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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 61-66

Reliability of a jugular venous pressure scale in cardiovascular clinical examination


1 Department of Physiology, Bhima Bhoi Medical College and Hospital, Balangir, Odisha, India
2 Department of Physiology, Raiganj Government Medical College and Hospital, Raiganj, India
3 Department of Physiology, Fakir Mohan Medical College and Hospital, Balasore, Odisha, India
4 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Mumbai, Maharashtra, India
5 Department of Anatomy, Rampurhat Government Medical College and Hospital, Rampurhat, West Bengal, India

Date of Submission23-Jan-2020
Date of Decision17-Mar-2020
Date of Acceptance20-Mar-2020
Date of Web Publication01-Aug-2020

Correspondence Address:
Dr. Shaikat Mondal
Department of Physiology, Raiganj Government Medical College and Hospital, Raiganj - 733 134, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCPC.JCPC_4_20

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  Abstract 


Background: Noninvasively jugular venous pressure (JVP) is measured at bedside commonly by card and ruler. New tools have been developed for the measurement of JVP with the basis of this method. However, these tools have some limitations. Aim: The aim of this study was (1) to develop a JVP scale which would be devoid of common problems faced with currently available devices and (2) to test the provisional validity and reliability of the device in the estimation of JVP. Materials and Methods: We used two common plastic rulers – one as vertical and one as horizontal. The vertical ruler was cut at the level of 5 cm mark. A piece of aluminum sheet was used to make an adapter in which the vertical ruler can slide. This adapter was attached to the horizontal ruler. Both the rulers were equipped with spirit-level capsules. This device was used by 16 raters to measure JVP on five individuals twice. Inter-rater, intra-rater, and test–retest reliability were checked by the intraclass correlation coefficient (ICC) in IBM® SPSS® Statistics Version 20 software package. Results: For average measures, inter-rater ICC was 0.998 (P < 0.001), intra-rater ICC was 0.981 (P < 0.001), and test–retest ICC was 0.829 (P = 0.001). Inter- and intra-rater reliability was “excellent,” whereas test–retest reliability was “good.” Conclusions: Developed JVP scale is low cost and easy to build at any resource-limited settings. This would be an adjunct tool for bedside cardiovascular examination of patients with good to excellent reliability. This would also be used for teaching cardiovascular physiology for medical and allied science students.

Keywords: Cardiovascular examination, central venous pressure, jugular veins, jugular venous pressure, physical examination, reproducibility of results


How to cite this article:
Mondal H, Mondal S, Das D, Alam N, Saha K. Reliability of a jugular venous pressure scale in cardiovascular clinical examination. J Clin Prev Cardiol 2020;9:61-6

How to cite this URL:
Mondal H, Mondal S, Das D, Alam N, Saha K. Reliability of a jugular venous pressure scale in cardiovascular clinical examination. J Clin Prev Cardiol [serial online] 2020 [cited 2020 Aug 12];9:61-6. Available from: http://www.jcpconline.org/text.asp?2020/9/2/61/291229




  Introduction Top


Estimation of jugular venous pressure (JVP) is a part of the bedside cardiovascular examination.[1] Although there are evidences that the bedside measurement of JVP may be inaccurate,[2] it is still a method to roughly estimate the central venous pressure of the patient.[3] Hence, the method of JVP estimation is still taught in clinical medicine, cardiology, and physiology.[4],[5],[6],[7]

From historical time to today's age of video-based instructions, JVP is measured at bedside by a two-object method. We call it “two-object method” as we use two objects to make an instrument – a horizontal object and a vertical object. For the horizontal object, clinicians commonly use a card, pencil, pen, or a ruler. The lower edge of this object is positioned above the visible pulsation of the internal jugular vein. Then, the vertical object (commonly a ruler with centimeter marking) is held on the sternal angle, and the vertical distance from the sternal angle to the lower end of the horizontal object is noted. As a convention, 5 cm is added to the reading to get the final reading of JVP in cm of water.[8]

In recent literature, Vincent et al. reported a “Zaria-made jugulometre” which uses the basis of classic two-object method with a convenient coupling of two objects.[9] Further advancement of the device leads to commercial introduction of “Jugulometer” as reported by Ogunlade et al.[10] However, the “Jugulometer” is not procurable from any online store for global usage.

