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Jugular Vein Pressure (JVP): Physical Exam

    Definition
    • The jugular venous pressure (JVP) reflects pressure in the right atrium (central venous pressure); the venous pressure is estimated to be the vertical distance between the top of the blood column (highest point of oscillation) and the right atrium.
    Anatomy
    • Right and left internal jugular veins
      • Largest paired neck veins draining the head and neck
      • Originate from the dural venous sinuses
      • Exit the skull via the jugular foramen
      • Descend through the neck alongside the internal carotid arteries
      • Joins the subclavian veins at the base of the neck
      • Located posterior and superior to the medial fourth of the clavicle, running cephalad until it passes under the sternocleidomastoid muscle
      • Not directly visible, identifiable only via pulsations transmitted to the surface of the neck
      • Right internal jugular vein
        • Communicates directly with the right atrium via the superior vena cava
    • Right and left external jugular veins
      • Drain superficial scalp and face structures
      • As they descend through the lateral neck the pass diagonally over the top of the sternocleidomastoid muscles
      • Empty into the subclavian veins
    • Sternal angle of Louis
      • The bony ridge adjacent to the second rib where the manubrium joins the body of the sternum
      • Remains roughly 5 cm above the right atrium regardless of the patients position
    Physiology
    • Pressure changes from right atrial filling, contraction, and emptying cause fluctuations in the JVP and its waveforms that are visible to the examiner.
    Indications

    • Routine cardiac examination in the evaluation of:
      • Constrictive pericarditis
      • Heart failure
      • Pericardial tamponade
      • Pulmonary hypertension
      • Superior vena cava obstruction
      • Tricuspid stenosis
    • To determine the central venous pressure
    Technique

    • Begin with the patient relaxing comfortably in bed, head on a pillow (to relax the sternocleidomastoid muscles), view of neck and chest should be unobstructed (if possible), and the head of the bed elevated 30°- 45°
    • Turn the patient's head slightly away from the side you are inspecting and extend the chin (ensure the sternocleidomastoid muscles are still relaxed)
    • Use tangential light to identify the external jugular veins and then the internal jugular vein pulsations (lower half of the neck)
      • If jugular venous pulsations cannot be seen, lower/raise the head of the bed until observed
    • Take care to distinguish internal jugular pulsations from the carotid artery pulsations
      • Observe the pulsations in the right side of the neck while timing the carotid artery pulse on the left side of the neck with the examiners right third finger
    • Observe if both the left and right jugular veins distend at approximately the same degree of elevation during the same phase of respiration
    • Observe for the fluttering waves in inspiration and expiration (this identifies the top of the venous column)
      • In order to find the top of the column, the head of the bed may need to raised and lowered several times
      • Avoid exaggerated breathing or breath holding because it distorts the normal mean venous pressure
    • Focus on the right internal jugular vein
      • Look for pulsations in the suprasternal notch
    • Identify the highest point of pulsation
      • Extend a long rectangular card/ruler horizontally from this point and a centimeter ruler vertically from the sternal angle (make an exact right angle)
      • Measure the vertical distance (in centimeters) above the sternal angle where the horizontal card crosses the ruler
      • Add to this distance 4 cm (the distance from the sternal angle to the center of the right atrium)
    Results
    • Normal:
      • JVP is 6 to 8 cm above the right atrium
    • Abnormal/elevated:
      • JVP is > 9 cm above the right atrium (> 4 cm above the sternal angle)
    Interpretation

    • JVP falls in hypovolemia
    • JVP rises with:
      • Constrictive pericarditis
      • Pericardial compression/tamponade
      • Pulmonary hypertension
      • Right/left heart failure
      • Superior vena cava obstruction
      • Tricuspid stenosis
    Pearls

    • The jugular veins/pulsations are difficult to detect in children < 12 years of age
    • Consider the patient's volume status
      • Hypovolemic patients may need to lie flat before you can observe neck veins
      • Increased JVP (or volume-overload) you may need to elevate the head of the bed 60°- 90°
    • In patients with obstructive lung disease, venous pressure may appear elevated on expiration only and the veins collapse during inspiration (dose not indicate heart failure)
    • To determine if jugular venous distention is due to pressure from below or are simply prominent, use the method of "stripping" the vein
    • Place our adjacent forefingers over a distended segment of the external jugular vein
    • Strip the vein of its blood by moving your fingers apart while maintaining firm pressure on the vein (the vein should be flat as you maintain pressure on it)
    • To test for "filling from below" (from the heart back up into the veins), release only the finger closest to the heart (keep the other finger in its place)
    • If the central venous pressure is high enough, the vein will fill in a retrograde fashion ("from below")
    References

    1. Bickley LS et al. Bates' Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2013;361-5.
    2. Marieb EN, Hoehn K. Anatomy & Physiology. 3rd ed. San Fransisco, CA: Pearson Benjamin Cummings. 2008;668-71.
    3. Orient, JM. Sapira's Art and Science of Bedside Diagnosis. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2010;398-403.
    4. Walker HK et al. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 19.
    Editors & Reviewers

    Editors:

    • Anthony J. Busti, MD, PharmD, FNLA, FAHA

    Last Reviewed: July 2015