How to Do the Valsalva Maneuver Step by Step

The Valsalva maneuver is a controlled breathing technique in which you exhale forcefully against a closed airway, building pressure inside your chest and abdomen. The basic version takes about 15 seconds and requires no equipment. Despite its simplicity, research shows that the majority of people, including medical professionals, perform it incorrectly, which limits its effectiveness for everything from popping your ears on a flight to resetting an abnormally fast heart rhythm.

How to Perform the Standard Valsalva Step by Step

The technique itself is straightforward, but the details matter more than most people realize. Here is what a properly performed standard Valsalva looks like:

Take a breath: Inhale a moderately deep breath. You do not need to fill your lungs to maximum capacity, just a comfortable, full breath.
Close your airway: Pinch your nose shut with your fingers and close your mouth. Some people find it easier to keep their mouth closed and bear down without pinching the nose, depending on the purpose. If you are trying to equalize ear pressure, you need the nose pinched.
Bear down and push: Try to exhale forcefully against your closed airway. Think of the effort as similar to straining during a bowel movement. You should feel pressure building in your chest, face, and ears.
Hold for 15 seconds: Maintain that sustained effort for a full 15 seconds. This is the part most people cut short. A quick one- or two-second strain is not enough for most therapeutic applications.
Release and breathe normally: Let go of your nose, open your mouth, and breathe normally. The moments immediately after release are physiologically important, as this is when blood pressure and heart rate shift significantly.

The target pressure for medical applications is around 40 mmHg of expiratory force, roughly equivalent to blowing hard enough to move the column of mercury in a blood pressure gauge. In practice, without a gauge to measure, a good rule of thumb is to blow as if you are trying to inflate a stiff balloon. If you are only feeling light pressure in your face, you are not pushing hard enough. If you are seeing stars or feeling faint, ease off slightly.

Why Most People Do It Wrong

A study surveying emergency department doctors found that only about one in ten would position a patient correctly for the maneuver, and roughly the same fraction would instruct the patient to blow for at least 15 seconds. Nearly two-thirds told patients to blow “as long as you can” without specifying a duration, and fewer than one in ten used any device to gauge how hard the patient was actually straining.¹ If emergency physicians are getting the technique wrong most of the time, it is reasonable to assume the general public is, too.

The two most common mistakes are insufficient duration and insufficient force. A brief grunt or two-second strain does not generate enough sustained intrathoracic pressure to produce the desired physiological effects. The second mistake is body position. For the standard medical version, sitting semi-reclined or lying flat tends to work better than sitting bolt upright, because gravity affects how blood pools during the maneuver. Yet the majority of practitioners in that survey had patients sitting upright or in other suboptimal positions.

The Modified Valsalva and Why It Works Better

If you are using the Valsalva to try to stop a racing heart, specifically a type of rapid heartbeat called supraventricular tachycardia (SVT), there is a modification that roughly doubles your chances of success. The standard Valsalva converts SVT to a normal rhythm in only about 17 to 19 percent of cases in emergency settings.² That is better than nothing, but it means the technique fails about four out of five times when performed the conventional way.

A large trial known as REVERT tested a simple tweak: after straining for 15 seconds while sitting semi-reclined at 45 degrees, the patient was immediately laid flat on their back and their legs were raised to about a 45-degree angle by an assistant for another 15 seconds. This postural change boosted the conversion rate to 43 percent, compared to 17 percent for the standard technique. In practical terms, for every three patients who tried the modified version, one extra patient avoided the need for medication.³

Multiple meta-analyses have confirmed this advantage. One found the modified version roughly tripled the odds of converting to a normal rhythm after a single attempt.⁴ Another pooled analysis found a success rate about double that of the standard approach.⁵ The reason the leg raise helps is that it sends a surge of blood back toward the heart at exactly the moment the chest pressure is released, amplifying the vagal reflex that slows the heart’s electrical activity.

Here is the modified technique step by step:

Position: Sit semi-reclined at roughly 45 degrees, as if in a recliner or hospital bed with the back angled up.
Strain: Take a breath, close your airway, and bear down forcefully for 15 seconds, just as in the standard version.
Lie flat immediately: As soon as the 15 seconds are up, lie completely flat on your back.
Raise your legs: Have someone lift both of your legs to about 45 degrees. Hold this position for 15 seconds.
Return to sitting: After the leg-raise period, sit back up and check whether your heart rhythm has returned to normal.

Even with the improved technique, the maneuver does not work every time. A Cochrane review noted that while the evidence supports the Valsalva as a safe, non-invasive first step before medications, the overall data from randomized trials remain limited.⁶ If the maneuver does not work after one or two attempts, medical treatment with drugs like adenosine is typically the next step.

