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Vagal maneuver

January 14, 2023

A vagal maneuver is an action used to stimulate the parasympathetic nervous system by activating the vagus nerve. The vagus nerve is the longest nerve of the autonomic nervous system and helps regulate many critical aspects of human physiology, including heart rate, blood pressure, sweating, and digestion through the release of acetylcholine. Common maneuvers that activate the vagus nerve include the Valsalva maneuver and carotid sinus massage, which can serve diagnostic or therapeutic functions.

Clinical indications

There are both diagnostic and therapeutic indications for the use of vagal maneuvers in clinical practice.

Diagnostic:

Therapeutic:

  • Vagal maneuvers are the first-line treatment of hemodynamically stable supraventricular tachycardia, serving to slow down or terminate the arrhythmia.[3] Vagal maneuvers have a reported success rate of conversion to sinus rhythm for SVT around 20-40%, possibly being higher for AVNRT (an SVT associated with a bypass tract).[4] Whereas the modified Valsalva maneuver is most effective in adults,[5] cold water immersion may be preferred as a safe, effective, and non-invasive treatment for pediatric SVT.[6]
  • Vagal maneuvers may be used to terminate hemodynamically stable ventricular tachycardia.[7][8]
  • Various vagal maneuvers are suggested for the elimination of hiccups.[9]
  • Vagal maneuvers may decrease temporary pain through sinoaortic baroreceptor mediated anti-nociception (inhibition of pain conduction, release of substance P and noradrenaline).[10][11]

Types of vagal maneuvers

While many physical maneuvers can elicit autonomic responses, only some are appropriate for use in a clinical setting. The vagal maneuvers most often used for diagnostic or therapeutic purposes are those that can be reliably performed at bedside or in an office setting with minimal risk. A list of vagal maneuvers are listed below:[12][4]

Other less clinically useful physical maneuvers that elicit a similar autonomic response through stimulation of the vagus nerve include:

  • Coughing
  • Gagging and/or vomiting
  • Breath holding
  • Swallowing
  • Deep respirations
  • Rectal examination
  • Intracardiac catheter placement
  • Nasogastric tube placement
  • Squatting
  • Trendelenburg position

Physiology

 
Parasympathetic nervous system mediated by vagal innervation

Vagal maneuvers serve to stimulate the vagus nerve (cranial nerve X) through various mechanisms. The longest nerve in the body, the vagus nerve serves both motor and sensory functions through afferent and efferent signaling to and from the brain. The vagus nerve releases the neurotransmitter acetylcholine,[13] and is a main mediator for the parasympathetic nervous system.

The vagus nerve exits the skull through the jugular foramen, moving down through the carotid sheath and dividing many times to influence multiple organ systems and directly innervating the pharynx, larynx, esophagus, heart, lung, and GI tract. Due to this wide nerve distribution, many physiologic process may be influenced through its stimulation, including heart rate and blood pressure.[14]

Stimulation of the vagus nerve through vagal maneuvers is thought to effect afferent fibers that carry sensory information from its distribution throughout the body to the nucleus tractus solitarii (NTS) in the dorsal medullary complex, where it is then relayed to other areas of the brain. This stimulation can also be done more directly through a therapy called Vagus Nerve Stimulation (VNS), which utilizes an implanted neuro-stimulator device and is approved clinically for controlling seizures in epilepsy patients and drug resistant depression.[15]

Vagal maneuvers make use of the vagus nerve's afferent and efferent bifunctional role, triggering reflexes (like the baroreceptor reflex, chemoreceptor reflex) and utilizing those afferent nerve fibers to increase nerve activity. This results in increased parasympathetic signaling through its efferent distribution and is mediated by the chemical messenger acetylcholine.[4]

