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Concept: Valsalva maneuver


Venipuncture is one of the most painful events for children in hospitals. Valsalva maneuver (VM) decreases the incidence and severity of pain on venipuncture pain in adults. This study was designed to evaluate VM as compared with Eutectic Mixture of Local Anesthetic (EMLA(®)) cream for venipuncture pain in children.

Concepts: Neurology, Anesthesia, Local anesthesia, Pain, Local anesthetic, Valsalva maneuver, Virtual machine


Patients who increase stoke volume or cardiac index more than 10 or 15% after a fluid challenge are usually considered fluid responders. Assessment of fluid responsiveness prior to volume expansion is critical to avoid fluid overload, which has been associated with poor outcomes. Maneuvers to assess fluid responsiveness are well established in mechanically ventilated patients; however, few studies evaluated maneuvers to predict fluid responsiveness in spontaneously breathing patients. Our objective was to perform a systematic review of literature addressing the available methods to assess fluid responsiveness in spontaneously breathing patients. Studies were identified through electronic literature search of PubMed from 01/08/2009 to 01/08/2016 by two independent authors. No restrictions on language were adopted. Quality of included studies was evaluated with Quality Assessment of Diagnostic Accuracy Studies tool. Our search strategy identified 537 studies, and 9 studies were added through manual search. Of those, 15 studies (12 intensive care unit patients; 1 emergency department patients; 1 intensive care unit and emergency department patients; 1 operating room) were included in this analysis. In total, 649 spontaneously breathing patients were assessed for fluid responsiveness. Of those, 340 (52%) were deemed fluid responsive. Pulse pressure variation during the Valsalva maneuver (∆PPV) of 52% (AUC ± SD: 0.98 ± 0.03) and passive leg raising-induced change in stroke volume (∆SV-PLR) > 13% (AUC ± SD: 0.96 ± 0.03) showed the highest accuracy to predict fluid responsiveness in spontaneously breathing patients. Our systematic review indicates that regardless of the limitations of each maneuver, fluid responsiveness can be assessed in spontaneously breathing patients. Further well-designed studies, with adequate simple size and power, are necessary to confirm the real accuracy of the different methods used to assess fluid responsiveness in this population of patients.

Concepts: Hospital, Evaluation, Cardiology, Assessment, Psychometrics, Responsiveness, Valsalva maneuver, Maneuver


The determination of Eustachian tube dysfunction (ETD) subtypes in daily routines is based on symptoms of the patient, otoscopy, nasopharyngoscopy, tympanometry, pure tone audiometry, and Valsalva’s test, even though this clinical assessment is often not sufficient to clearly diagnose the subtype. In the study, we have evaluated the possibility of the determination of different subtypes of ETD by pressure chamber measurements.

Concepts: Patient, Eustachian tube, Otitis media, Ear, Pure tone audiometry, Patulous Eustachian tube, Valsalva maneuver, Ear clearing


To describe the baseline hemodynamic variables and response time of hemodynamic changes associated with the Valsalva maneuver using noninvasive continuous cardiac output monitoring (Nexfin). Hemodynamic monitoring provides an integral component of advanced clinical care and the ability to monitor response to treatment interventions. The emergence of noninvasive hemodynamic monitoring provides clinicians with an opportunity to monitor and assess patients rapidly with ease of implementation. However, the responsiveness of this method in tracking dynamic changes that occur has not been fully elucidated. A prospective observational study was conducted involving 44 healthy volunteers (age = 38 ±12 years). Participants performed a Valsalva maneuvers to illicit dynamic changes in blood pressure, cardiac output, cardiac index, systemic vascular resistance index (SVRI), and stroke volume. Changes in these hemodynamic parameters were monitored while performing repeated standardized Valsalva maneuvers. Baseline hemodynamic values were obtained in all 44 participants, and showed an interaction with age, accompanying a significant decline in cardiac index ( r = -.66, p < .05) and stroke volume ( r = -.68, p < .05), and an increase in SVRI ( r = .67, p < .05) with increasing age. The Valsalva maneuver, performed in 20 participants, resulted in a change of 10% from baseline blood pressure and cardiac index, which was detected within 4.53 s ( SD = 4.36) and 3.31 s ( SD = 2.21), respectively. Noninvasive continuous cardiac monitoring demonstrated the ability to rapidly detect logical and predictable hemodynamic changes. These observations suggest that such Nexfin technology may have useful clinical applications.

