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

Abstract

Background: The 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.

Methods: A 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.

Results: All 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%.

Conclusions: A 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.

Keywords: Cross-sectional area; Internal jugular vein; Positive end-expiratory pressure; Trendelenburg position.

Fig. 1

Ultrasound images of the right internal jugular vein from one patient in four different maneuver combinations for the largest and smallest sizes recorded. Largest cross-sectional area measured during S0 (A), S10 (C), T0 (E) and T10 (G), respectively. Smallest cross-sectional area measured during S0 (B), S10 (D), T0 (F) and T10 (H). CA: carotid artery, Max: largest values during a respiratory cycle, Min: smallest values during a respiratory cycle, S0: supine baseline, S10: a positive-end expiratory pressure (PEEP) of 10 cmH₂O, T0: a 10° Trendelenburg tilt position, T10: a 10° Trendelenburg tilt position combined with a PEEP of 10 cmH₂O.