Valsalva maneuver

General treatment measures for all STE ACS and high- and intermediate-risk NSTE patients include admission to hospital, oxygen administration (if oxygen saturation is low, less than 90%), continuous multi-lead ST-segment monitoring for arrhythmias and ischemia, frequent measurement of vital signs, bed rest for 12 hours in hemodynamically stable patients, avoidance of Valsalva maneuver (prescribe stool softeners routinely), and pain relief (Fig. 5-3). 

Second, reflux may occur after transient increases in intraabdominal pressure (stress reflux).3 An increase in intraabdominal pressure such as that occurring during straining, bending over, coughing, eating, or a Valsalva maneuver may overcome a weak lower esophageal sphincter, and thus may lead to reflux. 

Aggravated by movement, supine positioning, coughing, sneezing, neck flexion, straight-leg raise, Valsalva maneuver, and palpation of spine... 

Vagal maneuvers Maneuvers that stimulate the activity of the parasympathetic nervous system and thereby inhibit atrioventricular nodal conduction. Examples of vagal maneuvers include cough, carotid sinus massage, and Valsalva maneuver. 

Valsalva maneuver A vagal maneuver in which the patient bears down against a closed glottis, as if having a bowel movement. 

Crack, the heat stable form of cocaine, when smoked and followed by deep inhalation plus a Valsalva maneuver to increase uptake, and cough triggered by the sniffed substance can cause pulmonary barotrauma. The increased intra-alveolar pressure can cause alveolar rupture, with consequent air dissection through the peribronchial connective tissue in the mediastinum, pleural space, pericardium, peritoneum, or subcutaneous soft tissues. 

In both cases, pneumothorax occurred with a delay after cocaine inhalation. The authors suggested that it was therefore unlikely that these cases of pneumothorax were due to direct traumatic effects of the drug powder inhaled, to barotrauma due to exaggerated inspiration, or to a Valsalva maneuver. Histological examination in both cases showed small foreign body granulomas with polarized material in the subpleural parenchyma. The authors proposed that the pleural damage could have been directly caused by a filler substance known as mannite (a fine white powder comprised of insoluble cellulose fibers). 

In all likelihood, a prolonged Valsalva maneuver while smoking crack cocaine causes of pneumoperitoneum. Repeated, deep, vigorous inhalation can cause an abrupt imbalance of pressures in the pulmonary alveolar-capillary complex. Free air from ruptured alveoli then dissects along fascial planes and can collect in the mediastinum and retroperitoneum. 

The authors of the second case reported that five such cases have been reported in the past 4 years in the British literature the respiratory complications were thought to be due to severe physical exercise or secondary to vomiting. It is therefore possible that this complication may not be due to a direct effect of MDMA, but rather a consequence of repeated Valsalva maneuvers associated with the dance habits of ecstasy users or vomiting induced by the drug. 

Valsalva maneuver (paradoxical embolism, or low flow) Carotid/vertebral dissection (Ch. 6)... 

A less-invasive alternative is to inject air bubbles or other echocontrast material intravenously if there is a patent foramen ovale, they can be detected by transcranial Doppler sonography of the middle cerebral artery, particularly with a provocative Valsalva maneuver. There is considerable variation in the methods used to detect patent foramen ovale and this influences the diagnostic sensitivity and specificity. It is also uncertain what size of shunt is "clinically relevant" and some bubbles may pass to the brain through pulmonary rather than cardiac shunts (Droste ef al. 1999, 2002 Schwarze ef al. 1999),... 

Variables capable of increasing the lOP (e.g., tight clothing, stress, Valsalva maneuvers, holding breath) should be accounted for, to the extent possible. 

Quinn, R.J., Meredith, Ch., Slade, L. The effect of the Valsalva maneuver on the diameter of the common hepatic duct in extrahepatic biliary obstruction. J. Ultrasound Med. 1992 11 143-145... 

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