References

  1. ^ Rivasi, Giulia; Rafanelli, Martina; Ungar, Andrea (1 August 2018). "Usefulness of Tilt Testing and Carotid Sinus Massage for Evaluating Reflex Syncope". The American Journal of Cardiology. 122 (3): 517–520. doi:10.1016/j.amjcard.2018.04.033. ISSN 0002-9149. PMID 29954601. S2CID 49597948.
  2. ^ Pasquier, Mathieu; Clair, Mathieu; Pruvot, Etienne; Hugli, Olivier; Carron, Pierre-Nicolas (12 October 2017). "Carotid Sinus Massage". The New England Journal of Medicine. 377 (15): e21. doi:10.1056/NEJMvcm1313338. ISSN 1533-4406. PMID 29020587.
  3. ^ Page, Richard L.; Joglar, José A.; Caldwell, Mary A.; Calkins, Hugh; Conti, Jamie B.; Deal, Barbara J.; Estes, N. A. Mark; Field, Michael E.; Goldberger, Zachary D.; Hammill, Stephen C.; Indik, Julia H. (5 April 2016). "2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". Circulation. 133 (14): e506–574. doi:10.1161/CIR.0000000000000311. ISSN 1524-4539. PMID 26399663.
  4. ^ a b c Niehues, Logan J.; Klovenski, Victoria (9 July 2021). Vagal Maneuver. StatPearls Publishing. PMID 31855402.
  5. ^ Ceylan, Ezgi; Ozpolat, Cigdem; Onur, Ozge; Akoglu, Haldun; Denizbasi, Arzu (1 September 2019). "Initial and Sustained Response Effects of 3 Vagal Maneuvers in Supraventricular Tachycardia: A Randomized, Clinical Trial". Journal of Emergency Medicine. 57 (3): 299–305. doi:10.1016/j.jemermed.2019.06.008. ISSN 0736-4679. PMID 31443919. S2CID 201631721.
  6. ^ Campbell, Marion; Buitrago, Silvia Ruiz (January 2017). "BET 2: Ice water immersion, other vagal manoeuvres or adenosine for SVT in children: Table 2". Emergency Medicine Journal. 34 (1): 58–60. doi:10.1136/emermed-2016-206487.2. ISSN 1472-0205. PMID 27974431. S2CID 29012408.
  7. ^ Wei, J. Y.; Greene, H. L.; Weisfeldt, M. L. (January 1980). "Cough-facilitated conversion of ventricular tachycardia". The American Journal of Cardiology. 45 (1): 174–176. doi:10.1016/0002-9149(80)90235-0. ISSN 0002-9149. PMID 7350763.
  8. ^ Hess, D. S.; Hanlon, T.; Scheinman, M.; Budge, R.; Desai, J. (March 1982). "Termination of ventricular tachycardia by carotid sinus massage". Circulation. 65 (3): 627–633. doi:10.1161/01.cir.65.3.627. ISSN 0009-7322. PMID 7055883.
  9. ^ "UpToDate". www.uptodate.com. Retrieved 11 November 2021.
  10. ^ Srivastava, Anubha; Kumar, Sanjay; Agarwal, Anil; Khetan, Dheeraj; Katharia, Rahul; Mishra, Prabhaker; Khati, Shikha; Gautam, Sujeet; Sandeep, Khuba (1 January 2021). "Evaluation of efficacy of Valsalva for attenuating needle puncture pain in first time nonremunerated voluntary plateletpheresis donors: A prospective, randomized controlled trial". Asian Journal of Transfusion Science. 15 (1): 68–74. doi:10.4103/ajts.AJTS_95_20. ISSN 0973-6247. PMC 8294442. PMID 34349460.
  11. ^ Kumar, Sanjay; Khuba, Sandeep; Agarwal, Anil; Gautam, Sujeet; Yadav, Madhulika; Dixit, Aanchal (December 2018). "Evaluation of efficacy of Valsalva maneuver for attenuating propofol injection pain: a prospective, randomized, single blind, placebo controlled study". Korean Journal of Anesthesiology. 71 (6): 453–458. doi:10.4097/kja.d.18.00017. ISSN 2005-6419. PMC 6283717. PMID 29843507.
  12. ^ "UpToDate". www.uptodate.com. Retrieved 11 November 2021.
  13. ^ Lund, D D; Oda, R P; Pardini, B J; Schmid, P G (1 March 1986). "Vagus nerve stimulation alters regional acetylcholine turnover in rat heart". Circulation Research. 58 (3): 372–377. doi:10.1161/01.RES.58.3.372. PMID 3719926. S2CID 17017695.
  14. ^ Kenny, Brian J.; Bordoni, Bruno (2021), "Neuroanatomy, Cranial Nerve 10 (Vagus Nerve)", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30725856, retrieved 11 November 2021
  15. ^ Nemeroff, Charles B.; Mayberg, Helen S.; Krahl, Scott E.; McNamara, James; Frazer, Alan; Henry, Thomas R.; George, Mark S.; Charney, Dennis S.; Brannan, Stephen K. (July 2006). "VNS Therapy in Treatment-Resistant Depression: Clinical Evidence and Putative Neurobiological Mechanisms". Neuropsychopharmacology. 31 (7): 1345–1355. doi:10.1038/sj.npp.1301082. ISSN 1740-634X. PMID 16641939. S2CID 11455427.

