Avoid the Valsalva Maneuver for Equalizing!

[Angelo Farina]

My experience as an instructor is that, by far, the most of injuries happen to people who did not manage to equalize.
I evaluate the risk that a diver "over equalizes" doing a Valsalva with excessive pressure is quite smaller than the risk of not equalizing.
The point is that 2/3 of my students who were struggling to equalize were attempting to do it using Valsalva. And for most of them the problem was solved teaching them another method (different for each of them).
So yes, Valsalva does well for a large number of beginners. But it also fails for a significant number of them (more specifically for those on the low end of the bell curve, those with problematic tubes). So a good instructor needs to manage other equalizing methods, and to be able to train the students to use them, when Valsalva fails. Or, better, even when Valsalva works, but something else works better.
We are all different, and it is better to know various methods, and to use the one working better.

 

[Joneill]

How many OW students have you taught?

None - I’m not an instructor nor have I ever claimed to be.

I do NOT find they all can comfortably use Valsalva, sitting in a classroom. Nothing to do with descents. They just blow harder, which is my point. It is too easy to just blow harder. Yes yes Yes, equalize early and often...but first you've got to equalize correctly.

I did not say that all can clear with Valsava - just that it is the most commonly used method.

My concern is that you started a post with a title suggesting that everyone should avoid using Valsalva; which is misguided, in my opinion, as it’s a completely valid technique.

You are suggesting that blowing harder/too hard via Valsava is the root cause of these barotrauma posts you linked but do you have actual proof of that beyond anectdotal posts? I personally believe that the blowing too hard as one descends is not the actual cause of the injuries - I’d bet it’s actually not effectively clearing your ears (via whatever method) properly before you get too deep or continuing to clear as needed throughout the dive.

I’m certainly open to being convinced otherwise, but my take on @doctormike ‘s reply (that you requested) was that he did not feel that blowing too hard unto itself would be a widespread root cause of diving barotrauma either?

 

[Joneill]

My experience as an instructor is that, by far, the most of injuries happen to people who did not manage to equalize.
I evaluate the risk that a diver "over equalizes" doing a Valsalva with excessive pressure is quite smaller than the risk of not equalizing.
The point is that 2/3 of my students who were struggling to equalize were attempting to do it using Valsalva. And for most of them the problem was solved teaching them another method (different for each of them).
So yes, Valsalva does well for a large number of beginners. But it also fails for a significant number of them (more specifically for those on the low end of the bell curve, those with problematic tubes). So a good instructor needs to manage other equalizing methods, and to be able to train the students to use them, when Valsalva fails. Or, better, even when Valsalva works, but something else works better.
We are all different, and it is better to know various methods, and to use the one working better.

I fully agree… which is why the OP should not be telling people to avoid using a specific equalizing technique. Try to learn many different techniques and use what you find what works best for you!

 

[tursiops]

None - I’m not an instructor nor have I ever claimed to be.

I did not say that all can clear with Valsava - just that it is the most commonly used method.

My concern is that you started a post with a title suggesting that everyone should avoid using Valsalva; which is misguided, in my opinion, as it’s a completely valid technique.

You are suggesting that blowing harder/too hard via Valsava is the root cause of these barotrauma posts you linked but do you have actual proof of that beyond anectdotal posts? I personally believe that the blowing too hard as one descends is not the actual cause of the injuries - I’d bet it’s actually not effectively clearing your ears (via whatever method) properly before you get too deep or continuing to clear as needed throughout the dive.

I’m certainly open to being convinced otherwise, but my take on @doctormike ‘s reply (that you requested) was that he did not feel that blowing too hard unto itself would be a widespread root cause of diving barotrauma either?

We, and doctormike, are not really talking about the same thing.
I stand by my avoiding Valsalva, as it is unnecessary and other techniques are just as easy to teach and less subject to poor technique.
It seems that many instructors teach only Valsalva, because that is all they know and it works for them. The fact that it does not work for all their students leads to the problems.
I interpret the DAN material as proof that there are safer methods than Valsalva.
You and doctormike have this backwards.....it is NOT that Valsalva is the root problem, it is that equalizing too late is the root problem. But if all the diver knows is Valsalva, then they just try harder....

It is kind of like the incessant PPB question on SB, with many claiming it is a useless course because you should have learned that in your OW class.
Well, you should have learned how to equalize your own ears, not the instructor's ears, in your OW class, and do it at the surface, then almost continuously as you descend through the upper waters. But you didn't....you learned to squeeze your nose and blow, but not all the subtleties, or even when. Why should a new diver be taught only one method? Why should a new diver be placed in the position of only knowing something that can potentially hurt them? Why should a new diver be put at a disadvantage because their Eustachian tubes are weird?
I wonder how doctormike explains the many posts of SB of ear troubles from Valsalva? He kind of wishes it away as not the root cause.
We'll once somebody is out of OW class, it is too late to address the root cause. You'v got to stop the cain of events further along the chain...like the method of equalizing.

 

[doctormike]

I’m certainly open to being convinced otherwise, but my take on @doctormike ‘s reply (that you requested) was that he did not feel that blowing too hard unto itself would be a widespread root cause of diving barotrauma either?

I really don't have statics on this, but I would suspect that most people who have problems with the Valsalva and who don't know any other methods would eventually just thumb the dive if they really couldn't equalize and were having pain. I guess there might be some people who kept trying until they hurt themselves, but that would probably the exception rather than the rule....

