Free On-line Access

SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira


ISSN: 0103-507X
Online ISSN: 1982-4335

Ícone Fechar

How to Cite


Westphal GA, Freitas FGR. Distensibilidade da jugular interna, uma possibilidade não invasiva para avaliar responsividade a fluidos?. Rev Bras Ter Intensiva. 2015;27(3):190-192





Jugular vein distensibility, a noninvasive parameter of fluid responsiveness?

Distensibilidade da jugular interna, uma possibilidade não invasiva para avaliar responsividade a fluidos?

Glauco Adrieno Westphal1,2, Flávio Geraldo Rezende de Freitas3

1 Centro Hospitalar Unimed - Joinville (SC), Brazil
2 Hospital Municipal São José - Joinville (SC), Brazil
3 Hospital São Paulo, Universidade Federal de São Paulo - São Paulo (SP), Brazil

Conflicts of interest: None.

Corresponding author: Glauco Adrieno Westphal, Rua Oscar Schneider, 237 - Bairro Atiradores, Zip code: 89203-040 - Joinville (SC), Brazil. E-mail:


Most critically ill patients in intensive care units (ICU) require fluid administration for volume expansion at some point during their hospital stay.(1) In most cases, initial volume expansion does not require more sophisticated or invasive measures. Clinical history data and clinical signs of low flow may suggest the likelihood of a response to the initial fluid infusion. As suggested by Vincent and Weil, “the concept of volemic expansion parallels that of feeding a crying baby who may be thirsty or hungry. The baby’s response to feeding is rapidly apparent as a need is satisfied”.(2)

Unfortunately, this basic principle is not frequently used in practice. A recent analysis of more than 2,000 fluid challenges showed that critically ill patients tend to be treated in the same manner, regardless of the initial response to volume expansion. Half of the patients who were responsive to the initial fluid challenge did not receive additional fluid and were subjected to hypoperfusion, and half of the non-responsive patients received fluid and were subjected to fluid overload. In addition, the initial clinical evaluation of the cardiovascular response of approximately 1/3 of the patients was uncertain. Even in these cases, additional fluid tended to be administered to more than half of the patients without a more thorough evaluation.(3) These findings suggest that the fluid challenge frequently depends on a “proof of faith”, which is more strongly based on the belief of the possibility of a clinical response to a fluid challenge than on objective parameters.

It is essential to use monitoring methods capable of quickly and precisely identifying volume deficits to minimize tissue damage related to hypovolemia and avoid iatrogenic fluid overload.(4,5)

Several invasive and noninvasive methods, known as dynamic parameters for the evaluation of the cardiovascular responsiveness to volume, have been suggested to improve volume replacement. Among these measures, the respiratory change in arterial pulse pressure (∆Pp) is likely the most well-known method; its first historical reference was in 1669, when Lomer reported a pathological intensification of blood pressure changes in a case of pericarditis, defined by Kussmaul as pulsus paradoxus or ‘paradoxical pulse’.(6) In 1899, Otto Frank developed an experimental model consisting of air chambers that simulated the heart-vessel interaction, which helped to define the relationship between arterial tone, stroke volume, and arterial pulse pressure.(7,8) Mechanical ventilation with positive pressure reverses the intrathoracic pressure and increases arterial pressure during inspiration, which was defined as reversed pulsus paradoxus in 1973.(9) In 1978, researchers began to evaluate the relationship between the volemic state and systolic arterial pressure variation,(10-17) until 2000, when Michard et al.(18) demonstrated the high accuracy of the clinical use of ∆Pp in the evaluation of fluid responsiveness in septic patients. The pressure changes observed in the arterial bed match those found in the venous bed. Thoracic pressurization acts on the right heart and vena cava, influencing blood return to the heart resulting in changes of the central venous pressure during ventilatory movements.(19-22)

In an individual’s responsive to volume, the pressure around the intrathoracic veins (mechanical inspiration) exceeds the internal vessel pressure, and the vascular structure tends to collapse.(22) This constriction generated in the intrathoracic portion of the venous bed during mechanical inspiration functions as a flow resistor, engorging and distending the extrathoracic portions of the great venous vessels, such as the intradiaphragmatic portion of the inferior vena cava (IVC) and the jugular veins. Therefore, responsive patients tend to present with an increase in the inspiratory collapse index of the superior vena cava (SVC) and in the distensibility indices of the inferior vena cava (IVC) and the internal jugular veins during mechanical ventilation.(21,23)

In this issue of RBTI, Broilo et al.(24) reinforce the idea that the respiratory variation in the internal jugular vein diameter (ΔDRIJ) is correlated with the respiratory variation in the inferior vena cava diameter (ΔDIVC), suggesting that the internal jugular distensibility may be an easy, noninvasive alternative to evaluate fluid responsiveness in mechanically ventilated patients. IVC imaging can be difficult in obese patients and patients with abdominal distension and ascites, and SVC imaging requires transesophageal echocardiography, which limits its application.(23) Because internal jugular vein imaging does not require transesophageal echocardiography and is technically more simple than visualizing the IVC, this technique seems to be a simple and promising bedside method for the evaluation of fluid responsiveness. However, the limitations of the study should be considered when interpreting the results. Broilo et al.(24) evaluated the correlation between ΔDRIJ and ΔDIVC without testing the capacity of ΔDRIJ to predict fluid responsiveness to volemic expansion based on the cardiac output behavior. In addition, recent studies have questioned the accuracy of ΔDRIJ in predicting the response to volume infusion.(25,26) Thus, as the authors themselves forewarn, the results should be interpreted with caution until new studies are published. We also highlight that the method is applicable for sedated and mechanically ventilated patients. Additionally, data on patients with conditions that lead to an increase in venous pressure (cor pulmonale or ventricular insufficiency) as well as to jugular vein engorgement due to the inadequate position of the head of the bed should be interpreted with caution.(23,24)


