Valsalva maneuver
Encyclopedia
The Valsalva maneuver or Valsalva manoeuvre is performed by moderately forceful attempted exhalation
against a closed airway
, usually done by closing one's mouth and pinching one's nose shut. Variations of the maneuver can be used either in medical
examination as a test of cardiac function and autonomic nervous
control of the heart
, or to "clear" the ear
s 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
, a 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 (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 responses described below but will not force air into the Eustachian tubes. Closing the glottis is also an alternative to closing the mouth in performing the Eustachian tube maneuver since this will also prevent the lung volume from escaping that way.
The normal physiological response consists of 4 phases, which are marked on the figure at right:
Deviation from this response pattern signifies either abnormal heart function or abnormal autonomic nervous control
of the heart.
Valsalva is also used by dentists following extraction of a maxillary molar tooth. The maneuver is performed to determine if a perforation or antral communication exists.
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 yawn
ing. The effectiveness of the "yawning" method can be improved with practice; some people are able to achieve release or opening by moving their jaw
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.
During swallowing or yawning, several muscles in the pharynx (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 or yawning is successful in equalizing middle ear pressure. Contrary to popular belief, the jaw does not pinch the tubes shut 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 an external pressure measuring device, thus eliminating or minimizing the pressure on the Eustachian tubes. Straining or 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.
membrane is permeable. If some of the inert gas-laden blood passes through the patent foramen ovale (PFO), it avoids the lungs and the inert gas is more 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
with severe neurological consequences (gas bubbles in the brain
or damages to the spinal cord
). Repeated Valsalva maneuvers are also suspected to increase the permeability of the foramen for divers at risk.
. 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 of most other murmurs, including aortic stenosis and atrial septal defect
.
The Valsalva maneuver works by decreasing preload to the heart. A complementary maneuver for differentiating disorders is the Handgrip maneuver
, which increases afterload.
The Valsalva maneuver alters heart rate through sympathetic
stimulation (i.e. the accelerator nerve). Neuro-muscular junctions at the sinoatrial node
(SAN) release the neurotransmitter norepinephrine
(noradrenaline), which increases the SAN's depolarisation rate.
These effects decrease the time between pacemaker action potentials, which results in a faster heartbeat. In later phases of the Valsalva maneuver (phases II and III), heart rate is reduced due to parasympathetic
interplay.
reported that during the second spacewalk of Space Shuttle
mission STS-134
, astronaut Drew Feustel was able to clear tears from his eye by wiggling down far enough in his Extravehicular Mobility Unit
(spacesuit) to make use of "a spongy device called a Valsalva that is typically used to block the nose in case a pressure readjustment is needed." The tears came about because some of a film of anti-fogging agent (liquid soap) came free from the inside of the helmet and floated into his eye.
In November 2011 ESA astronaut Samantha Cristoforetti
posted on Twitter a picture of her demonstrating the use of the Valsalva device in the Sokol space suit
Exhalation
Exhalation is the movement of air out of the bronchial tubes, through the airways, to the external environment during breathing....
against a closed airway
Airway
The pulmonary airway comprises those parts of the respiratory system through which air flows, conceptually beginning at the nose and mouth, and terminating in the alveoli...
, usually done by closing one's mouth and pinching one's nose shut. Variations of the maneuver can be used either in medical
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
examination as a test of cardiac function and autonomic nervous
Autonomic nervous system
The autonomic nervous system is the part of the peripheral nervous system that acts as a control system functioning largely below the level of consciousness, and controls visceral functions. The ANS affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils,...
control of the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
, or to "clear" the ear
Ear
The ear is the organ that detects sound. It not only receives sound, but also aids in balance and body position. The ear is part of the auditory system....
s and sinuses
Aerosinusitis
Aerosinusitis, also called barosinusitis, sinus squeeze or sinus barotrauma is a painful inflammation and sometimes bleeding of the membrane of the paranasal sinus cavities, normally the frontal sinus...
(that is, to equalize pressure between them) when ambient pressure changes, as in diving
Scuba diving
Scuba diving is a form of underwater diving in which a diver uses a scuba set to breathe underwater....
