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Valsalva Maneuver

Last reviewed by Dr. Raj MD on January 12th, 2022.

What is Valsalva Maneuver ?

Valsalva maneuver pertains to attempted forced exhalation against the closed airway. It is done by closing the mouth and pinching the nose shut while pressing out.

It is done to clear the ears during coughing, bowel movement, or as an id in diagnostic procedure and treatment. (5)

It was named after Antonio Valsalva who is a famous physician in the 18th century. During those times, it was used to evaluate the cardiovascular system. It can be done both consciously and unconsciously by those people who are engaged movements encounter resistance such as in strength training. (4)

There are various types of Valsalva maneuver. They include the following:

  • Do it yourself (DIY)
  • Standard or quantitative
  • Unintentional such as coughing or during bowel movement
  • Modified Valsalva
  • Reversed Valsalva

Valsalva maneuver.picture

Image 1 : A simple Valsalva maneuver routine
Photo Source : www.ehealthstar.com


A weightlifter performing Valsalva maneuver while lifting.image
Figure 2 : A weightlifter performing Valsalva maneuver while lifting
Picture Source : www.kingofthegym.com

The four stages/phases of Valsalva maneuver

  • I – The first phase begins with the onset of straining along with increased intrathoracic pressure. In this phase, the blood pressure rises but the heart rate remains constant.
  • II – The second phase is the continued strain wherein there is a significant decrease in venous return. The stroke volume and the pulse pressure will be reduced too. At this stage, the blood pressure drops and the heart rate increases.
  • III – This is the release phase. The strain is released by decreasing the intrathoracic pressure. The pulmonary blood flow becomes normal.
  • IV – The last stage is the recovery phase. The heart rate return to baseline and the blood pressure overshoots. (11)

Valsalva maneuver as a diagnostic aid

Valsalva maneuver can be used to proactively check various medical conditions such as:

  • Uterine prolapse
  • Inguinal hernia
  • Prolapse of the vagina or bladder
  • Intrinsic sphincter deficiency in people with stress urinary incontinence
  • Varicocele during ultrasound procedure in a standing position
  • ETD (Eustachian tube dysfunction)
  • Neurogenic orthostatic hypotension
  • Cervical or lumbar radiculopathy ( pinched nerve in the neck or the lumbar spine)
  • (CSF) Cerebrospinal fluid leak
  • Chiari malformation (a congenital disorder involving the cerebellum)
  • Heart murmurs
  • Oroantral fistulas (abnormal connection between the mouth and maxillary sinuses)
  • (CHF) Congestive heart failure
  • Primary cough headache
  • Assessing the function of the autonomous nervous system (5, 6, 7)

Valsalva maneuver as a part of vagal maneuver

When performing this procedure, the patient should be put in supine position. The patient will bear down and strain against a closed glottis. If the patient finds it difficult to follow the instruction, then you have to try another option of doing it.Instruct the patient to put the tip of their own thumb in their mouth and act as if the patient is going to blow a balloon. A 15-second strain is as effective as 30 seconds in patients with supraventricular tachycardia. Valsalva maneuver helps increase the vagal tone. It is the preferred method because it is highly effective in patients with supraventricular tachycardia, especially in elderly patients.

  • If the patient shows transient slowing of the pulse during the maneuver, it suggests the patient has sinus tachycardia.
  • Sudden termination of tachycardia suggests paroxysmal supraventricular tachycardia.
  • Patients with atrial flutter has a sudden halving of the heart rate.
  • If there is no response, it could indicate ventricular tachycardia or other types of regular tachycardia. (10)

Why Valsalva maneuver is performed and what are its benefits?

  • It is used to equalize the pressure between the middle ear and the ambient pressure, especially when performing various activities like driving from a steep hill, scuba diving, plane landing, parachuting and descending of the elevator.
  • It is used to equalize the pressure between the air and ambient pressure in people with Eustachian tube dysfunction.
  • It is helpful for people with tinnitus (ringing in the ears). It can significantly decrease the ringing in the ears.
  • It helps clear the mucus and alleviate pain in people with sinusitis.
  • It can stop hiccups.
  • It is helpful in patients with enlarged prostate, which is common in older men.
  • It helps expel pus in people with middle ear infection.
  • It is helpful in people with swallowing difficulty (dysphagia).
  • People suffering from neurogenic bowel secondary to spinal cord injury can benefit from Valsalva maneuver. The procedure helps push the stool. (7, 8)

When is Modified valsalva maneuver used?

