Overview of Vagal Maneuver

Vagal maneuvers are methods used to help reset the heart’s rhythm and to diagnose and treat certain types of fast heart rates, called arrhythmias. They are usually the first technique tried to stop episodes of a fast heart rate called supraventricular tachycardia (SVT), or to tell the difference between SVT and other types of fast heart rates, specifically ventricular tachycardias (VT). There are several types of vagal maneuvers.

Some common examples include massaging the area around the carotid sinus in the neck (known as carotid sinus massage or CSM), bearing down as if you are having a bowel movement (referred to as a Valsalva maneuver or VM), and engaging the diving reflex which can be simply explained as holding your breath and immersing your face in cold water. Other less commonly used methods involve things like putting pressure on the eyes or inducing a gag reflex, and are not discussed here.

These methods can be quite successful when used early for the right patients. Specifically, for patients with a condition called atrioventricular nodal re-entrant tachycardia (AVNRT), where the electrical signals in the heart get ‘stuck’ in a fast loop, vagal maneuvers can successfully restore the heart’s normal rhythm in 20% to 40% of cases. They may have an even higher success rate in another fast heart rate condition called atrioventricular re-entrant tachycardia (AVRT), which involves an extra pathway in the heart’s electrical system.

Anatomy and Physiology of Vagal Maneuver

The Carotid Sinus Massage and Valsalva Maneuver are techniques that doctors use to control your heart rate. These tactics momentarily increase the blood pressure in your neck and arch of your aorta (a big artery that carries oxygen-rich blood from your heart to the rest of your body). This spike in blood pressure sets off a “baroreceptor reflex”, which boosts the calming signals sent from your brain to your heart through the vagus nerve, to slow down your heart rate.

These maneuvers target specific areas in your body. The carotid sinus, located at the meeting point of your neck’s internal and external carotid arteries, contains special sensors known as baroreceptors. These baroreceptors monitor changes in your blood pressure. When they sense a change, they send signals to a part of your brain known as the nucleus tractus solitarius, or NTS, through a nerve called the glossopharyngeal nerve.

Similarly, other baroreceptors in your aortic arch also monitor blood pressure changes. These receptors also send signals to the NTS, but through the vagus nerve. This increased flow of signals resulting from raised blood pressure stimulates the vagus nuclei in the brain. They, in turn, transmit calming signals to your heart along the right and left vagus nerves.

These two vagus nerves leave your brain via the jugular foramen (an opening in the base of your skull), intertwine themselves within the sheath of the carotid artery, and continue branching out to the heart, lungs, and digestive tract, maintaining a soothing influence over these organs.

Inside the heart, these nerves serve important roles. The right vagus nerve stimulates the sinoatrial (SA) node, your heart’s natural pacemaker. This results in slowed electrical activity within the SA node. The left vagus nerve mostly influences the atrioventricular (AV) node, which controls the communication between the atrium (the top section of your heart) and the ventricles (the bottom section of your heart), thus slowing down this communication process. The final result is a decrease in the speed and strength of your heart’s electrical signals, which can help to reduce or stop a too-fast heartbeat.

There’s also another interesting way to slow your heartbeat called the ‘Diving Reflex’. This is an automatic response often seen in aquatic animals and to a lesser extent in humans. It’s a physiological change that reduces your oxygen use and generally gets triggered when you hold your breath and expose your face to cold water.

The general account goes like this: the sensation of cold water on your face triggers impulses from the trigeminal nerve which is the main sensory nerve of the face. These impulses then encourage the vagus nuclei in your brain, which results in slowing down of the AV nodal conduction, slowing your heart rate in the process.

Why do People Need Vagal Maneuver

The treatment plan of a common type of heart rhythm disorder, called Supraventricular Tachycardia (SVT), starts with certain exercises known as vagal maneuvers. These exercises are particularly recommended for patients who are stable, meaning those who have steady heart rates and blood pressure. Vagal maneuvers include actions like coughing, bearing down like you’re having a bowel movement, or putting your face in ice-cold water. These actions stimulate the vagus nerves, which can in turn help slow down or even stop this rapid heartbeat.

On the diagnostic side, these exercises can also be helpful in distinguishing between SVT and another type of heart rhythm issue called Ventricular Tachycardia (VT). This is because vagal maneuvers can slow down the electric signals transmitted through the SA node (sinoatrial node, where the heart’s electrical signals begin) or AV node (atrioventricular node, a pathway of electrical impulses), which can help doctors understand the nature of the arrhythmia, or abnormal heart rhythm.

When a Person Should Avoid Vagal Maneuver

If you have an irregular heart rhythm condition known as unstable SVT, certain actions like vagal maneuvers shouldn’t be performed. Instead, healthcare professionals should urgently carry out a treatment called synchronized cardioversion to restore your normal heart rhythm.