, hyperbaric oxygen therapy
Hyperbaric oxygen therapy
Hyperbaric medicine, also known as hyperbaric oxygen therapy , is the medical use of oxygen at a level higher than atmospheric pressure. The equipment required consists of a pressure chamber, which may be of rigid or flexible construction, and a means of delivering 100% oxygen...
, or aviation
Aviation
Aviation is the design, development, production, operation, and use of aircraft, especially heavier-than-air aircraft. Aviation is derived from avis, the Latin word for bird.-History:...
.
The technique is named after Antonio Maria Valsalva
Antonio Maria Valsalva
Antonio Maria Valsalva , was an Italian anatomist born in Imola. His research focused on the anatomy of the ears. He coined the term Eustachian tube and he described the aortic sinuses of Valsalva in his writings, published posthumously in 1740...
, a 17th-century physician and anatomist from Bologna
Bologna
Bologna is the capital city of Emilia-Romagna, in the Po Valley of Northern Italy. The city lies between the Po River and the Apennine Mountains, more specifically, between the Reno River and the Savena River. Bologna is a lively and cosmopolitan Italian college city, with spectacular history,...
whose principal scientific interest was the human ear. He described the Eustachian tube
Eustachian tube
The Eustachian tube is a tube that links the nasopharynx to the middle ear. It is a part of the middle ear. In adult humans the Eustachian tube is approximately 35 mm long. It is named after the sixteenth-century anatomist Bartolomeo Eustachi...
and the maneuver to test its patency (openness). He also described the use of this maneuver to expel pus
Pus
Pus is a viscous exudate, typically whitish-yellow, yellow, or yellow-brown, formed at the site of inflammatory during infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule or...
from the middle ear.
A modified version is done by expiring against a closed glottis
Glottis
The glottis is defined as the combination of the vocal folds and the space in between the folds .-Function:...
. This will elicit the cardiovascular responses described below but will not force air into the Eustachian tubes. Closing the glottis is also an alternative to closing the mouth in performing the Eustachian tube maneuver since this will also prevent the lung volume from escaping that way.
Physiological response
- Initial pressure rise: On application of expiratory force, pressure rises inside the chest forcing blood out of the pulmonary circulationPulmonary circulationPulmonary circulation is the half portion of the cardiovascular system which carries Oxygen-depleted Blood away from the heart, to the Lungs, and returns oxygenated blood back to the heart. Encyclopedic description and discovery of the pulmonary circulation is widely attributed to Doctor Ibn...
into the left atriumLeft atriumThe left atrium is one of the four chambers in the human heart. It receives oxygenated blood from the pulmonary veins, and pumps it into the left ventricle, via the mitral valve.-Foramen ovale:...
. This causes a mild rise in stroke volumeStroke volumeIn cardiovascular physiology, stroke volume is the volume of blood pumped from one ventricle of the heart with each beat. SV is calculated using measurements of ventricle volumes from an echocardiogram and subtracting the volume of the blood in the ventricle at the end of a beat from the volume...
. - Reduced venous return and compensation: Return of systemic blood to the heart is impeded by the pressure inside the chest. The output of the heart is reduced and stroke volume falls. This occurs from 5 to about 14 seconds in the illustration. 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 above normal, but the cardiac outputCardiac outputCardiac output is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute. CO may be measured in many ways, for example dm3/min...
and blood flow to the body remains low. During this time the pulse rate increases. - Pressure release: The pressure on the chest is released, allowing the pulmonary vessels and the aortaAortaThe aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...
to re-expand causing a further initial slight fall in stroke volume (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. - 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 (24 seconds on). The stroke volume 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
Autonomic nervous system
The autonomic nervous system is the part of the peripheral nervous system that acts as a control system functioning largely below the level of consciousness, and controls visceral functions. The ANS affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils,...
of the heart.
Valsalva is also used by dentists following extraction of a maxillary molar tooth. The maneuver is performed 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 the Eustachian tubes closed, preventing pressure equalization across the ear drum, with painful results. To avoid this painful situation, divers, caissonCaisson (engineering)
In geotechnical engineering, a caisson is a retaining, watertight structure used, for example, to work on the foundations of a bridge pier, for the construction of a concrete dam, or for the repair of ships. These are constructed such that the water can be pumped out, keeping the working...
workers and aircrew attempt to open the Eustachian tubes by swallowing
Swallowing
Swallowing, known scientifically as deglutition, is the process in the human or animal body that makes something pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. If this fails and the object goes through the trachea, then choking or pulmonary aspiration...
