Valsalva Maneuver

Published: January 7, 2016
Last reviewed: April 27, 2017

What is the Valsalva maneuver?

The Valsalva maneuver is a forceful attempted exhalation against a closed airway. It can be used to clear the ears, unintentionally during coughing or a bowel movement or as a diagnostic or treatment aid.

How it is performed

Instruction: Take a deep breath, close your mouth and pinch your nose with the thumb and index finger and attempt to breathe out gently, keeping your cheek muscles tight, not allowing them to bulge out (Picture 1).

If you are using the maneuver to clear your ears and you feel you need to struggle with it, do not use it, because you may damage your ears.

Valsalva maneuver

Picture 1. The Valsalva maneuver
(free image use)

Types of the Valsalva maneuver:

  • “Do it yourself,” as described above
  • “Standard” or “quantitative:” blowing out with an open glottis into a tube of a sphygmomanometer against the pressure 40 mm Hg [14,68]
  • Unintentional, for example, during coughing or a bowel movement (with a closed glottis–the space between the vocal cords–but with an open nose)
  • Modified Valsalva
  • Reversed Valsalva

NOTE: Merely holding the breath, without attempted exhalation or physical activity, like in the game “who can hold the breath longer,” is not already the Valsalva maneuver.

Physiological Effects

Valsalva maneuver increases the pressure in the nose, maxillary sinuses (on both sides of the nose), mouth, throat (pharynx and larynx above and below the vocal cords), Eustachian tubes, middle ear, inner ear [55], chest (intrathoracic pressure), eye (intraocular pressure), within the skull (intracranial pressure), in the cerebrospinal fluid (CSF), in the abdomen and rectum [5,43,81].


Valsalva maneuver blood pressure heart rate

Picture 2. Mean arterial blood pressure and heart rate changes during the Valsalva maneuver.
Fluctuations of blood pressure using 40 mm Hg blowing pressure
are about 20 mm Hg above and below the normal levels [43].
(free image use)

Phase 1. The onset of blowing. The pressure within the chest and abdomen increases and presses upon the arteries in the chest, which results in an increase in mean arterial blood pressure. This activates the baroreceptor reflex, which results in an increase in parasympathetic (vagal) activity and hence in a drop in heart rate. The increased intrathoracic pressure also reduces the amount of blood that comes into the right atrium (decreased venous return or preload).

Phase 2. A decrease of venous return results in a lower amount of blood that is ejected from the heart, which results in a decrease of central venous pressure and consequently in a decrease of mean arterial blood pressure. This activates the baroreflex, which results in a decrease of the parasympathetic (vagal) activity and consequent increase of the heart rate, and in an increase in sympathetic activity, which constrict the arteries (an increase of peripheral resistance), which results in a slight rises of the blood pressure at the end of phase 2 (2b).

Phase 3. Relaxation – the end of the maneuver. The intrathoracic pressure decreases, so the intrathoracic arteries widen, which results in a brief drop in blood pressure. At the same time, the venous blood fills the heart.

Phase 4. The heart ejects the blood into the arterial system against increased peripheral resistance (which has developed in phase 2), so the blood pressure rises again (blood pressure overshoot). This activates the baroreflex, which results in a drop in heart rate (bradycardia). Eventually, both the blood pressure and heart rate normalize.

Chart 1. Valsalva Maneuver







Intrathoracic pressure Increased Increased Increased Normal Normal
Mean arterial blood pressure Increased Decreased Increase* Decrease* Increased
Heart rate Decreased Increased Decrease* Increase* Decreased
Sympathetic activity Decreased Decreased Increased Increased Increased
Parasympathetic (vagal) activity Increased Increased Decreased Decreased Increased

References: [5,25,62,71,80] NOTE: Increased and decreased means above the usual level, while increase and decrease mean just a change from the previous level, not necessary going above or below the usual level.


A variant of Valsalva maneuver is performed against a closed glottis (the space between the vocal cords) with or without a closed mouth and with an open nose. We perform this maneuver unintentionally during coughing, sneezing, gagging, vomiting, bending, sexual intercourse, straining during urination or a bowel movement due to constipation, lifting heavy objects or getting off the bed using arm and upper trunk muscles [5]. The maneuver is also used in sports, such as weightlifting, throwing, rowing, swimming, etc. This maneuver (with an open nose) does not affect the pressure in the mouth, nose, sinuses or ears.

