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Hiccups Colleen Tallen M.D. Palliative Care Lecture Series October 17, 2013.

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Presentation on theme: "Hiccups Colleen Tallen M.D. Palliative Care Lecture Series October 17, 2013."— Presentation transcript:

1 Hiccups Colleen Tallen M.D. Palliative Care Lecture Series October 17, 2013

2 Objectives What are hiccups? Why do we hiccup? Who gets hiccups? How do we treat hiccups?

3 What is Hiccups? The term "hiccup" derives from the sound of the event. "Hiccough" erroneously implies an association with respiratory reflexes. The medical term, singultus (sing-guhl-tuhs), is thought to have originated from the Latin, singult, which translates roughly as "the act of catching one's breath while sobbing." Also called “synchronous diaphragmatic flutter”

4 What is Hiccups? An involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles accompanied by sudden inspiration that ends with abrupt closure of the glottis, making the classic hiccup sound. Persistent or protracted hiccups - lasting more than 48 hours Intractable hiccups - lasting more than one month

5 Who Hiccups? Equal incidence between men and woman overall Higher incidence in men (82%) than women for protracted hiccups Organic cause identified in 93% of men and 8% of women Organic incidence is 80%. Psychogenic incidence is 20% More common in children Seen in utero More common in the evening (Circadian rhythm)

6 Why Hiccup? Considered pathologic because serves no useful function Unknown etiology Normally brainstem action that closes the glottis never activated when brainstem stops respirations (one inhibited/one activated). Abnormal when both activated Hypothesis based on Medulla controls both actions Damage to medulla can cause intractable hiccups May involve dopamine, serotonin, opioid, calcium channel, GABA pathways

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8 Why Hiccups? Reflex arch for hiccups Afferent pathway (periphery to central) - vagus, phrenic or thoracic sympathetic fibers (phrenic C3-5, anterior scalene C5-7, external intercostals T1-11, glottis- recurrent laryngeal component of vagus) Central connection - Phrenic nerve nuclei (neuron cell bodies located in the more medial portions of the anterior horn at cervical levels C3–C5 that innervate the diaphragm via the phrenic nerve) Inspiratory and glottis control centers in posterior lower medulla, reticular part of brainstem and hypothalamus Efferent pathway (center to periphery) - phrenic nerve to diaphragm. Involves the accessory respiratory muscles

9 WHY HICCUP? ETIOLOGYEXAMPLES CNS VascularStroke, infarct, SLE, vascular disorders, aneurysm, basilar artery insufficiency TumorAstrocytoma, carvenoma, brainstem tumors, glioblastomas, metastasis InflammationNeuromyelitis, multiple sclerosis, pneumonia, encephalitis, meningitis TraumaBrain injury MiscellaneousSeizure, cranial herpes infection, hydrocephalus,Parkinsons, tobacco use, multiple sclerosis PERIPHERAL PATHWAY Chest cavityMediastinal diseases, lymphadenopathy/diaphragmatic tumors, mediastinal tumor, pleurisy, pulmonary edema HeartMyocardial ischemia GIEsophageal tumors, GERD & gastritis, Stomach volvulus, H. Pylori, hepatomegaly, pancreatitis, gastric distention, Lower AbdomenGynecologic tumors, prostate cancer, intra-abdominal tumors, bowel obstruction MiscellaneousCancers, nephrosis, UTI, psychological EXTRINSIC CAUSES SurgeryAnesthetic agents, post-op disturbances ChemotherapyChemotherapeutics, steroids DrugsAnti-parkinson treatment, psychiatric meds, azithromycin,bisphosphonates (hypocalcemia), morphine (hypocapnea), sulfonamides, steroids, methydopa, diazapam, barbiturates, Librium InstrumentalAtrial pacing, catheter ablation, central venous cath, esophageal stent, bronchoscopy, tracheostomy, shaving beards MiscellaneousElectrolyte imbalance, ethanol users, TB, chronic renal failure, stress/anxiety/grief/psychogenic, anorexia

