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Department of Medicine, New York University School of Medicine,, New York, NY
To the Editor:
We read with considerable interest the recent reports by Lierz and Felleiter (1) and Schuepfer et al. (2), describing anesthetic techniques for treatment of idiopathic persistent hiccups, or singultus.
While traditional treatments of this sometimes disabling malady have relied on increasing PaCO2 (breath holding, breathing into a paper bag), recent reports in the anesthesiology literature have included therapy using diaphragm relaxation (baclofen or phrenic nerve block) (2,3), or positive airway pressure under general anesthesia (1).
We have had success with a novel and simple method combining these three principles—hypercapnia, diaphragm immobilization, and positive airway pressure—which we describe as "supra-supramaximal inspiration."
Patients are instructed to inspire maximally, hold the breath for 10 seconds, then add an additional, small, "supra-maximal" inspiration, without any expiration. The breath is held for 5 seconds, followed by a third, "supra-supramaximal" inspiration, held for 5 seconds, before resuming normal breathing. In these three cumulative breaths, the lung volume asymptotically approaches functional vital capacity. We have achieved immediate and permanent termination to hiccups in all six patients who recently presented with persistent hiccups.
This technique may terminate spasmodic diaphragm contractions by effectively immobilizing the diaphragm for 20 seconds, while also increasing PaCO2. Lung expansion may also result in a reflex decrease in phrenic nerve tone. In our limited experience, we have found this a useful method before resorting to pharmacologic or interventional techniques.
References
Department of Anaesthesiology and Intensive Care Medicine, Marienkrankenhaus Soest, Soest, Germany Department of Intensive Care Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
In Response:
We appreciate the interest in our article.
Numerous household remedies for the therapy of singultus are known. Among many others are drinking cold water or various maneuvers for controlling the breath. Most patients tried these treatments long before visiting a physician.
We also treated cases successfully with the method described by Morris et al. in their letter and recommend this simple method before using pharmacologic or interventional therapies. In our published case (1), breath control alone did not terminate the spastic diaphragm contractions, therefore alternative methods had to be used.
Gentle endoscopic massage of the region of the cardia is another therapeutic approach that has not been mentioned yet. An article published by Beda describes successful treatment of chronic singultus with an average duration of 10 days in 34 patients (2). We think that this procedure should also be considered as a treatment option.
The numerous letters and personal communications concerning our case report show the significance of hiccups as a worldwide problem with numerous different therapies. Recommendations range from breathing exercises to the implantation of a phrenic nerve stimulator. The small number of comparable patients and the lack of controlled studies prevent evidence-based recommendations for therapy. Currently patients profit mostly from the exchange of personal experiences.
Footnotes
Dr. Schuepfer does not wish to respond.
References
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