Interesting article in the Emergency Medicine Journal on the use of Valsalva maneuver or the ‘forcible exhalation against a closed airway’ for reverting Paroxysmal supraventricular tachycardia (SVT).
Techniques to stimulate a vagal response such as the Valsalva or dunking the head in a bowel of ice water, or carotid sinus massage are usually attempted as first line management before pharmacological interventions are used1.
Despite the wide use of the Valsalva, there is currently no gold-standard on how to perform the technique.
Usually the patient is managed sitting up, and I have seen various instructions given to the patient from “blow through this straw” to “close your mouth, pinch your nose and try to unblock your ears” and even, “pretend you are really constipated and ‘push down’ really hard to do a poo” ( not a good instruction to give an elderly patient… believe me ).
In this study, a modified Valsalva manoeuvre based on a literature review was adopted as departmental standard.
In a retrospective 6-month audit of patients managed before the introduction of this standard, only 1 out of 19 patients was successfully reverted by Valsalva.
After standardising the technique, 6 out of 19 were reverted2. Not bad.
How to perform the valsalva:
Following routine observations, cardiac monitoring and obtaining a 12-lead ECG to confirm the diagnosis of SVT the following procedure was used:
- The patients bed was raised to its full height.
- The head of the trolley was then lowered so that the patient was in a Trendelenberg (head down) position of around 10-15 degrees3.
- The patient was then instructed to blow through a length of suction tubing as hard as possible for at least 15 seconds. For the study, this tubing was connected to a pressure gauge with the aim of generating 40mmHg pressure.
- If not successful the patient would relax for a minute before attempting the maneuver again….up to 2 more times.
- If SVT persisted at this point pharmacological intervention was initiated.
The exclusion criteria for this technique included:
- Glasgow Coma Score <15/15
- Evidence of new heart failure
- Cardiac-sounding chest pain
- Systolic blood pressure <90 mm Hg
The paper concludes:
This appears to be safe, simple and more effective than current practice and, as it can be adapted by patients for use at home, has the potential to reduce presentations to hospital, prevent the need for cannulation and decrease drug costs.
Could orgasm revert SVT?
But thats not where the story ends….
What about the really, really modified Valsalva?
I have already explored the use of vagal stimulation generated during orgasm for the management of persistent hiccups.
So the question must be asked: Can the big-O successfully terminate persistent SVT?
Could it be a case of out with the Adenosine and in with the Viagra?
Clearly much more research needs to be conducted in this field.
- usually Adenosine [↩]
- that’s an improvement from 5.3% to 31.7% with no reported significant adverse
- Using the supine position is thought to augment the patients’ vagal toneÂ as well as increasing venous return. The authors propose these effects are increased by the Trendelenberg position [↩]