Ultrasound Accurately Reflects the Jugular

Venous Examination but Underestimates

Central Venous Pressure
Gur Raj Deol, Nicole Collett, Andrew Ashby and Gregory A. Schmidt

Chest 2011;139;95-100; Prepublished online August 26, 2010;

DOI 10.1378/chest.10-1301
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 CHEST Original Research
CRITICAL CARE

Ultrasound Accurately Reflects the Jugular

Venous Examination but Underestimates
Central Venous Pressure
Gur Raj Deol, MD; Nicole Collett, MD; Andrew Ashby, MD;
and Gregory A. Schmidt, MD, FCCP

Background: Bedside ultrasound examination could be used to assess jugular venous pressure
(JVP), and thus central venous pressure (CVP), more reliably than clinical examination.
Methods: The study was a prospective, blinded evaluation comparing physical examination of
external jugular venous pressure (JVPEXT), internal jugular venous pressure (JVPINT), and
ultrasound collapse pressure (UCP) with CVP measured using an indwelling catheter. We com-
pared the examination of the external and internal JVP with each other and with the UCP and
CVP. JVPEXT, JVPINT, UCP, and CVP were compared graphically using Bland-Altman plots, and
correlation coefficients were calculated.
Results: The correlation coefficients comparing CVP to UCP, JVPEXT, and JVPINT were 0.62, 0.57,
and 0.50, respectively. When UCP was compared with JVPEXT and JVPINT, correlation coeffi-
cients were 0.91 and 0.81, respectively. Last, the correlation coefficient comparing JVPEXT and
JVPINT was 0.98. The Bland-Altman graphical comparison of methods technique revealed that
CVP was often underestimated by UCP, and clinical examination of JVPEXT and JVPINT. In con-
trast, there was no systematic bias between UCP and either JVPEXT or JVPINT, nor between
JVPEXT and JVPINT.
Conclusions: Ultrasound examination is capable of measuring accurately the JVP as judged from
the internal or external jugular vein. However, like the JVP, ultrasound typically underestimates
CVP. A systematic bias between UCP and CVP suggests the presence of a variable degree of
venous tone, possibly signaling contraction of jugular venous smooth muscle.
Trial registry: ClinicalTrials.gov; No.: NCT01099241; URL: clinicaltrials.gov
CHEST 2011; 139(1):95–100

Abbreviations: CVP 5 central venous pressure; JVP 5 jugular venous pressure; JVPEXT 5 external jugular venous pres-
sure; JVPINT 5 internal jugular venous pressure; UCP 5 ultrasound collapse pressure

Thethecentral venous pressure (CVP) is a measure of

filling pressure of the whole heart and a major
CVP can be estimated by physical examination of the
jugular venous pressure (JVP), facilitating differential
determinant of the cardiac output.1 This has led to its diagnosis and empirical resuscitation even before
longstanding role as a guiding parameter in the man- central venous catheters can be inserted. Yet, the JVP
agement of patients with septic shock,2,3 acute lung has been criticized as difficult to measure reliably,
injury,4 trauma, and following high-risk surgery. The because of a perceived loss of clinical examination
skills5-9 and the increasing prevalence of obesity in criti-
Manuscript received May 21, 2010; revision accepted July 5, 2010. cally ill patients.10,11
Affiliations: From the Department of Internal Medicine, University
of Iowa, Iowa City, IA. JVP is recognized as the level at the top of the blood
Correspondence to: Gregory A. Schmidt, MD, FCCP, Department column in the (usually internal) jugular vein, seen as
of Internal Medicine, University of Iowa, 200 Hawkins Dr, C33-GH,
Iowa City, IA 52242; e-mail: gregory-a-schmidt@uiowa.edu the height at which the vein collapses. Accurate deter-
© 2011 American College of Chest Physicians. Reproduction mination of the JVP is often challenged by patient
of this article is prohibited without written permission from the positioning and anatomy as well as by ambient lighting
American College of Chest Physicians (http://www.chestpubs.org/
site/misc/reprints.xhtml). and the presence of devices and dressings. Ultrasound
DOI: 10.1378/chest.10-1301 examination yields clear images of the jugular vein,

