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Valsalva maneuver1Antonio Maria Valsalva5
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Valsalva maneuver1
Valsalva maneuver
The
Valsalva maneuver
or
Valsalva manoeuvre
is performed by moderately forceful attempted exhalation againsta closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up aballoon. Variations of the maneuver can be used either in medical examination as a test of cardiac function andautonomic nervous control of the heart, or to "clear" the ears and sinuses (that is, to equalize pressure between them)when ambient pressure changes, as in diving, hyperbaric oxygen therapy, or aviation.The technique is named after Antonio Maria Valsalva,
[1]
a 17th-century physician and anatomist from Bolognawhose principal scientific interest was the human ear. He described the Eustachian tube and the maneuver to test itspatency (openness). He also described the use of this maneuver to expel pus from the middle ear.A modified version is done by expiring against a closed glottis. This will elicit the cardiovascular responsesdescribed below but will not force air into the Eustachian tubes.
Physiological response
Blood pressure (systolic) 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.
The normal physiological responseconsists of four phases.
[2]
1.1.Initial pressure riseOn application of expiratoryforce, pressure rises inside thechest forcing blood out of thepulmonary circulation into theleft atrium. This causes a mildrise in stroke volume.2.2.Reduced venous return andcompensationReturn of systemic blood to theheart is impeded by the pressureinside the chest. The output of the heart is reduced and strokevolume falls. This occurs from 5to about 14 seconds in theillustration. The fall in stroke volume reflexively 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 abovenormal, but the cardiac output and blood flow to the body remains low. During this time the pulse rateincreases (compensatory tachycardia).3.3.Pressure releaseThe pressure on the chest is released, allowing the pulmonary vessels and the aorta to re-expand causing afurther initial slight fall in stroke volume (20 to 23 seconds) due to decreased left ventricular return andincreased aortic volume, respectively. Venous blood can once more enter the chest and the heart, cardiacoutput begins to increase.4.4.Return of cardiac outputBlood return to the heart is enhanced by the effect of entry of blood which had been dammed back, causing arapid increase in cardiac output (24 seconds on). The stroke volume usually rises above normal beforereturning to a normal level. With return of blood pressure, the pulse rate returns towards normal.
Valsalva maneuver2Deviation from this response pattern signifies either abnormal heart function or abnormal autonomic nervous controlof the heart. Valsalva is also used by dentists following extraction of a maxillary molar tooth. The maneuver isperformed to determine if a perforation or antral communication exists.
Normalizing middle-ear pressures
When rapid ambient pressure increase occurs as in diving or aircraft descent, this pressure tends to hold theEustachian tubes closed, preventing pressure equalization across the ear drum, with painful results.
[3][4][5]
To avoidthis 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 toequalize middle ear pressure, carries with it the risk of auditory damage from over pressurization of the middle
ear.
[4][6][7][8]
It is safer, if time permits, to attempt to open the Eustachian tubes by swallowing a few times, oryawning. The effectiveness of the "yawning" method can be improved with practice; some people are able to achieverelease or opening by moving their jaw forward or forward and down, rather than straight down as in a classicalyawn.
[4]
Opening can often be clearly heard by the practitioner, thus providing feedback that the maneuver wassuccessful.During swallowing or yawning, severalmuscles in thepharynx (throat) act to elevate the soft palate and open the
throat. One of these muscles, the tensor veli palatini, also acts to open the eustachian tube. This is why swallowing oryawning is successful in equalizing middle ear pressure. Contrary to popular belief, the jaw does not pinch the tubesshut when it is closed. In fact, the eustachian tubes are not located close enough to the mandible to be pinched off.People often recommend chewing gum during ascent/descent in aircraft, because chewing gum increases the rate of salivation, and swallowing the excess saliva opens the eustachian tubes.In a clinical setting the Valsalva maneuver will commonly be done either against a closed glottis, or against anexternal pressure measuring device, thus eliminating or minimizing the pressure on the Eustachian tubes. Strainingor blowing against resistance as in blowing up balloons has a Valsalva effect and the fall in blood pressure can resultin dizziness and even fainting.
Diving
In diving, the Valsalva maneuver is often used on descent to equalise the pressure in the middle ear to the ambientpressure. If the Valsalva maneuver is conducted during ascent, residual airoverpressure in the middle-ear can
potentially be released through the Eustachian tubes. During decompression stops at the end of a dive, if the diverunwittingly slightly descends again and makes a Valsalva to relieve his ears, there exists a non-negligible risk totransfer nitrogen bubbles from one side of the heart to the other one if the foramen membrane is permeable. If someof the inert gas-laden blood passes through the patent foramen ovale (PFO), it avoids the lungs and the inert gas ismore likely to form large bubbles in the arterial blood stream, causing decompression sickness.A Valsalva maneuver at the end of a diving must never be attempted as it can cause a decompression accident withsevere neurological consequences (gas bubbles in the brain or damages to the spinal cord). Repeated Valsalvamaneuvers are also suspected to increase the permeability of the foramen for divers at risk.
Cardiology
The Valsalva maneuver may be used to arrest episodes of supraventricular tachycardia.
[9][10]
The maneuver cansometimes be used to diagnose heart abnormalities, especially when used in conjunction with echocardiogram.
[11]
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 of mostother murmurs, including aortic stenosis and atrial septal defect.
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