Some coaches recommend using a short (1-2 sec) Valsalva maneuver as a speed accelerator during sprints [63], but there seems to be the lack of reliable studies about its effectiveness.

Valsalva maneuver does not occur during singing [60].

Compulsive Valsalva maneuver has been described in children [73] and individuals with autism [74].

Valsalva as a Diagnostic Aid

Valsalva maneuver can be used as a provocative test to check for:

  • An inguinal (groin) hernia [22]
  • Prolapse of the uterus, bladder or vagina (pelvic floor weakness) [11]
  • Varicocele (engorged veins in the scrotum) during ultrasound in a standing position [53]
  • Intrinsic sphincter deficiency in stress urinary incontinence [10]
  • A pinched nerve in the neck or lumbar spine (cervical or lumbar radiculopathy). The maneuver is positive when it triggers pain in the neck, shoulder, arm or lower back.
  • Eustachian tube dysfunction (ETD) [4,52]
  • Neurogenic orthostatic hypotension [82]
  • Chiari malformation (a congenital disorder of the cerebellum); the Valsalva maneuver (coughing) triggers a headache at the back of the head [9]
  • Cerebrospinal fluid (SCF) leak through the nose after long-term repeated use of the Valsalva maneuver [26]
  • Heart murmurs. Valsalva increases murmurs in hypertrophic cardiomyopathy and mitral valve prolapse and decreases them in atrial septal defects and aortic stenosis [1].
  • Congestive heart failure [65]
  • Abnormal connections between the mouth and maxillary sinuses (oroantral fistulas) after a tooth extraction [3]
  • Primary cough headache [14]
  • Function of the autonomous nervous system [25,59,62,67]:
    • An abnormal blood pressure response (for example, an absence of the blood pressure rise in phase 4) suggests an abnormality of the sympathetic system.
    • An abnormal heart rate response suggests an abnormality of the parasympathetic system.

Valsalva as a Treatment Aid (Benefits)

Valsalva maneuver can help:

  • Equalize the pressure between the middle ear and the ambient pressure (ear clearing) during scuba diving, driving from a steep hill, elevator descending, parachuting or plane landing [13] or in individuals with Eustachian tube dysfunction (ETD) [44]
  • Decrease ringing in the ears (tinnitus) [42]; it may increase tinnitus in some individuals [anecdotal reports]
  • Clear mucus and relieve pain in sinusitis [anecdotal reports]
  • Expel pus from a clogged ear in middle ear infection [15]
  • Voiding in older men with an enlarged prostate [35]
  • Stop hiccups [33]
  • Promote swallowing is individuals with difficulty swallowing (dysphagia) [38,39]
  • Push the stool out in individuals with neurogenic bowel due to spinal cord injury [29]
  • Interrupt palpitations (supraventricular tachycardia (SVT), including atrial fibrillation) [32]; the maneuver alone is effective in only 5-25% cases [2,7]; it is also somewhat effective in children [37].

Modified Valsalva Maneuver

Modified Valsalva maneuver is used to terminate an attack of abnormal heart rhythm (arrhythmia) called supraventricular tachycardia (SVT); it includes blowing against a closed glottis followed by lying down face up and raising legs with the help of an assistant [2]. According to one Cochrane systematic review, the modified maneuver may be effective in 19-54% of cases and there is insufficient evidence to either recommend it or advise against it in SVT [79].

Valsalva, Pregnancy and Labor

During pregnancy, the pressure in the abdomen is increased, so pregnant women should avoid exercises that include Valsalva in order to further increase the pressure.

There is insufficient evidence about the benefit of the Valsalva maneuver (purple pushing) during the second stage of the labor [45,46,47,48]. Valsalva during labor may result in a rupture of an eardrum [24].

Valsalva and Stuttering

According to one hypothesis, the Valsalva mechanism may be involved in stuttering, but there seems to be the lack of studies on this topic [18].

Valsalva Dangers

For a healthy individual, a single Valsalva maneuver by using a moderate blowing force is probably not dangerous.

Clearing Ears Dangers

Clearing (popping) ears using a violent Valsalva maneuver during a plane flight or diving may cause a damage of the inner ear and may push unwanted material from the mouth into the middle ear [36,55]. The Toynbee maneuver–pinching the nose followed by swallowing–is considered safer [35] and equally effective [77]. Yawning may also effectively clear the ears [36].

