The Valsalva manoeuvre—cardiovascular effects and performance technique: a critical review

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Abstract

Variations in the technique of the Valsalva manoeuvre (VM) have been shown to greatly influence the pattern of cardiovascular response (CVR) to the test. Intra-strain tachycardia, post-strain bradycardia, Valsalva ratio, and baroreflex sensitivity decrease in proportion to an increase in lung volume and a decrease in strain pressure at VM. In conditions of completely expanded lungs and low strain pressure many subjects reveal an intra-strain bradycardic response to VM instead of the usual tachycardic one. Intra-strain arterial hypotension and post-strain hypertension decrease with decrease in strain pressure. The changes in heart rate and blood pressure during an expiratory VM are greater than the responses observed during completition of an inspiratory VM. The rate of the deep inspiration prior to strain has an impact particularly on phase I of the VM. The magnitude of the CVR correlates with the strain duration, particularly at high levels of strain pressure, and depends on the baseline level of the cardiovascular parameters and their variations.

The paper discusses the possible mechanisms of different CVRs to variations in the technique of the VM. Some practical recommendations are suggested.

Introduction

In 1851, Ernst Heinrich Weber reported a considerable deceleration or even a transitory arrest of the heart in response to the Valsalva manoeuvre (VM). Some years later, Donders (1854) reached the opposite conclusion finding a significant tachycardia as a typical response to the VM. The reason for this apparent discrepancy has remained unclear. One might assume, however, that some differences in experimental conditions and/or in the technique of the VM were involved. The next 150 years witnessed thousands of studies on cardiovascular effects of the VM in normal and diseased subjects. The studies took into consideration a number of experimental conditions and factors affecting the cardiovascular response (CVR) to the VM. Thus, it was suggested that the VM tests should be performed in the morning at least 2 h after a light breakfast. Subjects were requested to abstain from coffee and cigarettes on the previous evening. The room temperature and the subject's age were to be taken into account (Wieling, 1993).

Suprisingly, much less attention has been paid to the effects of the variations in the performance technique such as volume and rate of the prestrain breath, extent and rate of the strain pressure increase, changes in lung volume and strain pressure, duration of the strain period, depth and rate of the poststrain breathing. All these technical conditions have been shown to affect the patterns of CVR to the VM (Looga, 1970).

The purpose of the present paper is to review the cardiovascular effects and their mechanisms of some common but mostly neglected, variations in the performance technique of the VM.

Section snippets

Fundamental mechanisms of the cardiovascular response to the Valsalva manoeuvre

Table 1 presents a schematic overview on the fundamental mechanisms of the CVR to the Valsalva manoeuvre. According to Hamilton et al. (1936), this response is divided into four basic phases. If a final deep breath precedes the VM, as is usually the case, the concomitant CVR is treated as phase 0.

In all phases, the CVR may be divided further into an earlier subphase (E) and a subsequent later subphase (L). As a rule, the subphase E is related to the primary mechanical disturbance of arterial

Prestrain final breath

Straining by VM may be initiated after a deep inspiration (inspiratory VM), at the end of expiration (expiratory VM), or at some intermediate level of the preceding inspiration (intermediate VM). Different researchers have employed one of these variants. However, most studies ignored the role of the depth and rate of the preceding breath in the pattern of CVR to VM. The completion of this breath has been commonly left to the discretion of the experimental subjects.

However, the depth of the

Strain pressure

The strain pressure indirectly determines the force of the straining action by VM. Usually it is measured by the elevation of the gas pressure in airways after a forced exhalation into a manometer to a predetermined level and maintaining it there for a scheduled period. During this procedure the glottis must be open in order to prevent an unequal rise of pressures in the mouth and in the lungs. However, the glottis in subjects performing the VM may readily tend to be closed since it is easier

Strain duration

In most VM studies the duration of the straining has been 15 s. During this period all intra-strain phases of the CVR to VM are usually distinguishable. If the duration is shorter, phases I and IIE, or only phase I may be observed, and when longer, phase IIL, and less often phase IIE will be lengthened (depending mainly on the level of strain pressure; Fig. 7). If the duration of the VM is not fixed and the subjects are asked to perform the VM as long as they feel comfortable, the duration of

Baseline level

The magnitude and pattern of the CVR to the VM are usually estimated in reference to the baseline mean level. However, the baseline cardiovascular indices are not stable, showing perpetual regular and irregular fluctuations under the influence of various external and internal stimuli. Therefore, in all Valsalva studies efforts have been made to exclude or diminish the influences of various erratic stimuli on the autonomic control.

According to one of the methods the subject rests in a quiet

Methodological recommendations

In order to stabilize the CVR to VM, one should control and record the breathing movements before, during, and after the test, including the depth and rate of the final inspiration prior to the onset of the strain. Also, the subjects are recommended to observe the course of the baseline parameters and initiate the VM voluntarily by themselves without any command from the researcher. It is important to repeat the VM only after a full restoration of the baseline heart rate values from the

Acknowledgement

I am grateful to Professor Johannes Piiper for many helpful suggestions.

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