The two-object method has some limitations which are shown in [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. The major problem is keeping the horizontal object at a perfect horizontal level. This has been solved by using a spirit level on the horizontal object.[9],[10] “Zaria-made jugulometre” uses padding beyond the scale marking on the vertical ruler [Figure 1]e. Although this was intended for not hurting the individual, it may provide lower reading. If the coupling of the adapter is not perfect, then there may be undetectable inclination of the vertical ruler [Figure 1]f. This could be eliminated using a spirit level on the vertical ruler. The flat padding is not also a good choice for placing the scale on sternal angle when the individual is inclined at 45° [Figure 1]g. This problem has been solved by “Jugulometer” which used a tapering shape of the vertical ruler [Figure 1]h. However, the shape may not be suitable for all individuals. Furthermore, both of thse scales are having an excess portion beyond the scale markings and the scale starts with zero [Figure 1]g and h]. If we can use a ruler which starts marking from 5 cm, we can get the reading of JVP directly from the scale reading.
Figure 1: Common problem of available devices used for bedside jugular venous pressure measurement – (a) Horizontal card may bend (b) Thickness of pen or pencil may provide inaccurate reading (c) Vertical ruler may be inclined (d) Excess material beyond scale marking may provide lower reading and starting of scale from zero needs addition of 5 cm to the reading (e) Padding beyond scale marking may provide lower reading (f) Vertical ruler may be inclined due to maladjustment of adapter (g) Difficulty in maintaining proper vertical position for vertical ruler (h) Excess material beyond scale may provide lower reading and scale starting with 0 needs addition of 5 cm to the reading

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With this background, the aim of this study was to first develop a JVP scale which should help us to overcome the barriers we are currently facing with the available devices for the estimation of JVP at bedside. Further, the device was planned to make with low-cost components with possible less number of simple tools and second, to test the provisional validity (does it estimates what is supposed to estimate) and reliability (does it estimate the same in a repeated session of estimation) of the newly developed device to check its feasibility to use in the bedside cardiovascular examination.


  Materials and Methods Top


Ethical statement

The first part of the study is concerned with the development of an instrument which does not involve any human individuals or animals. For the second part of the study, the recruitment of individuals and conduction of the experiment was done after obtaining permission form the institute (No: 17/PHY/2019). We further declare that the study was conducted in full accordance with the ethical statement by the Declaration of Helsinki.[11]

Materials

[Figure 2] shows the materials used for the development of the device, which are as follows: from left to right – a hacksaw blade to cut the plastic ruler, a piece of aluminum sheet cut from an old empty deodorant bottle, a pair of 12 inch plastic ruler, an instant adhesive to fix the scale with the adapter, a couple of spirit level capsule, Polyvinyl carbon (PVC) tape to cover the aluminum sheet, and a pair of scissors.
Figure 2: Materials used for the development of jugular venous pressure scale

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Method of making jugular venous pressure scale

The method of making the JVP scale is shown in [Figure 3].
Figure 3: Procedure of making the jugular venous pressure scale – (a) ruler was cut a 5 cm mark (b) an aluminum sheet was cut (c) The aluminum sheet was covered by polyvinyl carbon tape (d) The sheet was wrapped and excess portion was cut and discarded (e) Shape was secured with polyvinyl carbon tape (f) The adapter was attached by glue on the horizontal ruler (g) A spirit level was attached on the horizontal ruler (h) A spirit level was attached on the vertical ruler (i) Jugular venous pressure scale in assembled form

