Forced inspiratory suction and swallow tool (FISST): an automation of Valsalva maneuver variants for therapeutic interventions

INTRODUCTION

The Valsalva maneuver and its modifications have been utilized across several conditions in medicine; however, there have been difficulties in its application. Thus, at the University of Texas Health Science Center in San Antonio, we designed and patented an affordable and accessible device that mimics Valsalva called "Forced Inspiratory Suction and Swallow Tool (FISST).

AREAS COVERED

In this review, we discuss the premise for the design of FISST, based on applications of the law of conservation energy, the continuity equation, and Bernoulli's principle. We then detail the mechanism by which FISST stimulates hiccup cessation by increasing negative inspiratory pressure when drinking through the apparatus, causing diaphragmatic contraction and disruption of the hiccup reflex. We then detail the efficacy and future applications of FISST in addressing other pathologies.

EXPERT OPINION

FISST has been used to address hiccups by utilizing its reverse-Valsalva effect to increase parasympathetic stimulation by increasing vagal tone. In a prospective study that we conducted on a cohort of 249 hiccup subjects worldwide, this tool achieved 92% effectiveness. Additionally, several cases, including a published case report, have found FISST successful in terminating supraventricular tachycardias (SVT). FISST may be further utilized in diagnosing or addressing various upper airway pathologies and should be explored further.

Successful Treatment of Persistent Hiccups in an Advanced Palliative Cancer Patient With Gabapentin: A Case Report

Hiccups may appear to be a common normal phenomenon that does not warrant treatment in the general population. However, severe and persistent hiccups can become annoying and distressing and may decrease the quality of life, especially in cancer patients. The management of hiccups remains challenging. Despite trying many pharmacological and non-pharmacological methods, there is no clear evidence to support the management guidelines. In our case, we successfully treated persistent hiccups of more than four days duration in a patient with acute myeloblastic leukemia with gabapentin.

Prevalence and associated factors of orphan symptoms in advanced cancer patients: a multicenter observational study

PURPOSE

The aims of this study were to examine the prevalence of myoclonus, sweating, pruritus, hiccup, and vesical and rectal tenesmus, and to explore associated factors in patients with advanced cancer.

METHODS

This multicenter prospective cohort study was conducted in 23 inpatient hospices/palliative care units in Japan from January to December 2017. The prevalence and characteristics of each symptom were assessed on admission and in the 3 days before death. We selected factors that might influence the occurrence of each symptom and investigated the association.

RESULTS

A total of 1896 patients were enrolled. The prevalence of orphan symptoms rose from admission to the 3 days before death: myoclonus 1.3 to 5.3% (95% CI 0.9-1.9%/4.3-6.5%), sweating 1.8 to 4.1% (95% CI 1.3-2.6%/3.1-5.1%), hiccup 1.1 to 1.8% (95% CI 0.7-1.7%/1.2-2.6%), and tenesmus 0.7 to 0.9% (0.4-1.2%/0.5-1.5%). Prevalence of pruritus fell from 3.5 to 2.5% (95% CI 2.7-4.4%/1.8-3.4%). Sweating, pruritus, and hiccups persisted throughout the day in nearly half of the patients. Myoclonus was significantly associated with brain tumors, sweating with opioids and antipsychotics, pruritus with liver and biliary tract cancer, cholestasis and severe diabetes, hiccup with male gender, digestive tract obstruction, severe diabetes, and renal failure. Vesical tenesmus was associated with urinary cancer, antipsychotics, and anticholinergics and rectal tenesmus with pelvic cavity cancer.

CONCLUSION

We found that orphan symptoms occurred in 0.5-5.0% of patients, increased over time except for pruritus, and persisted in half of the patients.

Treatment of persistent hiccups after arthroplasty: effects of acupuncture at PC6, CV12 and ST36

OBJECTIVE

There are multiple treatment options for hiccups, including non-pharmacological therapies, but little evidence of superiority of one treatment over another. The aim of this study was to investigate the effects of acupuncture on persistent hiccups after arthroplasty.

METHODS

From April 2010 to December 2015, 15 patients with primary unilateral total hip/knee arthroplasty were diagnosed with persistent hiccups and given acupuncture at PC6, CV12 and ST36. Each acupuncture session lasted 30 min. The total number of treatment sessions was determined by the persistence of symptoms, but acupuncture was administered no more than three times over the course of a week. The hiccups assessment instrument (HAI) was used to assess the severity of hiccups pre-treatment and post-treatment. Adverse events were also recorded.

