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The jugular venous pressure (JVP, sometimes referred to as jugular venous pulse) is the indirectly observed pressure over

the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different forms of heart and lung disease. Classically three upward deflections and two downward deflections have been described.

Visualization The veins of the neck, viewed from in front. The patient is positioned under 45, and the filling level of the jugular vein determined. Visualize the internal jugular vein when looking for the pulsation. In healthy people, the filling level of the jugular vein should be less than 3 centimetres vertical height above the sternal angle. A pen-light can aid in discerning the jugular filling level by providing tangential light.

Above, it lies upon the rectus capitis lateralis, behind the internal carotid artery and the nerves passing through the jugular foramen; lower down, the vein and artery lie upon the same plane, the glossopharyngeal and hypoglossal nerves passing forward between them; the vagus descends between and behind the vein and the artery in the same sheath (the carotid sheath), and the accessory runs obliquely backward, superficial or deep to the vein. At the root of the neck, the right internal jugular vein is a little distance from the common carotid artery, and crosses the first part of the subclavian artery, while the left internal jugular vein usually overlaps the common carotid artery. The left vein is generally smaller than the right, and each contains a pair of valves, which are placed about 2.5 cm above the termination of the vessel.

The JVP is easiest to observe if one looks along the surface of the sternocleidomastoid muscle, as it is easier to appreciate the movement relative to the neck when looking from the side (as opposed to looking at the surface at a 90 degree angle). Like judging the movement of an automobile from a distance, it is easier to see the movement of an automobile when it is crossing one's path at 90 degrees (i.e. moving left to right or right to left), as opposed to coming toward one.
Pulses in the JVP are rather hard to observe, but trained cardiologists do try to discern these as signs of the state of the right atrium.

The mean pressure in the right atrium is normally <7mmhg (9cm="" h2o);="" as="" the="" sternal="" angle="" is="" approximately="" 5cm="" above="" the="" right="" atrium,="" the="" normal="" jugular="" pressure="" pulse="" should="" not="" be="">4cm (9cm-5cm) above the sternal angle. Therefore, in a healthy patient with normal right atrial pressure: - Sitting at a 45 degs angle - the transition point between the distended vein and the collapsed vein may or may not be visible; if it is visible, the pulsation will be seen just above the clavicle; - Lying flat - the jugular vein will be distended and the pulsation will not be visible; - Sitting upright - the upper part of the vein will be collapsed and the transition point between it and the distended vein will be obscured, so the pulsation will not be seen

THE PROCEDURE - Explain the procedure to the patient. - Ensure there is adequate lighting. - Adopt a position on the patients right. - While ensuring privacy and maintaining the patients dignity, expose the upper chest. Remove any restrictive clothing from around the patients neck and chest. - Position the patient at an angle of 45 degs, leaving one pillow under the head . - Ask the patient to turn her or his head to the left . - Observe the level of the jugular venous pulsations just above the clavicle. - Measure the vertical distance (cm) between the sternal angle (manubrio sternal joint or angle of Louis) and the highest visible level of jugular vein pulsation. The normal distance is <4cm; add="" 5cm="" to="" this="" because="" the="" right="" atrium="" is="" 5cm="" below="" the="" sternal="">

- If it is difficult to see the jugular venous pulsation, shine a bright light directly onto the patients neck. - If it is still difficult to see jugular venous pulsation or there is uncertainty whether the pulsation is venous or arterial, some authorities recommend gentle compression on the right upper quadrant of the abdomen. This will transiently increase venous pressure resulting in a more prominent internal jugular vein. Venous pulsation usually returns to normal after a few seconds (even with continued abdominal pressure); if it remains elevated this suggests right-sided heart failure. - Document the findings of whether the jugular venous pulsation is visible and, if so, whether it is normal or elevated

The JVP and carotid pulse can be differentiated several ways:


multiphasic - the JVP "beats" twice (in quick succession) in the cardiac cycle. In other words, there are two waves in the JVP for each contractionrelaxation cycle by the heart. The first beat represents that atrial contraction (termed a) and second beat represents venous filling of the right atrium against a closed tricuspid valve (termed v) and not the commonly mistaken 'ventricular contraction'. These wave forms may be altered by certain medical conditions; therefore, this is not always an accurate way to differentiate the JVP from the carotid pulse. The carotid artery only has one beat in the cardiac cycle.

non-palpable

- the JVP cannot be palpated. If one feels a pulse in the neck, it is generally the common carotid artery. occludable - the JVP can be stopped by occluding the internal jugular vein by lightly pressing against the neck. It will fill from above. varies with head-up-tilt (HUT) - the JVP varies with the angle of neck. If a person is standing, his JVP appears to be lower on the neck (or may not be seen at all because it is below the sternal angle). The carotid pulse's location does not vary with HUT.

varies

with respiration - the JVP usually decreases with deep inspiration. Physiologically, this is a consequence of the FrankStarling mechanism as inspiration decreases the thoracic pressure and increases blood movement into the heart (venous return), which a healthy heart moves into the pulmonary circulation.

The jugular venous pulsation has a biphasic waveform.


The " a " wave corresponds to right Atrial contraction and ends synchronously with the carotid artery pulse. The peak of the 'a' wave demarcates the end of atrial systole. The " c " wave corresponds to right ventricular Contraction causing the triCuspid valve to bulge towards the right atrium. The " x " descent follows the 'a' wave and corresponds to atrial relaXation and rapid atrial filling due to low pressure.

JVP Waveform

The " x' " (x prime) descent follows the 'c' wave and occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole. The x' (x prime) descent can be used as a measure of right ventricle contractility. The " v " wave corresponds to Venous filling when the tricuspid valve is closed and venous pressure increases from venous return - this occurs during and following the carotid pulse. The " y " descent corresponds to the rapid emptYing of the atrium into the ventricle following the opening of the tricuspid valve.

Certain wave form abnormalities, include "Cannon awaves", or increased amplitude 'a' waves, are associated with AV dissociation (third degree heart block), when the atrium is contracting against a closed tricuspid valve, or even in ventricular tachycardia. Another abnormality, "c-v waves", can be a sign of tricuspid regurgitation. The absence of 'a' waves may be seen in atrial fibrillation.

An

elevated JVP is the classic sign of venous hypertension (e.g. right-sided heart failure). JVP elevation can be visualized as jugular venous distension, whereby the JVP is visualized at a level of the neck that is higher than normal. The paradoxical increase of the JVP with inspiration (instead of the expected decrease) is referred to as the Kussmaul sign, and indicates impaired filling of the right ventricle. The differential diagnosis of Kussmaul's sign includes constrictive pericarditis, restrictive cardiomyopathy, pericardial effusion, and severe right-sided heart failure.

Raised

JVP, normal waveform Bradycardia Fluid overload Heart Failure Raised JVP, absent pulsation Superior vena cava syndrome Large 'a' wave (increased atrial contraction pressure) tricuspid stenosis Right heart failure Pulmonary hypertension Cannon 'a' wave (atria contracting against closed tricuspid valve) Atrial flutter Premature atrial rhythm (or tachycardia) third degree heart block Ventricular ectopics Ventricular tachycardia Absent 'a' wave (no unifocal atrial depolarisation) atrial fibrillation

Large

'v' wave (c-v wave) Tricuspid regurgitation Slow 'y' descent Tricuspid stenosis Cardiac Tamponade Prominent & Deep 'y' descent Constrictive pericarditis Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration, drops with expiration) Pericardial effusion Constrictive pericarditis Pericardial tamponade

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