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  1. A ruler was cut at the level of 5 cm mark and the smaller piece was discarded – larger one would act as the vertical scale
  2. A piece of aluminum sheet was cut with the help of scissor to make its breadth less than that of the ruler – this would be used to make the adapter
  3. The mid-portion and edges of the sheet were covered with PVC tape – to reduce chances of injury and for relatively smooth sliding
  4. The sheet was positioned and folded over a ruler – to make the perfect slit opening for the vertical ruler
  5. After cutting excess portion, the sheet was secured in its position by covering it thrice with PVC tape – this would maintain shape of the slit opening
  6. The adapter was attached on the horizontal ruler with the help of instant adhesive – the vertical ruler can be inserted in the adapter attached on the horizontal ruler
  7. A spirit-level capsule was attached on the horizontal ruler on its upper edge
  8. At the top end of the vertical ruler, another spirit level capsule was attached
  9. Horizontal ruler was inserted in the adapter – the final JVP scale.


Measurement procedure

After obtaining written consent and explaining the procedure, five males were recruited as a convenience sample. Apparently healthy adult individuals (age >18 completed years) with easily identifiable jugular venous pulsation was recruited. The individual was positioned at 45° to the horizontal plane, as shown in [Figure 4]. The neck was turned slightly toward left and the highest visible jugular venous pulsation was identified by inspection with the help of a bright torch. The jugular venous pulse was confirmed by palpation. Now, the vertical ruler of JVP scale was positioned at the sternal angle of the individual. Then, lower end of the horizontal ruler was positioned just above the highest visible pulsation. Both the scales were checked for leveling. The reading was noted from the centimeter scale of the vertical ruler where the lower end of the horizontal scale is. This reading indicates JVP in cm of water.
Figure 4: Measurement of jugular venous pressure by the jugular venous pressure scale

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Provisional validity

After written consent, we recruited 16 raters from faculty members and students. All of them were briefed about the device and the procedure on how JVP can be measured with the device. The brief procedure can be found in supplementary file (https://doi.org/10.6084/m9.figshare.12254021.v1). The reading of JVP from each rater was recorded on a pro forma. This pro forma also collects opinion of the rater about the ease of using the device in 5-point Likert-type scale. As the actual JVP and JVP measured by this JVP scale may be different, it was not possible to test the validity of the device. However, the opinion of the raters would give us an idea about the acceptability of the device. Furthermore, if the raters can measure the JVP by the scale as it is measured by the two-object method, it would establish the provisional validity.

Reliability of the device

Each of the rater estimated JVP of five individuals twice (i.e., test and retest) with a gap of 15 min in the same environmental condition. These data were used for the reliability test. First measurement data from 16 raters on five individuals were used to test inter-rater intraclass correlation coefficient (ICC). The readings of test and retest of the first rater measuring five individuals were used to test intra-rater reliability. The readings of test and retest on the first individual by 16 raters were used for test–retest reliability.

Statistical methods

Statistical analysis was carried out in Microsoft office Excel® “data analysis tool” (Microsoft: USA) and IBM® SPSS® Statistics Version 20 software package (IBM Corp., Armonk, NY, USA). Descriptive statistic was used to show the frequency of the data in mean, standard deviation, standard error of mean, range, and 95% confidence interval.

For scoring of the opinions obtained from the raters, each response was coded as strongly agree = 5, agree = 4, neither agree nor disagree = 3, disagree = 2, and strongly disagree = 1 for positive statements and strongly agree = 1, agree = 2, neither agree nor disagree = 3, disagree = 4, and strongly disagree = 5 for negative statements.

For inter-rater reliability, the most suited statistical test was “two-way, mixed effect, mean of k raters, absolute agreement.” For intra-rater and test–retest reliability, the most-suited test was “two-way, mixed effect, mean of k measurement, absolute agreement.”[12] On the IBM® SPSS® Statistics Version 20 software package, brief steps were: Analyze – Scale – Reliability Analysis – Statistics – Intraclass correlation coefficient (Model: Two-Way Mixed, Type: Absolute Agreement, Confidence interval 95%)”.


