Jugular venous pressure

Syed Farrukh Umair

Position of the patient
 establishing adequate exposure and a quiet
environment are critical.
 Initially, the patient should rest supine with the upper
body elevated 30 to 45 degrees. Most exam tables
have an adjustable top.
 If not, use 2 or 3 pillows.
 Remember that although assessment of pulse and
blood pressure are discussed in the vital signs
section they are actually important elements of the
cardiac exam
Normal Anatomy
Anatomical description
1. The right IJ runs between the two heads
(sternal and clavicular) of the
sternocleidomastoid muscle (SCM) and up in
front of the ear. This muscle can be identified
by asking the patient to turn their head to the
left and into your hand while you provide
resistance to the movement. The two heads
form the sides of a small triangle, with the
clavicle making up the bottom edge. You
should be able to feel a shallow defect formed
by the borders of these landmarks.
AD-CONTD…2
1. Note, you are trying to identify impulses
originating from the IJ and transmitted to the
overlying skin in this area. You can't actually
see the IJ. The External Jugular (EJ) runs in
an oblique direction across the
sternocleidomastoid and, in contrast to the IJ,
can usually be directly visualized. If the EJ is
not readily apparent, have the patient look to
the left and valsalva. This usually makes it
quite obvious.
AD-CONTD-3
1. EJ distention is not always a reliable indicator
of elevated CVP as valves, designed to
prevent the retrograde flow of blood, can exist
within this vessel causing it to appear
engorged even when CVP is normal. It also
makes several turns prior to connecting with
the central venous system and is thus not in a
direct line with the right atrium.
 Basic anatomical logic
 Its importance lies in the fact that the IJ is in
straight-line communication with the right atrium.
 The IJ can therefore function as a manometer,
with distention indicating elevation of Central
Venous Pressure (CVP). This in turn is an
important marker of intravascular volume status
and related cardiac function.
OBservation
 Take your time. Look at the area in question
for several minutes while the patient's head is
turned to the left. The carotid artery is
adjacent to the IJ, lying just medial to it. If you
are unsure whether a pulsation is caused by
the carotid or the IJ, place your hand on the
patient's radial artery and use this as a
reference. The carotid impulse coincides with
the palpated radial artery pulsation and is
characterized by a single upstroke timed with
systole.
 The venous impulse (at least when the patient is in
sinus rhythm and there is no tricuspid regurgitation)
has three components, each associated with the
aforementioned a, c and v waves. When these are
transmitted to the skin, they create a series of flickers
that are visible diffusely within the overlying skin. In
contrast, the carotid causes a single up and down
pulsation. Furthermore, the carotid is palpable. The IJ
is not and can, in fact, be obliterated by applying
pressure in the area where it emerges above the
clavicle.
 Search along the entire projected course of
the IJ as the top of the pressure wave (which
is the point that you are trying to identify) may
be higher then where you are looking. In fact,
if the patient's CVP is markedly elevated, you
may not be able to identify the top of the
wave unless they are positioned with their
trunk elevated at 45 degrees or more (else
their will be no identifiable "top" of the column
as the entire IJ will be engorged).
 After you've found the top of the wave, see what
effect sitting straight up and lying down flat have on
the height of the column. Sitting should cause it to
appear at a lower point in the neck, while lying has
the opposite effect. Realize that these maneuvers do
not change the actual value of the central venous
pressure. They simply alter the position of the top of
the pulsations in relation to other structures in the
neck and chest.
 Shine a pen light tangentially across the neck. This
sometimes helps to accentuate the pulsations
Accentuation maneuvere
 Shine a pen light tangentially across the
neck. This sometimes helps to accentuate
the pulsations.
Hepato-Jugular Reflux
 If you are still uncertain, apply gentle pressure to the
right upper quadrant of the abdomen for 5 to 10
seconds. This elicits Hepato-Jugular Reflux which, in
pathologic states, will cause blood that has pooled in
the liver to flow in a retrograde fashion and fill out the
IJ, making the transmitted pulsations more apparent.
Make sure that you are looking in the right area when
you push as the best time to detect any change in the
height of this column of blood is immediately after
you apply hepatic pressure.
