The Valsalva maneuver consists of a moderately forceful attempt to exhale into a closed airway, usually accomplished by closing one's mouth and pinching one's nose closed while expelling air as if blowing up a balloon. Manipulated changes may be used in medical tests such as testing of cardiac function and autonomic nervous system control of the heart, or to clear the ears and sinuses (i.e., to equalize the pressure between them) when environmental pressure changes, such as during scuba diving, hyperbaric oxygen therapy or air travel.
It is accomplished by expiration of the closed glottis. This will cause the cardiovascular response described below but will not force air into the Eustachian tube.
history
The technique is named after Antonio Maria Valsalva, a 17th-century physician and anatomist from Bologna whose main scientific interest was the human ear. He describes the Eustachian tube and procedures to test its patency (patency). He also described using this method to drain pus from the middle ear.
Physiological reaction
Normal physiological responses include four stages.
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initial pressure rise
- With exhalation, the pressure within the chest increases, forcing blood from the pulmonary circulation into the left atrium. This results in a slight increase in stroke volume during the first few seconds of the procedure.
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Reduce venous return and compensation
- The return flow of blood throughout the body to the heart is impeded by chest pressure. Cardiac output decreases and stroke volume decreases. This occurs between 5 and approximately 14 seconds. The decrease in stroke volume reflexively causes vasoconstriction and an increase in pressure (15 to 20 seconds). This compensation can be dramatic, with pressure returning to near or even above normal levels, but cardiac output and blood flow to the body remain low. During this period the pulse rate increases (compensated tachycardia).
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pressure relief
- Chest pressure is released, allowing the pulmonary vessels and aorta to re-dilate, resulting in a further slight decrease in stroke volume (20 to 23 seconds) due to reduced left atrial return and increased aortic volume, respectively. Venous blood can again enter the chest and heart, and cardiac output begins to increase.
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cardiac output recovery
- The effect of blood returning to the heart is blocked from entering, resulting in a rapid increase in cardiac output (after 24 seconds). Stroke volume often remains higher than normal before returning to normal levels. As blood pressure recovers, pulse rate returns to normal.
Deviations from this response pattern suggest abnormal cardiac function or abnormal autonomic control of the heart. Valsalva is also used by dentists after extraction of maxillary molars. This procedure is performed to determine if perforation or sinus communication is present.
application
Normalizes middle ear pressure
When environmental pressure increases rapidly during a dive or airplane descent, this pressure tends to keep the Eustachian tube closed, preventing the pressure on the eardrum from equalizing, with painful results. To avoid this painful situation, divers, caisson workers, and crew members attempted to open the Eustachian tubes by swallowing, which tended to open the tubes and allow the ears to balance on their own.
If this fails, the Valsalva action can be used. This maneuver, when used as a tool to equalize pressure in the middle ear, carries the risk of hearing damage due to over-pressurization of the middle ear. The Valsalva maneuver produces a pressure of approximately 20-40 mm Hg. If time permits, it is safer to try to open the Eustachian tube by swallowing a few times or yawning, or by using the Valsalva technique, where when slight pressure is felt, a very small amount of air is gently drawn into the closed nostrils with the fingers, and then more To the point where it hurts when released. The effectiveness of the "yawn" method can be improved with practice; some people are able to achieve a release or opening by moving their jaw forward or forward and downward, rather than straight down as in a classic yawn, and some A person can do this by activating the tensor tympani muscle without moving their jaw at all, and the sound the individual hears is a low rumble. The opening sound can often be clearly heard by the practitioner, providing feedback that the operation was successful.
During swallowing or yawning, several muscles in the pharynx (throat) lift the soft palate and open the throat. One of these muscles, tensor palatini, also serves to open the Eustachian tube. This is why swallowing or yawning can successfully equalize the pressure in the middle ear. Contrary to popular belief, the jaw does not pinch the tube when closed. In fact, the Eustachian tube is not close enough to the mandible to be pinched off. It is often recommended to chew gum during ascent/descent in an airplane because gum increases the rate of salivation and swallowing excess saliva opens the Eustachian tubes.
In the clinical setting, the Valsalva maneuver is typically performed with a closed glottis or an external pressure-measuring device to eliminate or minimize pressure on the Eustachian tube. Blowing air forcefully or against resistance like a balloon can produce the Warsalva effect, which can cause dizziness or even fainting due to a drop in blood pressure.