January 14, 2023
vagal, maneuver, vagal, maneuver, action, used, stimulate, parasympathetic, nervous, system, activating, vagus, nerve, vagus, nerve, longest, nerve, autonomic, nervous, system, helps, regulate, many, critical, aspects, human, physiology, including, heart, rate. A vagal maneuver is an action used to stimulate the parasympathetic nervous system by activating the vagus nerve The vagus nerve is the longest nerve of the autonomic nervous system and helps regulate many critical aspects of human physiology including heart rate blood pressure sweating and digestion through the release of acetylcholine Common maneuvers that activate the vagus nerve include the Valsalva maneuver and carotid sinus massage which can serve diagnostic or therapeutic functions Contents 1 Clinical indications 2 Types of vagal maneuvers 3 Physiology 4 ReferencesClinical indications EditThere are both diagnostic and therapeutic indications for the use of vagal maneuvers in clinical practice Diagnostic Vagal maneuvers most commonly the Valsalva maneuver can be used to distinguish between ventricular tachycardia and supraventricular tachycardia by slowing the rate of conduction at the SA or AV nodes 1 Vagal maneuvers most commonly carotid sinus massage are used to diagnose carotid sinus hypersensitivity 2 Therapeutic Vagal maneuvers are the first line treatment of hemodynamically stable supraventricular tachycardia serving to slow down or terminate the arrhythmia 3 Vagal maneuvers have a reported success rate of conversion to sinus rhythm for SVT around 20 40 possibly being higher for AVNRT an SVT associated with a bypass tract 4 Whereas the modified Valsalva maneuver is most effective in adults 5 cold water immersion may be preferred as a safe effective and non invasive treatment for pediatric SVT 6 Vagal maneuvers may be used to terminate hemodynamically stable ventricular tachycardia 7 8 Various vagal maneuvers are suggested for the elimination of hiccups 9 Vagal maneuvers may decrease temporary pain through sinoaortic baroreceptor mediated anti nociception inhibition of pain conduction release of substance P and noradrenaline 10 11 Types of vagal maneuvers EditWhile many physical maneuvers can elicit autonomic responses only some are appropriate for use in a clinical setting The vagal maneuvers most often used for diagnostic or therapeutic purposes are those that can be reliably performed at bedside or in an office setting with minimal risk A list of vagal maneuvers are listed below 12 4 Valsalva maneuver Carotid sinus massage or Czermak Hering test Cold water immersion diving reflex Eyeball pressure also known as the oculocardiac reflex or Aschner Dagnini reflex Other less clinically useful physical maneuvers that elicit a similar autonomic response through stimulation of the vagus nerve include Coughing Gagging and or vomiting Breath holding Swallowing Deep respirations Rectal examination Intracardiac catheter placement Nasogastric tube placement Squatting Trendelenburg positionPhysiology Edit Parasympathetic nervous system mediated by vagal innervation Vagal maneuvers serve to stimulate the vagus nerve cranial nerve X through various mechanisms The longest nerve in the body the vagus nerve serves both motor and sensory functions through afferent and efferent signaling to and from the brain The vagus nerve releases the neurotransmitter acetylcholine 13 and is a main mediator for the parasympathetic nervous system The vagus nerve exits the skull through the jugular foramen moving down through the carotid sheath and dividing many times to influence multiple organ systems and directly innervating the pharynx larynx esophagus heart lung and GI tract Due to this wide nerve distribution many physiologic process may be influenced through its stimulation including heart rate and blood pressure 14 Stimulation of the vagus nerve through vagal maneuvers is thought to effect afferent fibers that carry sensory information from its distribution throughout the body to the nucleus tractus solitarii NTS in the dorsal medullary complex where it is then relayed to other areas of the brain This stimulation can also be done more directly through a therapy called Vagus Nerve Stimulation VNS which utilizes an implanted neuro stimulator device and is approved clinically for controlling seizures