measurement
1. Once you identify JVD, try to estimate how
high in cm the top of the column is above the
Angle of Louis. The angle is the site of the
joint which connects the manubrium with the
rest of the sternum. First identify the supra-
sternal notch, a concavity at the top of the
manubrium. Then walk your fingers
downward until you detect a subtle change in
the angle of the bone, which is approximately
4 to 5 cm below the notch. This is roughly at
the level of the 2nd intercostal space.
Mst-2
1. The vertical distance from the top of the
column to this angle is added to 5cm, the
rough vertical distance from the angle to the
right atrium with the patient lying at a 45
degree angle. The sum is an estimate of the
CVP. However, if you can simply determine
with some accuracy whether JVD is present
or not, you will be way ahead of he game!
Normal is 7-9 cm.
Angle of louis
CVP
REVIEW
 The highest point of this pulsating column of blood is
called the head. The height of this head varies
somewhat with respiration: falls slightly with
inspiration when the negative intra-thoracic pressure
encourages venous return to the heart; rises again
with expiration when the positive intra-thoracic
pressure impedes venous return to the heart.
 The mean height of this column (averaged over
inspiration and expiration) represents the hydrostatic
pressure within the right atrium, the normal
magnitude of which is 6 – 10 cm H2O.
 Jugular venous pressure (JVP) is commonly
expressed as the vertical height (in cm) of
this column of blood (the head) in relation to
the sternal angle (angle of Louis).
 With the help of 2 rulers, this vertical height in
relation to the sternal angle can be
determined by the method of triangulation
shown below.
 Since the sternal angle is 5 cm above the
right atrium in an adult – irrespective of
whether he/she is supine, reclining, or sitting
upright – the hydrostatic pressure in the right
atrium (in cm of H2O) is equal to the vertical
height (in cm) of the column of blood above
the sternal angle plus 5 cm.
REVIEW-2
 In a normal subject, the head of the jugular
venous pulse is commonly seen at the level
of the clavicle when he/she is reclining at an
angle of 45o.
 To put it in another way, a JVP more than 5
cm above the sternal angle is elevated.
Waves of JVP
Description of waves
 Three positive waves (a, c, & v) and 2
negative descents (x & y) have been
described for internal jugular venous
pulsation, although the c wave is so small in
a normal subject that it is usually not
visible to the naked eye.
 The positive a wave is the most prominent; it
represents right atrial contraction. As the right
atrium contracts, venous blood is pumped
across the triscupid valve into the right
ventricle but backpressure is also transmitted
to the valveless internal jugular vein. This
backpressure accounts for the a wave.
 Following the a wave is the x descent, which
represents the dissipation of the back
pressure that is responsible for the a wave.
 The small c wave occurs early during the x
descent and corresponds to right ventricular
contraction during systole and closure of the
tricuspid valve causing a transient pressure
rise in the right atrium and the internal jugular
veins.
 The v wave represents a steady rise in pressure
within the right atrium and internal jugular veins as
venous return continues during the rest of ventricular
systole when the triscupid valve is closed.
 The v wave is followed by the y descent, which
represents the end of ventricular systole, the opening
of the triscupid valve, and the passive emptying of
blood from the right atrium into the right ventricle.

 After the y descent, the cycle repeats itself.

Features that distinguish JVP from
Carotid
 Features that distinguish the internal jugular
venous pulsation from carotid arterial
pulsation include:
 Internal jugular venous pulsation is a series of
2 or 3 positive waves (depending on whether
the c wave is obvious to the naked eye) in
each cardiac cycle while carotid pulsation has
only 1 positive wave in each cardiac cycle.
Contd…2
 The pulsating column of venous blood in the
internal jugular vein has a definite upper
level, above which the vein is collapsed, while
the pulsating carotid artery does not have an
upper level or head.
 Internal jugular venous pulsation decreases
with inspiration and increases with expiration.
This is not the case in the carotid artery.
Contd--3
 Performing a valsalva maneuver (breathing
out forcefully against a closed glottis)
increases intra-thoracic pressure and internal
jugular venous pulsation. Not so with the
carotid artery pulse.
 Internal jugular venous pulsation is seen at
the skin surface but it is not palpable. Carotid
pulsation is deeper but it is palpable.