, 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
Swallowing
Swallowing, known scientifically as deglutition, is the process in the human or animal body that makes something pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. If this fails and the object goes through the trachea, then choking or pulmonary aspiration...
a few times, or yawn
Yawn
A yawn is a reflex of simultaneous inhalation of air and stretching of the eardrums, followed by exhalation of breath. Pandiculation is the act of yawning and stretching simultaneously....
ing. The effectiveness of the "yawning" method can be improved with practice; some people are able to achieve release or opening by moving their jaw
Jaw
The jaw is any opposable articulated structure at the entrance of the mouth, typically used for grasping and manipulating food. The term jaws is also broadly applied to the whole of the structures constituting the vault of the mouth and serving to open and close it and is part of the body plan of...
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.
During swallowing or yawning, several muscles in the pharynx (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 or yawning is successful in equalizing middle ear pressure. Contrary to popular belief, the jaw does not pinch the tubes shut 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 an external pressure measuring device, thus eliminating or minimizing the pressure on the Eustachian tubes. Straining or 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.
Diving
In diving, if the Valsalva maneuver is conducted during ascent, residual air overpressure in the middle-ear can potentially be released through the Eustachian tubes. During decompression stops at the end of a dive, if the diver unwittingly slightly descends again and makes a Valsalva to relieve his ears, there exists a non-negligible risk to transfer nitrogen bubbles from one side of the heart to the other one if the foramenForamen ovale (heart)
In the fetal heart, the foramen ovale , also ostium secundum of Born or falx septi, allows blood to enter the left atrium from the right atrium. It is one of two fetal cardiac shunts, the other being the ductus arteriosus...
membrane is permeable. If some of the inert gas-laden blood passes through the patent foramen ovale (PFO), it avoids the lungs and the inert gas is more likely to form large bubbles in the arterial blood stream, causing decompression sickness
Decompression sickness
Decompression sickness describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurization...
.
A Valsalva maneuver at the end of a diving must never be attempted as it can cause a decompression accident
Decompression sickness
Decompression sickness describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurization...
with severe neurological consequences (gas bubbles in the brain
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...
or damages to the spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...
). Repeated Valsalva maneuvers 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 tachycardiaSupraventricular tachycardia
Supraventricular tachycardia is a general term that refers to any rapid heart rhythm originating above the ventricular tissue. Supraventricular tachycardias can be contrasted to the potentially more dangerous ventricular tachycardias - rapid rhythms that originate within the ventricular...
. 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
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is a disease of the myocardium in which a portion of the myocardium is hypertrophied without any obvious cause...
murmurs, viz. those of dynamic subvalvular left ventricular outflow obstruction; whereas it decreases the intensity of most other murmurs, including aortic stenosis and atrial septal defect
Atrial septal defect
Atrial septal defect is a form of congenital heart defect that enables blood flow between the left and right atria via the interatrial septum. The interatrial septum is the tissue that divides the right and left atria...
.
| Effect of Valsalva | Cardiac Finding |
|---|---|
| Decreased | |
| Aortic Stenosis | |
| Pulmonic Stenosis Pulmonic stenosis Pulmonic stenosis, also known as Pulmonary stenosis, is a dynamic or fixed obstruction to flow from the right ventricle of the heart to the pulmonary artery. It is usually first diagnosed in childhood.... |
|
| Tricuspid Regurgitation Tricuspid insufficiency Tricuspid insufficiency , a valvular heart disease also called tricuspid regurgitation , refers to the failure of the heart's tricuspid valve to close properly during systole. As a result, with each heart beat some blood passes from the right ventricle to the right atrium, the opposite of the... |
|
| Increased | |
| Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy is a disease of the myocardium in which a portion of the myocardium is hypertrophied without any obvious cause... , mitral valve prolapse Mitral valve prolapse Mitral valve prolapse is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. There are various types of MVP, broadly classified as classic and nonclassic. In its nonclassic form, MVP carries a low risk of... |
|
The Valsalva maneuver works by decreasing preload to the heart. A complementary maneuver for differentiating disorders is the Handgrip maneuver
Handgrip maneuver
The handgrip maneuever is performed by clenching one's fist forcefully for a sustained time until fatigued. Variations include squeezing an item such as a rolled up washcloth.- Physiological Response :...
