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Table 2 When, why and how to use normal respiration or Valsalva maneuver during an echo study

From: Respiratory maneuvers in echocardiography: a review of clinical applications

WHEN WHY HOW
Poor 2D image quality To optimize the quality of the echo view Expiration:
better parasternal and often apical access to the heart
   Inspiration:
brings the diaphragm down improving access to the heart
M-mode measurements of the LV or 2D-quantitation To avoid measurement errors due to excessive translational motion of the heart Quiet respiration/held end-expiration
Doppler measurements (flow/tissue velocities) To avoid measurement errors due to excessive translational motion of the heart End-expiratory apnea
Estimation of right atrial (RA) pressure To elicit the inspiratory response of the inferior vena cava in order to assess the collapsibility index Inspiration/brief sniff
Evaluation of systolic pulmonary artery pressure in patients with stable, chronic COPD that cannot been assessed by conventional TTE To assess the respiratory variation in superior vena cava (SVC) systolic forward flow Normal respiration
Assessment of left ventricular diastolic function To unmask elevated LV filling pressure in patients with normal or reduced LV systolic function and Standardized Valsalva maneuver
  pseudo-normal filling pattern at baseline decrease in the mitral E/A ratio of 0.5 or more during Valsalva
  impaired relaxation pattern at baseline increase in peak A wave velocity during Valsalva
Cardiac tamponade To assess respiratory variation in cardiac volumes and flow (see text) Normal respiration
Constrictive pericarditis To assess respiratory variation in mitral, tricuspid, pulmonary and hepatic vein flow
(see table 1)
Normal respiration
Restrictive cardiomyopathy To assess respiratory variation in mitral, tricuspid, pulmonary and hepatic vein flow
(see table 1)
Normal respiration
Detection of Patent Foramen Ovale by TTE or TEE To assess the appearence of contrast in the LA shortly after injection of saline contrast into an upper extremity vein, with good opacification of the RA Normal respiration
within 3 cardiac cycles after injection of saline contrast
   Valsalva maneuver
during the release phase
Hypertrophic cardiomyopathy with mild or absent resting obstruction To unmask latent gradients/to increase LVOT gradient Valsalva maneuver
during the strain phase
  1. LV, left ventricle; RA, right atrium; SVC, superior vena cava; COPD, chronic obstructive pulmonary disease; TTE, transthoracic echocardiography; E, peak early diastolic velocity oF mitral inflow; A, peak late diastolic velocity of mitral inflow; TEE, transesophageal echocardiography; LA, left atrium; LVOT, left ventricular outflow tract.