Humming is as effective as Valsalva's maneuver and Trendelenburg's position for ultrasonographic visualization of the jugular venous system and common femoral veins

Matthew R Lewin, John Stein, Ralph Wang, Marsha M Lee, Martin Kernberg, Milana Boukhman, In-Hei Hahn, Resa E Lewiss
Annals of Emergency Medicine 2007, 50 (1): 73-7

STUDY OBJECTIVE: The purpose of this study is to compare ultrasonographic visualization of the jugular and common femoral veins by using a novel technique (humming) and 2 conventional techniques (Valsalva's maneuver and Trendelenburg's position). The Valsalva's maneuver and Trendelenburg's position are common methods for producing venous distention, aiding ultrasonographically guided identification and cannulation of the jugular and common femoral veins. We hypothesize that humming is as effective as either Valsalva's maneuver or Trendelenburg's position for distention and ultrasonographic visualization of these procedurally important blood vessels. Herein, we investigate a new method of venous distension that may aid in the placement of central venous catheters by ultrasonographic guidance.

METHODS: Healthy, normal volunteers aged 28 to 67 years were enrolled. Each subject's internal jugular, external jugular, and common femoral veins were measured in cross-section by ultrasonograph during rest (baseline), humming, Valsalva's maneuver, and Trendelenburg's position. Three measurements were recorded per observation in each position. Subjects were used as their own controls, and measurements were normalized to percentage increase in diameter during each maneuver or position for later comparison.

RESULTS: The study population consisted of 7 subjects, with a mean age of 47 years. Cross-sectional area was calculated for each vessel in 3 groups: baseline/control, Valsalva, Trendelenburg, and humming. The mean percentage change (+/-SD) relative to baseline cross-sectional area of the jugular vessels for each subject were external jugular vein: humming 134%+/-25% (95% confidence interval [CI] 124.9% to 146.9%), Valsalva 136%+/-23% (95% CI 121.3% to 147.5%), Trendelenburg 137%+/-32% (95% CI 120.7% to 156.9%); internal jugular vein: humming 137%+/-27% (95% CI 119.4% to 148.2%), Valsalva 139%+/-24% (95% CI 122.4% to 148.7%), Trendelenburg 141%+/-35% (95% CI 116.5% to 156.5%); common femoral vein: humming 131%+/-15% (95% CI 120.4% to 139.1%), Valsalva 139%+/-18% (95% CI 127.9% to 150.4%), Trendelenburg 132%+/-24% (95% CI 113.3% to 142.9%).

CONCLUSION: All 3 maneuvers distended the external jugular, internal jugular, and common femoral veins compared to baseline. There was no important difference in magnitude of cross-sectional area between any of the 3 maneuvers when compared with one another. Humming shares many physiologic similarities to Valsalva's maneuver and may be more familiar and easier to perform during procedures such as ultrasonographically guided central venous catheter placement and insertion of external jugular intravenous catheters.

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