Does This Patient Have Volume Overload?: The Rational Clinical Examination

Area of Science:

• Cardiology
• Critical Care Medicine
• Diagnostic Imaging

Background:

• Accurate assessment of intravascular volume is crucial for managing fluid balance, especially in patients with volume overload.
• Identifying reliable diagnostic methods for volume overload is essential for timely and effective patient management.

Purpose of the Study:

• To identify the most accurate clinical examination, radiographic, and laboratory findings for assessing intravascular volume overload in nonintubated patients.
• To evaluate the diagnostic accuracy of various methods in identifying patients with volume overload.

Main Methods:

• A systematic literature search of MEDLINE (1946 to January 6, 2026) was conducted to identify relevant English-language studies.
• Data extraction included sensitivity, specificity, and likelihood ratios (LRs), with estimates pooled using a 2-level mixed logistic regression model.
• Forty studies involving 11,490 adult patients were included in the analysis.

Main Results:

• Jugular venous distention (LR, 4.1), lower extremity edema (LR, 2.2), and crackles (LR, 2.7) were indicative of volume overload.
• Vascular congestion on chest radiography (LR, 5.9) and bilateral pulmonary B-lines on point-of-care ultrasonography (LR, 4.0) increased the likelihood of volume overload.
• A plasma brain-type natriuretic peptide (BNP) level ≥100 ng/mL was the strongest indicator (LR, 6.9), while absence of pulmonary B-lines (LR, 0.09) and BNP <100 ng/mL were useful for exclusion.

Conclusions:

• Plasma BNP levels ≥100 ng/mL and chest radiography findings of vascular congestion are highly useful for diagnosing volume overload.
• Absence of pulmonary B-lines on point-of-care ultrasonography or BNP levels <100 ng/mL can effectively exclude volume overload.
• These findings aid clinicians in making informed decisions regarding fluid management in patients with suspected volume overload.