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ORIGINAL RESEARCH • RECHERCHE ORIGINALE
EM Advances Defining normal jugular venous pressure with ultrasonography
Steven J. Socransky, MD; * Ray Wiss, MD; * Ron Robins, MD; † Alexandre Anawati, MD; * Marc-Andre Roy, MD; * I. Ching Yeung, BSc *
ABSTRACT RÉSUMÉ Objective: Determination of jugular venous pressure (JVP) by Objectif : La détermination de la pression veineuse jugulaire physical examination (E-JVP) is unreliable. Measurement of (PVJ) par un examen physique (PVJ par examen) n’est pas JVP with ultrasonography (U-JVP) is easy to perform, but the fiable. La mesure de la PVJ par échographie est facile à réaliser, normal range is unknown. The objective of this study was to mais la plage normale est inconnue. L’objectif de cette étude était determine the normal range for U-JVP. de déterminer la plage normale pour la PVJ par échographie. Methods : We conducted a prospective anatomic study on a Méthodes : Nous avons réalisé une étude anatomique convenience sample of emergency department (ED) patients prospective sur un échantillon de commodité de patients de over 35 years of age. We excluded patients who had findings plus de 35 ans s’étant présentés à l’urgence. Nous avons on history or physical examination suggesting an alteration exclu les patients dont les antécédents ou l’examen médical of JVP. With the head of the bed at 45 °, we determined the suggéraient une altération de la PVJ. En positionnant la tête point at which the diameter of the internal jugular vein (IJV) du lit à 45 degrés, nous avons déterminé par échographie le began to decrease on ultrasonography (“the taper”). Re- point où le diamètre de la veine jugulaire interne (VJI) com - search assistants used 2 techniques to measure U-JVP in all mence à se rétrécir (point de rétrécissement). Les assistants participants: by measuring the vertical height (in centimetres) de recherche ont utilisé deux techniques pour mesurer la PVJ of the taper above the sternal angle, and adding 5 cm; and by par échographie chez tous les participants : 1) mesure de la recording the quadrant in the IJV’s path from the clavicle to hauteur verticale (en cm) du point de rétrécissement au- the angle of the jaw in which the taper was located. To deter - dessus de l’angle sternal, plus 5 cm; 2) détermination du mine interrater reliability, separate examiners measured the quadrant du trajet de la VJI, de la clavicule à l’angle de la U-JVP of 15 participants. mâchoire où le point de rétrécissement a été repéré. Dif - Results: We successfully determined the U-JVP of all 77 par - férents examinateurs ont mesuré la PVJ par échographie de ticipants (38 male and 39 female). The mean U-JVP was 6.35 15 participants pour déterminer la fiabilité inter-évaluateurs. (95% confidence interval 6.11–6.59) cm. In 76 participants Résultats : Nous avons mesuré avec succès la PVJ par (98.7%), the taper was located in the first quadrant. Determi - échographie chez tous les participants (77, dont 38 hommes et nation of interrater reliability found κ values of 1.00 and 0.87 39 femmes). La valeur moyenne de la PVJ par échographie for techniques 1 and 2, respectively. était de 6,35 cm (intervalle de confiance [IC] de 95 %, de 6,11 à Conclusion: The normal U-JVP is 6.35 cm, a value that is 6,59 cm). Chez 76 patients (98,7 %), le point de rétrécissement slightly lower than the published normal E-JVP. Interrater reli - a été localisé dans le premier quadrant. Les valeurs de Kappa ability for U-JVP is excellent. The top of the IJV column is relativement à la fiabilité inter-évaluateurs étaient respective - located less than 25% of the distance from the clavicle to the ment 1,0 et 0,87 pour les techniques 1 et 2. angle of the jaw in the majority of healthy adults. Our findings Conclusion : La valeur normale de la PVJ par échographie est suggest that U-JVP provides the potential to reincorporate de 6,35 cm, une valeur légèrement inférieure à la valeur nor - reliable JVP measurement into clinical assessment in the ED. male publiée. La fiabilité inter-évaluateurs concernant la mesure However, further research in this area is warranted. de la PVJ par échographie est excellente. La partie supérieure de la VJI est située à moins de 25 % de la distance entre la clavi- cule et l’angle de la mâchoire chez la majorité des adultes en Keywords: jugular veins, ultrasonography, heart failure, central santé. Nos résultats suggèrent que la PVJ par échographie offre venous pressure la possibilité de réintégrer une mesure fiable de la PVJ dans l’évaluation clinique dans les services d’urgence. Cependant, des recherches plus poussées dans ce domaine sont néces saires.
