Korean J Crit Care Med.  2015 Aug;30(3):158-163. 10.4266/kjccm.2015.30.3.158.

The Effect of the Valsalva Maneuver on the External Jugular Vein

  • 1Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
  • 2Soonchunhyang University Cheonan Hospital, College of Medicine, Cheonan, Korea.
  • 3Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea. lehaji@catholi.ac.kr


The external jugular vein (EJV) is a useful intravenous (IV) cannulation site for anesthesiologists, although it has a relatively high failure rate. Unlike other central veins, visualization of the EJV is important during IV cannulation, and the Valsalva maneuver distends the jugular venous system. However, the relationship between the maneuver and EJV visibility remains unknown. This study compared EJV visibility before and after the Valsalva maneuver.
This was a prospective observational study that included 200 participants. After the induction of anesthesia, EJV visibility grade, depth from the skin to the EJV superficial surface (EJV depth), and EJV cross-sectional area (CSA) before the Valsalva maneuver were measured. The same parameters were measured after the Valsalva maneuver was performed. The EJV visibility grade was defined as grade A: good appearance and good palpation, grade B: poor appearance and good palpation, and grade C: poor appearance and poor palpation.
Patient body mass index and EJV depth affected the EJV visibility grade before the Valsalva maneuver (p < 0.05), although EJV CSA did not. The Valsalva maneuver distended EJV CSA and reduced EJV depth, although these changes were not correlated with EJV visibility grade. With regard to EJV visibility, 34.0% of grade B cases and 20.0% of grade C cases were improved by the Valsalva maneuver.
Although the Valsalva maneuver improved EJV CSA and EJV depth, it did not greatly affect EJV visibility grade.


jugular veins; ultrasonography; Valsalva maneuver

MeSH Terms

Body Mass Index
Jugular Veins*
Observational Study
Prospective Studies
Valsalva Maneuver*


  • Fig. 1. External jugular vein cross-sectional area (A) and external jugular vein depth measured by ultrasonography (B). D1: depth of 1; C: circumference.

  • Fig. 2. Flow diagram of the patients.

  • Fig. 3. Comparisons of external jugular vein cross-sectional area (A) and external jugular vein depth before and after the Valsalva maneuver at each EJV visibility grade (B). Visibility grade A: good appearance and good palpation of the EJV; visibility grade B: poor appearance and good palpation of the EJV; visibility grade C: poor appearance and poor palpation of the EJV. The blue-colored box represents EJV CSA or depth before the Valsalva maneuver, and the green-colored box represents EJV CSA or depth after the Valsalva maneuver. The box plot shows the median (solid line), interquartile ranges (box), and values within 1.5 interquartile ranges from each side of the box (whiskers). Outliers are indicated by solid circles. EJV: external jugular vein; CSA: cross-sectional area of the external jugular vein; EJV depth: depth from the skin to the external jugular vein superficial surface; *p < 0.05 compared with EJV visibility before the Valsalva maneuver.



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