What Is the Valsalva Maneuver, and Is It Safe?

The Valsalva maneuver is a breathing technique that can help slow down your heart rate when it’s beating too fast. In some cases, healthcare providers use this maneuver to monitor changes in your blood pressure and heart rate, which may help diagnose a range of conditions.

The technique was popularized in 1704 by Italian physician and surgeon Antonio Maria Valsalva. But it may have been used as early as the 11th century by Arab physicians. The technique requires you to try to exhale while pinching your nose and keeping your mouth shut, and bearing down as if you were having a bowel movement.  

This increases the pressure in the chest, triggering the autonomic nervous system (ANS), which helps control unconscious functions like breathing, to slow the heart rate down and reduce blood pressure. This technique can slow the heart rate in tachycardia, a condition where the heart beats too fast. 

Although the technique is considered safe for most patients, make sure to consult with your healthcare provider, especially a cardiologist, if you have a pre-existing heart condition. 

When to Use the Valsalva Maneuver

The Valsalva maneuver is a procedure used by healthcare providers across different disciplines. It can diagnose different conditions, and clear blockages.

• Diagnose or remove an ear canal blockage: The Eustachian tube, which connects the inside of the ear to the sinus, may become blocked after infection or as a result of other ear conditions. Doing the Valsalva maneuver can help clear this blockage and make it easier for an otolaryngologist (ear, nose, and throat doctor) to assess the ear canal.
• Adjust to changes in air pressure: You can use this method during flights to “pop” your ears and acclimate to the changes in altitude. Sucking on hard candy or chewing gum may help activate the response.
• Test for urine leakage: The Valsalva maneuver is helpful for diagnosing and characterizing urinary incontinence. It can detect the pressure at which urine begins to leak.
• Assess autonomic function: The changes in blood pressure and heart rate that occur during the Valsalva maneuver can help doctors understand how well your body’s ANS is working.
• Assess cardiovascular function: Looking at the changes in blood pressure and heart rate during the Valsalva maneuver can help healthcare providers detect an abnormal heart rate, arrhythmias, or murmurs. A tool called an electrocardiogram may also be used to track the changes in the heart’s electrical activity during the maneuver.
• Slow down the heart rate: The Valsalva maneuver can help slow down your heart rate and restore a healthy heart rhythm when your heart is experiencing tachycardia. This can occur as a result of anxiety, or physical activity.

How to Do It

If you're trying this technique, do it under a healthcare provider's advise and supervision to make sure you’re doing it correctly, and for the right amount of time.

If you get the all-clear from your provider, these are step-by-step instructions for performing the Valsalva maneuver:

• Step 1: Sit or lay in a comfortable position.
• Step 2: Take a deep breath.
• Step 3: Close your mouth and pinch your nose shut. 
• Step 4: Strain as if you’re attempting to defecate.
• Step 5: Exhale like you’re blowing up a balloon, keeping the mouth and nose shut.
• Step 6: Exhale using this method for 15 to 20 seconds.
• Step 7: Wait at least one minute before trying this again.

A healthcare professional uses these tools during the Valsalva maneuver to make a diagnosis:

• A mouthpiece: This is used to measure the pressure generated by the forced exhale. It is also known as Flack’s Test. A normal pressure reading is 40 mmHg.
• Electrocardiogram: This measures the electrical signals produced by the heart. During a Valsalva maneuver, the changes in electrical patterns help diagnose heart conditions.
• Blood pressure monitor: This measures blood pressure in the arteries. The changes in blood pressure that occur during the Valsalva maneuver can signal different ANS or heart conditions. It is often used alongside an electrocardiogram. 
• Finger cuff device: This tracks how blood pressure and heart rate change during the Valsalva maneuver.

Phases of the Valsalva Maneuver

There are four phases of the Valsalva maneuver. These are detailed below.

Phase 0

Before the maneuver itself starts, the patient is asked to take a deep breath. This increases the amount of deoxygenated blood flowing back to the heart. It also activates the ANS, which increases the blood pressure in the arteries. For testing of the ANS, a healthcare provider may ask you to breathe in as usual instead.

Phase 1

This involves straining and breathing out while the mouth and nose remain closed. This increases the blood pressure across the body’s blood vessels. It may also lead to a slight increase in the heart rate. 

Phase 2

Straining and breathing out with the mouth and nose closed continues. The increase in pressure from Phase 1 squeezes more blood toward the heart. The heart rate increases while the blood pressure returns to the person’s regular baseline.

Phase 3

After 15 to 20 seconds, the patient stops straining and breathing out. This causes a brief drop in blood pressure.

Phase 4

During the recovery process, the blood pressure “overshoots.” This means it goes higher than the patient’s regular baseline. This activates the ANS which helps the blood pressure and heart rate return to normal.

Benefits of the Valsalva Maneuver

There are many reasons that this centuries-old technique is still used today. It is non-invasive, fast, and useful for a number of different types of diagnostic tests. It is also used to clear ear blockages, and slow down heart rates.

Under the instruction of healthcare professional like a cardiologist, you may use this technique to help manage tachycardia or arrhythmia, restoring an abnormal heart rate back to normal.

Potential Risks

The Valsalva maneuver is considered a safe procedure. However, there are extra risks involved for the following conditions:

Underlying Cardiovascular Conditions

This technique may be harmful for people with high blood pressure or other heart problems. In this situation, it may lead to an increased heart rate, chest pain, or stroke. Please consult with your healthcare provider before trying this procedure.

If this technique doesn’t help restore the heart rate, you should see a healthcare professional immediately, especially if accompanied by shortness of breath and chest pain.

Retinopathy

This is a disease caused by the growth of abnormal blood vessels in the eye. The increase in blood pressure during the maneuver may cause blood vessels in the eye to burst. As the blood pools, it causes the appearance of red or yellow small discs in the eye. This may cause floaters, blurring or a red hue in your vision. Fortunately, this condition resolves itself in a matter of weeks.

A Quick Review

The Valsalva maneuver is a breathing technique that can help slow down your heart rate when it’s beating too fast.  It is used across multiple medical specialties to diagnose different medical conditions. It is considered a safe procedure for the majority of people.