Written by Joshua Belfer
Spoon Feed
In children with paroxysmal supraventricular tachycardia (pSVT), a modified Valsalva maneuver significantly improved conversion rates and patient satisfaction compared with the standard Valsalva maneuver.
Blow, flip, convert? A simple trick for SVT
Paroxysmal SVT is the most common pathologic tachyarrhythmia in children. Vagal maneuvers are recommended first-line therapy for stable SVT, but traditional approaches often have only modest success. This randomized controlled trial evaluated whether a modified Valsalva maneuver could improve cardioversion rates compared with the standard maneuver. The modified Valsalva maneuver involves a forced expiratory strain followed by rapid repositioning to a supine position with passive leg elevation, which increases venous return and augments vagal stimulation of the AV node.
Investigators randomized 90 children with PSVT into three groups: conventional care, modified Valsalva maneuver (MVM), or standard Valsalva maneuver (SVM), with 30 patients in each group. The primary outcome was return to sinus rhythm within 5 minutes. Cardioversion occurred in 53.3% of children in the modified Valsalva group compared with 33.3% in the standard Valsalva group. Children undergoing the modified maneuver also reported higher satisfaction scores and had decreased dyspnea and reduced need for antiarrhythmic medications.
These findings mirror adult studies showing improved conversion rates with the modified Valsalva maneuver. This was a single-center study with a relatively small sample size, and the maneuver requires patient cooperation that may be difficult in younger children, which may limit generalizability.
How will this change my practice?
We all have our “special” diagnosis in the ED—the one that seems to find us more than anyone else—and mine is SVT. SVT loves to show up on my shift. I haven’t had great luck with traditional vagal maneuvers, but modifying the Valsalva maneuver may improve conversion rates. The main limitation is cooperation—difficult in younger children. But in older patients who can follow instructions, the modified Valsalva maneuver may offer a simple way to restore sinus rhythm and potentially avoid adenosine. I look forward to additional studies evaluating this in the pediatric population.
Source
Efficacy of modified versus standard Valsalva maneuvers on clinical outcomes and satisfaction of children with paroxysmal supraventricular tachycardia: randomized control trial. BMC Pediatr. 2025 Dec 17;25(1):1003. doi: 10.1186/s12887-025-06396-9. PMID: 41408522; PMCID: PMC12752250.
View JournalFeed Critical Appraisal
Critical Appraisal
Study Identification
Background
Study Question
Study Design & Conduct
Prospective / Retrospective: Prospective
Multicenter: No
Unit of Allocation: Children
Unit of Analysis: Children
Randomization Method: Computer-generated randomization process using https://www.random.org/
Allocation Concealment: Not reported
Blinding: Open-label (non-blinded design)
Follow-up Duration: 5 minutes for primary outcome; satisfaction assessed after 5 minutes
Population
- Cooperative children aged 7 to 17 years
- Both genders
- Hemodynamically stable
- Confirmed diagnosis of PSVT based on ECG
- Willing to be in the study
- Free from communication difficulties or psychiatric disorders
- Wide complex tachycardia
- Acute myocardial infarction
- Severe pulmonary insufficiency
- History of aortic stenosis or glaucoma
- Heart failure
- Inability to tolerate supine positioning or leg-raising movements
Number Enrolled: 90
Number Analyzed: 90
Key Baseline Characteristics
Sex: 56.7-63.3% female across groups
Disease Severity: PSVT diagnosis, no specific severity score reported
Care Setting Distribution: Pediatric Emergency Department and Pediatric Cardiac Intensive Care Unit
Additional Baseline Characteristics
- Residence (rural/urban)
- Educational level
- Birth order
- Past medical history (congenital heart lesions, anemia, diabetes mellitus, hypertension, valvular heart disease, gastrointestinal disease)
- Children's complaints at admission (palpitation, dyspnea, chest pain, pallor, sweating)
- Previous episodes of PSVT
- Administered antiarrhythmic drugs
Exposures / Interventions
Description: Modified Valsalva Maneuver (MVM)
Definition / Dose: Patient semi-recumbent (45-90°), blows into 10 mL syringe to push plunger to 40 mmHg for 15s, then immediately placed supine with legs elevated at 45° for 15s, then returned to semi-recumbent for 45s. Up to 3 attempts at 1-minute intervals.
