Teaching the Modified Valsalva Maneuver to Terminate SVT

Clinical Queries

Teaching the modified Valsalva maneuver to terminate SVT

During a recent American Nurses commonly position the Emergency Treatment of Supra- Heart Association (AHA) patient in a semi-Fowlers or supine ventricular Tachycardias (REVERT) Advanced Cardiovascular Life position and instruct the patient to randomized controlled study found Support (ACLS) course, one of perform the Valsalva maneuver by that more than 40% of patients the ED nurses stated that he exhaling forcefully against a closed were converted to sinus rhythm instructs patients to blow into glottis after a normal inspiratory with the postural modification to a 10-mL syringe as a vagal effort. The nurse typically instructs the standard Valsalva maneuver, maneuver to terminate supra- the patient to “breathe in, hold your compared with 17% with a stan- ventricular tachycardia (SVT). breath, and bear down hard like you dard Valsalva maneuver.3 The REVERT Can you explain this modified are having a bowel movement.” The researchers suggest that many Valsalva maneuver?—D.I., N.Y. nurse then assesses for signs that patients could avoid drug therapy the patient is adequately performing or even seeking healthcare for SVT Denise Drummond Hayes, MSN, RN, the maneuver, including neck vein if they are taught this technique. CRNP, responds: A modified Valsalva distension, increased abdominal Although generally well toler- maneuver, which involves perform- wall muscle tone, and a flushed ated, the Valsalva maneuver has ing a Valsalva maneuver with face.2 The nurse also closely several important contraindica- postural modifications, has been monitors the patient’s vital signs tions, including aortic stenosis, shown to be more effective than the and cardiac rate and rhythm. The recent myocardial infarction, standard Valsalva maneuver for patient should maintain the strain glaucoma, and retinopathy.3 restoring sinus rhythm in patients for 10 to 15 seconds and then Potential complications of perform- with SVT. Although various physical resume normal breathing.2 ing a Valsalva maneuver include rupture of the round window membrane of the ear.2 Assess Although generally well tolerated, the Valsalva maneuver patients for contraindications has several important contraindications, including aortic before initiating any Valsalva stenosis, recent myocardial infarction, glaucoma, and maneuver and assess for complica- retinopathy. Potential complications include rupture of tions afterward. ■ the round window membrane of the ear.

REFERENCES maneuvers can increase vagal tone, A modified Valsalva maneuver 1. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of only a few of them, including the involves a strain of 40 mm Hg adult patients with supraventricular tachycardia: a Valsalva maneuver, are used pressure for 15 seconds with the report of the American College of Cardiology/ American Heart Association Task Force on Clinical clinically for diagnostic or thera- patient in the semirecumbent Practice Guidelines and the Heart Rhythm Society. peutic purposes in patients with position, followed by supine Circulation. 2016;133(14):e506-e574. clinically stable, regular rhythm, repositioning with 15 seconds of 2. Frisch DR, Zimetbaum PJ. Vagal maneuvers. UptoDate. 2018. www.uptodate.com. narrow complex tachycardia with a passive leg raise at a 45-degree 3. Appelboam A, Reuben A, Mann C, et al. Postural 1 pulse. The local release of acetyl- angle. Instructing the patient to modiﬁ cation to the standard Valsalva manoeuvre choline in the heart caused by blow into a 10-mL syringe hard for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled parasympathetic (vagal) stimulation enough to move the plunger trial. Lancet. 2015;386(10005):1747-1753. slows the rate of impulse formation generates a strain of approxi- Denise Drummond Hayes is Senior Clinical Editor for in the sinoatrial node, and slows mately 40 mm Hg. Nursing2018 and a Basic Life Support/Advanced Cardiovascular Life Support Instructor at the Temple conduction velocity and lengthens This technique has been shown University Hospital System American Heart Associa- the refractory period in the atrioven- to be better for converting SVT into tion Training Center in Philadelphia, Pa. tricular node. Gradual slowing of the normal sinus rhythm. Researchers The author has disclosed no ﬁ nancial relationships tachycardia may result, followed by in the Postural Modification to the related to this article. 2 termination of the dysrhythmia. Standard Valsalva Manoeuvre for DOI-10.1097/01.NURSE.0000547735.82178.71

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