Vagal maneuvers

Overview

Vagal maneuvers involve physical actions that activate the vagus nerve, influencing the heart’s natural pacemaker and slowing down electrical impulses. The vagus nerve, extending from the brainstem to the abdomen, plays a vital role in the parasympathetic nervous system, which governs various bodily functions, including heart rate regulation.

Types of vagal maneuvers: Healthcare providers commonly employ the following vagal maneuvers:

• Valsalva maneuver: This maneuver involves bearing down, similar to the action during a bowel movement (defecation).
• Diving reflex: Triggering the diving reflex by immersing the face in cold water can activate the vagus nerve.
• Carotid sinus massage: Gently massaging the carotid sinus, a sensitive area in the neck, can stimulate the vagus nerve.
• Gag reflex: Inducing the gag reflex, which involves touching the back of the throat, can activate the vagus nerve.
• Coughing: Forceful coughing can also stimulate the vagus nerve.
• Handstand for 30 seconds: In some cases, healthcare providers teach parents how to help their children perform a handstand for approximately 30 seconds as a vagal maneuver.
• Applied abdominal pressure: By lying on your back and folding your lower body toward your face until your feet pass your head, you can apply abdominal pressure. Take a breath and strain for 20 to 30 seconds.

It is crucial to note that vagal maneuvers should only be performed under the guidance of a healthcare provider, especially when dealing with a rapid heart rate.

Risks

When medical professionals perform vagal maneuvers on patients who are a good fit for the procedures, complications are infrequent. Most issues are transient in nature. Among them are:

• Decreased blood pressure (hypotension)
• Slow heart rate (bradycardia)
• Rarely, atrial fibrillation, ventricular fibrillation, or ventricular tachycardia.

People run the risk of drowning when doing the diving reflex maneuver since they are breathing in cold water.
Rare, transient side effects are possible from carotid sinus massage. Massage of the carotid sinuses carries a one in 1,000 risk of stroke. Doctors’ advice against carotid sinus massage for those who:

• Have carotid artery disease.
• Is less than 10 years old.
• Have experienced a Transient Ischemic attack (TIA) or stroke in the past.
• Experience a whooshing sound in your carotid artery, known as a carotid bruit.
• Experience ventricular fibrillation, ventricular tachycardia, or a heart attack recetly.

Reasons for undergoing the procedure

Vagal maneuvers are often the initial treatment choice for supraventricular tachycardia (SVT), a condition characterized by an excessively fast heart rate. This approach is favored because it is low-risk and cost-effective, effectively slowing down a rapid heart rate. Vagal maneuvers have a success rate ranging from 20% to 40% in restoring certain fast heart rhythms (those exceeding 100 beats per minute) back to normal rhythms.

Furthermore, vagal maneuvers can assist healthcare providers in diagnosing the specific type of arrhythmia (irregular or abnormal heartbeat) a patient may have, as some heart rhythm disorders exhibit a characteristic response to these maneuvers.

It’s important to note that healthcare providers will only employ vagal maneuvers if the patient is considered stable. If a patient is unstable, characterized by:

• Chest pain
• Low blood pressure
• Oxygen deficiency in the body
• Shortness of breath
• Inadequate blood supply to vital organs

In such cases, healthcare providers will opt for cardioversion, which involves the use of medication or electrical shock to restore normal heart rhythm. If anyone experiences instability or feels unwell, seeking immediate medical attention by going to an emergency room or calling the local emergency number is essential.

Before the procedure

Your healthcare provider will conduct an electrocardiogram (EKG) to assess your heart rhythm, while also monitoring your heart rate, blood pressure, and oxygen levels.

During the procedure

The three most popular vagal movements by the doctors are performed as follows:

• Diving reflex: You will take several deep breaths while seated, hold them, and then rapidly submerge your entire face in a container of ice water. Soak your face as long as you can in the water. Alternatively, place an ice-cold, damp towel or a bag of ice water against your face.
• Valsalva maneuver: To perform the Valsalva maneuver, whether lying down or sitting up, begin by taking a deep breath and sealing your lips and nostrils as if you’re exhaling through a closed straw, maintaining this for ten to thirty seconds. Alternatively, a modified version involves having your healthcare provider lower the upper part of your bed while simultaneously raising your legs or bringing your knees to your chest. In this modified approach, you should continue the leg position for an additional 30 to 45 seconds while still holding your breath. For children, doctors sometimes use a different technique, instructing them to blow on their thumb without releasing any air. This maneuver can help elicit specific physiological responses.
• Carotid sinus massage: Your head will be rotated to one side while you lie on your back. Your doctor will press on your carotid sinus for five to ten seconds using their fingertips. They can try the other side of your neck or try again in a minute if it doesn’t work.

After the procedure

Following the performance of vagal maneuvers in an effort to resolve arrhythmia (irregular or abnormal heartbeats), your healthcare provider will conduct another electrocardiogram (EKG) to assess whether the maneuvers successfully restored your heart rhythm to a normal pattern. Should these maneuvers prove ineffective after two or three attempts, your healthcare provider may administer medication as an alternative approach to treat the arrhythmia. Additionally, medical or electrical cardioversion stands as another viable treatment option. In cases where vagal maneuvers do not yield the desired results, your healthcare provider may collaborate with a cardiologist, a specialist in heart-related matters, to further evaluate your condition.

Outcome

Vagal maneuvers can effectively reduce the heart rate during episodes of supraventricular tachycardia (SVT) in approximately 20% to 40% of cases. However, if recurrent episodes of fast heart rate persist, your healthcare provider may opt to prescribe medications or suggest alternative treatments, such as catheter ablation. Additionally, they may provide instructions for self-administering vagal maneuvers as a potential intervention method.