Timing: Upon admission
Classification Method: Randomization
Protocolized / Discretionary: Protocolized
Description: Standard Valsalva Maneuver (SVM) and Conventional Hospital Care (Control)
Definition: SVM: Patient semi-recumbent (45-90°), takes deep breath, seals lips tightly around 10 mL syringe, blows into syringe for 15s, then relaxes and resumes normal breathing, remains in same position for 60s. Control: Conventional hospital care without specific intervention.
Outcomes & Results
Primary Outcomes
Definition: Return to sinus rhythm
Time Point: Within the first 5 minutes of admission
Measurement Method: ECG monitoring, confirmed by treating physician
Results: MVM group: 53.3% (30% at 1 min, 20% at 3 min, 3.3% at 5 min); SVM group: 33.3% (13.3% at 1 min, 10% at 3 min, 10% at 5 min); Control group: 0%
Secondary Outcomes
Definition: Assessed using Short Assessment of Patient Satisfaction (SAPS) questionnaire
Time Point: After sinus rhythm restoring at 5 min post-implementation
Measurement Method: SAPS questionnaire (7 items, Likert scale 0-4, total score 0-28)
Results: MVM group mean: 25.56 ± 1.67; SVM group mean: 20.10 ± 2.57 (P=0.0001)
Definition: Severity of dyspnea
Time Point: 1, 3, and 5 minutes post-implementation
Measurement Method: Visual Analogue Scale (VAS) for dyspnea (0-100)
Results: MVM group showed significant reduction in dyspnea scores compared to control (P<0.001). At 1 min, 90% MVM had moderate dyspnea vs 36.7% control. At 3 min, 76.7% MVM had mild dyspnea vs 3.3% control. At 5 min, 96.7% MVM had absence of dyspnea vs 36.7% control.
Definition: Need for antiarrhythmic drugs for management of SVT episodes
Time Point: During hospital stay (implied)
Measurement Method: Clinical decision/records
Results: MVM group: 46.7% received antiarrhythmic drugs; SVM group: 66.7% received antiarrhythmic drugs; Control group: 100% received antiarrhythmic drugs (P=0.001)
Definition: Duration of hospital stay
Time Point: Not applicable (total duration)
Measurement Method: Hospital records
Results: MVM group mean: 1.23 ± 0.43 h; SVM group mean: 1.73 ± 0.82 h; Control group mean: 1.83 ± 0.74 h (F=6.614, P=0.002)
Risk of Bias
Risk of Bias - RoB 2
- Bias arising from the randomization process (Some concerns): The random sequence generation was computer-generated, which is appropriate. However, allocation concealment was not explicitly reported, raising some concerns about potential selection bias.
- Bias due to deviations from intended interventions (Some concerns): The study explicitly states a 'non-blinded design,' meaning participants and personnel were aware of the assigned intervention. While blinding is difficult for physical maneuvers, this could introduce performance bias. However, the primary outcome (sinus rhythm return) is objective (ECG confirmed), mitigating some of this risk.
- Bias due to missing outcome data (Low): There were no participants lost to follow-up, and all enrolled participants were analyzed, indicating a low risk of bias due to missing outcome data.
- Bias in measurement of the outcome (Some concerns): The primary outcome (sinus rhythm return) was objectively measured by ECG and confirmed by a physician. However, secondary outcomes like satisfaction and dyspnea are subjective and measured by validated scales, but blinding of outcome assessors for these subjective measures was not reported, which could introduce detection bias.
- Bias in selection of the reported result (Low): The study is registered (PACTR202407479098909), and all pre-specified primary and secondary outcomes appear to be reported, indicating a low risk of selective reporting.
Transparency
COI Statement Present: TRUE
