Jugular Venous Distention

DefinitionTop

Jugular venous pressure (JVP) was once among the central parts of the physical examination. Widespread use of numerous imaging techniques has diminished its importance; nevertheless, it provides important diagnostic information regarding volume status and cardiac pressures.

JVP is assessed clinically by positioning the patient supine with the head of the bed elevated between 30 and 45 degrees. It is visualized as a multiphasic pulse between the 2 heads of the sternocleidomastoid muscle, and if not immediately visible, it can be visualized by elevating or lowering the head of the bed until it comes into view. The height of this pulsation is then measured relative to the sternal angle. The sternal angle is ~5 cm above the right atrium independent of position; however, this may be an underestimate, particularly in older patients as well as in those with obesity or hyperinflation. JVP height above the sternal angle can be used to estimate the right atrial pressure. A JVP of 0 to 4 cm above the sternal angle is considered normal, whereas a JVP >4 cm is considered jugular venous distension.

Compared with the carotid pulse, the internal jugular vein pulse is multiphasic, nonpalpable, occludable with digital pressure, rises as the angle of the bed is lowered, falls as the angle of the bed is raised, falls with inspiration, raises with expiration, increases with abdominal pressure, is lateral in position, and is predominantly inward (downstroke). Certain abnormalities in the character of the JVP are associated with specific cardiovascular abnormalities.

Applying pressure over the upper abdomen can increase venous pressure via the abdominojugular reflux (AJR). If the JVP elevates >3 cm for >10 to 15 seconds following application of abdominal pressure, this finding is specific for elevated central venous pressure. Notably, obstructive pathology affecting the vena cava may cause abdominal pressure not to transmit freely to the jugular veins, causing an absent or diminished AJR.

Alternatively, filling of the external jugular veins may be assessed in some circumstances. Gross distension of the external jugular veins is often more easily observed than distension of the deeper internal jugular vein, but it is less specific.

Causes and PathogenesisTop

Venous distention is due to an increase in the venous blood pressure. Causes of jugular venous distention include:

1) Bilateral distention: Right (with or without left) ventricular failure, large pericardial effusion (including cardiac tamponade), constrictive pericarditis (often with paradoxical increase in JVP during inspiration, known as Kussmaul sign), restrictive cardiomyopathy, tension pneumothorax, mechanical obstruction of the superior vena cava (eg, by thoracic tumors, mediastinal lymphadenopathy, thrombosis, fibrosis, or aneurysms), superior vena cava syndrome (see Superior Vena Cava Syndrome), tricuspid stenosis or regurgitation (tricuspid regurgitation results in c-v waves with systolic increase in the venous pulse), pulmonary hypertension, pulmonary embolism.

2) Unilateral distention: Localized mechanical obstruction due to, for example, tumors (including goiters), thrombosis, large aneurysms, or lymphadenopathy. Left-sided distention may be caused by compression of the left brachiocephalic vein by an aortic aneurysm.

DiagnosisTop

1. Assess the vital signs (breathing, pulse, blood pressure [BP]), as the underlying condition may be life threatening (particularly cardiac tamponade, acute heart failure, tension pneumothorax, or pulmonary embolism).

2. Take a history and perform a cardiovascular examination: Elements of the past medical history, clinical context, associated symptoms, and timelines often help clarify the differential diagnosis. Findings of cardiovascular and respiratory examinations are associated with specific diagnoses. The AJR may help localize the cause. A pulsus paradoxus (difference in systolic BP between expiration and inspiration >10 mm Hg) should be examined if concerned for tamponade or obstructive lung disease. This is classically not present in restrictive cardiomyopathy or constrictive pericarditis, however, Kussmaul sign (an elevation of the JVP with inspiration) is present in these conditions.

3. Potential other diagnostic studies: Chest radiography, echocardiography, or both in patients with suspected heart failure, cardiac tamponade, constrictive pericarditis, or valvular heart disease. Ultrasonography of the neck as well as serum thyroid-stimulating hormone (TSH) and thyroid hormone levels in patients with a large goiter. Computed tomography (CT) of the chest, neck, or both in patients with superior vena cava syndrome or suspicion of cancer, lymphadenopathy, fibrosis, or aneurysm (accompanied by edema of the face and neck and distention of the veins of the upper half of the chest). Bronchoscopy as directed by other findings. Computed tomography angiography (CTA) in patients with suspected pulmonary embolism, intrathoracic tumor, or a large aneurysm.