  Results Top


The parts of the developed device are shown in [Figure 5]a and its assembled form is shown in [Figure 5]b. This device is devoid of limitations [Figure 1]a-h] of currently available devices used for bedside measurement of JVP.
Figure 5: (a) Component of jugular venous pressure scale (b) Jugular venous pressure scale in assembled form

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This device was successfully used to measure JVP on five individuals. The opinion of the raters about the scale is shown in [Table 1]. The most-favored feature was ease of taking the reading of JVP from the scale (4.81 ± 0.40), whereas the least-favored feature was its suitability of usage in the bedside estimation of JVP (3.94 ± 0.57).
Table 1: Survey response on the jugular venous pressure scale

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Descriptive statistics of test and retest is shown in [Table 2].
Table 2: Frequency distribution of measured jugular venous pressure (n=5) in cm of water by 16 observers

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ICC for inter-rater, intra-rater, and test–retest reliability is shown in [Table 3]. Inter-rater (0.998, P < 0.001) and intra-rater (0.981, P < 0.001) reliability was “excellent” for average measures. Test–retest reliability (0.829, P = 0.001) was “good” for average measures.
Table 3: Intraclass correlation coefficient for different types of reliability

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  Discussion Top


What is already known and what this study adds?

For a quick bedside assessment of JVP, two-object method is the most-practiced method despite its practical limitations. As it is a noninvasive method and anyone with moderate expertise can measure it, it is yet an academic pearl in medical teaching and for provisional diagnosis. The limitations of currently available devices have already been described in [Figure 1]. This study adds a device to cardiovascular examination which has potential to replace the current two-object method. Moreover, theoretically, it is devoid of limitations which are still there in “Zaria-made jugulometre” and “Jugulometer.”[9],[10] Furthermore, this device is easy to build and can be made in any resource-limited condition.

Validity and reliability of the device

This device is actually based on the concept of two-object method with robust theoretical and practical advancement. It is already criticized that there may not be perfect 5 cm distance from the sternal angle to the right heart.[13] For the validity of the device, we did not compare the actual JVP (measured by invasive procedure) with measured JVP by this scale due to nonavailability of such device in our settings. Instead, its validity was tested by checking if it is capable of measuring JVP on an individual as we measur by noninvasive method. Hence, we used the term “provisional validity.” The opinion of raters also supported the provisional validity of the device. The reliability of the device was established by three methods (inter-rater, intra-rater, and test–retest reliability) which ranged from “good” to “excellent” for average measurement. Hence, this device can be used reliably for the rough estimation of JVP.

Usage of the device

As this device can be disassembled and can be carried just as a couple of rulers, it may be used in any indoor and outdoor settings. Clinicians, paramedics, and medical students can use it for the measurement of JVP. This may be an adjunct device to cardiovascular teachings in undergraduate medicine or physiology classes. In our settings, we successfully used it in human cardiovascular examination in physiology. Even, in future, the device may be included in the objective structured clinical (/practical) examination. A study from Nigeria suggested that resident doctors have poor knowledge about JVP measurement procedure despite their traditional education.[14] A flowchart of the methodology may be easier to remember and helpful for teaching.[15] It can be created from the information in supplementary file (https://doi.org/10.6084/m9.figshare.12254021.v1) for further use.

Advantages and disadvantages of the device over other devices

This low-cost device can be easily made and disassembled to carry as a couple of ruler. This has potential to reduce operator effort in the measurement of JVP. There are some disadvantages of the device. For using JVP scale, we need to carry an extra device. In contrast, an ordinary ruler is sufficient for two-object method. The PVC-covered aluminum adapter may not last long and making of the device may be difficult for some less-interested person.

Components of the “Zaria-made jugulometre” (e.g., fiber horizontal scale, adapter, and light-emitting diode illumination system) are costlier than the materials used to make this JPV scale. In addition, “Jugulometer” is a commercial device which is difficult to procure. “Zaria-made jugulometre” and “Jugulometer” are also an extra device to carry like JVP scale. Making “Zaria-made jugulometre” requires more effort than making of our JVP scale.