From the *Emergency Department, Hôpital regional de Sudbury Regional Hospital, Northern Ontario Medical School of Medicine, Sudbury, Ont., and the †Emergency Department, Woodstock General Hospital, Woodstock, Ont.
Submitted Mar. 11, 2009; Revised Aug. 19, 2009; Accepted Sep. 1, 2009
This article has been peer reviewed.
CJEM 2010;12(4):320-4
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Defining normal JVP with ultrasonography
INTRODUCTION took place from 9 am to 10 pm, 7 days a week. Study approval was obtained from the HRSRH Research The evaluation of jugular venous pressure (JVP) is Ethics Committee. considered to be a standard component of the physical examination in patients suspected of having acute con - Study protocol gestive heart failure. 1 Other acute cardiorespiratory conditions such as pericardial tamponade and tension A research assistant (RA) approached potentially eligible pneumothorax may also be present with elevated JVP. patients for possible study inclusion. Inclusion criteria were Un fortunately, bedside assessment of JVP by visualiza - well-appearing adults 35 years of age or older. Exclusion tion of jugular venous pulsations has been found to be criteria are provided in Box 1 and were established to cap - inaccurate and unreliable. 2 Factors such as short or obese ture a study population likely to have a normal JVP. The necks make the visualization of jugular venous pulsations RA determined and documented the age, sex, height and difficult. 3 Connors and coauthors 4 found a low sensitivity weight of eligible patients who provided informed consent. and specificity among clinicians asked to determine Body mass index was also calculated. whether central venous pressure (CVP) was low, normal The RAs were first- or second-year medical students. or elevated. Similarly, Eisenberg and colleagues 5 found All had received medical school training in JVP mea - that physicians were correct only 55% of the time in assigning CVP to low, normal or high groupings. Finally, Cook 6 found only modest agreement between Box 1. Ex cl usio n cr iteria the JVP measurements of residents and staff physicians. Chief co mp la int( s) As a result of these limitations, the assessment of JVP • Cardioresp iratory may be underused by emergency physicians (EPs). This - Dyspnea, ch es t pa in , pa lp itatio ns , syn cope or pre syn cope is unfortunate, as the assessment of right-sided heart • Gastrointestin al pressures via JVP may have diagnostic utility. - Epigastric pain , anorex ia , dia rrhea , vo mi ting The measurement of JVP by ultrasonography (U-JVP) • Tr au ma represents an alternative to JVP determination by physi - - An y tra um a of the hea d, ne ck , ch es t or a bdom en cal examination (E-JVP). The internal jugular vein (IJV) • Comp la int suggesting hypo vo le mi a is readily identified by ultrasonography. The use of ultra - Medical hi st or y sonography to determine JVP was first described by Lip - • Cardiac ton 7 in 1999. Jang and colleagues 8 found elevated U-JVP - Angina, myocardial in fa rc tion, hea rt fa ilure, va lvulop at hy, ca rdia c myxo ma , peric ar ditis, peri car di al to be more accurate than chest radiography in diagnosing effusion congestive heart failure. However, the normal range for • Ne ck -r el at ed iss ues U-JVP has never been established. The objective of this - Ne ck sur gery, ne ck ra di at ion, neck burn, previous study was to determine the normal range for U-JVP. central line pl ac em ent in ne ck • Meta bolic METHODS - Unc ontrolled dia bet es me llit us , diabetes in si pidus • Superior vena cava syndr om e • Hy per vo le mi a Study design, setting and population Medicatio ns • Angiotensin-con ve rting enz ym e in hibitors This prospective anatomic study was conducted on a • Angiotensin re ceptor blockers convenience sample of patients presenting to