Equalizing Ear Pressure While Flying or Diving

This is probably the context in which most people encounter the Valsalva. When you descend in an airplane or dive underwater, the increasing external pressure pushes your eardrums inward. The Valsalva forces air up through your Eustachian tubes and into the middle ear space, equalizing the pressure and relieving that painful, plugged-up feeling. Antonio Maria Valsalva himself originally described the technique in 1704 specifically as a way to check whether the Eustachian tubes were open.⁷

For ear equalization, you do not need the full 15-second sustained strain used in medical applications. A shorter, gentler version works: pinch your nose, close your mouth, and blow gently until you feel or hear your ears pop. The key word is gently. Blowing too hard can damage the delicate structures of the inner ear or force mucus into the middle ear, which can lead to infection.

Scuba divers learn to equalize early and often during descent, ideally every meter or two in the first few meters. Waiting until your ears already hurt means the Eustachian tubes are being pinched shut by the pressure difference, making equalization harder. If the Valsalva is not working underwater, a technique called the Frenzel maneuver is an alternative. The Frenzel uses the tongue as a piston instead of chest pressure, which gives finer control. A study comparing the two approaches in a pressure chamber found that the Valsalva generated higher opening pressures in the Eustachian tube than the Frenzel, meaning it is a blunter instrument. The Frenzel produced lower, more controlled pressures.⁸ For casual flyers, the Valsalva is perfectly adequate. For divers going deeper, learning the Frenzel is worth the effort.

The Valsalva in the Weight Room

Lifters perform the Valsalva instinctively during heavy sets, and there is good biomechanical reason for it. Taking a big breath and bearing down before a heavy squat or deadlift dramatically increases intra-abdominal pressure, which acts like an internal brace for the spine. Research has confirmed that the Valsalva effectively raises intra-abdominal pressure, which in turn increases spinal stability and trunk rigidity during resistance exercise.⁹ A separate study measuring trunk stiffness found that elevated intra-abdominal pressure increased spinal stiffness by about 21 to 42 percent in flexion, depending on the level of pressure generated.¹⁰

The lifting version differs slightly from the medical version. You take a deep breath into your belly rather than your upper chest, brace your core muscles hard, and hold that pressure throughout the hardest portion of the rep (usually the bottom of a squat or the initial pull of a deadlift). You exhale at the top once the rep is completed. Some coaches teach a partial exhale through pursed lips during the exertion phase to keep pressure up without fully holding the breath, which can be a compromise for people concerned about blood pressure spikes.

The trade-off is real, though. The Valsalva causes a sharp, temporary spike in blood pressure. For young, healthy lifters, this is generally well-tolerated. For anyone with uncontrolled high blood pressure, a history of stroke, or heart disease, that pressure spike carries genuine risk. The standard advice in strength training circles is that the Valsalva is a tool for heavy compound lifts and should not be used for every exercise or every set.

When to Avoid the Valsalva

Although the maneuver is simple and generally safe for healthy people, the sudden pressure changes it creates affect multiple body systems at once. The main risks fall into a few categories.

The eye is surprisingly vulnerable. Straining hard enough can cause small blood vessels in the retina to burst, a condition called Valsalva retinopathy. Case reports have documented this occurring during activities as ordinary as yoga backbends, where the patient developed retinal hemorrhage and hazy vision in one eye after straining.¹¹ The condition happens during many everyday activities that involve straining: coughing, constipation, lifting heavy objects, and even playing wind instruments.¹² Most cases resolve on their own over weeks to months, but severe cases can impair vision temporarily.

People with the following conditions should generally avoid forceful Valsalva straining or do so only under medical guidance:

Uncontrolled hypertension: The blood pressure spike can be extreme, potentially triggering a stroke or heart attack in someone already at high risk.
Known retinal disease or recent eye surgery: The venous pressure rise in the head can worsen existing retinal problems.
Aortic stenosis or hypertrophic cardiomyopathy: These heart conditions can cause dangerous drops in blood flow when intrathoracic pressure rises suddenly.
Recent heart attack or unstable angina: The cardiovascular stress of the maneuver is inadvisable during acute cardiac events.
Cerebral aneurysm: The transient pressure increase could theoretically contribute to rupture in someone with a known weakness in a brain blood vessel.

For healthy people using the Valsalva to pop their ears or stabilize a heavy lift, the risk is low. The concern scales with how forcefully and how long you strain, and with your underlying health status.

How Doctors Use the Valsalva as a Diagnostic Tool

Beyond its therapeutic uses, the Valsalva is a surprisingly versatile diagnostic tool. Its value comes from the predictable way it shifts blood flow, blood pressure, and heart rate through distinct phases. By watching how a patient’s body responds, clinicians can detect problems that might not be visible at rest.

