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Measuring the Jugular Venous Pressure: Do Not Turn the Head!

  • David L. Jardine
    Correspondence
    Requests for reprints should be addressed to David Jardine, MD, University of Otago, Riccarton Ave, Christchurch, Canterbury 8021, New Zealand.
    Affiliations
    Department of Medicine, Christchurch School of Medicine, University of Otago, Christchurch, New Zealand

    Department of General Medicine
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  • Philip Adamson
    Affiliations
    Department of Medicine, Christchurch School of Medicine, University of Otago, Christchurch, New Zealand

    Department of Cardiology, Christchurch Hospital, Canterbury District Hospital Board, Christchurch, New Zealand
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  • Ian G. Crozier
    Affiliations
    Department of Cardiology, Christchurch Hospital, Canterbury District Hospital Board, Christchurch, New Zealand
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Published:February 03, 2022DOI:https://doi.org/10.1016/j.amjmed.2021.12.024
      On the acute medical ward, reliable bedside assessment of the patient's central blood volume is just as important now as it ever was. As the prevalence of heart failure increases, more elderly patients are being admitted with acute dyspnea secondary to volume overload. The best way to estimate blood volume at bedside is to measure the jugular venous pressure.

      McKenzie J. The Study of the Pulse, Venous, Arterial, and Hepatic, and of the Movements of the Heart. 1st ed Edinburgh: Young J Pentland; 1902: Part II, Pulsations in the veins and liver; Chapter 16, General introduction: P175–180.

      • Lewis T
      Early signs of cardiac failure of the congestive type.

      Strachan M, Ralston SH, Penman I, Hobson R, eds. Davidsons Principles and Practice of Medicine, 23rd ed. Chapter16; Cardiology, Newby DE, Grubb NR: 441–544. Philadelphia: Elsevier; 2018. p. 443.

      Baker T, Nikolic G, O'Connor S. Practical Cardiology. 2nd ed London: Churchill Livingston; 2008: Chapter 7, The patient with dyspnoea:254--284.

      Tally NJ, O'Connor S. Clinical Examination. 8th ed Philadelphia: Elsevier; 2018: Chaper 5, The cardiac examination:74--108.

      Just as important as the high jugular venous pressure in the dyspneic patient is the low jugular venous pressure in the hypotensive patient. Falls and postural symptoms are also common presentations, usually secondary to central hypovolemia. Common causes include infection, bleeding, and dehydration, often exacerbated by medications for heart failure and hypertension. In these patients the jugular venous pressure must be accurately assessed prior to decreasing diuretic and vasodilator treatment. During bedside teaching, students often struggle to confidently identify the jugular venous pressure waveform and appear doubtful when it is clearly demonstrated. The jugular venous pressure is measured vertically from the sternal angle to the top of the waveform (normal level 0-3 cm), but it should be remembered that this value underestimates central venous pressure when the chest is hyperexpanded.
      • Stein JH
      • Neuman A
      • Marcus RH
      Comparisons of estimates of right atrial pressure by physical exam and echocardiography in patients with congestive heart failure and reasons for discrepancies.
      Doctors of all grades frequently fail to estimate the level and significance of an abnormal jugular venous pressure.
      • Cook JD
      • Simel DL
      The Rational Clinical Examination. Does this patient have abnormal central venous pressure?.
      • Drasner MH
      • Rame JE
      • Stephenson LW
      • Dries DL
      Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure.
      • Chernomordik F
      • Berkovitch A
      • Schwammenthal E
      • et al.
      Short- and long-term prognostic implications of jugular venous distension in patients hospitalized with acute heart failure.
      Finding the top of the waveform is often difficult when the venous pressure is very high or very low, and harder when the neck is muscular, hairy, wrinkled, or jowled and the patient is dyspneic, swallowing, talking, or actively moving the head.
      • Cook JD
      • Simel DL
      The Rational Clinical Examination. Does this patient have abnormal central venous pressure?.
      ,
      • Brennan JM
      • Blair J
      • Goonewardena S
      • et al.
      A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure.
      The visibility of the jugular veins may be improved by changing the angle of observation and incident light, or by increasing intrathoracic pressure, for example, during expiration.
      • Assavapokee A
      • Thadanpion K
      Examination of the neck veins.
      How should the jugular venous pressure be examined? First and foremost, the neck muscles must be relaxed by supporting the head in a neutral position. The original observers of the jugular venous pressure (McKenzie and Lewis

      McKenzie J. The Study of the Pulse, Venous, Arterial, and Hepatic, and of the Movements of the Heart. 1st ed Edinburgh: Young J Pentland; 1902: Part II, Pulsations in the veins and liver; Chapter 16, General introduction: P175–180.