A modified Valsalva maneuver is helpful in people with arrhythmia or abnormal heart rhythm. It can help terminate the attack. To perform this procedure, you need to blow against a closed glottis. The patient should be lying down face up and gently raise the leg. You will need an assistant to do this. However, this procedure is only effective in about 54% cases.

When a woman is pregnant, the pressure in the abdominal area increases. Hence, pregnant women are advised to avoid Valsalva maneuver to prevent further increase in pressure in the abdominal area. On the other hand, Valsalva maneuver is helpful in women who are in active labor.

It helps in purple pushing during the second stage of labor. However, this should be done with utmost care because doing it the wrong way could result to rupture of an eardrum. (6)

Dangers or Contraindications

Valsalva maneuver can be potentially dangerous if not done right. Hence, when performing Valsalva maneuver, one should be very cautious and see to it that everything is performed accordingly. A single Valsalva maneuver using moderate blowing force in a healthy individual is not dangerous at all.

However, the procedure is contraindicated in people with severe coronary heart disease or those who recently had a heart attack.Β  It is also contraindicated in people with aortic aneurysm, severely increased or decreased blood pressure, severe dehydrations, and severe bleeding. (3)

Valsalva maneuver as a part of exercise routine

Valsalva maneuver is useful to people who want to improve their weight training performance. It is a specific breathing method that you can use to improve not just your performance in weight training, but also your safety.

Many strength and conditioning trainers recommend Valsalva maneuver to include in the weight lifting exercises. The maneuver is usually performed during the work phase of the lift. Prior to exercising, the person should take a deep breath and hold the breath through the most difficult phase of the lifting process.

To complete the lift, a powerful exhale should be made. Improper breathing might have severe consequences in weight lifting.

Valsalva maneuver can significantly increase the rigidity of the torso. Hence, it will be easier for your body to support the heavy loads. It is the reason why those performing heavy lifting are advised to include Valsalva maneuver as part of their exercise routine. (1, 2, 4, 9)

Valsalva maneuver in women with incontinence

Making Valsalva maneuver a part of exercise helps in improving incontinence in women. About 30% of women are unable to contract their pelvic floor muscles voluntarily.

Performing Valsalva maneuver religiously can help address the problem with incontinence. On the first few weeks of the exercise program, you won’t notice any improvement.

It will definitely take some time, but is proven to work especially if done the right way. Performing Valsalva maneuver while holding the breath lead to contraction of muscles in the thighs and buttocks. The pelvic exercise along with Valsalva maneuver is popularly known as the Kegel exercise. (6)

Valsalva’s test and spinal Pain

Valsalva maneuver is the test used to assess the presence of lesions or injuries to the spine. When abdominal pressure is increased, the intrathecal pressure increases too. Intrathecal is anything that is happening in the spinal canal.

During the Valsalva maneuver, the intrathecal pressure increases which leads to pain secondary to lesion, herniated disc, or anything that occupies the space in the spinal canal.

When pain is felt in such area during Valsalva maneuver, then you have to consult your doctor to thoroughly assess your condition.

Valsalva technique in elderly people

Valsalva maneuver as a form of exercise can help a lot in elderly patients. However, precaution should be observed, especially in patients with osteoporosis because of some limitations in performing range of motion exercises.

Precaution should be given as well to elderly with high blood pressure as strenuous exercises can further elevate the blood pressure.Β  (8)


  1. http://reebokcrossfitnuernberg.com
  2. www.breathing.com
  3. www.gustrength.com
  4. www.bodybuilding.com
  5. https://www.ncbi.nlm.nih.gov
  6. www.physiotherapy-treatment.com
  7. https://en.wikipedia.org
  8. www.ehealthstar.com
  9. Essentials of Strength Training and Conditioning 4th Edition edited by Haff , G. Gregory , Triplett , N. Travis
  10. Evidence Based Medicine by Steven McGee
  11. http://rwjms1.umdnj.edu

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