JAMA Clinical Reviews Does This Patient Have Volume Overload? The Rational Clinical Examination
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Feb 23, 2026 Alan Lyles, professor of medicine and senior author on the Rational Clinical Examination, walks through practical tools for assessing volume overload. He discusses symptoms and bedside signs, the value and limits of peripheral edema, crackles, chest x‑ray, and BNP. He also explores POCUS techniques — JVP, IVC, and lung B‑lines — and how clinicians can integrate them into practice.
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Crackles And CXR Vascular Congestion Are Specific Not Sensitive
- Lung crackles and radiographic vascular congestion are highly specific but not very sensitive for pulmonary edema. Their presence strongly supports volume overload; absence does not exclude it.
Use BNP ~100 Ng/L To Strengthen Or Exclude Diagnosis
- Use BNP with a cutoff around 100 ng/L to help rule out or in volume overload. A normal BNP gives a strong negative likelihood ratio; elevated BNP plus CXR congestion strongly supports overload.
Interpret BNP Cautiously In Obese Patients
- BNP performance is limited in real time and can be affected by body habitus, especially morbid obesity. Interpret BNP cautiously in obese patients where levels may be misleading.