Limitation of the study

We recruited only healthy volunteers for this study. The range of the JVP was narrow. Hence, its accuracy in the measurement of JVP in patients with very low or very high JVP has not been ascertained. Currently, this is a major practical limitation of the device.

Future directions

The adapter used in this device is made up of an aluminum sheet wrapped with PVC tape. It might not give us smooth sliding of the ruler. Hence, further modification with similar or lower cost alternative is needed. The horizontal object used in this device is a ruler. This may be replaced by a thin yet sturdy object to reduce the size. An arrangement of digital reading from the scale would further make the device interesting.


  Conclusions Top


A low-cost JVP scale has been made with commonly available materials. This device is the solution to the difficulty faced in the measurement of JVP by the two-object method. The device would be an adjunct to cardiovascular teachings as well as a tool for bedside JVP measurement. However, this device is not capable of measuring actual JVP as obtained by invasive method. Hence, its diagnostic value is similar to that of the classic two-object method. However, this device has both theoretical and practical advantages over other available methods. Further modification of the device may be tried to enhance the ease of usage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Sarika Mondal, Freelance Medical Writer, Kolkata, India, for her encouragement, moral support, and allotment of time in her busy postpartum period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Garg N. Jugular venous pulse: An appraisal. Indian Acad Clin Med. 2000;1:260-9.  Back to cited text no. 1
    
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Chua Chiaco JM, Parikh NI, Fergusson DJ. The jugular venous pressure revisited. Cleve Clin J Med 2013;80:638-44.  Back to cited text no. 2
    
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Grubb N, Spratt J, Bradbury A. The cardiovascular system. In: Douglas G, Nicol F, Robertson C, editors. Macleod's Clinical Examination. 12th ed. UK: Churchill Livingstone; 2009. p. 124-6.  Back to cited text no. 4
    
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Timmis AD, Archbold A. Cardiovascular system. In: Glynn M, Drake WM, editors. Hutchison's Clinical Methods. 23rd ed. UK: Elsevier Ltd.; 2012. p. 174-5.  Back to cited text no. 5
    
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Varshney VP, Bedi M. Clinical examination of the cardiovascular System. In: Ghai's Textbook of Practical Physiology. 9th ed. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.; 2019. p. 227-9.  Back to cited text no. 6
    
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Jain AK. Clinical examination of the cardiovascular system (CVS). In: Manual of Practical Physiology for MBBS. 5th ed. Himachal Pradesh, India: Arya Publications; 2017. p. 221.  Back to cited text no. 7
    
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Applefeld MM. The jugular venous pressure and pulse contour. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed., Ch. 19. USA: Butterworths; 1990; Available from: https://www.ncbi.nlm.nih.gov/books/NBK300. [Last accessed on 12 May 2019].  Back to cited text no. 8
    
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Vincent SY, Nathaniel GG, Peter YD, Solomon DS. Zaria-made jugulometre: Assessing its usefulness in bedside medicine. Nig J Cardiol 2015;12:77-80.  Back to cited text no. 9
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Ogunlade O, Asafa MA, Omole JG, Adalumo OA. A medical device: History, description and uses in non-invasive assessment of jugular venous pressure. Cardiol Cardiovasc Res 2018;2:4-7.  Back to cited text no. 10
    
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WMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects. Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects. [Last accessed on 17 Feb 2019].  Back to cited text no. 11
    
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Koo TK, Li MY. A Guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 2016;15:155-63.  Back to cited text no. 12
    
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Seth R, Magner P, Matzinger F, van Walraven C. How far is the sternal angle from the mid-right atrium? J Gen Intern Med 2002;17:852-6.  Back to cited text no. 13
    
14.
Ajuluchukwu JN, Inem VA. The examination of the jugular venous pressure (JVP): Variation of technique amongst Nigerian resident doctors. Niger Postgrad Med J 2000;7:124-8.  Back to cited text no. 14
    
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The Top 5 Reasons to Use Flowcharts. Available from: https://www.breezetree.com/articles/top-reasons-to-flowchart. [Last accessed on 17 May 2019].  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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