Application of the Valsalva maneuver in medicine and sport
DOI:
https://doi.org/10.12775/QS.2024.20.53363Keywords
Valsalva maneuver, Vagal maneuver, respiratory maneuver, autonomic systemAbstract
The Valsalva maneuver, named after Antonio Maria Valsalva, is one of the vagal maneuvers. It is defined as a forced expiration against a closed glottis, leading to an increase in intrathoracic and intra-abdominal pressure. Over the years it has become a subject of interest to many clinical researchers who have comprehensively studied its physiology and clinical significance. As a result, the application of the Valsalva maneuver has expanded to become a versatile technique applied across a wide range of medical specialties as a diagnostic and therapeutic tool. Additionally, it has found its use in sport among athletes. The aim of this article is to present the current state of knowledge about the clinical significance of the Valsalva maneuver and show that this simple physiological technique described in the 18th century remains a valuable tool in modern clinical practice and has found its use in sport. The review was based on chosen literature obtained from the PubMed electronic database, Google Scholar electronic database, and other scientific articles. Search terms included keywords listed below.
Keywords: Valsalva maneuver; vagal maneuver; respiratory maneuver; autonomic system
References
Niehues LJ, Klovenski V. Vagal Maneuver. 2023 Jul 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 31855402.
Jellinek E. H. (2006). The Valsalva manoeuvre and Antonio Valsalva (1666-1723). Journal of the Royal Society of Medicine, 99(9), 448–451. https://doi.org/10.1177/014107680609900915
Tiecks, F. P., Lam, A. M., Matta, B. F., Strebel, S., Douville, C., & Newell, D. W. (1995). Effects of the valsalva maneuver on cerebral circulation in healthy adults.
A transcranial Doppler Study. Stroke, 26(8), 1386–1392. https://doi.org/10.1161/01.str.26.8.1386
Srivastav S, Jamil RT, Zeltser R. Valsalva Maneuver. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 21, 2023.
Yale S. H. (2005). Antonio Maria Valsalva (1666 - 1723). Clinical medicine & research, 3(1), 35–38. https://doi.org/10.3121/cmr.3.1.35
Junqueira L. F., Jr (2008). Teaching cardiac autonomic function dynamics employing the Valsalva (Valsalva-Weber) maneuver. Advances in physiology education, 32(1), 100–106. https://doi.org/10.1152/advan.00057.2007
Fughelli, P., Stella, A., & Sterpetti, A. V. (2019). Antonio Maria Valsalva (1666-1723). Circulation research, 124(12), 1704–1706. https://doi.org/10.1161/CIRCRESAHA.119.315048
Smith, M. L., Beightol, L. A., Fritsch-Yelle, J. M., Ellenbogen, K. A., Porter, T. R., & Eckberg, D. L. (1996). Valsalva's maneuver revisited: a quantitative method yielding insights into human autonomic control. The American journal of physiology, 271(3 Pt 2), H1240–H1249. https://doi.org/10.1152/ajpheart.1996.271.3.H1240
Hamilton Wf, Woodbury Ra, Harper Ht. Physiologic Relationships Between Intrathoracic, Intraspinal And Arterial Pressures. Jama. 1936;107(11):853–856. doi:10.1001/jama.1936.02770370017005
Looga R. (2005). The Valsalva manoeuvre--cardiovascular effects and performance technique: a critical review. Respiratory physiology & neurobiology, 147(1), 39–49. https://doi.org/10.1016/j.resp.2005.01.003
Saldaña García, J., Torremocha López, A., & Dawid Milner, M. S. (2020). Influence of repetitions on the Valsalva maneuver. Clinical neurophysiology practice, 5, 104–111. https://doi.org/10.1016/j.cnp.2020.04.00
Pstras, L., Thomaseth, K., Waniewski, J., Balzani, I., & Bellavere, F. (2016). The Valsalva manoeuvre: physiology and clinical examples. Acta physiologica (Oxford, England), 217(2), 103–119. https://doi.org/10.1111/apha.12639
Krauze, T. (2006). The use of the Valsalva manoeuvre in the evaluation of cardiovascular system. Cardiology Journal, 13(2), 101-107.
