg 1995; 80: 925–32PubMedCrossRefGoogle Scholar
  16. 16.
    Yamakage M, Itoh T, Iwasaki S, Jeong S-W, Namiki A. Variation of “Pulse amplitude” Measured by a pulse oximeter may help predict intravascular volume Can J Anaesth 2005; 52: 207–8PubMedGoogle Scholar
  17. 17.
    Cohn JN, Pinkerson AL, Tristani FE. Mechanism of pulsus paradoxus in clinical shock. J Clin Invest 1967; 46: 1744–55PubMedGoogle Scholar
  18. 18.
    Dorlas JC, Nijboer JA. Photo-electric plethysmography as a monitoring device in anaesthesia. Application and interpretation. Br J Anaesth 1985; 57: 524–30PubMedCrossRefGoogle Scholar
  19. 19.
    Johansson A, Oberg PA. Estimation of respiratory volumes from the photoplethysmographic signal. Part i: experimental results. Med Biol Eng Comput 1999; 37: 42–7PubMedCrossRefGoogle Scholar
  20. 20.
    Lherm T, Chevalier T, Troche G, Souron V, Samaha T, Zazzo J. Correlation between plethysmography curve variation (dpleth), pulmonary capillary wedge pressure (pcwp) in mechanically ventilated patients. Br J Anaesth 1995; Suppl. 1: 41Google Scholar
  21. 21.
    Partridge BL. Use of pulse oximetry as a noninvasive indicator of intravascular volume status. J Clin Monit 1987; 3: 263–8PubMedGoogle Scholar
  22. 22.
    Shamir M, Eidelman LA, Floman Y, Kaplan L, Pizov R. Pulse oximetry plethysmographic waveform during changes in blood volume. Br J Anaesth 1999; 82: 178–81PubMedGoogle Scholar
  23. 23.
    Golparvar M, Naddafnia H, Saghaei M. Evaluating the relationship between arterial blood pressure changes and indices of pulse oximetric plethysmography. Anesth Analg 2002; 95: 1686–90PubMedCrossRefGoogle Scholar
  24. 24.
    Awad A, Ghobashy MA, Ouda W, Stout RG, Silverman DG, Shelley KH. Different responses of ear and finger pulse oximeter wave form to cold pressor test. Anesth Analg 2001; 92: 1483–6PubMedCrossRefGoogle Scholar
  25. 25.
    Hertzman AB. The blood supply of various skin areas as estimated by the photoelectric plethysmograph. Am J Physiol 1938; 124: 328–40Google Scholar
  26. 26.
    Shelley KH, Jablonka DH, Awad AA, Stout RG, Rezkanna H, Silverman DG. What is the best site for measuring the effect of ventilation on the pulse oximeter waveform? Anesth Analg 2006; 103: 372–7PubMedCrossRefGoogle Scholar
  27. 27.
    Shelley KH, Awad AA, Stout RG, Silverman DG. The use of joint time frequency analysis to quantify the effect of ventilation on the pulse oximeter waveform. J Clin Monit Comput 2006; 20: 81–7PubMedCrossRefGoogle Scholar
  28. 28.
    Shelley KH, Tamai D, Jablonka D, Gesquiere M, Stout RG, Silverman DG. The effect of venous pulsation on the forehead pulse oximeter wave form as a possible source of error in spo2 calculation. Anesth Analg 2005; 100: 743–7PubMedCrossRefGoogle Scholar
  29. 29.
    The acute respiratory distress syndrome network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301–8Google Scholar
  30. 30.
    Morelot-Panzini C, Lefort Y, Derenne JP, Similowski T. Simplified method to measure respiratory-related changes in arterial pulse pressure in patients receiving mechanical ventilation. Chest 2003; 124: 665–70PubMedCrossRefGoogle Scholar
  31. 31.
    Bendjelid K, Suter PM, Romand JA. The respiratory change in preejection period: a new method to predict fluid responsiveness. J Appl Physiol 2004; 96: 337–42PubMedCrossRefGoogle Scholar
  32. 32.
    Reuter DA, Kirchner A, Felbinger TW, Weis FC, Kilger E, Lamm P, Goetz AE. Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. Crit Care Med 2003; 31: 1399–404PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2007

Authors and Affiliations

  • Michael J. Gesquiere
    • 1
  • Aymen A. Awad
    • 1
  • David G. Silverman
    • 1
  • Robert G. Stout
    • 1
  • Denis H. Jablonka
    • 1
  • Tyler J. Silverman
    • 1
  • Kirk H. Shelley
    • 1
  1. 1.Department of AnesthesiologyYale University School of MedicineNew HavenUSA

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