Hiccupping, itching and sneezing | Edward Willett

We like to think we control our bodies. As I type this, my fingers oblg — er, obEY me pretty well, and if I choose to stand up and walk away, my legs won’t argue.

Sometimes, however, our bodies seem to have minds of their own: like when we’re hiccupping, itching and sneezing.

A hiccup results from an unexpected spasm of the diaphragm, the sheet of muscle that separates the chest from the abdominal cavity. This causes a sudden movement of air in the windpipe, which snaps shut in self-defense. “Hic!”

Hiccups are completely involuntary, and occur at regular intervals, from the usual four to 12 per minute all the way to 60 or even 100 per minute. They serve no known purpose beyond embarrassing us. Rapid gulping of food or drinking too much beer or other carbonated beverage may cause hiccups by overloading the stomach, thereby irritating the diaphragm, and alcohol may also release the body’s normal inhibition against hiccuping, but hiccups act neither to relieve the irritation or sober us up.

Hiccups that last more than a few minutes can be a symptom of liver infection, various tumors, pneumonia, stroke, kidney failure and even a heart attack. Stress and anxiety can also bring on hiccups, as can general anesthesia.

There are probably as many cures for hiccups as there are families, handed down from generation to generation. One favorite — a sudden fright — dates back to Plato, at least. Hippocrates suggested using a feather to stimulate sneezing. Breathing into a paper bag won’t cure hiccups, but it can lessen their force, because hiccups tend to weaken as the level of carbon dioxide in the blood increases.

There’s some scientific evidence in support of swallowing a little granulated sugar; it may activate an enzyme that halts diaphragm spasms. Finally, for really intractable hiccups, there are drugs and even surgical procedures. (But what if you’re one of those people who get hiccups during general anesthesia? You could get hiccups during the surgery to cure you of your hiccups!)

Almost as little understood as hiccupping is itching (“pruritis” in doctor-talk). Many plants, drugs and toxins can make our skin itch, as can dryness and even stress. Whatever brings on the itch, our response is the same: scratching, a reflex action unique to itching and apparently designed to remove noxious substances from the skin. Nobody is sure why it also relieves the itch: one theory is that it keeps our skin so busy feeling fingernails that it doesn’t have time to transmit the itch signal; another is that it releases an endorphin, a natural opiate-like substance.

One other interesting note: it’s impossible to talk about itching without itching. So give yourself a good scratch, and we’ll move on to sneezing.

Unlike hiccupping and itching, the purpose of sneezing is clear: to get stuff out of your nose. It’s your body’s biggest gun in the battle against foreign invaders in your nasal passages — everything from dust, molds and pollen to cold germs. If the invader is big and irritating enough, it triggers the sneeze reflex directly just by annoying the mucous membranes; but some people can sneeze themselves silly in the presence of something as apparently harmless as cat dandruff.

In that instance, and in other allergy and disease-triggered sneezes, the immune system gets things going by producing antibodies that bind to special “mast cells” in the mucous membranes. When these antibodies come into contact with the allergen or germ they’re specific to, the mast cells explode, releasing histamines and other substances which hit the mucous membrane walls like shrapnel. The mucous membranes don’t like that, and send a message to the nose, which passes it to the brain stem (the most primitive part of our brain), which summons up a 300-kilometre-an-hour blast to blow the offending material out of your head.

About the worst thing you can do when you feel that blast coming on is try to suppress it. The air has to go somewhere, and if you don’t let it out you force it up into the Eustachian tubes, which lead to the ears. That can send germs and viral particles into the inner ear or even damage your eardrums. So let it out!

Well, covering your nose and mouth is acceptable.

The signs and symptoms of cow’s milk allergy

What Are Intractable Hiccups?

We all get hiccups once in a while. But they usually last for a few minutes, then go away.

In extraordinarily rare cases, hiccups can last for more than a month. These are known as “intractable hiccups.” Other terms to describe the same condition include “chronic hiccups” and “intractable singultus” — which is another way to say hiccups.

