Peg Esper
DEFINITION AND INCIDENCE
The term “hiccups” describes the spasmodic movement of the diaphragm that is followed by a rapid closure of the glottis. Men are more likely to experience episodes of hiccups, which can occur between 2 and 60 times per minute (Ripamonti & Fusco, 2002). The medical term for “hiccup” is derived from the Latin word singultus, which means “a gasp or sigh” (Krakauer, Zhu, Bounds et al., 2005).
Hiccups have been classified in the literature as being episodic (or a “bout” of hiccups); protracted, which last over 48 hours; or intractable, lasting longer than 1 month (Waller & Caroline, 2000). These classifications appear to be more arbitrarily than scientifically based, and most individuals would probably agree that hiccups lasting more than a few hours is likely to be personally defined as intractable.
Hiccups can be experienced by individuals with and without a documented illness. The benign occurrence of hiccups is generally limited. Healthy individuals rarely require intervention beyond self-help measures. Individuals with advanced illness, however, may develop an intractable form of hiccups that can become debilitating and lead to such symptoms as anxiety, depression, dyspnea, nausea, pain, and fatigue. The actual incidence of hiccups in individuals with cancer and other chronic illnesses has not been well documented, but the occurrence of idiopathic singultus is reported to be 1:100,000 people in the general population (Petroianu, 2005).
ETIOLOGY AND PATHOPHYSIOLOGY
Hiccups are attributed to a variety of causes but generally can be placed into one of the six following categories (Krakauer et al., 2005; Ripamonti & Fusco, 2002):
▪ Conditions that cause inflammation of the peripheral branches of the phrenic and vagal nerves, such as gastric and abdominal distention (having a variety of causes, including bowel obstruction and intraabdominal hemorrhage), excessive ingestion of food, sudden changes in the gastric temperature, esophageal reflux or obstruction, pleuritis, pericarditis, pulmonary edema, pneumonia, and mediastinal or cervical tumors
▪ Central nervous system disorders, such as intracranial tumors, head injury, and stroke
▪ Infectious disorders (infrequent), including meningitis, abscess, tuberculosis, and influenza
▪ Psychogenic disturbances, such as anxiety, emotional stress, and excitement
▪ Idiopathic causes, when a causative factor is not identified; because extensive evaluation is often unwarranted in a terminally ill patient
Hiccups generally involve the left diaphragm but have a minimal effect on ventilation. An increase in P co2 decreases the frequency of hiccups (Waller & Caroline, 2000).
In patients near death, gastric distension is most likely the underlying cause of hiccups, accounting for 95% of cases (Twycross, 1997).
ASSESSMENT AND MEASUREMENT
A complete evaluation for hiccups includes identification of possible contributing etiologies. The ability to intervene and the methods of intervention will be based on the patient’s current stage of illness.
HISTORY AND PHYSICAL EXAMINATION
Underlying medical diagnoses often suggest the cause of hiccups. The history and physical examination should be directed to rule out the causes discussed. In addition, the following aspects of the history and physical examination should be considered:
▪ Length of the episode and its effect on the patient’s quality of life
▪ Review of medications (renal hemodialysis patients have been reported to have hiccups following ingestion of “star fruit”) (Noble & Green, 2001)
▪ Comprehensive medical history to evaluate for history of any recent surgery, stroke, or renal dialysis
▪ Measures, if any, the patient has used in an attempt to relieve the hiccups (a patient who indicates that inducing emesis relieved hiccups may have increased acidity causing the hiccup problem)
▪ Check for foreign bodies in the ear canal, since they can stimulate hiccups
▪ Examination of the body for possible sources of irritation to the diaphragm, vagus, and phrenic nerves (Petroianu, 2005)
▪ Evaluation for neurological findings that may be associated with hiccups such as multiple sclerosis and increased intracranial pressure (Petroianu, 2005)
DIAGNOSTICS
Diagnostic tests will generally not yield a cause for hiccups. However, a radiographic study may be beneficial in patients with an optimal performance status. Laboratory studies may be used to evaluate for electrolyte disturbances that may be related.
INTERVENTION AND TREATMENT
Treatment for hiccups in end-stage illness is often questionable. However, if an underlying cause is identified and the treatment is consistent with the goals of care and desires of the patient and family, treatment is appropriate. For example, if the underlying cause is related to pneumonia, treating the pneumonia with the intent of providing comfort—in this case, relief of distressing hiccups—is entirely appropriate. In addition, if medications are identified as a possible cause, discontinuing the offending medication and substituting another may also be appropriate.
Pharmacological Interventions
The pharmacological approaches to hiccups can be organized into several categories: phrenic and/or vagal stimulation, reduction of gastric distention, muscle relaxation, and central suppression of the hiccup reflex. Table 29-1 summarizes a number of possible pharmacological interventions.
