What is the appropriate management for a patient presenting with a hiccup in the chest?

Management of Hiccups ("Hiccup in Chest")

For acute hiccups presenting with chest discomfort, address underlying gastroesophageal reflux by avoiding alcohol and spicy foods, and if severe respiratory compromise develops, immediately apply continuous positive airway pressure with 100% oxygen. 1

Initial Assessment and Risk Stratification

When a patient presents with hiccups localized to the chest region, first determine the duration and severity:

• Acute hiccups (< 48 hours): Usually benign, self-limited, and require minimal intervention 2, 3
• Persistent hiccups (48 hours to 2 months): Warrant investigation for underlying pathology 4
• Intractable hiccups (> 2 months): Require comprehensive workup and aggressive management 4

The most common identifiable cause is gastric overdistension, followed by gastroesophageal reflux and gastritis 5. In the chest region specifically, consider myocardial ischemia, mediastinal lesions, or diaphragmatic irritation 3, 4.

Immediate Management for Acute Hiccups

First-Line Interventions

Lifestyle modifications:

• Eliminate alcohol and spicy foods to prevent gastroesophageal reflux 1
• Address gastric distention if present 3

Physical maneuvers (if simple measures fail):

• Breath-holding techniques 4
• Vagal stimulation maneuvers 6

Management of Severe Cases with Respiratory Compromise

A critical pitfall is failing to recognize when hiccups cause respiratory distress, which can progress to laryngospasm and post-obstructive pulmonary edema. 1

Escalation algorithm for respiratory compromise:

1. Apply continuous positive airway pressure with 100% oxygen using reservoir bag and facemask while ensuring upper airway patency 1

2. Consider Larson's maneuver if respiratory distress persists: Apply deep pressure with middle fingers in the "laryngospasm notch" (between posterior mandible and mastoid process) while performing jaw thrust 7, 1

3. Administer propofol 1-2 mg/kg IV if oxygen saturation is falling despite above measures 7, 1

4. Suxamethonium 1 mg/kg IV for severe cases with total airway closure and worsening hypoxia (alternative routes: IM 2-4 mg/kg, intralingual 2-4 mg/kg, or intraosseous 1 mg/kg if no IV access) 7

5. Atropine may be required to treat bradycardia 7

6. Surgical airway in extremis 7

Pharmacological Treatment for Persistent Hiccups

When simple measures fail and hiccups persist beyond 48 hours:

First-line pharmacotherapy:

• Baclofen is the treatment of choice for persistent hiccups, offering both safety and efficacy 2, 3

Alternative agents:

• Chlorpromazine (traditional first-line, but carries risks of hypotension, sedation, extrapyramidal symptoms, and QT prolongation) 8, 3
• Gabapentin 4
• Metoclopramide 3

Diagnostic Workup for Persistent Cases

Critical warning signs requiring immediate investigation:

• Duration > 48 hours 4
• Associated weight loss or depression (complications of untreated persistent hiccups) 8
• Chest pain suggesting myocardial ischemia 3
• Neurological symptoms suggesting brain tumor or traumatic brain injury 8

Focused investigations based on chest localization:

• Upper gastrointestinal endoscopy, pH monitoring, and manometry (gastroesophageal reflux is the most common pathological cause) 2, 3
• Chest imaging for mediastinal masses or diaphragmatic pathology 3
• ECG/cardiac workup if myocardial ischemia suspected 3, 4
• Abdominal ultrasound 3

Common Pitfalls to Avoid

• Dismissing persistent hiccups as benign: Hiccups > 48 hours can indicate serious pathology including myocardial infarction, brain tumors, or renal failure 3, 4
• Failing to monitor for respiratory complications: Severe hiccups can cause laryngospasm leading to post-obstructive pulmonary edema and hypoxic cardiac arrest 1
• Overlooking gastroesophageal reflux: This is the most important gastrointestinal cause and should be systematically evaluated 2, 3
• Ignoring consequences of untreated persistent hiccups: Can lead to depression, weight loss, and sleep deprivation 8, 3