T HE FLUCTUATION of the arterial 3. The relation between the blood pressure vari-
pressure with respiration was first noted ation and the respiratory phase is a function
by Stephen Hales in 1733.1 The subject of respiratory rate. At moderate rates the pres-
has since attracted the attention of many work- sure is falling during most of inspiration. At
ers and has a large literature. In spite of this slower rates inspiration is associated through-
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there are, as we hope to show, aspects of this out with rising pressure. This rate dependence,
apparently simple and easily observed phe- which we have found very regularly, does not
nomenon which remain mysterious. appear to have been widely recognized and
In this article we shall not attempt to review may account for some conflicting statements
the literature. We shall summarize our experi- made in the past. (fig. 3).
ence as a series of propositions supported by 4. Blood pressure swings are enhanced by the
illustrative records, merely indicating the rela- upright posture (fig. 4). The enhancement is
tion of our views to received opinion. We shall associated with an increase in the variation of
then discuss the underlying mechanisms and pulse pressure. The left hand side of the figure
describe some relevant experiments. shows that considerable pressure swings can
occur with little change in pulse pressure.
MATERIAL AND METHODS 5. Sinus arrhythmia does not contribute to
Some 50 records of blood pressure and respiration, the blood pressure swings. This statement is
many with additional information, from normal based on the frequent occurrence of an event
volunteers and from patients with normal circula-
tions, form the basic material of this report. All illustrated in figure 4. Gross arrhythmia sud-
pressures were measured with capacitance manom- denly appears where there has been little change
eters. Chest movements were recorded by a Manning of heart rate in previous respiratory cycles:
spirograph operating either a capacitance or photo- the pressure waves continue their course, the
electric pickup. slowing being compensated for by increased
RESULTS stroke volume. When present, slowing always
1. Abdominal and thoracic breathing have sim- appears in the descending limb of the pressure
ilar effects on the blood pressure (fig. 1). The wave, irrespective of the respiratory phase.
contrary view has often been expressed.2 The 6. During apnea regular pressure waves may
disparity probably arises from a failure to occur (fig. 5). These, which are conveniently
standardize respiratory rate. Unless care is called Traube waves,3 are not associated with
taken most subjects will breathe more deeply material pulse pressure changes unless, as some-
and more slowly with abdominal than with times happens, there is accompanying rate
thoracic respiration. change, when the slowing on the descending
2. The amplitude of the blood pressure swings limb is balanced by an increased pulse pressure.
increases with decreasing respiratory rate (fig. 2). The waves are often fugitive, but when they
This is generally agreed. We have found it to occur their rate is consistently about 6 per
hold down to rates of about 6 per minute. minute.
7. The blood pressure may exhibit fluctuations
From the Department of Medicine, St. Thomas's at a submultiple of the respiratory rate (fig. 6).
Hospital Medical School, London, England. This phenomenon is quite common, but is not
553 Circulation, Volume vI, October 19.58
554 RESPIRATORY VARIATIONS IN BLOOD PRESSURE
fa -
FIG. 1. From above downwards: time in seconds, '---- - .1 Iditn11..Aidh Ari.. Or,.. An. Al .Ai, A.1
INIII~NWIL
thoracic spirogram, abdominal spirogram, blood pres-
sure. The change from thoracic to abdominal breath- 1
i -L
ing does not alter the phase of the blood pressure
variations. In this and in all other figures inspiration FIG. 4. Two sections of a continuous tracing; the
corresponds to a downward movement of the spiro- left hand one with the subject supine, the right hand
gram. one, erect. In the erect posture the fluctuations in
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d11
v
11
vi 11 vh
Ill
D
ll&
Mr
aoo
- 1
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1 1A
will be seen later, the circumstances in which 111lus1uzlt n IiII
Ilt111111111L
the pure patterns occur support these inter-
pretations.
..,. He,,
.,,,, . ,
wve ,!
MECHANISM OF STROKE M\ODULATION
VOLUME
FIG. 7. An interpolated expiratory pause demon-
It is generally agreed that respiratory modu- strates that the fall of pressure accompanying inspira-
lation of stroke volume is produced as follows. tion does not depend on it but on the preceding ex-
Inspiration lowers intrathoracic pressure and piration.
enhances filling of the right heart from the -_-
_Rm
extrathoracic veins. Right ventricular stroke
volume thus increases, and hence the effective
(distending) pressure of the lesser circulation
rises. The rise in effective pressure in the pul-
monary veins leads to increased filling of the
left heart and so to increased left ventricular
stroke volume.