Michael J. Attubato, Edward S. Katz, Frederick Feit, Neil Bernstein, David Schwartzman, Itzhak Kronzon, Venous changes occurring during the valsalva maneuver: Evaluation by intravascular ultrasound, The American Journal of Cardiology, Volume 74, Issue 4,1994, Pages 408-410, ISSN 0002-9149, https://doi.org/10.1016/0002-9149(94)90417-0
Brugada, J., Katritsis, D. G., Arbelo, E., Arribas, F., Bax, J. J., Blomström-Lundqvist, C., ... & Moreno, J. (2019). 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. European Heart Journal, 41(5), 655-720. doi:10.1093/eurheartj/ehz467
Smith, G., Morgans, A., & Boyle, M. (2009). Use of the Valsalva manoeuvre in the prehospital setting: a review of the literature. Emergency medicine journal : EMJ, 26(1), 8–10. https://doi.org/10.1136/emj.2008.061572
Capilupi, M. J., Kerath, S. M., & Becker, L. B. (2020). Vagus Nerve Stimulation and the Cardiovascular System. Cold Spring Harbor perspectives in medicine, 10(2), a034173. https://doi.org/10.1101/cshperspect.a034173
Appelboam, A., Reuben, A., Mann, C., Gagg, J., Ewings, P., Barton, A., Lobban, T., Dayer, M., Vickery, J., Benger, J., & REVERT trial collaborators (2015). Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet (London, England), 386(10005), 1747–1753, https://doi.org/10.1016/S0140-6736(15)61485-4
Smith, G., & Boyle, M. J. (2009). The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre. Emergency medicine Australasia : EMA, 21(6), 449–454. https://doi.org/10.1111/j.1742-6723.2009.01228.x
Thiagaraj, A. K., Hughes-Doichev, R., & Biederman, R. W. W. (2019). Provocative maneuvers to improve patent foramen ovale detection: A brief review of the literature. Echocardiography (Mount Kisco, N.Y.), 36(4), 783–786. https://doi.org/10.1111/echo.14297
Ginghina, C., Beladan, C. C., Iancu, M., Calin, A., & Popescu, B. A. (2009). Respiratory maneuvers in echocardiography: a review of clinical applications. Cardiovascular ultrasound, 7, 42. https://doi.org/10.1186/1476-7120-7-42
Zhao, E., Zhang, Y., Kang, C., Niu, H., Zhao, J., Sun, L., & Liu, B. (2017). Influence of the Valsalva maneuver on cardiac hemodynamics and right to left shunt in patients with patent foramen ovale. Scientific reports, 7, 44280. https://doi.org/10.1038/srep44280
Kumar S, Van Ness G, Bender A, et al. Standardized Goal-Directed Valsalva Maneuver for Assessment of Inducible Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr. 2018;31(7):791-798 https://doi.org/10.1016/j.echo.2018.01.022
Nagueh, S. F., Smiseth, O. A., Appleton, C. P., Byrd, B. F., 3rd, Dokainish, H., Edvardsen, T., Flachskampf, F. A., Gillebert, T. C., Klein, A. L., Lancellotti, P., Marino, P., Oh, J. K., Popescu, B. A., & Waggoner, A. D. (2016). Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography, 29(4), 277–314. https://doi.org/10.1016/j.echo.2016.01.011
Ibrahim O, Sibbald M, Szczeklik W, Leśniak W. Heart Murmurs. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.I.1.107.2. Accessed June 22, 2024.
Jelinek, Herbert & Abawajy, Jemal & Kelarev, Andrei & Chowdhury, Morshed & Stranieri, Andrew. (2014). Decision trees and multi-level ensemble classifiers for neurological diagnostics. AIMS Medical Science. 1. 1-12. 10.3934/medsci.2014.1.1.
Andrew Stranieri, Jemal Abawajy, Andrei Kelarev, Shamsul Huda, Morshed Chowdhury, Herbert F. Jelinek, An approach for Ewing test selection to support the clinical assessment of cardiac autonomic neuropathy, Artificial Intelligence in Medicine,Volume 58, Issue 3, 2013, Pages 185-193, ISSN 0933-3657.
https://doi.org/10.1016/j.artmed.2013.04.007
Kumar, Chandra & Van Zundert, André. (2018). Intraoperative Valsalva maneuver: a narrative review. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 65. 10.1007/s12630-018-1074-6.