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© 2011 American College of Chest Physicians
including the collapse point, even in obese subjects.12
We hypothesized that bedside ultrasound examination
could be used to assess the JVP more reliably than
clinical examination. Furthermore, we reasoned that
ultrasound could estimate the value of the JVP, poten-
tially speeding diagnosis and therapy in critically ill
patients before CVP could be measured invasively.

Materials and Methods

The study was performed prospectively in the medical ICU of
the University of Iowa Hospitals and Clinics and included
mechanically ventilated and spontaneously breathing subjects, all
of whom had central venous catheters placed as part of their clini-
cal management. Patients were eligible for the study, regardless
of diagnosis or neck size, as long as the central venous catheter
terminated in the superior vena cava. Age, sex, BMI, ICU admis-
sion diagnosis, severity of illness as measured by the Acute Physi-
ology and Chronic Health Evaluation II score, and degree of sedation Figure 1. Internal jugular vein area of collapse. The internal
(Richmond Agitation Sedation Scale) were recorded for all patients. jugular vein is shown in longitudinal view (left is cephalad). The
Consecutive patients admitted to the ICU were screened daily. skin surface is at the top of the figure and the total depth is 2.6 cm.
All eligible subjects were approached, and informed consent was Thin dotted arrows mark the anterior border of the vein, which
obtained as soon as possible after ICU admission. Informed consent appears echo-free (dark). The solid arrow shows the point of vein
collapse.
was obtained directly from the patient or from a surrogate decision
maker when the subject was unable to make informed decisions.
The study was approved by the University of Iowa institutional The CVP was read in millimeters of mercury and converted to
review board (ID number 200706777) and is listed on clinicaltrials. centimeters of water (1 mm Hg 5 1.36 cm H2O).
gov (NCT01099241). Finally, we marked the phlebostatic axis (intersection of the
midaxillary line and a perpendicular extended to the fourth inter-
costal space at the sternum) and determined the vertical distance
Measurements
between the sternal angle and the phlebostatic axis in order to
The observer estimated JVP by visual examination of the exter- convert JVPEXT, JVPINT, UCP, and CVP to values typically used
nal jugular vein (JVPEXT) on the side opposite the central venous clinically. We preferred this approach to referencing each mea-
catheter using a previously published method.13 The bed angle surement directly to the phlebostatic axis in order to minimize
was adjusted to yield the best view of the collapsing vein, and this error in judging pressure. Furthermore, the distance between the
angle was recorded. Tangential lighting was used when needed sternal angle and the phlebostatic axis is known to be quite vari-
and the observer could compress the base of the neck or strip the able between subjects and typically is not 5 cm H2O.14
veins to facilitate recognition of the anatomy. The apex of venous
pulsations was located and respiratory variation noted. The site of Analysis
the venous meniscus was found at end-expiration, and the vertical
distance between this level and the sternal angle was measured Our primary hypothesis was that the internal jugular vein col-
with a ruler, using a yardstick and level to accurately reference the lapse point as judged by portable ultrasound (UCP) would equal
vein to the sternal angle. The JVPEXT was recorded in centime- the CVP as measured by the central venous catheter. Secondary
ters of water. In a similar fashion, the internal jugular vein was analyses included comparing clinical examination of the JVPEXT
examined (also on the side opposite the catheter), taking care to and JVPINT with each other and with the UCP and CVP. JVPEXT,
distinguish jugular from carotid pulsations, and the internal JVP JVPINT, UCP, and CVP were compared graphically using Bland-
(JVPINT) was recorded. The investigator was blinded to the bedside Altman plots, and correlation coefficients were calculated.
monitor display of CVP before and during these clinical examina-
tions as well as for the ultrasound studies below.
Maintaining a constant bed angle, ultrasound gel was applied Results
over the jugular vein (opposite the central venous catheter). A
Sonosite Titan 180 or M-Turbo (SonoSite Inc; Bothell, Washington) Of 38 patients who provided informed consent,
portable ultrasound machine with a 13.6-MHz broadband linear 11 were orally intubated and mechanically ventilated,
array transducer was used to visualize the internal jugular vein. and 27 were not ventilated. Patient characteristics are
The probe was moved superiorly on the neck rotating between given in Table 1. The median time between admis-
longitudinal and transverse views to locate the area of vein col-
lapse. Using the longitudinal view, the apex of the zone of collapse sion to the ICU and study procedures was 1 day. Thirty-
at end-expiration was marked on the neck (Fig 1). Using the two- three examinations were performed in patients with
ruler method described above, the height above the sternal angle internal jugular catheters, with the remaining patients
was measured and the value recorded as the ultrasound collapse having subclavian catheters (two patients) and percu-
pressure (UCP). taneously inserted central catheter lines (three patients).
Without changing the bed angle, the central venous catheter
was zeroed at the level of the sternal angle. The venous waveform Subjects having percutaneously inserted central cath-
was recorded along with a simultaneous plethysmographic tracing, eter lines were accepted only when the pressure trac-
and the value at the base of the “a” wave at end-expiration was taken. ing showed clear respiratory variation. JVPEXT was

