Trick of the Trade: Hum-out the jugular veins

Placing an IV in the external jugular vein requires venous distension maneuvers. This means having the patient perform a Valsalva maneuver or be placed in a Trendelenburg position.

Have you ever had a patient who didn't quite get the Valsalva maneuver concept, or couldn't tolerate a head-down position?

Trick of the Trade: Humming
Have the patient hum during IV placement. Humming increases the venous size of the external jugular (EJ), internal jugular (IJ), and common femoral vein (CFV). It is a closed-mouth, forced expiration which increases intrathoracic pressure.

This was found in a study done by several creative faculty in our department at UCSF! Using normal volunteers, the 3 veins were visualized by ultrasonography. Each vein's cross-sectional area was calculated under each of the following conditions:

• Baseline
• Valsalva maneuver
• Trendelenburg position
• Humming

The authors found that humming was just as good as the Valsalva maneuver and Trendelenburg position in dilating the 3 veins (EJ, IJ, CFV). See the ultrasound images demonstrating this phenomenon.

Give it a try.
Have the patient hum to maximize the vein's size.
Your humming along is optional.

Reference
Lewin M, Stein J, Wang R, et al. Humming Is as Effective as Valsalva’s Maneuver and Trendelenburg’s Position for Ultrasonographic Visualization of the Jugular Venous System and Common Femoral Veins. Ann Emerg Med. 2007; 50(1): 73-7.