Jacob, G., Diedrich, L., Sato, K., Brychta, R. J., Raj, S. R., Robertson, D., Biaggioni, I., & Diedrich, A. (2019). Vagal and Sympathetic Function in Neuropathic Postural Tachycardia Syndrome. Hypertension (Dallas, Tex. : 1979), 73(5), 1087–1096. https://doi.org/10.1161/HYPERTENSIONAHA.118.11803
Park, J. W., Okamoto, L. E., Kim, S. H., Baek, S. H., Sung, J. H., Jeon, N., Gamboa, A., Shibao, C. A., Diedrich, A., Kim, B. J., & Biaggioni, I. (2023).
Use of Valsalva Maneuver to Detect Late-Onset Delayed Orthostatic Hypotension. Hypertension (Dallas, Tex. : 1979), 80(4), 792–801. https://doi.org/10.1161/HYPERTENSIONAHA.122.20098
Pratiwi, Anggi. (2023). The Implementation of Valsava Manuever on Pain Reduction During IV Cannulation : A literature review. JIKO (Jurnal Ilmiah Keperawatan Orthopedi). 7. 69-76. 10.46749/jiko.v7i2.136.
Agarwal, A., Sinha, P. K., Tandon, M., Dhiraaj, S., & Singh, U. (2005). Evaluating the efficacy of the valsalva maneuver on venous cannulation pain: a prospective, randomized study. Anesthesia and analgesia, 101(4), 1230–1232. https://doi.org/10.1213/01.ane.0000167270.15047.49
Kumar, S., Gautam, S. K., Gupta, D., Agarwal, A., Dhirraj, S., & Khuba, S. (2016). The effect of Valsalva maneuver in attenuating skin puncture pain during spinal anesthesia: a randomized controlled trial. Korean journal of anesthesiology, 69(1), 27–31. https://doi.org/10.4097/kjae.2016.69.1.27
Ghods, A. A., Roshani, A., Mirmohammadkhani, M., & Soleimani, M. (2022). Effects of Valsalva Maneuver on Pain and Vasovagal Reaction During the Removing of Femoral Arterial Sheath After Percutaneous Coronary Intervention: A Randomized Controlled Trial. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses, 37(6), 900–906. https://doi.org/10.1016/j.jopan.2022.01.016
Nazemroaya, B., Aghadavodi, O., Honarmand, A., & Ahmadian, S. (2021). A Comparative Study of Valsalva Maneuver, Lidocaine, and Valsalva Maneuvers with Administration of Lidocaine to Reduce the Pain Associated with Administration of Etomidate During General Anesthesia. Anesthesiology and pain medicine, 11(3), e113408. https://doi.org/10.5812/aapm.113408
Kumar, S., Khuba, S., Agarwal, A., Gautam, S., Yadav, M., & Dixit, A. (2018). Evaluation of efficacy of Valsalva maneuver for attenuating propofol injection pain: a prospective, randomized, single blind, placebo controlled study. Korean journal of anesthesiology, 71(6), 453–458. https://doi.org/10.4097/kja.d.18.00017
Stocker-Ghafoor, Soleen & Tognella, A. & Stocker, Daniel & Hötker, A. & Kaniewska, M. & Sartoretti, T. & Euler, André & Vonlanthen, R. & Bueter, Marco & Alkadhi, H.. (2023). Diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias. Hernia. 27. 1-9. 10.1007/s10029-023-02830-y
Madhavan, A.A. & Carr, C.M. & Carlson, Matthew & Lane, John. (2019). Imaging Findings Related to the Valsalva Maneuver in Head and Neck Radiology. American Journal of Neuroradiology. 40. 10.3174/ajnr.A6309.