, which increases afterload.
The Valsalva maneuver alters heart rate through sympathetic
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...
stimulation (i.e. the accelerator nerve). Neuro-muscular junctions at the sinoatrial node
Sinoatrial node
The sinoatrial node is the impulse-generating tissue located in the right atrium of the heart, and thus the generator of normal sinus rhythm. It is a group of cells positioned on the wall of the right atrium, near the entrance of the superior vena cava...
(SAN) release the neurotransmitter norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
(noradrenaline), which increases the SAN's depolarisation rate.
These effects decrease the time between pacemaker action potentials, which results in a faster heartbeat. In later phases of the Valsalva maneuver (phases II and III), heart rate is reduced due to parasympathetic
Parasympathetic nervous system
The parasympathetic nervous system is one of the two main divisions of the autonomic nervous system . The ANS is responsible for regulation of internal organs and glands, which occurs unconsciously...
interplay.
Neurology
The Valsalva maneuver is used to aid in the clinical diagnosis of problems or injury in the nerves of the cervical spine. Upon performing the Valsalva maneuver, intraspinal pressure slightly increases. Thus, neuropathies or radicular pain may be felt or exacerbated, and this may indicate impingement on a nerve by an intervertebral disc or other part of the anatomy.Urogenital
The Valsalva maneuver is used to aid diagnosis of intrinsic sphincteric deficiency (ISD) in urodynamic tests. Valsalva leak point pressure is the pressure that is associated with urine leakage. Although there is no consensus on the normal value, values > 60 cm H2O are considered normal. Also, when examining women with pelvic organ prolapse, asking the patient to perform the Valsalva maneuver is an almost invariable step to demonstrate maximum organ descent.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, a 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.Valsalva device in spacesuits
On 25 May 2011, NASANASA
The National Aeronautics and Space Administration is the agency of the United States government that is responsible for the nation's civilian space program and for aeronautics and aerospace research...
reported that during the second spacewalk of Space Shuttle
Space Shuttle
The Space Shuttle was a manned orbital rocket and spacecraft system operated by NASA on 135 missions from 1981 to 2011. The system combined rocket launch, orbital spacecraft, and re-entry spaceplane with modular add-ons...
mission STS-134
STS-134
STS-134 was the penultimate mission of NASA's Space Shuttle program. The mission marked the 25th and final flight of . This flight delivered the Alpha Magnetic Spectrometer and an ExPRESS Logistics Carrier to the International Space Station. Mark Kelly served as the mission commander...
, astronaut Drew Feustel was able to clear tears from his eye by wiggling down far enough in his Extravehicular Mobility Unit
Extravehicular Mobility Unit
The Space Shuttle/International Space Station Extravehicular Mobility Unit is an independent anthropomorphic system that provides environmental protection, mobility, life support, and communications for a Space Shuttle or International Space Station crew member to perform extra-vehicular activity...
(spacesuit) to make use of "a spongy device called a Valsalva that is typically used to block the nose in case a pressure readjustment is needed." The tears came about because some of a film of anti-fogging agent (liquid soap) came free from the inside of the helmet and floated into his eye.
In November 2011 ESA astronaut Samantha Cristoforetti
Samantha Cristoforetti
Samantha Cristoforetti is an engineer, the third woman astronaut in the European Space Agency, and the first Italian woman astronaut.-Biography:...
posted on Twitter a picture of her demonstrating the use of the Valsalva device in the Sokol space suit
Sokol space suit
The Sokol space suit is a type of Russian space suit, worn by all who fly on the Soyuz spacecraft. It was introduced in 1973 and is still used . The Sokol is described by its makers as a rescue suit, and it is not capable of being used outside the spacecraft in a spacewalk or extra-vehicular...