Valsalva Maneuver

1. Technique
   1. Forceful expiration against a closed mouth and nose
2. 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
3. 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. 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
         3. 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
   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
4. References
   1. Bates (1991) Physical Exam, 5th ed, Lippencott, p. 302