Won, H. J., Kim, P. N., & Lee, J. S. (2017). Changes in echogenicity of hepatic hemangiomas during the valsalva maneuver. Journal of clinical ultrasound : JCU, 45(6), 328–331. https://doi.org/10.1002/jcu.22456
Lorenc, T., Krupniewski, L., Palczewski, P., & Gołębiowski, M. (2016). The value of ultrasonography in the diagnosis of varicocele. Journal of ultrasonography, 16(67), 359–370. https://doi.org/10.15557/JoU.2016.0036
Haldar, Rudrashish; Khandelwal, Ankur; Gupta, Devendra; Srivastava, Shashi; Rastogi, Amit; Singh, Prabhat K.. Valsalva maneuver: Its implications in clinical neurosurgery. Neurology India 64(6):p 1276-1280, November–December 2016. | DOI: 10.4103/0028-3886.193832
Baker, C., Karsy, M., & Couldwell, W. T. (2019). Resection of Pituitary Tumor with Lateral Extension to the Temporal Fossa: The Toothpaste Extrusion Technique. Cureus, 11(10), e5953. https://doi.org/10.7759/cureus.5953
Konate, M., Sarfi, D., El Bouhairi, M., & Benyahya, I. (2021). Management of Oroantral Fistulae and Communications: Our Recommendations for Routine Practice. Case reports in dentistry, 2021, 7592253. https://doi.org/10.1155/2021/7592253
Chen, L., & Cha, J. (2021). Removing Foreign Bodies From the Maxillary Sinus: Sinus Area Classification and Technique Selection. Compendium of continuing education in dentistry (Jamesburg, N.J. : 1995), 42(9), e5–e8.
Cimsir, M. T., & Yildiz, M. S. (2021). Could the Valsalva manoeuvre be an alternative to the tenaculum for intrauterine device insertion?. The European journal of contraception & reproductive health care : the official journal of the European Society of Contraception, 26(6), 503–506. https://doi.org/10.1080/13625187.2021.1934442
Mulder, F. E., Shek, K. L., & Dietz, H. P. (2012). What's a proper push? The Valsalva manoeuvre revisited. The Australian & New Zealand journal of obstetrics & gynaecology, 52(3), 282–285. https://doi.org/10.1111/j.1479-828X.2012.01446.x
Mohd Hamdan, M. H., Saniasiaya, J., & Narayanan, P. (2021). Valsalva manoeuvre to detect isolated hyoid bone fracture. BMJ case reports, 14(7), e243756. https://doi.org/10.1136/bcr-2021-243756
Daneshgari F. (2001). Valsalva leak point pressure: steps toward standardization. Current urology reports, 2(5), 388–391. https://doi.org/10.1007/s11934-996-0025-x
Smith, Matthew & Tysome, James. (2015). Tests of Eustachian Tube Function: A Review. Clinical otolaryngology: official journal of ENT-UK; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 40. 10.1111/coa.12428.
Karpf M. Lymphadenopathy. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 149. Available from: https://www.ncbi.nlm.nih.gov/books/NBK256/
Williams, E. A., Pelto, H. F., Toresdahl, B. G., Prutkin, J. M., Owens, D. S., Salerno, J. C., Harmon, K. G., & Drezner, J. A. (2019). Performance of the American Heart Association ( AHA ) 14-Point Evaluation Versus Electrocardiography for the Cardiovascular Screening of High School Athletes: A Prospective Study. Journal of the American Heart Association, 8(14), e012235. https://doi.org/10.1161/JAHA.119.012235
Mahowald, M. K., Fender, E. A., Prasad, A., & Nishimura, R. A. (2020). Exertional Syncope in an Athlete: The Answer is in the History and Exam. Circulation. Cardiovascular imaging, 13(4), e009992. https://doi.org/10.1161/CIRCIMAGING.119.009992
Vasileff, W. K., Nekhline, M., Kolowich, P. A., Talpos, G. B., Eyler, W. R., & van Holsbeeck, M. (2017). Inguinal Hernia in Athletes: Role of Dynamic Ultrasound. Sports health, 9(5), 414–421. https://doi.org/10.1177/1941738117717009
Radmilovic, J., D'Andrea, A., D'Amato, A., Tagliamonte, E., Sperlongano, S., Riegler, L., Scarafile, R., Forni, A., Muscogiuri, G., Pontone, G., Galderisi, M., & Russo, M. G. (2019). Echocardiography in Athletes in Primary Prevention of Sudden Death. Journal of cardiovascular echography, 29(4), 139–148. https://doi.org/10.4103/jcecho.jcecho_26_19
