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Correspondence / American Journal of Emergency Medicine 34 (2016) 2222-2249 2247

Katarina E. Göransson, RN, PhD Secondly, although the VM is considered as a very low-risk procedure
Umut Heilborn, MD, PhD [7], the proposed technique is not ideal from the safety point of view. In
Therese Djärv, MD, PhD⁎ phase 3 of the VM, when the sudden drop of arterial pressure may not
Emergency Medicine Function, Karolinska University Hospital, SE-171 77 be counteracted fast enough by cerebral autoregulation [8], the
Stockholm, Sweden semirecumbent position could pose a slightly higher risk of a momentary
Department of Medicine Solna, Karolinska Institutet brain hypoperfusion compared with the supine position (especially in pa-
SE-171 77 Stockholm, Sweden tients with cerebral artery stenosis or in patients who are already
⁎Corresponding author. Department of Medicine experiencing lightheadedness due to SVT), whereas in phase 4, when
Solna Karolinska Institutet, SE-171 76 Stockholm, Sweden. the arterial pressure overshoot is combined with the dilated cerebral ar-
Tel.: +46 70 7902183; fax: +46 8 517 70000 teries due to cerebral reactive hyperemia [9], lowering the patient's
E-mail address: head can increase the risk of brain hyperperfusion leading to the danger
of a possible cerebral aneurysm rupture [10]. Although such adverse ef- fects were never observed in the study by Appelboam et al [4], consider-
ation should be given to these issues.
References In light of the above, we would like to propose an alternative
modification to the VM for a potentially better and safer treatment
[1] Goransson KE, Heilborn U, Selberg J, von Scheele S, Djarv T. Pain rating in the ED—a
comparison between 2 scales in a Swedish hospital. Am J Emerg Med 2015.
of SVT, which builds on the technique studied by Appelboam et al
[2] Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence while addressing the above concerns. The proposed technique consists
of pain in emergency medical care. Am J Emerg Med 2002;20(3):165–9. of performing the standard 15-second, 40–mm Hg VM in the supine po-
[3] Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health
sition followed by passive leg elevation immediately after the maneuver
Res 2005;15(9):1277–88.
(to 45°) and optional passive arm raise. Such a postural variant com-
bines the advantage of the supine position during the VM with the in-
creased postmaneuver venous return while limiting the risk of the
potential brain hypoperfusion in phase 3 (thanks to the supine posi-
tion) or brain hyperperfusion in phase 4 (thanks to the unchanged
In search of the optimal Valsalva maneuver head level). It would also be simpler to perform compared with the
position for the treatment of supraventricular technique studied by Appelboam et al and could require less assistance
tachycardia☆ when performed with leg elevation only. While the added brain protec-
tion of such a modified VM technique would be difficult to quantify, its
effectiveness in the treatment of SVT should be appropriately studied.

To the Editor,
Leszek Pstras
Nalecz Institute of Biocybernetics and Biomedical Engineering
Despite the common use of the Valsalva maneuver (VM) for the Polish Academy of Sciences, Warsaw, Poland
noninvasive emergency treatment of supraventricular tachycardia Corresponding author. Nalecz Institute of Biocybernetics and
(SVT), there is still no widely accepted criterion standard on how Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4
this vagal maneuver should be performed in terms of patient position 02-109, Warsaw, Poland
to provide the highest chance of restoring the sinus rhythm. Different E-mail address:
body positions including supine, sitting, or semirecumbent are used
for the VM in the emergency department settings [1,2]; however, be- Federico Bellavere, MD
cause of the relatively low rate of cardioversion from SVT reported by Rizzola Foundation Hospital
some studies [3], other patient positions or their modifications are San Donà di Piave (Venezia), Italy
being proposed.
Appelboam et al [4] studied recently the VM performed in the
semirecumbent position with patient repositioning after the maneuver
to a supine position with passive leg elevation to 45°. Such a postural References
modification increases venous return and hence amplifies the post-
Valsalva arterial pressure overshoot with the corresponding increase [1] Taylor DM, Wong LF. Incorrect instruction in the use of the Valsalva manoeuvre for
paroxysmal supraventricular tachycardia is common. Emerg Med Australas 2004;
in the vagal tone, thus leading to the higher efficacy of cardioversion
from SVT compared with the standard semirecumbent position (the [2] Walker S, Cutting P. Impact of a modified Valsalva manoeuvre in the termination of
successful restoration of the sinus rhythm occurred in 43% of patients paroxysmal supraventricular tachycardia. Emerg Med J 2010;27:287–91.
in the modified VM group vs 17% in the control group [4]). This random- [3] Smith G, Morgans A, Boyle M. Use of the Valsalva manoeuvre in the prehospital set-
ting: a review of the literature. Emerg Med J 2009;26:8–10.
ized controlled trial study has been since widely commented and per- [4] Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. Postural modifica-
ceived as an important step in improving noninvasive emergency tion to the standard Valsalva manoeuvre for emergency treatment of supraventricu-
treatment of SVT and reducing the use of drugs in the emergency de- lar tachycardias (REVERT): a randomised controlled trial. Lancet 2015;386:1747–53.
[5] Wong LF, Taylor DM, Bailey M. Vagal response varies with Valsalva manoeuvre tech-
partments (especially the highly unpleasant adenosine). There are, nique: A repeated measures clinical trial in healthy subjects. Ann Emerg Med 2004;
however, 2 aspects of this technique which should be given 43:477–82.
consideration. [6] Smith G, Broek A, Taylor DM, Morgans A, Cameron P. Identification of the optimum
vagal manoeuvre technique for maximising vagal tone. Emerg Med J 2015;32:51–4.
Firstly, the highest post-Valsalva vagal tone is normally obtained [7] Pstras L, Thomaseth K, Waniewski J, Balzani I, Bellavere F. The Valsalva manoeuvre:
after the VM performed in the supine position [5,6], and hence, the pro- physiology and clinical examples. Acta Physiol 2016;217:103–19.
posed patient repositioning may not be necessarily advantageous com- [8] Perry BG, Mündel T, Cochrane DJ, Cotter JD, Lucas SJ. The cerebrovascular response to
graded Valsalva maneuvers while standing. Physiol Rep 2014;2:e00233.
pared with the fully supine position.
[9] Perry BG, Cotter JD, Mejuto G, Mündel T, Lucas SJ. Cerebral hemodynamics during
graded Valsalva maneuvers. Front Physiol 2014;5:1–7.
[10] Tiecks FP, Lam AM, Matta BF, Strebel S, Douville C, Newell DW. Effects of the
Valsalva maneuver on cerebral circulation in healthy adults. Stroke 1995;26:
☆ The authors declare no conflict of interest. 1386–92.