Bowel Movement Dangers

Prolonged straining at the toilet can trigger fainting (defecation syncope) [69]. In individuals with both severe coronary heart disease and constipation, but unlikely in healthy individuals, straining at the toilet may trigger a heart attack. This may occur due to a significant drop in blood pressure and heart rate and artery dilation that result from a combination of Valsalva maneuver and irritation of the vagus nerve in the rectum by the pressure of the stool.

Weightlifting Dangers

Complications of repeated Valsalva maneuvers during weightlifting:

  • Fainting [82]
  • Transient global amnesia: temporary (<24 hours) confusion due to severe memory loss after repeated Valsalva maneuvers [28]
  • Spontaneous cerebrospinal fluid (CFS) leak (clear liquid dropping out from one nostril) [26]
  • Brain bleeding in individuals with brain aneurysms, heart attack in individuals with heart disease, or stroke in individuals prone to excessive blood clotting (insufficient evidence about the cause-effect relationship) [21,30,31,50]

Valsalva maneuver was previously believed to increase the trunk stability and strength during resistance (powerlifting) exercises, such as squat, deadlift and bench press, but this has not been confirmed by studies [6,16]. Valsalva maneuver may be equally effective as forced exhalation in maintaining strength during weightlifting [16].

In one study, during weightlifting, the mean blood pressure while using Valsalva was 311/284 mm Hg, and while using forced exhalation, it was 198/175 mm Hg [17]. Blood pressure as high as 480/350 mm Hg during weightlifting using Valsalva has been observed [21].

Valsalva Retinopathy

Valsalva retinopathy [8] means bleeding in front of the retina (the membrane that lines the eyeball and enables vision) due to Valsalva maneuver, for example, during severe coughing, straining on the toilet, blowing musical instruments (trumpet), bodybuilding, marathon running [64], labor or even pregnancy alone [34]. Symptoms may include temporary vision loss and floaters in the visual field [8]. Individuals with idiopathic thrombocytopenia are at increased risk of Valsalva retinopathy [58].

In one study, long-term (occupational) lifting of heavy weight was associated with increased risk of detachment of the retina [27].

Other Side Effects and Complications

  • Dizziness, vertigo [23] or fainting, for example, during playing brass instruments [43] or in individuals with diabetic neuropathy [25] or spinal cord disorders [61]
  • Fainting lasting for few seconds after vigorous coughing (cough syncope) in individuals with asthma, pulmonary hypertension or chronic obstructive pulmonary disease (COPD) (bronchitis, emphysema), especially in overweight ones [70,72]
  • Headache. Valsalva maneuver can be responsible for a headache during sexual intercourse, bending or straining at the toilet [14,75], migraine attack [75] or a sinus headache in sinusitis [76]. NOTE: A headache triggered by Valsalva can suggest a brain tumor or other serious disorder with increased intracranial pressure [54,76]
  • Urine leakage in individuals with spinal cord injury (flaccid bladder or “detrusor areflexia”) [51]
  • An inguinal hernia (after long-term coughing, straining at the toilet or weightlifting) [78]
  • Glaucoma (in high-resistance brass instrument musicians) [40,41]
  • Spontaneous pneumothorax in susceptible individuals, mainly young tall males (for example, during sexual activity [56], playing musical instrument or blowing balloons [57])
  • Sudden death (rarely) [38]

Contraindications for Valsalva Maneuver

  • Severe coronary heart disease or recent heart attack
  • Severely increased or decreased blood pressure
  • Aortic aneurysm
  • Severe dehydration or bleeding (hypovolemia)
  • Reference: [49]

Reversed Valsalva – Müller’s Maneuver

Müller’s maneuver is the opposite of the Valsalva maneuver and includes forced exhalation followed by an attempted forceful inhalation with a closed mouth and nose or just with a closed glottis.

The test can be used to evaluate weakness of the soft palate and throat walls in individuals with obstructive sleep apnea [19]; the test is considered unreliable [20].

The reversed Valsalva maneuver can also be used to equalize the pressure in the middle ears in individuals with patulous Eustachian tubes.

