Hiccups
Colleen Tallen M.D.
Palliative Care Lecture Series
October 17, 2013
Objectives
• What are hiccups?
• Why do we hiccup?
• Who gets hiccups?
• How do we treat hiccups?
What is Hiccups?
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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”
What is Hiccups?
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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
Who Hiccups?
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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)
Why Hiccup?
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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
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Medulla controls both actions
Damage to medulla can cause intractable hiccups
May involve dopamine, serotonin, opioid, calcium
channel, GABA pathways
Why Hiccups?
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Reflex arch for hiccups
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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 -
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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
WHY HICCUP?
ETIOLOGY
EXAMPLES
CNS
Vascular
Stroke, infarct, SLE, vascular disorders, aneurysm, basilar artery insufficiency
Tumor
Astrocytoma, carvenoma, brainstem tumors, glioblastomas, metastasis
Inflammation
Neuromyelitis, multiple sclerosis, pneumonia, encephalitis, meningitis
Trauma
Brain injury
Miscellaneous
Seizure, cranial herpes infection, hydrocephalus,Parkinsons, tobacco use, multiple sclerosis
PERIPHERAL PATHWAY
Chest cavity
Mediastinal diseases, lymphadenopathy/diaphragmatic tumors, mediastinal tumor, pleurisy,
pulmonary edema
Heart
Myocardial ischemia
GI
Esophageal tumors, GERD & gastritis, Stomach volvulus, H. Pylori, hepatomegaly, pancreatitis,
gastric distention,
Lower Abdomen
Gynecologic tumors, prostate cancer, intra-abdominal tumors, bowel obstruction
Miscellaneous
Cancers, nephrosis, UTI, psychological
EXTRINSIC CAUSES
Surgery
Anesthetic agents, post-op disturbances
Chemotherapy
Chemotherapeutics, steroids
Drugs
Anti-parkinson treatment, psychiatric meds, azithromycin,bisphosphonates (hypocalcemia),
morphine (hypocapnea), sulfonamides, steroids, methydopa, diazapam, barbiturates, Librium
Instrumental
Atrial pacing, catheter ablation, central venous cath, esophageal stent, bronchoscopy, tracheostomy,
shaving beards
Miscellaneous
Electrolyte imbalance, ethanol users, TB, chronic renal failure, stress/anxiety/grief/psychogenic,
anorexia
Understand the “why” will help with
“how” to treat
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Injury to brain
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Ischemia/stroke - may improve with anticoagulants
Inflammation (multiple sclerosis, encephalitis) steroids
Space occupying lesions(tumors, aneurysm)resection, steroids
Infection - meningitis - antibiotics. herpes zosteracyclovir. H. pylori - antibiotics
Understand the “why” will help with
“how” to treat
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Medications that may effect the hiccup reflex arch
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Bupivacaine epidural, propofol- interrupts inhibitory
reflex of phrenic nerve and afferent visceral sensory
pathway
Chemotherapy - Cisplatin - releases 5hydroxyltryptamine 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)
Understand the “why” will help with
“how” to treat
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Instrumentation
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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)
Understand the “why” will help with
“how” to treat
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GI causes
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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
How to treat hiccups?
Non-pharmacologic
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Hold breath
Hyperventilate (re-breath into paper bag)
Sneeze
Gargle
How to treat hiccups?
Non-pharmacologic
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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
How to treat hiccups?
Non-pharmacologic
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Rubbing 5th cervical vertebrae
Diaphragmatic pacing electrodes
Acupuncture
Massage or relaxation techniques
How to treat hiccups?
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Dopamine antagonists
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Chlorpromazine (Thorazine) - central dopamine
antagonist
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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)
How to treat hiccups?
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Dopamine antagonists
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Haloperidol - central dopamine antagonist
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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
How to treat hiccups?
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Calcium Channel blockers (anti-spasmotic effect
on smooth muscle?)
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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)
How to treat hiccups?
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Antiemetic with central anti-dopaminergic effect
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Metoclopramide (Reglan)
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Dopamine antagonist
Helps with gastric distension
Recommended: 5-10mg po/IV q8hours
How to treat hiccups?
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Anti-spasmotic
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Baclofen
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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
How to treat hiccups?
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Anti-seizure medications
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Dilantin- 200 mg IV followed by 300 mg/day
Tegretol
Neurontin – normal titration
Valproic acid
How to treat hiccups?
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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
Sometimes I wrestle with my demons,
sometimes we just snuggle