OnExam

This manoeuvre is the most accurate estimate of right atrial pressure, volume status, and cardiac function of the patient. As adjuncts, consider performing the abdominojugular reflex and looking for Kussmauls sign.

Performing the Test

  1. Use the right internal jugular vein
  2. Position the patient supine, with the head of bed at a 30-45 degree angle. If the patient may be hypovolemic, lower the head of the bed. If they may be hypervolemic, raise the head of the bed.
  3. Have patient turn his/her head towards the left and position tangential lighting so it shines across the neck.
  4. Locate the right internal jugular vein between heads of sternocleidomastoid.
  5. Look for highest oscillation point in neck that can be occluded, multi-phasic, is non-palpable, and that descends with inspiration
  6. Measure the vertical distance (cm) from the highest point of oscillation (usually during expiration) to the sternal angle of Louis. Normal value is 3-4 cm above the angle.
    • > 3cm above sternal angle has been considered abnormal and corresponds to a central venous pressure of > 8cm (3+5).
    • Traditionally, > 4cm is considered abnormal but recent studies suggest that clinicians systematically underestimate JVP. In addition the distance from the right atrium to sternal notch may be closer to 8cm than the traditionally assumed value of 5cm.

Arterial vs Venous Waveforms

  • Arterial
    • Waveform: Fast, well-localized, uniphasic, outward deflection
    • Effect of position: Does not vary with position
    • Effect of respiration: Does not vary with respiratory cycle
    • Effect of palpation: Almost always palpable, pulsations with pressure
    • Not occludable
    • Abdominojugular reflex: No effect on carotid pulse
  • Venous
    • Waveform: Diffuse, biphasic and with slow upward deflection
    • Effect of position: Diminish toward clavicle as patient sits up/stands
    • Effect of respiration: Top of wave descends during inspiration
    • Effect of palpation: Non-palpable, pressure will obliterate pulsations
    • Occludable
    • Abdominojugular reflex: Produces a brief rise in venous pulse

References

  1. Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.
  2. Chatterjee K. Examination of the Jugular Venous Pulse. September 2010. Uptodate Online 18.3. Accessed January 3rd 2011 from http://www.uptodate.com/online/content/topic.do?topicKey=cardeval/2280&selectedTitle=4~150&source=search_result#H20
  3. McGee S. Evidence-Based Physical Diagnosis. Philadelphia, PA: Saunders, 2012.
  4. Panju A, Hemmelgarn B, Guyatt G, et al. Is this patient having a myocardial infarction? JAMA. 1988, 280(15): 1256-1263.
  5. Sinisalo J, Rapola J, Rossinen J and Kupari, M. (2007). Simplifying the Estimation of Jugular Venous Pressure. American Journal of Cardiology; 100(12), 1779-81.
  6. Wang C, Fitzgerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005, 294(15): 1944-1956.