  • References

      1. Valsalva maneuver  Family Practice Notebook
      2. Appelboam et al, 2015, Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial  The Lancet
      3. Closure of oro-antral communications
      4. Williams ME, 2009, Examining the Ears, Nose, and Oral Cavity in the Older Patient  Medscape
      5. Klabunde RE, Hemodynamics of a Valsalva Maneuver  CV Physiology
      6. Hagins M et al, 2006, The effects of breath control on maximum force and IAP during a maximum isometric lifting task  PubMed
      7. Lim SH et al, 1998, Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage  PubMed
      8. Duszak RS, Valsalva retinopathy clinical presentation  Emedicine
      9. Martins HA et al, 2010, Headache precipitated by Valsalva maneuvers in patients with congenital Chiari I malformation  PubMed
      10. Pajoncini C et al, 2002, Intrinsic sphincter deficiency: do the maximum urethral closure pressure and the Valsalva leak-point pressure identify different pathogenic mechanisms?  PubMed
      11. Kuncharapu I et al, 2010, Pelvic organ prolapse  American Family Physician
      12. Virk JS et al, 2013, Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: The Charing Cross Experience  PubMed Central
      13. Taylor HL, Practical ear cleaning  University of Michigan
      14. Lane RJM et al, 2013, Modified Valsalva test differentiates primary from secondary cough headache  PubMed Central
      15. 2013, Ear Congestion – Causes and Treatment for Congested Ears  Food Pyramid
      16. Ikeda ER et al, The Valsalva Maneuver Revisited: the Influence of Voluntary Breathing on Isometric Muscle Strength  PubMed Central
      17. Narloch JA et al, 1995, Influence of breathing technique on arterial blood pressure during heavy weightlifting  PubMed
      18. Wilder R, 2014, What causes stuttering? The Valsalva Hypothesis  Canadian Stuttering Association
      19. Terris DJ et al, 2000, Reliability of the Muller maneuver and its association with sleep-disordered breathing
      20. Soares MC et al, 2009, Use of Muller’s maneuver in the evaluation of patients with sleep apnea–literature review  PubMed
      21. Haykowski MJ et al, 1996, Aneurysmal subarachnoid hemorrhage associated with weight training: three case reports  PubMed
      22. LeBlanc KE et al, 2013, Inguinal hernias: diagnosis and management American Family Physician
      23. Evaluation of the “dizzy” patient  Dartmouth College
      24. Baum JD et al, 2010, Clinical Presentation and Conservative Management of Tympanic Membrane Perforation during Intrapartum Valsalva Maneuver  PubMed Central
      25. Tiecks FP et al, 1995, Effects of the Valsalva Maneuver on Cerebral Circulation in Healthy Adults, A Transcranial Doppler Study  Stroke
      26. Goyal V et al, 2011, Don’t hold your breath  PubMed Central
      27. Mattioli S et al, 2012, Occupational Lifting Tasks and Retinal Detachment in Non-Myopics and Myopics: Extended Analysis of a Case-Control Study  PubMed Central
      28. Owen D et al, 2007, Classical diseases revisited: transient global amnesia  PubMed Central
      29. Stiens SA et al, Neurogenic bowel: What you should know U.S. Department of Veterans Affairs
      30. Matsuda M et al, 2007, Circumstances, activities, and events precipitating aneurysmal subarachnoid hemorrhage  PubMed
      31. Arboix A et al, 2010, Cardioembolic Stroke: Clinical Features, Specific Cardiac Disorders and Prognosis
        PubMed Central
      32. Ruan C-H et al, 2010, Instantly Converting Atrial Fibrillation into Sinus Rhythm by a Digital Rectal Exam on a 29-year-Old Male  PubMed Central
      33. Hiccups (Hiccoughs)
      34. Al-Mujaini AS et al, 2008, Valsalva retinopathy in pregnancy: a case report  PubMed Central
      35. Voiding facilitatory maneuvers  Bergen Urological Associates, P.A.
      36. Machado R, Ear ye, ear ye  Flight Training Magazine
      37. From the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, Part 6: Pediatric Basic and Advanced Life Support  Circulation
      38. Sperry K, 1994, Achalasia, the Valsalva maneuver, and sudden death: a case report  PubMed
      39. Spieker MR, 2000, Evaluating dysphagia  American Family Physician
