IMPORTANCE: Accurate assessment of intravascular volume facilitates management decisions about fluid management in patients with volume overload.
OBJECTIVE: To identify the most accurate clinical examination, radiographic, and laboratory findings for assessing volume overload in nonintubated patients.
DATA SOURCES AND STUDY SELECTION: MEDLINE was searched (1946 to January 6, 2026) to identify peer-reviewed English-language studies about the diagnostic accuracy of the clinical examination of spontaneously breathing patients with intravascular volume overload.
DATA EXTRACTION AND SYNTHESIS: Three authors independently extracted data for each finding and calculated sensitivity, specificity, and likelihood ratios (LRs). A 2-level mixed logistic regression model was used to pool estimates.
RESULTS: Forty studies, involving 11?490 adult patients, were included, with a prevalence of volume overload of 35% to 69%. Thirty-three of those studies evaluated patients with dyspnea. Prevalence of volume overload was more likely when the physical examination revealed jugular venous distention with the highest point of pulsation more than 3 cm in a vertical line above the sternal angle (LR, 4.1 [95% CI, 2.9-5.6]; specificity, 92%), lower extremity edema (LR, 2.2 [95% CI, 1.5-3.1]; specificity, 80%), or crackles on auscultation (LR, 2.7 [95% CI, 1.7-4.5]; specificity, 81%). Vascular congestion on chest radiography increased the likelihood of intravascular volume overload (LR, 5.9 [95% CI, 2.9-12.0]; specificity, 91%). Point-of-care ultrasonography that identified bilateral pulmonary B-lines suggested volume overload (LR, 4.0 [95% CI, 2.6-6.1]; specificity, 77%), and absence of pulmonary B-lines made volume overload unlikely (LR, 0.09 [95% CI, 0.04-0.23]; sensitivity, 93%). Inferior vena cava collapsibility index of less than 50% increased the likelihood of volume overload (LR, 3.9 [95% CI, 2.5-6.1]; specificity, 79%), and a collapsibility index of at least 50% made it less likely (LR, 0.22 [95% CI, 0.11-0.45]; sensitivity, 82%). Point-of-care ultrasonographic measurement of jugular venous pressure (JVP; >8 cm) also increased the likelihood of volume overload (LR, 2.8 [95% CI, 2.2-3.5]; specificity, 71%), although JVP of 8 cm or less identified patients less likely to have volume overload (LR, 0.26 [95% CI, 0.20-0.33]; sensitivity, 81%). A plasma brain-type natriuretic peptide (BNP) level of 100 ng/mL or higher was the single best test to identify those most likely to have volume overload (LR, 6.9 [95% CI, 2.4-20.4]; specificity, 87%), and a normal value made it less likely (LR, 0.14 [95% CI, 0.08-0.24]; sensitivity, 87%).
CONCLUSIONS AND RELEVANCE: A BNP level of 100 ng/mL or higher and presence of vascular congestion on chest radiography may be the most useful tests to identify patients with volume overload. Absence of pulmonary B-lines using point-of-care ultrasonography or BNP levels of less than 100 ng/mL may be most useful to exclude volume overload.
| Discipline Area | Score |
|---|---|
| Emergency Medicine |  |
| Respirology/Pulmonology |  |
| Intensivist/Critical Care | |
| Hospital Doctor/Hospitalists | Coming Soon... |
| Internal Medicine | Coming Soon... |
| Cardiology | Coming Soon... |
This an entry in the JAMA Rational Clinical Exam series on tests for volume overload. The criterion standard was a blinded and independent multi-physician medical record review (most often) right-heart catheterization with central venous pressure by central venous catheter, or discharge diagnosis. The search yielded 40 papers (English only in Medline). The results: + and - likelihood ratios (LRs) were for jugular venous distension 4, 0.7; rates 3, 0.6; pedal edema 2, 0.7; pulmonary vascular congestion on chest x-ray 6, 0.5; brain-type natriuretic peptide 7, 0.1, respectively. Using ultrasound, B lines were 4, 0.09; inferior vena cava collapse 4, 0.2; jugular venous pressure 3, 0.3. Although to be clinically useful LRs should be >10 or <0.1, LRs from different tests can be multiplied together to get a summary LR. This paper is a useful and much needed summary to help clinicians quantitatively estimate the probability of volume overload in their patients.
Excellent review of the sensitivity and specificity of the many tools we use to assess volume. POCUS continues to change the landscape of physical examination. The article also confirms the sensitivity of BNP measurement. Having been trained decades ago, the examination of neck veins to determine central venous pressure has lost its place in the exam. Perhaps ultrasound can resurrect its use.
Unfortunately, the assessment of 'volume status' is not really static and should be interpreted as responsiveness to fluid or the presence of hypoxemia. In the former, fluid may be useful. In the latter, fluid may be dangerous. This study confirms that. Further study is unlikely to change that.
Good analysis of the most useful markers for volume overload in clinical practice; actionable and relevant. Methods are sound; can trust the results.
This is a well-executed systematic review that quantifies what experienced clinicians already know. The study's value lies in providing precise likelihood ratios for comparative test performance rather than introducing practice-changing findings.
