Vagal maneuver

Action used to slow down the heart rate by stimulating the vagus nerve

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

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There 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

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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]

* 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 position

## Physiology

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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

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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.