The jugular veins: gateway to the heart

We appreciate Woodhouse’s interest in our article1 and agree that teaching of the examination of the jugular venous pulsation should be clear. However, his apparent criticism of our approach regarding the positioning of the patient simply reflects differences in the intended purpose of that examination.

Our article begins: “Inspection of the jugular veins provides a simple means of determining whether pressures in the right side of the heart are normal or elevated,” and it was written as a practical guide for clinicians on the most useful clinical technique for this purpose.

The reference point we suggest for measurement of pressure is the sternal angle, and since it is not anatomically possible for any part of the internal or external jugular vein to be above that level when the patient is supine, then this makes the use of the supine position redundant for the detection of an elevated right atrial pressure. As such, it would be erroneous to recommend that position as the preferred one when the physician is attempting to evaluate whether the right atrial pressure is elevated. Moreover, the assessment of the jugular venous pulsation in the sitting position has been found to be good when specifically studied.2

We assume that Woodhouse’s preference for the supine position relates to teaching sessions in which the intention is simply to let students identify a venous pulsation in the neck, and perhaps better understand its waveform. We agree that, in that position, it will almost always be visible in individuals who are asymptomatic, although it may appear non-pulsatile if the right atrial pressure is elevated, and it may therefore be harder for students to visualise.

Given that the assessment of venous waveform is in general of much less clinical utility than the use of the jugular veins as a manometer,3 we recommend that medical educators focus their teaching on the latter, as soon as students are confident with the location and appearance of a venous pulsation.