Jugular venous distention resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2] Mandana Chitsazan, M.D. [3]

Overview

Jugular venous pressure (JVP) is considered the most useful finding for assessing the ventricular filling pressures and central venous pressure (CVP) at the bedside. The jugular venous pressure is measured as the vertical distance between the top of venous pulsation and the angle of Louise, i.e., where the manubrium meets the body of the sternum. A distance of >3cm is considered jugular venous distension (JVD) or an elevated jugular venous pressure (JVP).

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Acute heart failure
• Cardiac Tamponade
• Massive pulmonary emboli
• Right ventricular myocardial infarction
• Tension Pneumothorax

Common Causes

Common causes of jugular venous distension include:

• Congestive heart failure
• Cardiomyopathy
• Cor pulmonale
• Constrictive pericarditis
• Chronic obstructive pulmonary disease (copd)
• Fluid overload
• Pulmonary embolism
• Pulmonary hypertension
• Pulmonary valve stenosis
• Restrictive cardiomyopathy
• Right atrial myxoma
• Right heart failure
• Right ventricular myocardial infarction
• Tension pneumothorax

Diagnosis

Shown below is an algorithm summarizing the diagnosis of jugular venous distension.

Jugular Venous Distension

With pulmonary edema

Without pulmonary edema

Congestive heart failure

Increased right atrial pressure

Venous obstruction

Increased intrathoracic pressure

❑ Restriction of right atrial and right ventricular filling: ❑ Cor pulmonale (Massive pulmonary emboli, COPD) ❑ Pulmonary Hypertension ❑ Pulmonary valve stenosis ❑ Constrictive pericarditis ❑ Cardiac Tamponade ❑RV Failure: ❑ Cardiomyopathy ❑ RV myocardial infarction ❑ Fluid overload due to renal diseases ❑ Tricuspid valve incompetence ❑ Tricuspid valve stenosis or obstruction

❑ Superior vena cava obstrcution

❑ Positive pressure ventilation ❑ A large pleural effusion ❑Tension Pneumothorax

Treatment

• The management of jugular venous distension should be directed towards the underlying causes.
• Treatment of congestive heart failure usually includes diuretics (for symptom relief), beta blockers, angiotensin converting enzyme inhibitors (ACE-I) /aldosterone receptor blockers (ARB).
  • For a complete guide on the treatment of congestive heart failure, click here.
    
• Treatment of right ventricular myocardial infarction includes reperfusion, maintenance of right ventricular preload, decreasing right ventricular afterload, restoring cardiac rate/rhythm and atrioventricular synchrony, and inotropic support.
  • For a complete guide on the treatment of right ventricular myocardial infarction, click here.
    
• Treatment of massive pulmonary embolism usually includes fibrinolytic therapy.
  • For a complete guide on the treatment of pulmonary embolism, click here.
    
• Treatment of pericardial tamponade usually includes pericardiocentesis.
  • For a complete guide on the treatment of cardiac tamponade, click here.
    
• Treatment of tension pneumothorax includes immediate needle decompression followed by chest tube insertion.
  • For a complete guide on the treatment of tension pnemuothorax, click here.
    

Do's

• If the JVP does not seem elevated when the patient is supine, a provocative test, i.e., abdominojugular reflux test, might be performed. By increasing venous return and pressure, theabdominojugular reflux test, also known as hepatojugular reflux test, helps better assessemt of jugular venous pulsations.

Don'ts

• JVD only provides clues to the presence of an elevated central venous pressure (CVP).
• Clinicians should avoid making decisions about the degrees of CVP elevation based on the JVP measurement.