in epilepsy patients and drug resistant depression 15 Vagal maneuvers make use of the vagus nerve s afferent and efferent bifunctional role triggering reflexes like the baroreceptor reflex chemoreceptor reflex and utilizing those afferent nerve fibers to increase nerve activity This results in increased parasympathetic signaling through its efferent distribution and is mediated by the chemical messenger acetylcholine 4 References Edit Rivasi Giulia Rafanelli Martina Ungar Andrea 1 August 2018 Usefulness of Tilt Testing and Carotid Sinus Massage for Evaluating Reflex Syncope The American Journal of Cardiology 122 3 517 520 doi 10 1016 j amjcard 2018 04 033 ISSN 0002 9149 PMID 29954601 S2CID 49597948 Pasquier Mathieu Clair Mathieu Pruvot Etienne Hugli Olivier Carron Pierre Nicolas 12 October 2017 Carotid Sinus Massage The New England Journal of Medicine 377 15 e21 doi 10 1056 NEJMvcm1313338 ISSN 1533 4406 PMID 29020587 Page Richard L Joglar Jose A Caldwell Mary A Calkins Hugh Conti Jamie B Deal Barbara J Estes N A Mark Field Michael E Goldberger Zachary D Hammill Stephen C Indik Julia H 5 April 2016 2015 ACC AHA HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia A Report of the American College of Cardiology American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society Circulation 133 14 e506 574 doi 10 1161 CIR 0000000000000311 ISSN 1524 4539 PMID 26399663 a b c Niehues Logan J Klovenski Victoria 9 July 2021 Vagal Maneuver StatPearls Publishing PMID 31855402 Ceylan Ezgi Ozpolat Cigdem Onur Ozge Akoglu Haldun Denizbasi Arzu 1 September 2019 Initial and Sustained Response Effects of 3 Vagal Maneuvers in Supraventricular Tachycardia A Randomized Clinical Trial Journal of Emergency Medicine 57 3 299 305 doi 10 1016 j jemermed 2019 06 008 ISSN 0736 4679 PMID 31443919 S2CID 201631721 Campbell Marion Buitrago Silvia Ruiz January 2017 BET 2 Ice water immersion other vagal manoeuvres or adenosine for SVT in children Table 2 Emergency Medicine Journal 34 1 58 60 doi 10 1136 emermed 2016 206487 2 ISSN 1472 0205 PMID 27974431 S2CID 29012408 Wei J Y Greene H L Weisfeldt M L January 1980 Cough facilitated conversion of ventricular tachycardia The American Journal of Cardiology 45 1 174 176 doi 10 1016 0002 9149 80 90235 0 ISSN 0002 9149 PMID 7350763 Hess D S Hanlon T Scheinman M Budge R Desai J March 1982 Termination of ventricular tachycardia by carotid sinus massage Circulation 65 3 627 633 doi 10 1161 01 cir 65 3 627 ISSN 0009 7322 PMID 7055883 UpToDate www uptodate com Retrieved 11 November 2021 Srivastava Anubha Kumar Sanjay Agarwal Anil Khetan Dheeraj Katharia Rahul Mishra Prabhaker Khati Shikha Gautam Sujeet Sandeep Khuba 1 January 2021 Evaluation of efficacy of Valsalva for attenuating needle puncture pain in first time nonremunerated voluntary plateletpheresis donors A prospective randomized controlled trial Asian Journal of Transfusion Science 15 1 68 74 doi 10 4103 ajts AJTS 95 20 ISSN 0973 6247 PMC 8294442 PMID 34349460 Kumar Sanjay Khuba Sandeep Agarwal Anil Gautam Sujeet Yadav Madhulika Dixit Aanchal December 2018 Evaluation of efficacy of Valsalva maneuver for attenuating propofol injection pain a prospective randomized single blind placebo controlled study Korean Journal of Anesthesiology 71 6 453 458 doi 10 4097 kja d 18 00017 ISSN 2005 6419 PMC 6283717 PMID 29843507 UpToDate www uptodate com Retrieved 11 November 2021 Lund D D Oda R P Pardini B J Schmid P G 1 March 1986 Vagus nerve stimulation alters regional acetylcholine turnover in rat heart Circulation Research 58 3 372 377 doi 10 1161 01 RES 58 3 372 PMID 3719926 S2CID 17017695 Kenny Brian J Bordoni Bruno 2021 Neuroanatomy Cranial Nerve 10 Vagus Nerve StatPearls Treasure Island FL StatPearls Publishing PMID 30725856 retrieved 11 November 2021 Nemeroff Charles B Mayberg Helen S Krahl Scott E McNamara James Frazer Alan Henry Thomas R George Mark S Charney Dennis S Brannan Stephen K July 2006 VNS Therapy in Treatment Resistant Depression Clinical Evidence and Putative Neurobiological Mechanisms Neuropsychopharmacology 31 7 1345 1355 doi 10 1038 sj npp 1301082 ISSN 1740 634X PMID 16641939 S2CID 11455427 Retrieved from https en wikipedia org w index php title Vagal maneuver amp oldid 1102225881, wikipedia, wiki, book, books, library,

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