The simultaneous application of positive-end expiratory pressure with the Trendelenburg position minimizes respiratory fluctuations in internal jugular vein size

Abstract

BackgroundThe respiratory cycle alters the size of the right internal jugular vein (RIJV). We assessed the changes in RIJV size during the respiratory cycle in patients under positive pressure ventilation. Moreover, we examined the effects of positive-end expiratory pressure (PEEP) and the Trendelenburg position on respiratory fluctuations.MethodsA prospective study of 24 patients undergoing general endotracheal anesthesia was performed. Images of the RIJV were obtained in the supine position with no PEEP (baseline, S0) and after applying three different maneuvers in random order: (1) a PEEP of 10 cmH2O (S10), (2) a 10° Trendelenburg tilt position (T0), and (3) a 10° Trendelenburg tilt position combined with a PEEP of 10 cmH2O (T10). Using the images when the area was smallest and largest, cross-sectional area (CSA), anteroposterior diameter, and transverse diameter were measured.ResultsAll maneuvers minimized the fluctuation in RIJV size (all P = 0.0004). During the respiratory cycle, the smallest CSA compared to the largest CSA at S0, S10, T0, and T10 decreased by 28.3 8.5, 8.0, and 4.4%, respectively. Furthermore, compared to S0, a 10° Trendelenburg tilt position with a PEEP of 10 cmH2O significantly increased the CSA in the largest areas by 83.8% and in the smallest areas by 169.4%.ConclusionsA 10° Trendelenburg tilt position combined with a PEEP of 10 cmH2O not only increases the size of the RIJV but also reduces fluctuation by the respiratory cycle.

Effects of positive airway pressure on basilic vein diameter and venous flow velocity in healthy volunteers

“… 17 Preprocedural assessment of adequate CVR has been incorporated in the international guidelines. 18 – 20 Positive intrathoracic pressure has been reported to sensibly increase the diameter of jugular veins 21 , 22 due to heart-lung interactions, a common phenomenon that can be used at our advantage to ease the difficulty of central line placement in the internal jugular vein. 23 We hypothesized that the same phenomenon might affect the veins of the upper extremities, to the extent that preprocedural CVR estimation may not be reliable in patients receiving uninterruptable positive pressure respiratory support.…”

Effects of incrementally increasing tidal volume on the right internal jugular vein in pediatric patients

“…In another study evaluating the effects of PEEP on RIJV in adult patients, 10 cmH 2 O PEEP combined with a 20° Trendelenburg position not only increased the size of the RIJV, but also attenuated the fluctuations caused by the respiratory cycle (26). PEEP is known to increase intrathoracic pressure by compressing the superior vena cava (24).…”

Effect of Trendelenburg position on right and left internal jugular vein cross-sectional area

“…Valsalva maneuver, application of positive end-expiratory pressure and Trendelenburg position) are associated with a higher rate of successful IJV cannulation [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Many past studies have compared IJV CSA with and without ultrasound images [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. However, most studies concern the RIJV and not the LIJV.…”