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Written by Samuel Rouleau
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Check out the latest installment in JAMA’s Rational Clinical Exam series, which covers intra-vascular volume overload.
This article will restore your faith in the physical exam!
The authors included 40 studies of over 11,000 total patients to evaluate the performance of physical exam, imaging, and laboratory findings for identifying intra-vascular volume overload.
Physical Exam
- Jugular venous distention (JVD) is specific (92%) but not sensitive (35%) for predicting volume overload. The positive likelihood ratio performed the best for physical exam techniques, LR 4.1.
- With the patient reclined to 30–45 degrees, jugular venous pulsation higher than 3 cm from the sternal angle meets criteria for JVD.
- Pulmonary crackles on auscultation are caused by the opening of fluid-filled alveoli. Similarly, the specificity (81%) and positive LR (2.7 95% CI 1.7-4.5) perform well, but the sensitivity is 56%.
- Lower extremity edema performed similarly to pulmonary crackles, and the grading system for lower extremity edema is not reproducible. Performance characteristics: specificity 80%, sensitivity 44%, positive LR 2.2.
CXR
- There are many radiographic findings of pulmonary edema. This review found that pulmonary vascular congestion has high specificity (91%) and high positive LR 5.9.
- Check out this great 1985 study for more on CXR in pulmonary edema.
POCUS
- The presence of pulmonary B-lines had the best specificity (77%) and positive LR 4.0.
- A positive test was defined as > 2 B-lines in 2 different lung zones bilaterally.
- For IVC ultrasound, only 377 patients were included.
- IVC collapsibility ≥ 50% had a good sensitivity for ruling out volume overload: sensitivity 82%, negative LR 0.22.
- IVC distention (over 2 cm) with collapsibility < 50% had a specificity of 79% and positive LR 3.9.
- POCUS evaluation of JVP was examined in 10 studies, but 9 different techniques were used, so the performance characteristics are likely not reproducible.
Labs
- A normal BNP makes volume overload less likely: sensitivity 87% and negative LR 0.14.
- The studies with NT-pro-BNP used different cutoffs and could not be evaluated.
How will this change my practice?
Brief takeaways:
- For every technique, do it the same, standardized way every time.
- JVD is the best physical exam finding for predicting volume overload.
- BNP has reasonable sensitivity, but a high BNP should be correlated with physical exam or other imaging findings to confirm volume overload.
- On POCUS, pulmonary B-lines have the best positive LR.
- IVC ultrasound is not the end-all, be-all. We do it because it’s easy. The reason why pulmonary B-lines perform better is because L heart and pulmonary pressures are elevated before systemic filling pressure.
- Never do an isolated IVC ultrasound and make treatment decisions—check the heart too at a minimum! If residents do this on rounds, I will fake “syncopize” to get them to remember this point!
Source
Does This Patient Have Volume Overload?: The Rational Clinical Examination. JAMA. 2026 Feb 23. doi: 10.1001/jama.2026.0446. Epub ahead of print. PMID: 41729549