RESULTS

Absolute resolution was observed in all 15 patients after less than three acupuncture sessions. Of these, 10 patients required only one acupuncture session, 3 patients required two sessions and 2 patients required three sessions. The HAI score improved after each round of acupuncture treatment (P<0.05). The average HAI score improved significantly post-acupuncture compared to baseline values pre-treatment (P<0.05). Symptoms accompanying the hiccups included pain in the diaphragmatic area (five patients), mild dyspnoea (three patients), dysphagia (two patients) and nausea/vomiting (one patient). All these accompanying symptoms disappeared at the point of resolution of the hiccups. There were no adverse effects related to acupuncture during the study period.

CONCLUSION

Based on our results, acupuncture may represent a potential treatment option for hiccups after arthroplasty. Caution must be exercised, however, given the lack of a control group. Accordingly, randomised controlled trials will be required to verify the efficacy and effectiveness of acupuncture for the treatment of hiccups.

Gabapentin Therapy of Hiccups

OBJECTIVE:

To determine whether gabapentin is effective in the treatment of persistent or intractable hiccups.

DATA SOURCES:

A search of MEDLINE (1966-March 2013) using the MeSH search terms gabapentin, hiccups, and hiccups/drug therapy was performed. Additional databases searched included Web of Science (1945-March 2013) and International Pharmaceutical Abstracts (1970-March 2013) using the text words gabapentin and hiccups. Bibliographies of relevant articles were reviewed for additional citations.

STUDY SELECTION AND DATA EXTRACTION:

All data sources were considered for inclusion. Preference was given for articles written in English, although one abstract in German was used.

DATA SYNTHESIS:

Because of the low incidence of persistent or intractable hiccups, few if any controlled clinical trials are conducted on the efficacy of drug treatment. Therefore, most of the data involve case reports or case series. We evaluated 17 case reports and 2 case series involving gabapentin therapy for persistent or intractable hiccups. Therapeutic outcomes with gabapentin were positive in all cases, with temporal evidence suggesting an effect, but outcomes often were obscured by combination therapy and comorbidities in some cases. Case reports suggest that gabapentin might be useful as a second-line agent in patients undergoing stroke rehabilitation or in the palliative care setting where chlorpromazine adverse effects are undesirable. Gabapentin was very well tolerated, with only a few minor adverse effects.

CONCLUSIONS:

Gabapentin has a similar body of evidence as other pharmacotherapeutic agents used to treat hiccups. Gabapentin is well tolerated and should be considered as a second-line agent in selected patients.

Management of intractable hiccups: an illustrative case and review

Often thought of as a benign and self-limited condition, hiccups can become persistent or intractable, and thus be associated with substantial morbidity and distress. In such cases, an underlying etiology is often present, and may be overlooked. Debilitating hiccups can present a major challenge to optimal symptom management. Various causes of protracted hiccups have been identified including metabolic abnormalities, central nervous system pathology, malignancy, medications, and disorders attributed to cardiac, pulmonary and gastrointestinal etiologies. We present a case of intractable hiccups in a patient with an advanced hematological malignancy and review specific therapies for the management of persistent hiccups.

Gabapentin in the treatment of persistent hiccups in advanced malignancy

Hiccups are a distressing symptom in advanced malignancies in the setting of palliative care. A case of persistent hiccups treated with oral Gabapentin is presented to highlight the clinical and ethical dilemmas in patients with advanced malignancy. A 70-year-old male with non-small cell cancer of the lung with widespread metastases presented with persistent hiccups. The patient and family sought only symptom relief from home, without hospitalization or further investigations. The hiccups were dramatically relieved by oral Gabapentin, highlighting the recent reports that mention this molecule as being useful for hiccups. Gabapentin is a simple tool that may be utilized by palliative care physicians to relieve hiccups in advanced malignancies.

Persistent hiccups with continuous intrathecal morphine infusion

OBJECTIVE

To report a case of hiccups secondary to intrathecal (IT) morphine infusion.

METHODS

Case report and discussion.

RESULTS

The hiccups in our patient resolved on substitution of IT morphine infusion with hydromorphone.

DISCUSSION

We report a case of a 44-year-old man who developed persistent hiccups with IT morphine infusion pump therapy. The hiccups persisted despite various nonpharmacological and pharmacological measures. The untoward symptom resolved after substitution of IT hydromorphone for IT morphine.