Strength Training
The Valsalva maneuver is generally considered the best breathing pattern for generating maximum force, and is often used in powerlifting to stabilize the torso during exercises such as the squat, deadlift, and bench press, as well as both lifts in Olympic weightlifting. In addition, competitive strongmen often use the Valsalva maneuver in tasks such as log presses, yoke walks, and stone rigging, as well as any other strongman movements.
pain management
The Valsalva maneuver can be used as a means of reducing pain during lumbar puncture.
Regulate heart rhythm
The Valsalva maneuver can be used to arrest episodes of supraventricular tachycardia. Blood pressure (BP) rises at the onset of stress - because increased intrathoracic pressure (ITP) increases pressure in the aorta. It then decreases as ITP compresses the veins, reducing venous return and cardiac output. This inhibits baroreceptors leading to tachycardia and increased peripheral vascular resistance (PVR). When the glottis opens and ITP returns to normal, cardiac output recovers but peripheral vasoconstriction occurs. Blood pressure therefore rises above normal levels, which stimulates baroreceptors, causing bradycardia and blood pressure falling to normal levels.
medical diagnosis
cardiology
This procedure is sometimes used to diagnose heart abnormalities, especially when combined with an echocardiogram. For example, the Valsalva maneuver (stage II) increases the intensity of the hypertrophic cardiomyopathy murmur, the murmur of dynamic subvalvular left ventricular outflow tract obstruction. At the same time, the Valsalva maneuver (stage II) reduces the intensity of most other murmurs, including aortic stenosis and atrial septal defects. During the first few seconds of the Valsalva maneuver (first phase), the situation is reversed.
A UK-based randomized controlled trial (REVERT) showed that in cardiovascularly stable patients with supraventricular tachycardia, the modified Valsalva maneuver started in the semi-recumbent position and then repositioned the patient to the supine position immediately after straining, Passive leg raising improved the success rate by 43% compared with the traditional Valsalva maneuver, which was only 17% effective in terminating SVT.
Neuroscience
The Valsalva maneuver is used to aid in the clinical diagnosis of cervical spine nerve problems or injuries. During the Valsalva maneuver, there is a slight increase in intraspinal pressure. As a result, neuropathy or radicular pain may be felt or worsened, which may indicate impingement of the nerve by the disc or other part of the anatomy. Headache and pain during the Valsalva maneuver are also one of the main symptoms of Arnold-Chiari malformation. The Valsalva maneuver can be used to check for dural tears after certain spinal surgeries, such as microdiscectomy. Increased pressure within the spine can cause cerebrospinal fluid (CSF) to leak out of the dura mater, causing headaches.
Valsalva maneuvers are associated with temporary global amnesia.
Palpation of supraclavicular lymph nodes
Because lymph nodes may be buried, asking the patient to perform the Valsalva maneuver can push the dome of the lung upward, bringing the deep lymph nodes to a more easily palpable location. Palpation can identify supraclavicular lymph node enlargement, which is a diagnostic indicator of cancer. The reported prevalence of malignancy in supraclavicular lymphadenopathy ranges from 54% to 85%.
Oral-sinus communication
A variation of the Valsalva maneuver is used to help diagnose oral-sinus communication, a connection between the oral cavity and the maxillary sinus.
Urogenital Medicine
The Valsalva maneuver is used to aid in the diagnosis of intrinsic sphincter deficiency (ISD) on urodynamic testing. Valsalva leak pressure is the minimum vesicular pressure associated with urine leakage. Although there is no consensus on the threshold, values >60 cm H 2 O are generally considered to indicate bladder neck hyperactivity and normal sphincter function. Additionally, when examining women with pelvic organ prolapse, ask the patient to perform the Valsalva maneuver to demonstrate maximal descent of the pelvic organs.
complication
preretinal
Valsalva retinopathy is a pathological syndrome associated with Valsalva maneuver. It manifests as epiretinal hemorrhage (preretinal hemorrhage) in people with a history of transient increases in intrathoracic pressure and may be associated with heavy lifting, severe coughing, straining to go to the toilet, or vomiting. If bleeding blocks the visual axis, vision loss may occur and the patient may notice floaters in the field of vision. Usually this does not cause permanent visual impairment and vision recovers completely.
cardiovascular and gastrointestinal tract
Cardiac arrest and other cardiovascular complications may occur due to attempts to induce defecation using the Valsalva maneuver. Another complication of this approach is esophageal fissure
Valsalva device in space suit
Some space suits contain a device called a Valsalva device that allows the wearer to block their nose to perform the Valsalva maneuver while wearing the suit. Astronaut Drew Feustel described it as "a sponge-like device called a Valsalva that is typically used to block the nose when pressure needs to be readjusted." One use for this device is to equalize pressure during suit pressurization.