So @tursiops I can't really explain away these posts and I clearly didn't say that it can't happen. I'm just saying that I see a fair number of patients with dive related ear issues, and I have yet to see someone cause damage from a Valsalva. Again, that doesn't mean that it's impossible, and maybe I should really read the whole thread before commenting (I only started here because I was tagged). But I don't think that Valsalva should be prohibited because of this concern. I usually tell people with any sort of barotrauma to GENTLY alternate Valsalva and Toynbee maneuvers to get the ET open again.

 

[Angelo Farina]

I do not know any instructor who teaches only Valsalva. I had mostly contact with CMAS and PADI instructors, and a couple of NAUI ones. All were teaching at least 3 different methods.
Here in Italy many old school instructors start with Marcante-Odaglia, switch to Valsalva when it fails, and then to Toynbee as the last one.
I do not know the "standard" order in other countries, but I know that the PADI instructor's manual mandates to explain many different methods.
What I have seen is that usually students get an equalizing accident while attempting to do Valsalva. None of my 1500 students ever had a barothrauma or timpanic damage while attempting any other method.
So yes, Valsalva is widely the method used by more divers, but it is also the method which more frequently fails to provide proper equalization.
My opinion is that the other methods (and particularly BTV) work thanks to good control of muscles, which also translates in good perception of the success of the manouvre. Valsalva is fast and dirty and powerful, works well also with people having poor control of their muscles, but does not elicit good perception of the effectiveness of the equalization.
This makes the diver thinking to have equalized, and descend further.
This explains the number of accidents due to missed equalization which I observed among my students attempting to unsuccesfully use Valsalva.
Using other methods the failure rate is the same, or even larger: but these missed equalizations do not translate into accidents, as using other methods the diver has a precise perception that the equalization has not happened, and so avoids to dive deeper (or, in some cases, switches to Valsalva, who also fails, but having done a forceful equalization attempt the diver thinks to have solved the problem and descends).
I have seen this scheme many times, particularly in divers who, as me, tendentially use BTV. After an unsucccesfull BTV, one pinches his nose and performs a Valsalva, which is considered more powerful and always effective. And after the forced Valsalva equalization, he thinks that everything is OK and descends further, causing the accident...

 

[doctormike]

Valsalva is fast and dirty and powerful, works well also with people having poor control of their muscles, but does not elicit good perception of the effectiveness of the equalization.
This makes the diver thinking to have equalized, and descend further.
This explains the number of accidents due to missed equalization which I observed among my students attempting to unsuccesfully use Valsalva.
Using other methods the failure rate is the same, or even larger: but these missed equalizations do not translate into accidents, as using other methods the diver has a precise perception that the equalization has not happened, and so avoids to dive deeper (or, in some cases, switches to Valsalva, who also fails, but having done a forceful equalization attempt the diver thinks to have solved the problem and descends).

I'm not an instructor, but I'm not sure I understand the pathophysiology you are describing here. The pain from failed equalization is due to a pressure gradient across the tympanic membrane, causing stretch and discomfort. If you are breathing during descent or ascent, ambient pressure is always equal to nasopharyngeal pressure. That's what a regulator does.

So whatever the reason for any equalization measure failing may be, the outcome is the same. On descent, it's the inability for gas to pass from the NP up the ET to the middle ear cleft. I don't understand why the pain of failed Valsalva would be different than the pain of any other failed equalization method.

 

[Angelo Farina]

I'm not an instructor, but I'm not sure I understand the pathophysiology you are describing here. The pain from failed equalization is due to a pressure gradient across the tympanic membrane, causing stretch and discomfort. If you are breathing during descent or ascent, ambient pressure is always equal to nasopharyngeal pressure. That's what a regulator does.

So whatever the reason for any equalization measure failing may be, the outcome is the same. On descent, it's the inability for gas to pass from the NP up the ET to the middle ear cleft. I don't understand why the pain of failed Valsalva would be different than the pain of any other failed equalization method.

Most of the equalization accidents I have seen did not involve any pain. Pain comes later, even hours later.
If the diver has pain while drscending, usually he does not descend further, and in most cases this prevents the accident...

 

[doctormike]

Most of the equalization accidents I have seen did not involve any pain. Pain comes later, even hours later.
If the diver has pain while drscending, usually he does not descend further, and in most cases this prevents the accident...

Right, exactly. So my question was why you feel that certain types of failed equalization and continued descent cause pain and other's don't. If your middle ear cleft is filled with gas, inadequate equalization will cause a pressure gradient and pain as you descent. If it is filled with fluid, you won't have that effect, but that would imply either blood in the middle ear (from prior barotrauma) or from a middle ear effusion (very unusual in an adult).

Now it is true that forceful Valsalva with a blocked ET can increase intracranial pressure and possibly cause inner ear injury with transmitted pressure through the perilymph, but that's beyond the scope of your comment (although not of this entire thread).

But if we are talking about an equalization accident causing middle ear barotrauma, the middle ear gas is either at ambient pressure or it isn't. And the further it is from ambient, the more it hurts, no matter how you are trying to equalize.

 

[Angelo Farina]

It appears that some divers do not perceive pain until too late.
A missed BTV is easily detected, because a succesfull BTV is clearly perceived. A missed Valsalva instead can be confused with a succesful one, as the strong pressure caused by lungs overwhelms the neural receptors of the tube.
It is also an acoustical effect. While doing the BTV, the driver is breathing normally. The regulator is very noisy, so when the BTV is opening the tube, you hear the loud noise of the reg through it.
It is impossible to confuse a working BTV with a failed one.
During a Valsalva the airways are closed, so there is no loud noise perceived when the tubes open...