      40. O’Hare F et al, 2009, Trumpet tension  PubMed Central
      41. Ritch R et al, 2000, Glaucoma – an occupational hazard for musicians  Associated Musicians of Greater New York
      42. Crummer RW et al, 2004, Diagnostic approach to tinnitus  American Family Physician
      43. Pott F et al, 2000, Middle cerebral artery blood velocity during a Valsalva maneuver in the standing position  Journal of Applied Physiology
      44. Moser R, 2009, Eustachian tube dysfunction  WebMD
      45. Valsalva’s maneuver
      46. Lemos A et al, 2011, The Valsalva maneuver duration during labor expulsive stage: repercussions on the maternal and neonatal birth condition  PubMed
      47. Roberts J et al, 2007, Best practices in second stage labor care: maternal bearing down and positioning  PubMed
      48. Osborne K et al, 2009, Pushing Techniques Used by Midwives When Providing Second Stage Labor Care  Marquette University Research
      49. Valsalva manevuer
      50. Rayu SM et al, 2004, Physiology for Nurses, p. 87
      51. Hsieh J et al, 2014, Bladder management  SCIRE Project
      52. Bluestone CD et al, 2005, Eustachian Tube: Structure, Function, Role in Otitis Media, Volume 2, p. 155
      53. Chen P et al, 2006, Ultrasound of the acute scrotum  Medscape
      54. Secondary headache
      55. Bove F, Vertigo  Skin Diver Online
      56. Shi-ping L, 2010, Diagnosis and treatment of primary spontaneous pneumothorax  PubMed Central
      57. Dejene S et al, 2013, Pneumothorax, music and balloons: A case series  PubMed Central
      58. Karagiannis D et al, 2006, Valsalva retinopathy associated with idiopathic thrombocytopenic purpura and positive antiphospholipid antibodies  Eye
      59. Mistovich J, 2008, The Valsalva maneuver  EMS1
      60. Deirdre M, 2011, Dispelling Vocal Myths. Part 2: “Sing It Off the Chords!”  ReadPeriodicals
      61. van Lieshout JJ et al, 1991, Singing-induced hypotension: a complication of a high spinal cord lesion  PubMed
      62. Valsalva maneuver  Vanderbilt University Medical Center
      63. Acceleration Techniques and Speed Development  BrianMac Sports Coach
      64. Labriola LT et al, 2009, Marathon’s runner retinopathy  PubMed
      65. Marantz PR et al, 1990, Clinical diagnosis of congestive heart failure in patients with acute dyspnea  PubMed
      66. Sikirov A et al, 1990, Cardio-vascular events at defecation: are they unavoidable?  PubMed
      67. Novak P et al, 2011, Quantitative Autonomic Testing  PubMed Central
      68. Circulatory autonomic testing  New York Medical College
      69. Definition of defecation syncope  MedicineNet
      70. Dicpinigaitis PV et al, 2014, Cough syncope  PubMed
      71. Klabunde RE, Arterial baroreceptors  CV Physiology
      72. Deshmukh A et al, 2008, Cough syncope in a patient with severe chronic obstructive pulmonary disease  ScienceDirect
      73. Aicardi J et al, 1988, Syncopal attacks compulsively self-induced by Valsalva’s maneuver associated with typical absence seizures. A case report  PubMed
      74. Stephenson JB et al, 2001, Anoxic seizures: self-terminating syncopes  PubMed
      75. Chawla J, Migraine Headache Differential Diagnoses  Emedicine
      76. Aroon M, Question: Positional and Valsalva type headaches  Doctors Lounge
      77. Hidir Y et al, 2011, A comparative study on efficiency of middle ear pressure equalization techniques in healthy volunteers  PubMed
      78. Inguinal hernia causes  Mayo Clinic
      79. Smith GD et al, 2015, The effectiveness of the Valsalva Manoeuvre for stopping an abnormal heart rhythm  Cochrane
      80. Dawson SL et al, 1999, Critical closing pressure explains cerebral hemodynamics during the Valsalva maneuver  Journal of Applied Physiology
      81. DeLisa JA, et al, 2005, Physical Medicine and Rehabilitation: Principles and Practice, Volume 1, p. 1645
      82. Goldstein DS et al, 2009, Neurogenic Orthostatic Hypotension, A Pathophysiological Approach Circulation

2 Responses to Valsalva Maneuver


    It’s an excellent presentation. Thanks sir.

  2. Patricia Schroeder RN says:

    Great article! Very detailed with visuals. Helped explain episodes of pre-syncope my husband was having.

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