Hiccup: mystery, nature and treatment

Hiccup is the sudden onset of erratic diaphragmatic and intercostal muscle contraction and immediately followed by laryngeal closure. The abrupt air rush into lungs elicits a "hic" sound. Hiccup is usually a self-limited disorder; however, when it is prolonged beyond 48 hours, it is considered persistent whereas episodes longer than 2 months are called intractable. A reflex arc involving peripheral phrenic, vagal and sympathetic pathways and central midbrain modulation is likely responsible for hiccup. Accordingly, any irritant in terms of physical/chemical factors, inflammation, neoplasia invading the arc leads to hiccups. The central causes of hiccup include stroke, space occupying lesions and injury etc, whereas peripheral causes include lesions along the arc such as tumors, myocardial ischemia, herpes infection, gastroesophageal reflux disease and applied instrumentations on human body etc. Besides, various drugs (eg, anti-parkinsonism drugs, anesthetic agents, steroids and chemotherapies etc) are the possible etiology. An effective treatment of persistent hiccup may be established upon the correct diagnosis of lesion responsible for the serious event. The pharmacotherapy of hiccup includes chlorpromazine, gabapentin, baclofen, serotonergic agonists, prokinetics and lidocaine. Non-pharmacological approaches such as nerve blockade, pacing, acupuncture and measures to hold breathing are also successful. Finally, alternative medicines and remedies are convenient to treat hiccups with uncertain effect. In conclusions, hiccup is likely to result from lesions involving the hiccup reflex arc. The lesion may need to be localized correctly for ablative treatment in patients with intractable hiccup. Apart from lesion ablation, drugs acting on reflex arc may be effective, while some other conventional measures may also be tried.

Low-dose Gabapentin for Intractable Hiccups in a Heart Transplant Recipient

Intractable hiccups can be a serious complication in transplant recipients. Unfortunately, many of the pharmacotherapies used to stop hiccups are associated with severe side effects as well as drug-drug interactions with immunosuppressants. We report a case of a heart transplant recipient who had had intractable hiccups for 2 months, resulting in severe insomnia, diminished appetite, and weight loss. To treat the hiccups, treatment with oral baclofen (5–10 mg 3 times daily) was started. After 6 weeks of therapy, the baclofen was titrated down and discontinued because it had not stopped the hiccups and was causing severe central nervous system side effects. Gabapentin (100 mg twice daily) was then prescribed and within 24 hours of the start of that treatment, the hiccups had resolved completely. After 3 weeks of therapy, the patient had no side effects and the gabapentin was subsequently discontinued. One year after stopping the gabapentin, the patient remains free of hiccups. Gabapentin appears to be a promising medication for the treatment of intractable hiccups in thoracic transplant recipients because of its lack of serious side effects at low doses, rapid onset of action, and lack of drug-drug interactions with transplant medications.

Acupuncture treatment for persistent hiccups in patients with cancer

OBJECTIVE

The objective of this study was to investigate the effects of acupuncture treatment for persistent hiccups in cancer patients.

DESIGN

The study design was a retrospective case series.

SETTINGS/LOCATION

The study setting was the Clinical Research Center of the National Institutes of Health.

SUBJECTS

The subjects were 16 adult male patients ages 27-71 with cancer, with persistent hiccups.

INTERVENTIONS

There were one to three acupuncture sessions over a 1-7-day period.

OUTCOME MEASURES

Treatment efficacy was measured using a hiccup assessment instrument pre- and post-treatment. The effects of acupuncture on common symptoms reported by all patients were also evaluated.

RESULTS

Thirteen (13) patients experienced complete remission of persistent hiccups (p < 0.0001); 3 patients experienced decreased hiccups severity. Significant improvement was observed in discomfort (p < 0.0001), distress (p < 0.0001), and fatigue (p = 0.0078).

CONCLUSIONS

This case series demonstrates that acupuncture may be a clinically useful, safe, and low-cost therapy for persistent hiccups in patients with cancer.

Ultrasound-guided Pulsed Radiofrequency Lesioning of the Phrenic Nerve in a Patient with Intractable Hiccup

Persistent and intractable hiccups (with respective durations of more than 48 hours and 1 month) can result in depression, fatigue, impaired sleep, dehydration, weight loss, malnutrition, and aspiration syndromes. The conventional treatments for hiccups are either non-pharmacological, pharmacological or a nerve block treatment. Pulsed radiofrequency lesioning (PRFL) has been proposed for the modulation of the excited nervous system pathway of pain as a safe and nondestructive treatment method. As placement of the electrode in close proximity to the targeted nerve is very important for the success of PRFL, ultrasound appears to be well suited for this technique. A 74-year-old man suffering from intractable hiccups that had developed after a coronary artery bypass graft and had continued for 7 years was referred to our pain clinic. He had not been treated with conventional methods or medications. We performed PRFL of the phrenic nerve guided by ultrasound and the hiccups disappeared.

Novel use of amantadine: to treat hiccups

Persistent hiccups may have a considerable impact on general health through disturbance of diet, sleep, and mood. They can cause exhaustion, malnutrition, dehydration, wound dehiscence, and even death in extreme cases. We report a complex clinical case of intractable hiccups in a patient with cancer of the pancreas and Parkinson's disease and some of the problems encountered when attempting symptom control. We also discuss a potential therapeutic response to a novel agent, amantadine, unlicensed in the treatment of hiccups.