JVD, or jugular venous distention, is often thought about as a measure of a patient’s overall volume status.

Distention of the jugular veins in the neck is more precisely a reflection of the pressure in the central venous circulation/right side of the heart.

Equating JVD with the patient’s overall volume status assumes that the pressures on the right side of the heart mirror the pressures on the left side of the heart. Sometimes this is true! But there are also clinical contexts in which the pressures on the right side of the heart may be elevated independent of left heart pressures. We have listed a few of these scenarios below. If any of these are on your differential, consider looking for JVD on exam!

- Pulmonary embolism

- Pulmonary hypertension

- Tamponade physiology (pericardial effusion or constrictive pericarditis)

- Myocardial infarction with right heart involvement

- Tricuspid disease

- Can also see JVD with elevated intrathoracic pressures, such as in pneumothorax or pleural effusion.

We can also see elevated jugular venous pressures in acute exacerbations of heart failure. The likelihood ratio of JVD in acute heart failure is 5.1.

This aspect of the physical exam is more predictive of acute heart failure than rales in the lungs or peripheral edema.

Consider looking for JVD next time are you are assessing a patient for acute exacerbation of heart failure.

Some tips for measuring JVD:

- Patient positioning is key! Patient should be supine on a stretcher with their head resting on the stretcher (no pillow). Have them lift their chin and turn their head slightly away from the side you are examining.

- Start with the head of the bed at 30-45 degrees.

- Look for pulsations on the neck in the region of the SCM muscle. If your patient is in NSR, carotid pulsations will have one brisk, palpable upstroke per heartbeat, while venous pulsations will have multiples pulsations per heartbeat and will disappear if you apply gentle pressure to the neck with one finger.

- Find the highest level of pulsation on the neck, keeping in mind that this could be as high as the earlobe.

- Identify the Angle of Louis, which is the change in angle of the sternum as you move from the top of the sternum down 

- Use the width of your hand to measure the vertical distance from the highest point of pulsation on the neck to the Angle of Louis.

- What was that vertical distance? Add 5 to that number - 5 is the vertical distance from the AoL to the right atrium. This sum is your estimated CVP. Numbers greater than 9 are abnormal. 

- See the diagram below for a visual guide to this measurement.

References:

Applefeld MM. The Jugular Venous Pressure and Pulse Contour. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; Chapter 19. Available from:https://www.ncbi.nlm.nih.gov/books/NBK300/