| Agent | Suggested Dosing |
|---|---|
| Pharmacological Approaches | |
| Baclofen | 5 to 20 mg orally twice or three times daily |
| Carbamazepine | 200 mg orally three or four times daily |
| Chlorpromazine | 25 to 50 mg intramuscularly initially, followed by 25 to 50 mg orally three times daily |
| Gabapentin | 300 to 400 mg orally three times daily |
| Haloperidol | 5 mg intravenously every 6 hr initially and/or 1 to 4 mg subcutaneously three times daily |
| Methylphenidate | 5 mg orally twice daily |
| Metoclopramide | 10 mg intravenously over 2 min, followed by 10 orally three to four times daily |
| Simethicone-containing antacids | Four times a day (before meals and at bedtime) |
| Nonpharmacological Approaches | |
| Acupuncture | |
| Biting a lemon | |
| Breathing into a paper bag | |
| Drinking peppermint water (do not combine with metoclopramide) | |
| Dropping a cold key down the back of the shirt | |
| Holding breath | |
| Repeated tapping over C5 dermatome | |
| Supra-supramaximal inspiration | |
| Swallowing a teaspoon of dry sugar | |
| Swallowing dry bread | |
Complementary and Nonpharmacological Interventions
Nonpharmacological interventions for hiccups are numerous. Most patients and families have attempted these before contacting a clinician. It is still appropriate to try these approaches if they have not been attempted but to consider the degree of distress related to hiccups and add pharmacological approaches as appropriate. The use of Aschner’s oculocardiac reflex (compression of the eyeball) has been identified as one means of terminating hiccups (Petroianu, 2005). Table 29-1 lists a variety of other nonpharmacological methods to control hiccups.
Intensive Measures
Consideration of invasive and more intensive physical measures must be carefully evaluated for use in the palliative care setting. Such measures may include nasogastric tube insertion, transesophageal diaphragmatic pacing, and vagus nerve stimulation (Andres, 2005; Payne, Tiel, Payne et al., 2005; Petroianu, 2005).
PATIENT AND FAMILY EDUCATION
Hiccups can be a distressing symptom for both patient and family. As with all symptoms, patients and families should be taught about the probable underlying cause and proposed treatment plan(s) and urged to contact their clinician if the planned interventions are not effective. They also need to be reassured that control of distressing symptoms is the highest priority in their plan of care, in keeping of course with the wishes and goals of the patient and family. The consequences of no treatment should be part of the overall goal-setting discussion.
EVALUATION AND PLAN FOR FOLLOW-UP
Treatment is judged successful when the hiccups are resolved (in terms of patient-determined goals) or do not recur. In some cases, several trials and combinations of different interventions may occur before the symptom is resolved to the patient’s and family’s satisfaction. Although there is little in the literature regarding hiccups in end-of-life care, it is reasonable to expect them to occur as the patient status changes. Continual patient evaluation and inquiries about new or recurrent symptoms and their management are important factors.
Her current medications include a 50-mg fentanyl patch that is changed every 72 hours, 10 to 20 mg of immediate-release morphine for breakthrough pain every 2 to 3 hours as needed, senna 2 tablets three times daily, prednisolone 20 mg daily, and lorazepam 1 mg orally every 8 hours as needed for anxiety.
The ongoing hiccups have increased her pain level to the point where she has increased the frequency of her breakthrough medication. As a result, she is also starting to have more problems with constipation. She is starting to feel nauseated from the hiccups as well as experiencing increased agitation, anxiety, and frustration.
The physical examination revealed a mildly distended abdomen and slightly diminished bowel sounds. The liver was moderately enlarged, crossing the midline, and increased in size from her last examination. The clinician believes the etiology of her hiccups to likely be related to increased compression of the diaphragm and stomach from progressive hepatic metastasis but also multifactorial.
A trial of methylphenidate 10 mg orally every 6 hours is initiated. This relieved Mrs. C.’s nausea and her constipation has improved, but her hiccups have not resolved completely. A trial dose of chlorpromazine 25 mg is given and effectively stops the hiccups, but the patient experienced mild delirium with it. This led to the initiation of baclofen 5 mg three times daily. Within 24 hours, the patient had no further complaints of hiccups. She started to experience loose stools, which was believed to possibly be related to the methylphenidate, which had not been discontinued. The dosage of this was decreased to 10 mg orally twice daily, and the patient had no further problems with diarrhea but has maintained improved bowel function and has no nausea.
REFERENCES
Andres, D.W., Transesophageal diaphragmatic pacing for treatment of persistent hiccups, Anesthesiology 102 (2) ( 2005) 483.
Krakauer, E.L.; Zhu, A.X.; Bounds, B.C.; et al., Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 6-2005. A 58-year-old man with esophageal cancer and nausea, vomiting, and intractable hiccups, N Engl J Med 352 (8) ( 2005) 817–825.
Noble, J.; Green, H.L., In: Textbook of primary care medicine3rd ed. ( 2001)Mosby, St. Louis, pp. 187–189.
Payne, B.R.; Tiel, R.L.; Payne, M.S.; et al., Vagus nerve stimulation for chronic intractable hiccups. Case report, J Neurosurg 102 (5) ( 2005) 935–937.
Petroianu, G.A., Hiccups, In: (Editors: Rakel, R.E.; Bope, E.T.) Conn’s current therapy 200557th ed. ( 2005)Saunders, Philadelphia, pp. 12–16; Retrieved January 21, 2005, from MDConsult online database at www.mdconsult.com.
Ripamonti, C.; Fusco, F., Respiratory problems in advanced cancer, Support Care Cancer 10 (3) ( 2002) 204–216.
Twycross, R., Symptom management in advanced cancer. 2nd ed. ( 1997)Radcliffe Medical Press, Oxon, UK.
Waller, A.; Caroline, N., Handbook of palliative care in cancer. 2nd ed. ( 2000)Butterworth-Heinemann, Boston.