The carotid sinus massage is a strategy sometimes used to slow down a rapid heartbeat, but it’s not suitable for everyone. This includes individuals with a history of transient ischemic attack (a mini-stroke) or stroke, patients who have experienced a rapid heart rate, a disorganized heartbeat, or a heart attack within the last three months. If you’re older, you may be at a higher risk of carotid artery disease – a condition where the main blood vessels in the neck that carry blood to the brain become narrowed or blocked. So, a carotid sinus massage might not be right for you as it could lead to temporary or even permanent neurological symptoms. The massage should never be performed on both sides of the neck at the same time because it can risk cutting off blood supply to the brain. And for children under the age of ten, there’s just not enough research yet to suggest the use of carotid sinus massage.

The Valsalva Maneuver, another method to slow your heart rate, doesn’t have specific medical contraindications, meaning no particular health situations where it should be avoided. However, you should be able to follow instructions well. If you’re breathing too fast (tachypnea) or having difficulty breathing (dyspnea), it’s less likely to work.

The Diving Reflex, used to slow down the heart rate, requires you to be capable of immersing your face in a basin of ice water without the risk of inhaling liquid into your airways (aspiration). For adults, teens, and especially higher risk groups like young children or the elderly, a safer alternative is to use a plastic bag filled with ice water. This method helps to prevent any risk of choking or inhaling water into the airways.

Equipment used for Vagal Maneuver

The patient should have a constant 12 lead EKG, which is a test that checks for problems with the electrical activity of the heart. They also need to be set up with full telemetry monitoring. This includes a heart monitor to check the rhythm of the heart, pulse oximetry which measures oxygen levels in the blood, and a blood pressure monitor to keep an eye on the force of blood against the walls of the blood vessels. An intravenous (IV) line should be put in place to quickly deliver fluids if needed. Materials to secure the patient’s airway, an oxygen supply, and a crash cart (a set of emergency equipment) should be available at the bedside.

The Valsalva Maneuver, a technique where the patient blows into a syringe, often helps to slow down a fast heart rate. The necessary tool for this method is a 10 mL syringe.

The Diving Reflex can also be used to slow a fast heart rate. For children or older patients, a sealed bag of ice-cold water might be used. For adults, a basin of ice water (0 to 10 degrees C) or a sealed bag can both be used.

Who is needed to perform Vagal Maneuver?

The doctor who carries out and guides the patient through the procedure is called the provider. A nurse is also present at the bedside to help keep track of important body functions like heart rate and blood pressure, give medication, and perform a heart test called an EKG once the procedure is over. Other helpers might be needed to lift the patient’s legs during a special procedure called the modified Valsalva.

Preparing for Vagal Maneuver

The patient should be hooked up to a heart-monitoring device to supervise their heart rate. Also, a continuous pulse-checking device is entailed, along with regular blood pressure checks. It’s important to establish reliable intravenous (IV) access; this means the patient has a tube in their vein so that medicine or fluids can be given quickly if necessary.

If the initial treatment doesn’t work after two or three tries, the healthcare provider should have the right kind of heart medication on hand for the next step. On top of this, the provider should think about having medicines ready for use that can help the patient sleep or relax if it becomes necessary to reset the rhythm of the heart using electricity (a process called electrical cardioversion), or if a tube needs to be inserted into the patient’s airway to help them breathe (intubation). These may become necessary if the abnormal rhythm of the heart gets worse or if the patient’s condition becomes unstable.

How is Vagal Maneuver performed

Before any medical procedure, it’s key to have a clear understanding of what will be taking place. Therefore, your doctor will explain each step in detail and address any queries you may have. A special monitor will be used to keep track of your heart’s rhythm throughout.

One such procedure is the Carotid Sinus Massage. In this technique, you’ll be lying down with your neck stretched and turned away from the side that will be massaged. The massage is targeted at the carotid sinus, an area just below where your jaw bone meets your neck, in front of a prominent muscle in the neck (the sternocleidomastoid), and above the thyroid cartilage part of your neck. Your doctor will press this area in a certain direction for about 5-10 seconds. If the first try doesn’t work, it can be tried again after a minute. If that still doesn’t work, the process may be repeated on the other side. In some cases, other techniques may be used like a slight tip of your position, raising your legs, or applying pressure to your upper belly. This massage aims to stabilize your heart rate and solve any irregular rhythm in your heart.

Next is the Valsalva maneuver; it aims to increase internal chest pressure voluntarily. In this case, while lying down, you’ll be asked to take a deep breath, then forcefully exhale against a closed off pathway (imagine trying to breathe out with your nostrils and mouth closed) for 10-15 seconds. Variations of this technique can be trying to move a syringe’s plunger by blowing into it or, for children, blowing through a blocked-off straw or on their thumb.