10 Understand the “why” will help with “how” to treat Injury to brain Ischemia/stroke - may improve with anticoagulants Inflammation (multiple sclerosis, encephalitis) - steroids Space occupying lesions(tumors, aneurysm)- resection, steroids Infection - meningitis - antibiotics. herpes zoster- acyclovir. H. pylori - antibiotics

11 Understand the “why” will help with “how” to treat Medications that may effect the hiccup reflex arch Bupivacaine epidural, propofol- interrupts inhibitory reflex of phrenic nerve and afferent visceral sensory pathway Chemotherapy - Cisplatin - releases 5- hydroxyltryptamine from vagal afferents and initiates the emetic reflex Steroids may cause hiccups by steroid receptors in the efferent limb of hiccup reflex (may also help when steroids decrease inflammation)

12 Understand the “why” will help with “how” to treat Instrumentation Atrial pacing/catheter ablation for atrial fibrillation (right phrenic nerve close to right atrium) Esophageal stenting/bronchoscopy/tracheostomy - irritate afferent pathway of hiccup reflex arc Shaving or stoking someone’s chin - chin innervated by C5 that projects to the medulla (centrally mediated hiccups) Psychogenic (consider if hiccups stop while sleeping)

13 Understand the “why” will help with “how” to treat GI causes Mechanical - gastric distention relieve source ie reglan for gastroparesis, NG tube, simethicone GERD - proton pump inhibitors, H2 - blockers Arrhythmia-induced syncope has been reported as both the cause and the effect of hiccups Peritoneal dialysis - may improve with change in pH of dialysis solution

14 How to treat hiccups? Non-pharmacologic Hold breath Hyperventilate (re-breath into paper bag) Sneeze Gargle

15 How to treat hiccups? Non-pharmacologic Food/drinks to ingest - Pineapple juice, lemon wedges with bitters, sugar, honey/vinegar Iced water - drink fast or on “wrong side” of glass Pressure on eyeballs or carotid sinus Chest compression by pulling knees to chest or leaning forward

16 How to treat hiccups? Non-pharmacologic Rubbing 5th cervical vertebrae Diaphragmatic pacing electrodes Acupuncture Massage or relaxation techniques

17 How to treat hiccups? Dopamine antagonists Chlorpromazine (Thorazine) - central dopamine antagonist Approved for treating hiccups Blocks dopaminergic neurotransmission Oral/ IV/IM Recommended dose: 25-50 mg PO/IM q6-8 hours Personal dose: start at 3-6.25 mg IV/PO q4hours (titrate dose until hiccups resolved)

18 How to treat hiccups? Dopamine antagonists Haloperidol - central dopamine antagonist Dopamine antagonist PO/IM/SL (use IV cautiously. Increased chance of QT interval prolongation) Recommended: 1-4mg PO/SL q8hour Personal: Start low and titrate until hiccups resolved. May start with 0.5 mg dose Droperidol

19 How to treat hiccups? Calcium Channel blockers (anti-spasmotic effect on smooth muscle?) Nifedipine (Adalat) nimodipine (Nimotop) Carvedilol - non-cardio selective beta blocker, Ca channel blocker and antioxident Amantadine (weak antagonist NMDA receptor) Zyprexa (serotonergic antagonist. Brain injury cases)

20 How to treat hiccups? Antiemetic with central anti-dopaminergic effect Metoclopramide (Reglan) Dopamine antagonist Helps with gastric distension Recommended: 5-10mg po/IV q8hours

21 How to treat hiccups? Anti-spasmotic Baclofen GABA(B) receptor agonist Acts primarily at the spinal cord level by inhibiting spinal afferent pathways Studied in double blind reandomized contolled study that showed effectiveness Cautious use in elderly, renal failure

22 How to treat hiccups? Anti-seizure medications Dilantin- 200 mg IV followed by 300 mg/day Tegretol Neurontin – normal titration Valproic acid

23 How to treat hiccups? Ketamine Lidocaine Benzodiazapines Marijuana Combo - therapy ie COB (cisapride, omeprazole, baclofen) and COBG (add gabapentin) Sertraline (Zoloft) - Effects peripheral 5-HT4 receptors in GI tract reducing abnormal esophagus, gastric, diaphragm mobility

24 Sometimes I wrestle with my demons, sometimes we just snuggle


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