Vincent JL. Issues in contemporary fluid management. Crit Care. 2000;4 Suppl 2:S1-2. Link DOILink PubMed
Vincent JL, Weil MH. Fluid challenge revisited. Crit Care Med. 2006;34(5):1333-7. Link DOILink PubMed
Cecconi M, Hofer C, Teboul JL, Pettila V, Wilkman E, Molnar Z, Della Rocca G, Aldecoa C, Artigas A, Jog S, Sander M, Spies C, Lefrant JY, De Backer D; FENICE Investigators and the ESICM Trial Group. Fluid challenges in intensive care: the FENICE study: A global inception cohort study. Intensive Care Med. 2015 Jul 11. [Epub ahead of print] Link DOI
Kreimeier U. Pathophysiology of fluid imbalance. Crit Care. 2000;4 Suppl 2:S3-7. Link DOILink PubMed
Martin GS. Fluid balance and colloid osmotic pressure in acute respiratory failure: emerging clinical evidence. Crit Care. 2000;4 Suppl 2:S21-5. Link DOILink PubMed
Khasnis A, Lokhandwala Y. Clinical signs in medicine: pulsus paradoxus. J Postgrad Med. 2002;48(1):46-9. Link PubMed
Frank O. Die Grundform des arteriellen pulses. Erste Abhandlung: mathematische analyse. Zeitsch Biol. 1899;37:483-526.
Erlanger J, Hooker DR. An experimental study of blood-pressure and of pulse-pressure in man. Johns Hopkins Hosp Rep. 1904;12:145-378.
Massumi RA, Mason DT, Vera Z, Zelis R, Otero J, Amsterdam EA. Reversed pulsus paradoxus. N Engl J Med. 1973;289(24):1272-5. Link DOILink PubMed
Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005;103(2):419-28; quiz 449-5. Link DOILink PubMed
Jardin F, Farcot JC, Gueret P, Prost JF, Ozier Y, Bourdarias JP. Cyclic changes in arterial pulse during respiratory support. Circulation. 1983;68(2):266-74. Link DOILink PubMed
Pinsky MR, Summer WR. Cardiac augmentation by phasic high intrathoracic pressure support in man. Chest. 1983;84(4):370-5. Link PubMed
Coyle JP, Teplick RS, Long MC, Davison JK. Respiratory variations in systemic arterial pressure as an indicator of volume status [abstract]. Anesthesiology. 1983;59:A53.
Perel A, Pizov R, Cotev S. Systolic blood pressure variation is a sensitive indicator of hypovolemia in ventilated dogs subjected to graded hemorrhage. Anesthesiology. 1987;67(4):498-502. Link DOILink PubMed
Pizov R, Ya'ari Y, Perel A. Systolic pressure variation is greater during hemorrhage than during sodium nitroprusside-induced hypotension in ventilated dogs. Anesth Analg. 1988;67(2):170-4. Link PubMed
Pizov R, Ya'ari Y, Perel A. The arterial pressure waveform during acute ventricular failure and synchronized external chest compression. Anesth Analg. 1989;68(2):150-6. Link DOILink PubMed
Szold A, Pizov R, Segal E, Perel A. The effect of tidal volume and intravascular volume state on systolic pressure variation in ventilated dogs. Intensive Care Med. 1989;15(6):368-71. Link DOILink PubMed
Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, et al. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162(1):134-8. Link DOILink PubMed
Pinsky MR. Recent advances in the clinical application of heart-lung interactions. Curr Opin Crit Care. 2002;8(1):26-31. Review. Link DOILink PubMed
Magder S. Clinical usefulness of respiratory variations in arterial pressure. Am J Respir Crit Care Med. 2004;169(2):151-5. Link DOILink PubMed
Jardin F, Vieillard-Baron A. Monitoring of right-sided heart function. Curr Opin Crit Care. 2005;11(3):271-9. Link DOILink PubMed
Westphal GA, Silva E, Caldeira Filho M, Roman Gonçalves AR, Poli-de-Figueiredo LF. Variation in amplitude of central venous pressure curve induced by respiration is a useful tool to reveal fluid responsiveness in postcardiac surgery patients. Shock. 2006;26(2):140-5. Link DOILink PubMed
Guarracino F, Ferro B, Forfori F, Bertini P, Magliacano L, Pinsky MR. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care. 2014;18(6):647. Link DOILink PubMed
Broilo F, Meregalli A, Friedman G. Right internal jugular vein distensibility appears to be an alternative to inferior vena cava vein distensibility to evaluate fluid responsiveness. Rev Bras Ter Intensiva. 2015;27(3):205-11.
Sobczyk D, Nycz K, Andruszkiewicz P. Bedside ultrasonographic measurement of the inferior vena cava fails to predict fluid responsiveness in the first 6 hours after cardiac surgery: a prospective case series observational study. J Cardiothorac Vasc Anesth. 2015;29(3):663-9. Link DOILink PubMed
Charbonneau H, Riu B, Faron M, Mari A, Kurrek MM, Ruiz J, et al. Predicting preload responsiveness using simultaneous recordings of inferior and superior vena cava diameters. Crit Care. 2014;18(5):473. Link DOILink PubMed

Submission On-line

Indexed in




Associação de Medicina Intensiva Brasileira - AMIB

Rua Arminda nº 93 - 7º andar - Vila Olímpia - São Paulo, SP, Brasil - Tel./Fax: (55 11) 5089-2642 | e-mail:

GN1 - Systems and Publications