Jugular Venous Pressure (JVP) Examination - Clinical Skills - Dr Gill

Hello, my name's Alter Gil. I've been asked to do an examination uh of your neck blood vessels today, specifically the JVP, the jugular venus pulsation. Uh before we start, can I please confirm your name and date of birth? >> Yes, sure. It's Yani Nazareno, 30th of September, 96. >> Thank you. So, to the best of your knowledge, um do you have any problems with your stomach? >> Not that I'm aware of. Okay. So, in terms of doing the examination, it's going to involve you lying down, resting your head on the bed, and then me applying some pressure over the stomach. Okay. >> Okay. >> So, if just get you to lie down and relax, please. >> Okay. And if you turn your head to face that way. >> Super. So, having a look at the base of your neck to start off with and just try and relax for me. Let those muscle. There we go. So, I can see a nice pulsation coming through. And crucially, I can easily see two waveforms here. So there's two pulses coming through. I'm just going to touch your neck if you don't mind. Okay. So I can't feel that pulsation. So we're confirming that we do have the JVP that we're looking at. So if I get you to put your hands by your sides for me and I'm just going to put my hands on your uh abdomen and press here. Is that okay? So having a look and what I'm expecting to happen is this pulsation to move further up the neck. Okay, one, two, three, push. Okay, that's excellent. There's a nice surge up. So this confirms that we're in the right location. And if we were to draw a ruler up from here across and that's putting your JVP at about 3 cm above the maneubal sternal angle. So, we know that this is entirely normal for yourself. So, in terms of that, there's no concerning features. Do you have any questions for me at the moment? >> Um, no, not at all. >> Super. Thank you very much. >> Hello and welcome back to the channel. You've joined myself, Dr. James Gil, for another clinical skills video. Today we're going to be looking in depth at the JVP here, understanding the differences between the appearance of the JVP versus the corroted arteries and the um the importance of assessing the internal jugular venus pulsation as opposed to the external jugular venus pulsation. So with regard to the JVP, what we're doing is we're using it as a monometer, a way of looking at the pressure of the right atrium. If we had for example a a raised intrathoracic pressure then that would cause a rise. So we'd see the JVP increase in the position on the neck. Now the way that we're going to be able to tell that is by looking at the patient's neck we will see two waveforms in the JVP. So as we look at the patient's uh neck, we can see the sternocllymastoid muscle and we can see the external jugular vein uh highlighted by the veinfinder. Crucially because we're looking at the jugular venus pulsation, we can see the pulse highlighted there and we know that this is the JVP and not the corateed because we've got a double pulsation here which you can see clearly moving under the light of the veinfinder. it's pulsing twice with each beat as opposed to the corroted which would be pulsing uh once. We can confirm that by actually pressing over the JVP and it is impalpable. I'm unable to feel the pressure against my fingers. Now, crucially, um the external jugular vein can be used to assess the right atrial pressure. However, it's not something we prefer to use ideally because it can be a potentially torturous route and there may be the presence of vessels within it which may impact on the response to the hippatugular reflux test. In terms of other factors that we can see with regard to the JVP on inspiration, the JVP will fall because in order to breathe in, we've caused a reduction in pressure in the chest. So the air falls into our lungs because the vacuum we've made there. The same will be true of the JVP. By creating this vacuum, the pressure on the right atrium will reduce and the height of the JVP would fall. Conversely, on breathing out on expiration, we're increasing the pressure in the chest because we're allowing uh the patient or we're getting the body to exhale. Thus, we'd expect the JVP to rise up on the neck. So, we can perform the uh abdominal jugular um reflux by pressing into the abdomen. So, do one, two, three, push. And we can see there there's a easy fullness to the JVP and it's moving up nicely and a slight increase in the external jugular vein. So we do that once more. So by pressing onto the um the liver we're forcing blood into the right atrium which we're seeing transmitted with regard to the pressure to the right JVP. One, two, three. And there's that excellent filling of the JVP. And we can see that double waveform there. Obviously, it does settle back over after a couple of seconds um of pressure being applied. So an important part of any test such as looking at the JVP is to determine what an abnormality suggests. So an abnormality to the JVP would be the visible pulse being more than 3 cm above the sternal angle. When we talk about measuring the height of the JVP, we want to essentially take a ruler from the manubra sternal angle and measure upwards and correlate with how high up that is uh rising on the neck. Um so here we're probably getting 2 3 cm over the maneuver sternal angle. Thus we know that this is a normal height for the patient and would likely reflect a normal atrial pressure of less than 7 mm of mercury. So an abnormality to the JVP would be the visible pulse being more than 3 cm above the sternal angle and this is going to indicate issues with increased pressure to the right um atrium. Now classically that's often associated with right heart failure whereby the heart isn't able to pump properly leading to increased pressure in the venus system which will cause that rise in the level of the JVP. Similarly, we can have issues with congestive heart failure. Staying around the heart, constrictive pericarditis or cardiac tampenard all put physical pressure directly on the heart which we'll see with a raised pressure to the right atrium which will be transmitted backwards through the venus system to cause a rise in the internal jugular vein. We can have other causes of um raised JVP, but again they're all related to pressure. So for example, chronic pulmonary hypertension can do that. acute pulmonary hypertension as you may see from the presence of a pulmonary embolism and potentially even significant changes to the intrathoracic pathology um such as a tension pneumthorax where we've got compression of the lung and increased pressure within the thoracic cavity due to air being trapped and leaking into the thoracic space steadily squashing the heart which is one of the reasons why A tension pneumathorax needs to be addressed very very quickly. Ultimately this test is all about looking at the pressures within the chest and specifically the right atrium. And if we understand that then we appreciate why the abdominal jugular reflex or apat jugular reflex will result in an increased JVP when we're applying that pressure to the abdomen. With some patients, if the JVP is not clearly visible, it may be that we're dealing with a very healthy person and they have a very low right atrial pressure. In which case, we can confirm this by having them lie down horizontally at which point gravity is no longer acting on the JVP and we'll see it coming up the neck whilst the patient is in the horizontal position. So, if you could sit forward for me, please lie back please. At this point, the pressure should allow the JVP to once again become visible at the base of the neck. And here, because of the change in angle, the JVP has risen slightly higher as we would expect because now there is it's not having to push against gravity. Conversely, it could be that we have an unwell patient with a very high JVP and that pulsation has disappeared inside the skull. And again, when we lie the patient down, we would not see the visible presence of the JVP in such a patient. It is theoretically possible when we assess for the JVP that it might not be visible at the patient's neck when they're lying at 45°. we can attempt to um make it visible by applying pressure over the abdomen, the abdominal um jugular reflux that pushes blood through the venus system into the right atrium and results in the internal jugular vein pulsation rising on the neck. Hopefully, this has been a useful overview of the JVP and understanding what it means from a pathological perspective. If you've got any questions or comments, please put them down in the section below. And please, as ever, don't forget to like and subscribe. With that, thank you very much. We'll see you in the next one. Cheerio.