How is the Valsalva (Valsalva maneuver) performed in pediatric patients, particularly those with pre-existing medical conditions such as heart defects or respiratory problems?

How to Perform the Valsalva Maneuver in Children

In older children, have the child blow through a narrow straw to perform the Valsalva maneuver, while in infants and young children, apply ice to the face without occluding the airway instead. 1

Age-Specific Techniques

Infants and Young Children

• Apply ice to the face without occluding the airway as the preferred vagal maneuver 1
• This technique is safer and more practical than attempting a traditional Valsalva maneuver in this age group 1
• Ensure the airway remains patent throughout the procedure 1

Older Children and Adolescents

• Have the child blow through a narrow straw to generate the necessary intrathoracic pressure 1
• Alternative techniques include carotid sinus massage, which is also safe in this age group 1
• The child should maintain forced expiration for approximately 15-20 seconds based on adult physiology 2

Clinical Context and Indications

Primary Use: Supraventricular Tachycardia

• Vagal stimulation should be attempted first in hemodynamically stable children with SVT (Class IIa recommendation) 1
• Do not delay chemical or electric cardioversion if the patient is hemodynamically unstable 1
• Monitor the cardiac rhythm continuously during the maneuver to evaluate effectiveness 1
• A modified Valsalva technique has been successfully used in pediatric patients as young as 9 years old 3

When to Proceed Directly to Pharmacologic Treatment

• If the patient shows signs of hemodynamic instability, bypass vagal maneuvers and proceed to adenosine (Class I recommendation if IV/IO access available) 1
• If performing the Valsalva maneuver would unduly delay definitive treatment 1

Special Considerations for Children with Pre-existing Conditions

Cardiac Patients

• Valsalva maneuvers are safe in older children with cardiac conditions when used for SVT 1
• The maneuver can be used even in patients with congenital heart defects, as the guidelines do not contraindicate its use in this population 1
• However, consultation with a pediatric arrhythmia expert is strongly recommended for hemodynamically stable children before any arrhythmia therapy due to potential adverse effects 1

Respiratory Problems

• The technique of blowing through a straw may be more challenging in children with significant respiratory compromise 1
• Consider using ice application to the face as an alternative in children with respiratory distress 1
• Ensure adequate oxygenation is maintained throughout the procedure 1

Critical Pitfalls to Avoid

• Never occlude the airway when applying ice to an infant's face 1
• Do not persist with vagal maneuvers if the child becomes more unstable or if the procedure is taking too long 1
• Do not use Valsalva maneuvers as the sole intervention in hemodynamically unstable patients 1
• Be aware that the cardiovascular effects of the Valsalva maneuver are complex and can rarely cause complications, though this is primarily documented in adults with underlying cardiovascular disease 4, 5

Monitoring During the Procedure

• Maintain continuous ECG monitoring to assess rhythm changes 1
• Monitor for signs of hemodynamic deterioration including perfusion, blood pressure, and level of consciousness 1
• Have adenosine and resuscitation equipment immediately available 1