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

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