Tips and tricks for the persistent hiccup management in a Telemedicine encounter

The coronavirus disease 2019 (COVID-19) pandemic boosted Telemedicine encounters around the world, with physicians having to face a variety of clinical adversities daily. The conditions with a low level of scientific evidence to guide treatment, such as hiccups, are even more challenging in remote care. Hiccups (diaphragmatic and intercostal muscle contraction followed by laryngeal closure) are usually self-limited and benign after peripheral phrenic irritation. However, this symptom may be a life-threatening situation or related to severe diseases.⁽⁾ Our Telemedicine center evaluated 245,633 patients from January 2020 to April 2021, and 39 (0.016%) patients had hiccups as the main complaint. Although possible, we did not observe frequent serious situations; only 2 (5.1%) patients were referred to the emergency department immediately. A specific step-by-step guideline is suggested, and some tips and tricks may help low-risk patients. First key point is the remote detection of red flags, which requires a very detailed evaluation. The classically defined persistent hiccups (lasting for more than 48 hours) increase the pre-test probability of severe underlying conditions, but this symptom is difficult to be assessed by Telemedicine, and referral is the only feasible option.⁽⁾ We decided to consider intractable (more than 2 months) hiccups as mandatory face-to-face evaluation, as well as other temporal profiles related to neurological deficits, chest pain, abdominal pain, unexplained weight loss, ongoing malignancy or organic dysfunction.⁽⁾ This evaluation may detect stroke, central nervous system infection, toxic-metabolic disturbances, cardiac ischemia, malignancy, and acute abdomen cases. Any observed symptom implies immediate emergency department referral.

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