Concepts: Blood, Cardiology, Observational study, Artery, Integral, Cardiac output, Cardiac cycle, Valsalva maneuver


Non-pharmacological therapies, especially the physical maneuvers, are viewed as important and promising strategies for reducing syncope recurrences in vasovagal syncope (VVS) patients. We observed the efficacy of a modified Valsalva maneuver (MVM) in VVS patients. 72 VVS patients with syncope history and positive head-up tilt table testing (HUTT) results were randomly divided into conventional treatment group (NVM group, n = 36) and conventional treatment plus standard MVM for 30 days group (MVM group, n = 36). Incidence of recurrent syncope after 12 months (6.5% vs. 41.2%, P<0.01) and rate of positive HUTT after 30 days (9.7% vs.79.4%, P<0.01) were significantly lower in MVM group than in NVM group. HRV results showed that low frequency (LF), LF/ high frequency (HF), standard deviation of NN intervals (SDNN) and standard deviation of all 5-min average NN intervals (SDANN) values were significantly lower in the NVM and MVM groups than in the control group at baseline. After 30 days treatment, LF, LF/HF, SDNN, SDANN values were significantly higher compared to baseline in MVM group. Results of Cox proportional hazard model showed that higher SDNN and SDANN values at 30 days after intervention were protective factors, while positive HUTT at 30 days after intervention was risk factor for recurrent syncope. Our results indicate that 30 days MVM intervention could effectively reduce the incidence of recurrent syncope up to 12 months in VVS patients, possibly through improving sympathetic function of VVS patients.

Concepts: Epidemiology, Proportional hazards models, Randomized controlled trial, Standard deviation, Low frequency, High frequency, Valsalva maneuver, Tilt table test


The Valsalva maneuver (VM) involves expiratory effort against a closed mouth and/or glottis in the sitting or supine position with the increased intraoral and intrathoracic pressure raised to 40 mmHg for 15-20 sec after which the pressure is suddenly released and the breathing restored to normal. Complex cardiovascular and other physiologic changes occur during the VM. The VM has been used for diagnostic and therapeutic reasons as well as intraoperatively during specific surgical procedures. Although the VM is usually safe, rare complications have been reported. This review examines the published literature surrounding the VM and explores the physiologic changes that occur during its performance. Attempts have been made to understand its intraoperative uses and complications and how these can be prevented.

Concepts: Surgery, Thermodynamics, Anatomy, Supine position, Breathing, Underwater diving, Valsalva maneuver, Glottis


The Eustachian tube protects against secretion, germs and sound pressure from the nasopharynx, it acts as a drain, and serves pressure equalization in both directions so that the ear drum and sound-conducting apparatus can vibrate optimally. The incidence of Eustachian tube dysfunction in adults is about 1%, in children almost 40%. Symptoms are often unspecific. For diagnosis, the Eustachian tube score (ETS-5) can be used in patients with a perforated ear drum, and the ETS-7 score in patients with intact ear drum. Adenoid hypertrophy is a frequent cause of obstructive tube dysfunction in children. Treatment of obstructive dysfunction includes steroid nasal sprays and regular performance of the Valsalva maneuver, as well as tube dilation with the Bielefelder balloon catheter. The patulous Eustachian tube is treated with saline nasal irrigation, estrogen-nasal ointment, and craniocervical manual therapy; causal treatments are evaluated.