The dynamic implications of this mechanism
have not, so far as we are aware, been recog-
Q^ MM99-----
nized. It can be seen that the resistance and
the hydraulic capacitances of the lesser circula-
tion interpose a "lag" mechanism between FIG. 8. Respiratorv effects during tetraethylani-
inspiration and right ventricular output in- monium blockade. There is no rate change and sys-
crease on theone hand and the rise of effective tolic and diastolic pressure changes are proportionate.
For example, during the first slow' wave systolic and
pulmonary venous pressure and left ventricu- diastolic pressures both increase 25 per cent. This
lar filling on the other. It follows that, for a probably represents pure stroke volume modulation.
given depth of respiration, stroke volume mod-
ulation will decrease with increasing respiratory passive lung inflation, and the dependence of
rate. Moreover, while there is a primary phase the stroke volume on thoracic pressure rather
relationship between inspiration and increased than thoracic posture is thus confirmed (fig. 9).
stroke volume, with increasing rates, the phase The enhancement of stroke volume modulation
.of the stroke volume change will lag increas- by the assumption of the upright posture, which
ingly behind the corresponding respiratory is known to lower right auricular pressure,
phase. It thus comes about that at moderately suggests that the relationship between right
rapid rates stroke volume (and blood pressure) ventricular output and effective filling pressure
is falling throughout most of inspiration, the is not a linear one but is steeper when the
fall being due not to the accompanying in- filling pressure is low.
556 RESPIRATORY VARIATIONS IN BLOOD PRESSURE
of both femoral arteries causes a rise in brachial (and the phase lag decreases) as explained
pressure of 5 to 10 mm. Hg. Rhythmic com- above. Simultaneously the contribution of
pression and release of the arteries over awide peripheral resistance modulation increases as
range of repetition rates failed to evoke any the Traube frequency is approached. A normal
regenerative effects in the three subjects tested. subject achieves maximal blood pressure swings
Figure 10 shows the effect of short isolated by breathing at 6 per minute in the upright
inspirations and expirations (square-wave posture. He thus produces a large stroke volume
breathing). Since whether expiration is followed modulation and reinforces this by resonating
by constriction or dilatation depends on the the Traube oscillator.
repetition rate, it appears that the connection
between resistance change and respiratory act
cannot be a simple one. 'M m ^ m m m m P,%,
One must conclude that the nature of the 1 1W-1 1W1A1
W- hmo h*-, bmd
interaction between respiration and peripheral
resistance remains obscure. However, it is ..
__
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SUMMARY REFERENCES
The normal behavior of the respiratory blood HALES, S.: Statical Essavs. Vol. 2. London, W.
Innys, 1733.
pressure variations with alterations of respira- 2 LEWIS, T.: Studies of the relationship between
tory rate and pattern, and of posture is de- respiration and blood pressure. Part 2. J. Physiol.
37, 233, 1908.
scribed. 3 TRAUBE, L.: Uber periodische Thatickiets-Ausser-
An analysis of the results suggests that vari- ungen des vasomotorischen und Hemmungs-
ation in stroke volume and in peripheral re- Nervacentrums. Centralbl. f.d. med. Wissensch.
3, 881, 1865.
sistance both contribute to the larger swings 4 DORNHORST, A., HOWARD P., AND LEATHART,
of pressure. G. L.: Pulsus paradoxus. Lancet 1: 746 1952.
GUYTON, A., AND HARRIS, I.: Pressoreceptor-auto-
The mechanisms are discussed in the light nomic oscillation: a probable cause of vaso-
of some simple experiments and a formulation motor waves. Am. J. Physiol. 165, 158, 1951.
of the general pattern of their interaction is 6 MIINORSKY, N.: Introduction to Non-Linear Me-
chanics. Ann Arbor, i\Iich., J. W. Edwards,
attempted. 1947, Pp. 323 et. seq.
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Respiratory Variations in Blood Pressure
A. C. DORNHORST, P. HOWARD and G. L. LEATHART
Circulation. 1952;6:553-558
doi: 10.1161/01.CIR.6.4.553
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