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© 2011 American College of Chest Physicians
 Table 1—Characteristics of 38 Subjects

Demographic Value
Age, y 58.3 6 14.7
Male (female) ratio 19 (19)
Acute Physiology and Chronic 16.4 6 6.0
Evaluation II Score
BMI, kg/m2 30.5 6 9.2
ICU diagnosis, No.
Sepsis/septic shock/bacteremia 13
ALI/ARDS 4
GI bleed 4
Acute liver failure 4
Miscellaneous 13
Catheter CVP reading, mean 6 SD, cm H2O 13.9 6 5.9
Right internal jugular catheterization, No. 33
Mechanical ventilation, No. 11
Days to study from admission 2.07 6 2.87
Data are given as mean 6 SD unless otherwise mentioned. ALI 5 acute
lung injury; CVP 5 central venous pressure.

estimated successfully by clinical examination in 37 of

38 subjects, whereas JVPINT could be confidently
measured in only 26 of 38. No anatomic abnormali-
ties that could have compressed the veins, such as
cervical lymphadenopathy, were seen.
The values (mean 6 SD) for CVP, UCP, JVPEXT,
and JVPINT were 13.9 6 5.9, 9.2 6 3.3, 8.8 6 3.2, and
7.8 6 3.2, respectively (Fig 2, Table 2). Correlation
coefficients comparing CVP to UCP, JVPEXT, and
JVPINT were 0.62, 0.57, and 0.50, respectively. When
UCP was compared with JVPEXT and JVPINT, cor-
relation coefficients were 0.91 and 0.81, respectively.
Last, the correlation coefficient comparing JVPEXT
and JVPINT was 0.98. (Fig 2, Table 3).
The Bland-Altman graphical comparison of meth-
ods technique15 revealed that CVP was often under-
estimated by UCP as well as by clinical examination
of JVPEXT and JVPINT. In comparing CVP and
UCP, the mean bias was 5 cm H2O (CVP higher than
UCP). This difference increased as the absolute value
of the CVP increased. In contrast, there was no sys-
tematic bias between UCP and either JVPEXT or
JVPINT, nor between JVPEXT and JVPINT (Fig 3).