Glazer, T. A., & Telian, S. A. (2016). Otologic Hazards Related to Scuba Diving. Sports health, 8(2), 140–144. https://doi.org/10.1177/1941738116631524
Taylor, David. (1996). The Valsalva manoeuvre a critical review. South Pacific Underwater Medicine Society Journal. 26. ISSN:0813-1988. http://hdl.handle.net/11054/225
Picornell-Darder, I., Carrasco, J. L., Rostain, J. C., & Naquet, R. (1978). A study on the Valsalva manoeuvre in young healthy subjects. Electroencephalography and clinical neurophysiology, 45(5), 648–654. https://doi.org/10.1016/0013-4694(78)90165-7
Nitka, T. (2021). Pressure equalizing in freediving and scuba diving. ISBN: 978-83-959003-0-3
Apostolos, A., Drakopoulou, M., Trantalis, G., Synetos, Α., Oikonomou, G., Karapanayiotides, T., Tsioufis, C., & Toutouzas, K. (2022). The management of patent foramen ovale in divers: where do we stand?. Therapeutic advances in neurological disorders, 15, 17562864221103459. https://doi.org/10.1177/17562864221103459
Hackett, D. A., & Chow, C. M. (2013). The Valsalva maneuver: its effect on intra-abdominal pressure and safety issues during resistance exercise. Journal of strength and conditioning research, 27(8), 2338–2345. https://doi.org/10.1519/JSC.0b013e31827de07d
Prevett, Christina & Moore, R. (2024). Nuances of the Valsalva manoeuvre and bracing with regard to resistance training performance and its effects on the pelvic floor. Journal of Pelvic, Obstetric and Gynaecological Physiotherapy. 134. 10.62399/YXRS8863
Trevor W. Blanchard, Camille Smith, Sylvain G. Grenier, In a dynamic lifting task, the relationship between cross-sectional abdominal muscle thickness and the corresponding muscle activity is affected by the combined use of a weightlifting belt and the Valsalva maneuver, Journal of Electromyography and Kinesiology, Volume 28, 2016, Pages 99-103, ISSN 1050-6411, https://doi.org/10.1016/j.jelekin.2016.03.006.
Haykowsky, M. J., Eves, N. D., R Warburton, D. E., & Findlay, M. J. (2003). Resistance exercise, the Valsalva maneuver, and cerebrovascular transmural pressure. Medicine and science in sports and exercise, 35(1), 65–68. https://doi.org/10.1097/00005768-200301000-00011
Haykowsky, M., Taylor, D., Teo, K., Quinney, A., & Humen, D. (2001). Left ventricular wall stress during leg-press exercise performed with a brief Valsalva maneuver. Chest, 119(1), 150–154. https://doi.org/10.1378/chest.119.1.150
Niehues LJ, Klovenski V. Vagal Maneuver. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551575/
ANNITTA J. MOREHEAD, Chapter 18 - Sonographer's Perspective of Evaluating Diastolic Function, Editor(s): ALLAN L. KLEIN, MARIO J. GARCIA, Diastology, W.B. Saunders, 2008, Pages 215-229, ISBN 9781416037545, https://doi.org/10.1016/B978-1-4160-3754-5.50024-X.
Benet N, Kumar V, Sharma M, Gurwan B. Effect of Valsalva Maneuver by Heavy Weight Lifters on Ear and Its Attributes. Indian J Otolaryngol Head Neck Surg. 2023 Apr;75(Suppl 1):535-540. doi: 10.1007/s12070-023-03635-2. Epub 2023 Mar 7. PMID: 37206737; PMCID: PMC10188837.
Teitelbaum T, Shochat I, Grinblat G, Taha M, Braverman I. Hemotympanum as a Complication of a Valsalva Maneuver during Childbirth. Case Rep Otolaryngol. 2023 Aug 9;2023:3328895. doi: 10.1155/2023/3328895. PMID: 37593658; PMCID: PMC10432077.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Patrycja Karkos, Katarzyna Kuśmierczyk, Marta Jurga, Bartłomiej Gastoł, Karolina Mikołap, Marta Kras, Arkadiusz Staroń, Elena Sztemberg, Jakub Plizga, Agnieszka Głuszczyk
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Stats
Number of views and downloads: 232
Number of citations: 0