the emer - • Loop diureti cs gency department (ED) at Hôpital regional de Sudbury • Thi azid e diuretic s Regional Hospital (HRSRH). The HRSRH ED is the Physical e xam inatio n sole ED for Sudbury, Ont., (population of 160 000) and • Respir at or y di stress has an annual ED census of approximately 60 000 visits. • Abnormal vi ta l si gn s The hospital functions as the tertiary care referral cen - • Oxygen sa tura tion < 95 % tre for northeastern Ontario. The ED is the base hospi - • Hea rt mu rm ur tal for a College of Family Physicians of Canada emer - Other gency medicine residency program. The study took • Inabil ity to main ta in the po si tion needed to ha ve jugul ar venous pressure eval ua ted place from June through August 2007. Study enrolment
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surement by physical examination. One of the study tioned, 10,11 it is, to our knowledge, the most commonly authors (S.J.S.) provided the RAs with a half-day of used method to calculate E-JVP. training in ultrasound physics, ultrasound machine use The RAs then determined U-JVP by the quadrant and U-JVP measurement. In addition, each RA per - technique. With the participant’s head at 45 °, the RA formed 10 supervised training scans for U-JVP mea - visually divided (i.e., “eyeballed”) the area between the surement before enrolling patients. clavicle and the angle of the jaw into 4 quadrants (Fig. 2). Research assistants measured U-JVP with the head of The RA subsequently determined in which quadrant the the bed (HOB) at 45 ° and the participant’s legs parallel taper of the IJV was located. In a subset of 15 partici - to the ground. A goniometer was used to ensure accurate pants, 2 RAs measured U-JVP to determine interrater HOB angulation. A linear array probe set at a frequency reliability. of 15 MHz (The Esaote Group) was used to visualize the IJV. The top of the IJV was located in the longitudinal Data analysis view (i.e., probe indicator pointed toward the partici - pant’s head). The transverse view (i.e., probe indicator Data was collected using a standardized form and trans - pointed toward the participant’s right) was used as ferred by each RA to an Excel spreadsheet (Microsoft needed to confirm findings on the longitudinal view. The Corp.). Descriptive statistics were used as appropriate. RAs noted the point at which the diameter of the IJV We employed multivariate linear regression to deter - began to decrease (the “taper”) at end-expiration (Fig. 1) mine whether an association existed between the and identified the corresponding point on the skin. U-JVP and age, sex, height, weight or body mass index. Research assistants determined U-JVP in 2 ways: the We used the κ statistic to determine interrater reliabil - “ruler technique” and the “quadrant technique.” Using ity. For the purposes of determining interrater reliabil - the ruler technique, the height in centimetres of the IJV ity for U-JVP measured by the ruler technique, mea - taper (rounded to the nearest centimetre) above the surement differences between RAs of 1 cm or less were sternal angle was measured with a ruler; U-JVP was cal - considered identical and deemed to be in agreement. culated by adding 5 cm to this height. 9 Although the addition of 5 cm to determine JVP has been ques - RESULTS
Seventy-seven patients (38 male and 39 female) were enrolled, and U-JVP was successfully determined in all
Fig. 1. Ultrasonography image showing a longitudi - nal view of the internal jugular vein with the probe Fig. 2. The area between the clavicle and the angle of the indicator pointed toward the patient’s head. The jaw is visually divided into 4 quadrants to determine U-JVP asterisk marks the beginning of the taper. Used with by the quadrant technique. Used with permission from The permission from The EDE 2 Course Inc. EDE 2 Course Inc.