An improved form of the above, called the Modified Valsalva maneuver, has been found to be more effective. At the start, you’ll be in a sitting position. Then, like in the basic Valsalva maneuver, you’ll blow against a closed path or a syringe. Immediately after this, you’ll lie down, and your legs will be lifted up. This state will be held for 10-15 seconds and then your legs will be held in this manner for 45 seconds to a minute. This method can also be repeated as needed.

Finally, the Diving Reflex technique requires you to get comfortable, take multiple deep breaths, and then hold your breath. Your face will then be submerged into a basin of water. Your doctor will communicate with you to keep you calm throughout. You should stay in this position as long as you can comfortably, but you should come up for air when needed. For infants or young children, they’ll be laid down and a bag of ice water will be placed on their forehead and nose for up to 30 seconds. This is done to watch for a resolution of a rapid heart rate (known as SVT).

Possible Complications of Vagal Maneuver

When picked carefully, certain actions known as vagal maneuvers can be pretty safe for patients, with very few experiencing any complications. Some effects could just be an exaggerated version of what’s already happening due to the action, like a slower heart rate, long pauses between heartbeats, stopping of the heart, blockage in the electrical signal between the upper and lower heart chambers, or lower blood pressure. On rare occasions, other conditions with quick heartbeats may be brought on because of the action.

Let me explain a few examples:

Carotid Sinus Massage – This action can lead to neurological problems, but these are usually rare and don’t last very long. The overall risk of a stroke or a clot blocking off blood flow with constant neurological deficits is approximately 1 in 1000, which is enough to ask for a patient’s informed consent before performing the action.

Valsalva maneuver – In rare cases, the increase in pressures may result in the breakage of the round window of the ear, an opening that helps with hearing.

Diving Reflex – People, who can’t safely put their face in a basin of ice water, risk swallowing water or drowning. When using the method of a bag of ice water in kids, it’s important to avoid too long exposure to the skin or burns could happen. Also, always ensure that the patient’s airway isn’t blocked.

What Else Should I Know About Vagal Maneuver?

Vagal maneuvers are simple techniques that you can do and may be very helpful. They might stop your heart from beating too fast and could save you from having to go through more expensive and risky treatments such as being put to sleep (sedation), an electric shock to your heart (electrical cardioversion), or having to take a lot of drugs.

Frequently asked questions

1. How does the Vagal Maneuver work to reset my heart's rhythm? 2. Are there any specific contraindications or risks associated with the Vagal Maneuver that I should be aware of? 3. What are the success rates of Vagal Maneuvers in treating my specific heart condition? 4. Are there any alternative treatments or procedures that I should consider alongside Vagal Maneuvers? 5. How many times should I attempt the Vagal Maneuver before considering other treatment options?

Vagal maneuvers, such as the Carotid Sinus Massage and Valsalva Maneuver, can help control your heart rate by increasing blood pressure in specific areas of your body. These maneuvers stimulate the vagus nerve, which sends calming signals from your brain to your heart, resulting in a slower heart rate. Additionally, the Diving Reflex, triggered by holding your breath and exposing your face to cold water, can also activate the vagus nerve and slow down your heart rate.

You may need Vagal Maneuver if you have an irregular heart rhythm condition known as unstable SVT. Vagal maneuvers can help slow down a rapid heartbeat and restore your normal heart rhythm. It is a method that does not have specific medical contraindications, but it is important to be able to follow instructions well and not have any breathing difficulties.

You should not get a Vagal Maneuver if you have an irregular heart rhythm condition known as unstable SVT. Instead, synchronized cardioversion should be urgently carried out to restore your normal heart rhythm.

To prepare for a Vagal Maneuver, the patient should have a constant 12 lead EKG, full telemetry monitoring, and an intravenous (IV) line in place. They should also be hooked up to a heart-monitoring device and have regular blood pressure checks. The necessary tools for the Valsalva Maneuver include a 10 mL syringe, while for the Diving Reflex, a basin of ice water or a sealed bag of ice-cold water may be used.

The complications of Vagal Maneuver include slower heart rate, long pauses between heartbeats, stopping of the heart, blockage in the electrical signal between the upper and lower heart chambers, lower blood pressure, neurological problems, stroke or clot blocking off blood flow, breakage of the round window of the ear, swallowing water or drowning, burns from prolonged exposure to ice water, and blocked airway.

The symptoms that would require Vagal Maneuver include a rapid heartbeat, a common type of heart rhythm disorder called Supraventricular Tachycardia (SVT), and the need to distinguish between SVT and another type of heart rhythm issue called Ventricular Tachycardia (VT).

Join our newsletter

Stay up to date with the latest news and promotions!

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

We care about your data in our privacy policy.