      ,
      • Lewis T
      Early signs of cardiac failure of the congestive type.
      ) stated clearly that the head should not be rotated or over-extended. Finally, the trunk should be flexed to whatever angle makes the venous waveform most obvious, usually between 30° and 45°.
      • Assavapokee A
      • Thadanpion K
      Examination of the neck veins.
      If the jugular venous pressure is not easily seen because central venous pressure is low, the waveform will become visible only when the neck veins are lowered to the level of the heart by lying the patient down. Ideally, this should be done passively and gradually, using the electronic tilt of the bed head-end, while continuing to observe the neck. Any new waveform appearing during this maneuver is, by definition, venous. The same principle applies when venous pressure is high and the waveform is brought into view by passively flexing the trunk to 90°.
      When looking for the jugular venous pressure waveform, the position of the head is crucial. The external jugular veins lie outside the sternal head of the sternocleidomastoid muscle and so are often more easily seen than the internal jugular veins, which are partially buried in the gutter medial to the sternal head of the sternocleidomastoid (Figure).
      • Assavapokee A
      • Thadanpion K
      Examination of the neck veins.
      They are, however, susceptible to blockage by valves, superficial muscles, fascia, and external pressures, so it is imperative that the typical venous waveform is identified, indicating a direct connection between the external jugular vein and the right atrium. Some very respected texts of physical examination recommend routinely turning the head to the left while observing the anterior and posterior triangles of the neck for internal and external jugular pulsations, respectively.

      Strachan M, Ralston SH, Penman I, Hobson R, eds. Davidsons Principles and Practice of Medicine, 23rd ed. Chapter16; Cardiology, Newby DE, Grubb NR: 441–544. Philadelphia: Elsevier; 2018. p. 443.

      Baker T, Nikolic G, O'Connor S. Practical Cardiology. 2nd ed London: Churchill Livingston; 2008: Chapter 7, The patient with dyspnoea:254--284.

      Tally NJ, O'Connor S. Clinical Examination. 8th ed Philadelphia: Elsevier; 2018: Chaper 5, The cardiac examination:74--108.

      This instruction is often reinforced by diagrams and photographs showing the head fixed in a left-rotated position. We have observed that turning the head to the left, actively or passively, may make the external jugular waveform harder to see (see Supplementary Video, available online). The likely “damping” mechanism here is decreased jugular venous flow, which has been demonstrated by color Doppler studies during catheter placement and is secondary to tensing or stretching of the right sternocleidomastoid muscle.
      • Willeford KL
      • Reitan JA
      Neutral head position for placement of internal jugular venous catheters.
      Furthermore, the maneuver fully obliterates the neck veins on the left side from view. This is important because anatomically, the jugular veins are not perfectly symmetrical, and in some patients the waveforms are more easily seen on the left. Finally, turning the head to the left may also increase the length of overlap between the carotid and internal jugular vein, making discernment of their waveforms more difficult.
      • Willeford KL
      • Reitan JA
      Neutral head position for placement of internal jugular venous catheters.
      The proximity of these vessels often makes it very hard to distinguish a non-palpable internal jugular venous waveform from the carotid pulse.
      Figure
      FigureThe right panel shows the anterior view of the relevant anatomy of the neck. Note that the external jugular veins are on the surface of the sternocleidomastoid, whereas the internal jugular veins lie deeper and follow the line of the common carotid arteries (black arrows). The left panel photographs show the anterior “real life” view of the neck with the head partially extended in a neutral [non-rotated] position. The clavicular (C) and sternal (S) divisions of the sternocleidomastoid muscle are the major landmarks. The external jugular vein (EJV) is seen lateral to the clavicular division, whereas the internal jugular vein is less obvious, filling the gutter medial to the sternal division.
      Although head turning was discouraged by McKenzie and Lewis, who first highlighted the clinical value of measuring the jugular venous pressure at bedside,

      McKenzie J. The Study of the Pulse, Venous, Arterial, and Hepatic, and of the Movements of the Heart. 1st ed Edinburgh: Young J Pentland; 1902: Part II, Pulsations in the veins and liver; Chapter 16, General introduction: P175–180.

      ,
      • Lewis T
      Early signs of cardiac failure of the congestive type.
      it has, unfortunately, somehow crept into our teaching.

      Strachan M, Ralston SH, Penman I, Hobson R, eds. Davidsons Principles and Practice of Medicine, 23rd ed. Chapter16; Cardiology, Newby DE, Grubb NR: 441–544. Philadelphia: Elsevier; 2018. p. 443.

      Baker T, Nikolic G, O'Connor S. Practical Cardiology. 2nd ed London: Churchill Livingston; 2008: Chapter 7, The patient with dyspnoea:254--284.

      Tally NJ, O'Connor S. Clinical Examination. 8th ed Philadelphia: Elsevier; 2018: Chaper 5, The cardiac examination:74--108.

      Standard comprehensive medical textbooks do not comment on rotation, implying that the head should remain in a neutral position. The famous cardiologist, Joseph Perloff, included in his handbook of cardiovascular examination, a picture showing the head turned to the left as an example of how not to position the patient.

      Perloff JK. Physical Examination of the Heart and Circulation. 2nd ed. Philadephia: WB Saunders Co.; 1990: Chapter 4, The veins- jugular and peripheral;103--140.

      Unfortunately, for all the wrong reasons, this picture seems to have invaded the subconscious of some authors and teachers. The result is that our teaching is inconsistent, making the measurement of the jugular venous pressure, one of the most useful and subtle bedside skills, harder than it needs to be.
      In conclusion, we encourage our students to develop the skills necessary to reliably identify the jugular venous pressure by taking time to ensure the neck muscles are relaxed, with the head supported and partially extended in a neutral position. The trunk should be adjusted to the angle that best demonstrates the waveform.

      Acknowledgments

      The figure and video were prepared by the Department of Medical illustration, Christchurch Hospital. We thank Dr. David Cole for allowing us to photograph his neck.

      Appendix. SUPPLEMENTARY DATA

      References

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