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Defining normal JVP with ultrasonography
participants. The mean age was 49.6 (standard deviation Fine points in ultrasonography technique were high - [SD] 11.0, range 35–86) years. Three participants did lighted during RA training but were a potential source not consent to the collection of height and weight data. of variability in U-JVP measurement. The amount of The mean height of consenting participants was 170.0 pressure applied with the probe was not standardized. (SD 8.0, range 155–193) cm. The mean weight was During their training, RAs were encouraged to use light 82.8 (SD 27.0, range 41–218) kg. The mean body mass probe pressure to avoid falsely lowering U-JVP. The index was 28.6 (SD 9.4, range 14.5–73.1). Mean U-JVP longitudinal view was preferred over the transverse view was 6.35 (95% confidence interval 6.11–6.59) cm as because it is easier to appreciate the IJV taper in this determined by the ruler technique. In 76 participants view. However, it is possible to underestimate the U- (98.7%), the IJV taper was located in the first quadrant JVP in the longitudinal view by inadvertently obtaining when measured by the quadrant technique. There was an oblique or tangential view. For this reason, RAs were no statistically significant association found on regres - encouraged to hold the probe perpendicular to the skin. sion analysis between U-JVP measured by either tech - In addition, RAs were taught to slide the probe left to nique and participant age, sex, height, weight or body right and rotate the probe to ensure an optimal view of mass index. Fifteen participants had their U-JVP mea - the IJV. Finally, RAs were permitted to use the trans - sured by 2 RAs. Interrater reliability determination verse view to corroborate their findings on the longitu - found κ values of 1.00 and 0.87 for the ruler technique dinal view, as it is easier to centre the IJV on the screen and quadrant technique, respectively. with the transverse view. It is not known how often the RAs used the transverse view for this purpose. DISCUSSION It was not possible to obtain the gold standard of CVP measurement in this cohort of healthy partici - With the use of the ruler technique, our study found a pants. Although participants’ true CVP could not be normal mean U-JVP of 6.35 cm with a narrow 95% known with precision, we believe our exclusion criteria confidence interval. This is slightly lower than the were sufficient to ensure enrolment of a study group upper limit of normal (8–9 cm) cited in a commonly with normal CVP. used physical examination text. 9 We suspect most EPs The interrater reliability of U-JVP determination was do not carry rulers or tape measures, and are thus more found to be excellent. However, the vast majority of the likely to visually estimate JVP. Because of this, we also participants, who were selected for their likelihood of sought to determine normal U-JVP based on a quad - having a normal JVP, had the taper of their IJV fall 0, rant technique consistent with how EPs are likely to 1 or 2 cm above the sternal angle. The potential for spec - make such estimates in the ED. trum bias from this narrow range of values makes the With the use of the quadrant technique, all but 1 of excellent interrater reliability we found less impressive. the 77 participants had an IJV taper in the first quad - Future studies with a mix of participants with normal and rant. Said another way, the taper was located no more elevated U-JVP may provide more accurate estimates of than 25% of the way from the clavicle to the angle of the interrater reliability of U-JVP determination. the mandible in the vast majority of participants. For Future studies should focus on the training required both techniques, no significant association was found to perform U-JVP. Beyond this, it would be useful to between U-JVP and participant sex, age, height, weight determine the feasibility of its use in the ED and its or body mass index. Interrater reliability was excellent diagnostic test characteristics in conditions associated for both techniques. with elevated JVP.
Limitations and future directions CONCLUSION
Several limitations should be considered when inter - The normal U-JVP is 6.35 cm, a value that is slightly preting our findings. The 3 RAs who measured U-JVP lower than the published normal E-JVP. Interrater reli - had never performed ultrasonography before receiving ability for U-JVP determination is excellent. The top of the training required to perform this study. As U-JVP is the IJV column is located less than 25% of the distance a novel technique, training guidelines do not exist. The from the clavicle to the angle of the jaw in the majority training of the RAs included 10 training scans; although of healthy adults. Our findings suggest U-JVP provides this number is arbitrary, we felt it was adequate. the potential to reincorporate reliable JVP measure -
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ment into clinical assessment in the ED; however, fur - dynamic assessment of critically ill patients. Crit Care Med ther research in this area is warranted. 1984;12:549-53. 6. Cook DJ. Clinical assessment of central venous pressure in Competing interests: Drs. Socransky and Wiss are editors of the critically ill. Am J Med Sci 1990;299:175-8. The EDE 2 Course, which includes a chapter on the measure - ment of jugular venous pressure using bedside ultrasound. 7. Lipton BM. Determination of elevated jugular venous pres - None declared for all other authors. sure by real-time ultrasound. Ann Emerg Med 1999 ;34 :115 .
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