Discussion
Our findings showed that ultrasound was able to
image the internal jugular vein in all subjects, whereas
clinical examination was not always successful, sug-
gesting that ultrasound may be useful in estimating
JVP in patients who do not yet have central venous
catheters or have femoral catheters and who are dif-
ficult to examine clinically. The high degree of cor- Figure 2. The correlation between CVP and UCP, CVP and
relation between UCP and JVPEXT and JVPINT, along JVPINT, CVP and JVPEXT, UCP and JVPINT, UCP and JVPEXT,
and JVPINT and JVPEXT. CVP 5 central venous pressure;
with the lack of systematic bias, shows that ultrasound JVPEXT 5 external jugular venous pressure; JVPINT 5 internal
can estimate accurately the JVP as measured by the jugular venous pressure; UCP 5 ultrasound collapse pressure.

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© 2011 American College of Chest Physicians
Table 2—Values for CVP, Ultrasound Collapse Pressure,
Internal Jugular Venous Pressure, and External Jugular
Venous Pressure

Method of CVP Measurement Value

Central venous catheter (CVP) 13.9 6 5.9
Ultrasound collapse of IJV (UCP) 9.2 6 3.3
IJV examination (JVPINT) 7.8 6 3.2
EJV examination (JVPEXT) 8.8 6 3.2
Values are given as mean 6 SD. EJV 5 external jugular vein; IJV 5 internal
jugular vein; JVPEXT 5 external jugular venous pressure; JVPINT 5
internal jugular venous pressure; UCP 5 ultrasound collapse pressure.
See Table 1 for expansion of other abbreviation.

clinical examination. Therefore, ultrasound could

replace or supplement the clinical findings when the
examination is difficult or equivocal. Our findings are
strengthened by a rigorous methodology to maximize
the accuracy of the clinical examination.
On the other hand, all of the methods relying on
detection of the collapse point of the jugular veins
(UCP, JVPEXT, JVPINT) underestimated signifi-
cantly the actual CVP measured invasively. We con-
sidered numerous explanations for this discrepancy
between UCP (or JVP) and CVP. For example, fail-
ure to reference these independent measures to a
common zero point could produce the systematic
bias that we observed. However, our use of an easily
identified reference (the sternal angle), combined
with a strict protocol to correlate that reference point
to the CVP transducer and site of ultrasound exami-
nation in the neck should reduce the likelihood of
error. Alternatively, hemodynamic changes between
imaging of the jugular vein and measurement of the
CVP could explain different values. In this regard, we
did not change body position or bed angle between
measurements and allowed , 5-min interval between
measurements. Yet another potential explanation
relates to pressure of the ultrasound transducer on the
jugular vein. If the weight of the probe were allowed
to compress the vein, one would expect the collapse
point to occur below the measured CVP, resembling
our findings. First, however, we took care to apply
only the minimum pressure required to establish
ultrasonic coupling of skin and probe (and this was
often applied laterally, rather than from above). Second,

Table 3—The Correlation Coefficients of the

Comparison of Different Methods of CVP Measurement

Method of CVP Measurement Correlation Coefficient r

CVP and UCP 0.62
CVP and JVPINT 0.50
CVP and JVPEXT 0.57
UCP and JVPINT 0.81
UCP and JVPEXT 0.91 Figure 3. The Bland-Altman plots of the comparison between
JVPINT and JVPEXT 0.98 CVP and UCP, CVP and JVPINT, CVP and JVPEXT, UCP
and JVPINT, UCP and JVPEXT, and JVPINT and JVPEXT. See
See Tables 1 and 2 for expansion of abbreviations. Figure 2 legend for expansion of abbreviations.

