what is Maneuver
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what is a maneuver definition types
Maneuver (British spelling: manoeuvre) is a broad term with several meanings depending on context:
Core Definition
From Latin manus ("hand") via French manœuvre ("tactical movement") — a maneuver is a deliberate, controlled movement or action carried out with skill and intention to achieve a specific purpose.
By Context
1. Military / Naval
A planned movement of troops, ships, or aircraft to gain a strategic or tactical advantage. Large-scale coordinated training exercises involving military units are also called "maneuvers."
"The army conducted maneuvers as training for war."
2. Aviation
An intended and controlled variation from straight-and-level flight — e.g., a barrel roll, loop, or evasive turn.
3. Everyday / General
A series of deliberate movements to navigate around obstacles or into a desired position.
"She maneuvered her car into the tight parking space."
4. Social / Political
A strategic or calculated action to gain an advantage, influence a situation, or manipulate outcomes.
"A political maneuver to gain votes."
5. Medical (Clinical)
A specific physical technique or procedure performed with the hands (reflecting the Latin root manus). Examples:
- Heimlich maneuver — abdominal thrusts to relieve choking
- Valsalva maneuver — forced exhalation against a closed airway
- Epley maneuver — head repositioning to treat BPPV (vertigo)
- Leopold's maneuvers — palpation technique to assess fetal position
- Sellick's maneuver — cricoid pressure during intubation
Summary
| Context | Meaning |
|---|---|
| Military | Coordinated troop/ship movements |
| Aviation | Controlled flight path change |
| Navigation | Skillful physical movement |
| Politics/Social | Calculated strategic action |
| Medicine | Specific clinical hand technique |
The unifying idea is purposeful, skillful control of movement — whether of soldiers, aircraft, a vehicle, or one's own hands.
how and why inspiration intensifies most right sided murmurs
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inspiration increases right sided heart murmurs Carvallo sign mechanism physiology
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Why Inspiration Intensifies Most Right-Sided Murmurs
The Core Mechanism: Increased Venous Return
During inspiration, the diaphragm descends and chest wall expands, generating a more negative intrathoracic pressure. This negative pressure:
- Increases the pressure gradient between the extrathoracic veins and the right atrium
- Augments venous return to the right heart
- Increases right ventricular preload and stroke volume
- Enhances blood flow across right-sided valves (tricuspid and pulmonary)
Greater flow across a regurgitant or stenotic right-sided valve → louder murmur.
Step-by-Step Physiology
Inspiration
↓
↓ Intrathoracic pressure (more negative)
↓
↑ Pressure gradient: systemic veins → right atrium
↓
↑ Venous return to right heart
↓
↑ Right ventricular filling (preload) & stroke volume
↓
↑ Turbulent flow across tricuspid/pulmonary valve
↓
↑ Murmur intensity
Clinical Name: Carvallo Sign (Rivero-Carvallo Sign)
This inspiratory augmentation of right-sided murmurs is classically called the Rivero-Carvallo sign, most associated with tricuspid regurgitation. It distinguishes TR from mitral regurgitation (which is left-sided and does not increase with inspiration).
"Inspiration increases venous return to the right cardiac chambers, augmenting right-sided murmurs and diastolic sounds. Typically described as a classic sign of tricuspid regurgitation (vs other systolic murmurs) is the Carvallo sign: an increase in the intensity of the murmur with inspiration." — Fuster & Hurst's The Heart, 15th Ed.
Right-Sided Murmurs That Increase with Inspiration
| Condition | Type of Murmur | Notes |
|---|---|---|
| Tricuspid regurgitation | Holosystolic, LLSB | Classic Carvallo sign |
| Tricuspid stenosis | Mid-diastolic, LLSB | Increased flow across stenotic valve |
| Pulmonary stenosis | Ejection systolic | Murmur increases; exception: the ejection click of PS decreases with inspiration |
| Pulmonary regurgitation | Early diastolic | Increased RV diastolic filling |
"Murmurs of right-sided origin, such as tricuspid or pulmonic regurgitation, increase in intensity during inspiration. The intensity of left-sided murmurs either remains constant or decreases with inspiration." — Harrison's Principles of Internal Medicine, 22nd Ed.
Why Left-Sided Murmurs Don't Increase (or Decrease)
During inspiration, the expanded lungs pool blood in the pulmonary vasculature, transiently reducing venous return to the left heart. Additionally, inspiration increases left ventricular afterload (by increasing transmural LV pressure). These effects:
- Reduce LV preload and stroke volume
- Decrease or maintain left-sided murmur intensity
This is why left-sided murmurs (mitral regurgitation, aortic stenosis) are often best heard at end-expiration — when lung volumes are minimized and the heart is brought closer to the chest wall.
Notable Exception: Hypertrophic Obstructive Cardiomyopathy (HOCM)
Though HOCM produces a left-sided dynamic outflow murmur, inspiration decreases it further — because the increased LV afterload from negative intrathoracic pressure reduces the dynamic obstruction gradient.
"Negative intrathoracic pressures generated by inspiration lead to an increase in left ventricular afterload; therefore, the dynamic LV outflow tract systolic murmur of hypertrophic cardiomyopathy will decrease on inspiration." — Fuster & Hurst's The Heart, 15th Ed.
Summary Table
| Inspiration Effect | Murmur Type |
|---|---|
| ↑ Intensity | All right-sided murmurs (TR, TS, PS, PR) |
| ↓ Intensity | HOCM (left-sided dynamic obstruction) |
| No change / ↓ | Most left-sided murmurs (MR, AS, AR) |
| Exception | PS ejection click — decreases with inspiration (unlike the murmur itself) |
- Harrison's Principles of Internal Medicine, 22nd Ed.
- Fuster & Hurst's The Heart, 15th Ed.
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