Today I asked a colleague to help me practice short cases. He wanted me to do a cardiovascular case first. But because I had not prepared for that, I opted for a CNS case. I didn’t have the two small scales that are used to measure the Jugular Venous Distension or JVP as it is commonly known amongst residents. Its a difficult method to check for distension of Jugular Vein, but our seniors taught us to use this method and, well, we do the same. However, I remembered that I had once shared an interesting research paper with my Senior Registrar 3-4 years ago when we had a discussion on the same method. That paper proposed something new. Well, he thought it was interesting but didn’t suggest we change the method of checking JVP. We remained glued to the old method.
The following picture will show you what this method looks like.
This image was taken from this blog post. The theory behind this method is that identification of elevated jugular venous pressure not only helps us in diagnosing heart failure but also predicts prognosis and guides therapy. and guides therapy. Classic teaching recommends that JVP be estimated with the patient lying on an adjustable examination table with the upper trunk initially elevated 30° to 45° from the horizontal, while tangential light is used to visualize the venous pulse. The vertical distance from the sternal angle to the top of the venous column is measured using a ruler. Five centimeters added to this distance then gives JVP as an estimate of the true right atrial (RA) pressure.
However this method is a bit too complicated and the result is that most of the physicians either choose not to perform it or even if they do it, it is not performed correctly. The paper that I had found had pointed out this and other aspects of the “conventional method” of JVP and had suggested a new method of looking for Jugular Venous distension. The study was done with the aim to assess whether the estimation of jugular neck distension in sitting position could be used to detect elevated venous pressure or not. The Researchers found that a visible venous column above the clavicle in sitting position had a sensitivity of 65% and was 85% specific for a truly elevated venous pressure. They also noted that
The time-honored use of the sternal angle of Louis as the external reference point is based on the idea that the distance of the angle from the center of the right atrium is 5 cm regardless of the inclination of the upper body. Recent studies using computed tomography have shown, however,that this idea is genuinely false: the distance varies across subjects and changes markedly with the position of the upper body. Thus, the sternal angle has no true advantage over the right clavicle as the external point of reference.
They also noted that
A recent audit of the treatment of heart failure in the Finnish primary health care system showed that JVP was recorded in only 1% of 825 routine control visits to physicians and in no more than 3% of symptomatic visits. We believe that the main reason for these ?gures is the complicated nature of the classic method of Louis.
Sounds interesting. That this study will make it easier for me to examine patients for a raised jugular venous pressure is good to think of. But there are anecdotes where the candidate was unfortunately more up-to-date than the examiner and didn’t pass the long case just because the examiner was not aware of the recent updates in that particular topic. Yes! that has happened. So I guess I will have to be careful and try to master the “old” routine just to be on the safe side.
Here is the PDF file of that study which I had downloaded 3-4 years back from internet. Unfortunately I couldn’t find the exact link this time, so I thought of sharing it here with you.
What is your opinion on this examination? Should we keep doing the old routine because this was how we and our teachers before us were taught to examine the patients? Do let me know about your thoughts on this matter.