98 Original Research

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© 2011 American College of Chest Physicians
and perhaps more convincingly, error related to Active venoconstriction has been long recognized
probe pressure should have created a bias between to contribute to circulatory adaptation to exercise,
UCP and JVPEXT or JVPINT as well as between postural change, hemorrhage, reduced carotid sinus
UCP and CVP. As seen in Figures 2 and 3, UCP and pressure, hypoxia, and acceleration.24-27 Because 85% of
JVP were nearly identical. In a similar fashion, if neck the blood volume resides in the veins, control of venous,
tissues above the internal jugular vein tended to com- rather than arterial, tone has a greater ability to control
press the vein, JVPINT would tend to underestimate the cardiac output. This response is mediated by the
the true CVP. However, the vertical depth of the autonomic nervous system and is believed to reside
internal jugular vein averages about 1 cm and this largely in the splanchnic veins, particularly those
would be insufficient to bias the JVPINT by 5 cm H2O, within the liver.28 Nevertheless, venoconstriction has
because the specific gravity of neck tissues is roughly been documented in peripheral veins29-30 and in the
1.0.16,17 The precise anatomic location of the tip of the superior vena cava31 in animal models. Thus we believe
catheter should not create a bias as long as the trans- that veins have the potential to produce active wall
ducer is appropriately zeroed.18 Finally, we considered tension in a way that could explain our findings. The
the impact of mechanical ventilation or abdominal pres- degree to which the jugular vein or other large cen-
sure, but these should have similar impacts on both tral veins can constrict in humans is unknown.
UCP and JVP. Our measuring of values at end-expiration In summary, we found that ultrasound examination
lessens any error related to changes in juxtacardiac is capable of measuring accurately the JVP as judged
pressure. from the internal or external jugular vein, even when
If jugular veins act as passive, floppy tubes, they the physical examination is difficult. However, like
should collapse precisely at the level at which the the JVP, ultrasound typically underestimates the CVP.
atmospheric pressure just, and only just, exceeds the Discrepancies are sometimes quite large, especially at
luminal pressure (assuming no weight of the tissues high CVP, suggesting that measuring the ultrasound
superior to the jugular vein). At this point, the trans- collapse point (or the JVP) should not be assumed to
mural venous pressure just exceeds zero, producing reflect the true CVP. The excellent correlation and
collapse. The bias we found between UCP and CVP small bias at low CVP suggests that the UCP may be
led us to question this fundamental assumption that clinically useful in this setting.
jugular veins are passive. An alternative hypothesis is
that the jugular venous walls are capable of exerting
tone, presumably through contraction of smooth Acknowledgments
muscle in their walls. If this were true the vein would Author contributions: Dr Schmidt had full access to the data
collapse at a lower extrajugular pressure than if the and takes responsibility for the integrity of the data analysis.
Dr Deol: contributed to data collection and contribution to manu-
vein were simply passive (that is, the CVP will exceed script writing, analysis and interpretation of data, and revision of
the height of the collapse point by an amount equal the manuscript.
to the transmural pressure produced by muscle con- Dr Collett: contributed to study design and participated in data
collection.
traction). The pressure in the lumen should exceed Dr Ashby: contributed to data collection.
the extrajugular pressure by an amount related to the Dr Schmidt: contributed to study conception and design, supervi-
degree of active tension produced by the venous wall, sion of research, analysis and interpretation of data, drafting and
critical revision of the manuscript for intellectual content, and sta-
and this could account for largely varying discrepan- tistical analysis.
cies in different subjects. Financial/nonfinancial disclosures: The authors have reported
The discrepancy we found between JVP and CVP to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be dis-
has been reported previously,19-23 although this is not cussed in this article.
widely appreciated. For example, in a study comparing Other contributions: We thank the medical ICU nursing staff
clinical examination of the neck veins to the invasively for their invaluable support for the study.
measured CVP, observers at all levels of training under-
estimated the true CVP.20 In another study of clinical
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 Ultrasound Accurately Reflects the Jugular Venous Examination but
Underestimates Central Venous Pressure
Gur Raj Deol, Nicole Collett, Andrew Ashby and Gregory A. Schmidt
Chest 2011;139; 95-100; Prepublished online August 26, 2010;
DOI 10.1378/chest.10-1301
This information is current as of January 21, 2011
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