Concepts: Auditory system, Middle ear, Eustachian tube, Ear, Nasal irrigation, Patulous Eustachian tube, Valsalva maneuver, Ear clearing


Guidelines recommend exercise stress echocardiogram (ESE) for patients with hypertrophic cardiomyopathy (HC) if a 50 mm Hg gradient is not present at rest or provoked with Valsalva or amyl nitrite, to direct medical and surgical management. However, no study has directly compared all 3 methods. We sought to evaluate efficacy and degree of provocation of left ventricular outflow gradients by ESE, and compare with Valsalva and amyl nitrite. In patients with HC between 2002 and 2015, resting echocardiograms and ESEs within 1 year were retrospectively reviewed. Gradients elicited by each provocation method were compared. Rest and ESE were available in 97 patients (mean age 54 ± 18 years, 57% male); 78 underwent Valsalva maneuver and 41 amyl nitrite provocation. Median gradients (interquartile range) were 10 mm Hg (7,19) at rest, 16 mm Hg (9,34) with Valsalva, 23 mm Hg (13,49) with amyl nitrite, and 26 mm Hg (13,58) with ESE. ESE and amyl nitrite were able to provoke obstruction (≥30 mm Hg) and severe obstruction (≥50 mm Hg) more frequently than Valsalva. In patients with resting gradient <30 mm Hg (n = 83), provocation maneuvers demonstrated dynamic obstruction in 51%; in those with Valsalva gradient <30 mm Hg (n = 57), ESE or amyl nitrite provoked a gradient in 44%; and in those with amyl nitrite gradient <30 mm Hg (n = 20), ESE provoked a gradient in 29%. No demographic or baseline echocardiographic parameter predicted provocable obstruction. In conclusion, ESE is clinically useful; however, different provocation maneuvers may be effective in different patients with HC, and all maneuvers may be required to provoke dynamic obstruction in symptomatic patients.

Concepts: Cardiology, Echocardiography, Hypertrophic cardiomyopathy, Valsalva maneuver


The upside-down position is a little known modified Valsalva manoeuvre (VM). The aim of this study was to investigate the safety and the efficacy of the upside-down position for the treatment of paroxysmal SVT in children.

Concepts: Supraventricular tachycardia, Tachycardia, AV nodal reentrant tachycardia, Valsalva maneuver, Paroxysmal tachycardia


During neuronal activation, neurovascular coupling leads to a local decrease of deoxygenated hemoglobin concentration (deoxy-Hb) and thus forms the basis of many functional brain mapping methods. In animals, an elevated intracranial pressure (ICP) can attenuate or even reverse this deoxy-Hb signaling. To study the effect of an elevated ICP on functional brain imaging in humans, we used different breathing tasks to modify ICP and analyzed the resulting effect on neurovascular coupling in the motor cortex. Functional near-infrared spectroscopy (fNIRS) was performed on 45 subjects during alternating conditions of finger tapping and resting state combined with four different breathing maneuvers (normal breathing (NB), breath holding without Valsalva maneuver (BH), Valsalva maneuver with 15 mm Hg forced expiratory pressure against resistance (V15) and Valsalva maneuver with 35 mm Hg forced expiratory pressure against resistance (V35)) in randomized order. With escalation of breathing tasks the median amplitude of the functional deoxy-Hb decrease during finger tapping became smaller. In contrast, functional oxygenated hemoglobin concentration (oxy-Hb) and total hemoglobin concentration (total-Hb) responses did not show a significant alteration. The functional oxy-Hb map evoked by finger tapping withstood Valsalva challenges while the functional deoxy-Hb map identified the correct motor cortex in normal breathing conditions only and did not reveal a functional contrast during Valsalva maneuvers. In summary, we conclude that during ICP elevation, deoxy-Hb is not a reliable basis for functional brain imaging. This suggests that the validity of BOLD fMRI during increased ICP might be impaired.

Concepts: Oxygen, Brain, Intracranial pressure, Neuroimaging, Functional magnetic resonance imaging, Breathing, Valsalva maneuver, Brain mapping