Procedure

Valsalva Maneuver

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Valsalva Maneuver, Valsalva's Maneuver, Modified Valsalva Maneuver, Reverse Valsalva Maneuver

  • Technique
  1. Standard Valsalva Maneuver
    1. Forceful expiration against a closed mouth and nose
  2. Postural modification significantly increases efficacy in PSVT cardioversion
    1. Valsalva is initially performed with head of bed at 30-45 degrees
      1. In study, Patient blew into a manometer attempting to sustain 40 mmHg for 15 seconds
    2. Patient repositioned immediately after Valsalva Maneuver
      1. Patient is layed supine and legs are passively raised
    3. References
      1. Appelboam (2015) Lancet 384(10005):1747-53 +PMID:26314489 [PubMed]
      2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61485-4/abstract
  3. Reverse Valsalva Maneuver
    1. Patient is seated
    2. Exhales fully in regular fashion
    3. Pinches their nose, closes their mouth and inhales for 10 seconds
    4. Patient then resumes normal breathing after 10 seconds (opening mouth and removing hand from nose)
  • Physiology
  1. Increases intrathoracic pressure
    1. Briefly (<3-5 seconds) results in mildly increased Cardiac Output
  2. Decreases venous return
    1. After first 3-5 seconds, results in fall in Cardiac Output, and typically drop in Blood Pressure
  • Indications
  1. Pressure equalization of nose and sinuses
    1. Examples: Drop in altitude in plane flight or increased external pressure in diving
    2. Other maneuvers are preferred (Yawning, Swallowing)
  2. Evaluate Tympanic Membrane mobility
  3. Supraventricular Tachycardia
    1. Functions as a Vagal Maneuver
    2. See Techniques above (esp. Postural modification, Reverse Valsalva
    3. When Valsalva Maneuvers are effective in breaking SVT, they typically work within 15 seconds of maneuver
  4. Evaluate cardiac murmur
    1. Increases murmur or abnormal heart sounds
      1. Hypertrophic Cardiomyopathy
      2. Mitral Valve Prolapse
    2. Decreases murmur
      1. Atrial Septal Defect
      2. Aortic Stenosis
  • References
  1. Bates (1991) Physical Exam, 5th ed, Lippencott, p. 302
  2. Warrington (2024) Crit Dec Emerg Med 38(11): 17