One important application is testing the autonomic nervous system, the part of your nervous system that controls involuntary functions like heart rate and blood pressure. A measurement called the Valsalva ratio compares the longest interval between heartbeats after the strain is released to the shortest interval during the strain. A ratio below 1.21 is considered abnormal and suggests that the parasympathetic (rest-and-digest) branch of the nervous system is not functioning properly. This is a common screening test for diabetic neuropathy and other conditions that damage autonomic nerves.¹³

The maneuver also plays a role in detecting a patent foramen ovale (PFO), a small hole between the upper chambers of the heart that failed to close after birth. About a quarter of adults have one, and most never know it. During a bubble study, where saline with tiny air bubbles is injected into a vein, performing a Valsalva at the right moment can push bubbles through the hole from the right side of the heart to the left, making the defect visible on ultrasound. One study found that the detection rate for PFO jumped from about 59 percent at rest to 85 percent when the Valsalva was added.¹⁴ Another study using transcranial Doppler found that performing the Valsalva pushed detection of right-to-left shunting to 99 percent with that technique.¹⁵ Without the Valsalva, many of these PFOs would be missed entirely.

Situations Where You Are Already Doing It Without Realizing

One of the less obvious aspects of the Valsalva is how often your body performs some version of it without any conscious effort. Coughing, sneezing, and straining during a bowel movement all generate the same kind of closed-airway pressure increase. Blowing up balloons, playing a trumpet or oboe, and even laughing very hard can produce Valsalva-like effects. Childbirth involves sustained bearing-down efforts that are functionally identical to the maneuver.

This is worth knowing because it means the risks associated with the Valsalva are not limited to deliberate practice. The yoga patient who developed retinal hemorrhage was not trying to perform the maneuver. She was holding a challenging pose and straining without realizing she had created exactly the same pressure dynamics. Musicians who play brass or woodwind instruments for hours at a stretch are performing hundreds of small Valsalva-like exhalations per session, which is one reason wind players occasionally develop issues with venous congestion in the head and eyes.

If you have been told to avoid straining by a cardiologist or ophthalmologist, it helps to recognize these everyday triggers. Chronic constipation, for instance, is a surprisingly common source of repeated Valsalva-type straining that many patients do not think to mention to their doctor. Managing that with diet or stool softeners can reduce an ongoing source of pressure spikes that goes far beyond anything you would do intentionally in a gym or an emergency room.

From Ear Anatomy to Emergency Rooms

Antonio Maria Valsalva was an Italian anatomist who published his landmark work on the ear, De aure Humana Tractatus, in 1704. The forced exhalation technique he described was originally just a method for testing whether the Eustachian tubes were open.⁷ Over the following three centuries, clinicians realized the maneuver’s effects extended far beyond the ear. It is now used routinely in cardiology, neurology, and otolaryngology, and it remains one of the few medical interventions that has survived essentially unchanged for over 300 years. The modification involving leg elevation is the most significant refinement in its long history, and that only arrived in 2015 with the REVERT trial. For a technique first described to pop ears in the early eighteenth century, the Valsalva has proven remarkably durable.

1
PubMed. Incorrect instruction in the use of the Valsalva manoeuvre for paroxysmal supra-ventricular tachycardia is common
2
Annals of Emergency Medicine. Comparison of Treatment of Supraventricular Tachycardia by Valsalva Maneuver and Carotid Sinus Massage
3
The Lancet. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial
4
PubMed. Modified Valsalva maneuver for treatment of supraventricular tachycardias: A Meta-analysis
5
PubMed Central. Efficacy and safety of modified Valsalva maneuver for treatment of paroxysmal supraventricular tachycardia: a meta-analysis
6
Cochrane Database of Systematic Reviews. Effectiveness of the Valsalva Manoeuvre for terminating supraventricular tachycardia
7
PubMed Central. The life and work of Antonio Maria Valsalva (1666-1723) – Popping ears and tingling tongues.
8
PubMed Central. Prospective study on the Eustachian tube function during Frenzel maneuver in a hypobaric/hyperbaric pressure chamber
9
PubMed. The Valsalva maneuver: its effect on intra-abdominal pressure and safety issues during resistance exercise
10
PubMed Central. Lumbar spine stability can be augmented with an abdominal belt and/or increased intra-abdominal pressure
11
PubMed Central. Valsalva Retinopathy After Yoga in a Patient With No Clear Predisposing Condition
12
PubMed Central. Recurrent Optic Disc Pit Maculopathy Due to Valsalva’s Maneuver
13
PubMed Central. Methods of evaluation of autonomic nervous system function
14
PubMed Central. Influence of the Valsalva maneuver on cardiac hemodynamics and right to left shunt in patients with patent foramen ovale
15
PubMed Central. A Comparison of Transthroracic Echocardiograpy and Transcranial Doppler With Contrast Agent for Detection of Patent Foramen Ovale With or Without the Valsalva Maneuver