Valsalva maneuver

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

In medicine, the Valsalva maneuver is performed by forcibly exhaling against closed lips and pinched nose, forcing air into the middle ear if the Eustachian tube is open. This maneuver with slight modifications can be used as a test of cardiac function and autonomic nervous control of the heart or to ‘clear’ the ears (equalize pressure) when ambient pressure changes, as in diving or aviation.

The technique is named for Antonio Maria Valsalva, the 17th Century physician and anatomist from Bologna, whose principal scientific interest was the human ear. He described the Eustachian tube and the maneuver to test its patency.

Physiological response

The normal physiological response consists of 4 phases, which are marked on the figure below:

  1. Initial pressure rise: On application of expiratory force, pressure rises inside the chest forcing blood out of the pulmonary circulation into the left atrium. This causes a mild rise in blood pressure.
  2. Reduced venous return and compensation: Return of blood to the heart is impeded by the pressure inside the chest. The output of the heart is reduced, the blood pressure falls. This occurs from 5 to about 14 seconds in the illustration. The fall in blood pressure reflexly causes blood vessels to constrict with some rise in pressure (15 to 20 seconds). This compensation can be quite marked with pressure returning to near or even above normal, but the cardiac output and blood flow to the body remains low. During this time the pulse rate increases.
  3. Pressure release: The pressure on the chest is released, allowing the pulmonary vessels and the aorta to re-expand causing a further initial slight fall in pressure (20 to 23 seconds) due to decreased left ventricular return and increased aortic volume, respectively. Venous blood can once more enter the chest and the heart, cardiac output begins to increase.
  4. Return of cardiac output: Blood return to the heart is enhanced by the effect of entry of blood which had been dammed back, causing a rapid increase in cardiac output and of blood pressure (24 seconds on). The pressure usually rises above normal before returning to a normal level. With return of blood pressure, the pulse rate returns towards normal.

Deviation from this response pattern signifies either abnormal heart function or abnormal autonomic nervous control of the heart.


Blood pressure (systolic and diastolic) and pulse rate during a normal response to Valsalva’s maneuver. Forty millimeter mercury pressure is applied at 5 seconds and relieved at 20 seconds.

Normalizing middle ear pressures

When rapid ambient pressure increase occurs as in diving or aircraft descent, this pressure tends to hold the Eustachian tubes closed, preventing pressure equalization across the ear drum, with painful results. To avoid this painful situation, divers, caisson workers and aircrew attempt to open the Eustachian tubes by swallowing, which tends to open the tubes, allowing the ear to equalize itself.

If this fails, then the Valsalva maneuver may be used. It should be noted this maneuver, when used as a tool to equalize middle ear pressure, carries with it the risk of auditory damage from over pressurization of the middle ear. It is safer, if time permits, to attempt to open the Eustachian tubes by swallowing a few times, or yawning. The effectiveness of the "yawning" method can be improved with practise; some people are able to achieve release or opening by moving their jaws forward or forward and down, rather than straight down as in a classical yawn. Opening can often be clearly heard by the practitioner, thus providing feedback that the maneuver was successful.

Note that in a clinical setting the Valsalva maneuver will be done either against a closed glottis, or against an external pressure measuring device, in each case either eliminating or minimizing the pressure on the Eustachian tubes. Straining, blowing against resistance as in blowing up balloons has a Valsalva effect and the fall in blood pressure can result in dizziness and even fainting.

Cardiology

Diagnosis and interpretation of heart sounds

The maneuver can sometimes be used to diagnose heart abnormalities, especially when used in conjunction with echocardiogram. For example, the Valsalva maneuver classically increases the intensity of hypertrophic cardiomyopathy murmurs, viz. those of dynamic subvalvular left ventricular outflow obstruction; whereas it decreases the intensity all other murmurs, including aortic stenosis and atrial septal defect.

Effect of Valsalva Cardiac Finding
Decreased
Aortic Stenosis
Pulmonic Stenosis
Tricuspid Regurgitation
Increased
Hypertrophic cardiomyopathy, mitral valve prolapse

Treatment of supraventricular tachycardia

The Valsalva maneuver, especially the modified Valsalva maneuver may convert episodes of supraventricular tachycardia to sinus rhythm.[1]

The modified Valsalva maneuver is executed by:[2]

  • While the patient is seated, ask them to "blow into 10-mL syringes to move the plunger" for 15 seconds. This mimics a pressure of 40 mm Hg
  • "Then, the patient was suddenly brought to a supine position and his/her legs were raised at a 45-degree angle" for 45 seconds by the examiner.

An alternative version of the modified Valsalva maneuver is:[3]

  • While the patient is semi-recumbent at 45 degrees, ask them to blow into an aneroid manometer to create a pressure of 40 mm Hg for 15 seconds
  • "immediately at the end of the strain, [patients] were laid flat and had their legs raised by a member of staff to 45° for 15 s."
  • Patients "were then returned to the semi-recumbent position for a further 45 s before re-assessment of cardiac rhythm"

Neurology

The Valsalva maneuver is used to aid in the clinical diagnosis of problems or injury in the nerves of the cervical spine. Upon the exertion of pressure, neuropathies or radicular pain may be felt, and may indicate impingement on a nerve by an intervertebral disc or other part of the anatomy.

Valsalva retinopathy

A pathologic syndrome associated with the Valsalva maneuver is Valsalva retinopathy. It presents as preretinal hemorrhage (bleeding in front of the retina) in people with a history of transient increase in the intrathoracic pressure. The bleeding may be associated with a history of heavy lifting, forceful coughing, straining on the toilet, or vomiting. The bleeding may cause a reduction of vision if it obstructs the visual axis. Patients may also note floaters in their vision. Usually a full recovery of vision is made.

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See also


de:Valsalva-Versuch id:Manuver Valsava it:Manovra di Valsalva no:Valsalvas manøver sl:Manever po Valsalvi


  1. GitHub Contributors. Supraventricular tachycardia treatment with vagal maneuvers. GitHub. Available at https://openmetaanalysis.github.io/Supraventricular-tachycardia-treatment-with-vagal-maneuvers/. Accessed June 19, 2017.
  2. Çorbacıoğlu ŞK, Akıncı E, Çevik Y, Aytar H, Öncül MV, Akkan S; et al. (2017). "Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial". Am J Emerg Med. doi:10.1016/j.ajem.2017.05.034. PMID 28552271.
  3. Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A; et al. (2015). "Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial". Lancet. 386 (10005): 1747–53. doi:10.1016/S0140-6736(15)61485-4. PMID 26314489. Review in: Evid Based Med. 2016 Apr;21(2):61 Review in: Ann Intern Med. 2015 Dec 15;163(12):JC8 Review in: Evid Based Nurs. 2016 Jul;19(3):77

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