The longest recorded case of intractable hiccups continued for 60 years. Intractable hiccups are very uncommon — happening in about 1 in 100,000 people.

You should see your doctor if you have hiccups that go on for longer than 48 hours. This could be a sign of a health problem.

Hiccups that last more than 48 hours are called “persistent” or “protracted” hiccups.

Having hiccups for a long time can cause exhaustion, dehydration, and weight loss due to disrupted sleeping and eating patterns. It has also been known to cause irregular heartbeat and gastroesophageal reflux disease (also known as GERD), which occurs when the contents of your stomach come back up into your esophagus or mouth.

Causes

Finding a cause for your intractable hiccups may be a long process.

Intractable hiccups are not inherited, as most cases pop up in people without any family history.

You’ll have to talk to your doctor about your medical history and may have to go through blood tests, imaging, and other lab studies to find the cause. In some cases, a cause is never determined.

Intractable hiccups can be triggered by spicy foods, hot liquids, fumes, and surgery. They can also be associated with hundreds of conditions including the following:

• Diseases affecting the diaphragm (the muscle separating the chest and abdominal cavities), pneumonia, and pleurisy (a condition affecting the pleura, the inside membrane of the chest cavity and tissue around the lungs)
• Brain infections, injuries, tumors, or strokes
• Metabolic disorders (when your body can’t break down certain nutrients into energy, causing a buildup)
• Gastrointestinal diseases affecting the esophagus, stomach, or small or large intestines
• Psychological problems such as hysteria, shock, fear, and certain mental conditions
• Liver problems
• Kidney disorders
• Medications including chemotherapy, benzodiazepines (type of depressants), corticosteroids (used to treat inflammation), barbiturates (type of depressants), morphine (pain medication), and anesthetics (make you unconscious or relieve pain)
• Surgery

Treatment

The most effective way to stop intractable hiccups is to find the root medical cause and address that issue. Treatments to stop intractable hiccups can involve medications, non-medical therapies, or surgery.

Self-help techniques, such as sipping ice water, holding your breath, biting a lemon, swallowing sugar, breathing into a paper bag, or pulling your knees to your chest are usually tried first if no correctable cause can be found. Your treatment will depend on your case and your medical needs.

Medications

Although generations of doctors have yet to find a definitive cure for hiccups, there are several different treatments that can be effective.

All medications used for hiccups can cause side effects, so talk to your doctor about which one may be the best one for you. Medications used to treat intractable hiccups include:

• Baclofen a muscle relaxant
• Chlorpromazine a medicine used to treat psychiatric illnesses
• Haloperidol, a type of tranquilizer
• Metoclopramide, used to treat problems in the esophagus and GERD
• Anticonvulsant drugs such as phenytoin, valproic acid (Depakene, Depakote, Depakote® ER, Depakote® Sprinkle), gabapentin (Gralise, Horizant, Neurontin), and carbamazepine (Carbatrol, Epitol, Equetro, Tegretol)
• Sedatives
• Pain medication
• Stimulants

Your doctor may prescribe one of these medications for several weeks, raising the dose until your hiccups decrease. The dose may be slowly reduced until you can stop taking the medicine.

Talk to your doctor if the hiccups return after you stop taking the medication.

In rare cases, medication may not be effective in treating hiccups. This means your doctor may suggest another treatment plan.

Alternative Treatments

Surgery

If none of these treatments is effective, your doctor may suggest surgery.

The procedure could temporarily or permanently block the phrenic nerve in the neck. The phrenic nerve runs from the spinal cord to the diaphragm, causing it to contract and relax. This step is usually only taken when all other therapies have failed.

Transient Hiccups Associated with Oral Dexamethasone

Hiccups, or singulata (hiccup is singultus), are commonly experienced by most people at one time or another and are usually brief and self-limiting. Although pharmacotherapeutic agents are not generally considered causal in the etiology of hiccups, many clinicians empirically associate episodic hiccups in their patients as being drug induced. The two classes of drugs most often cited as causing hiccups are corticosteroids and benzodiazepines. This report involved a patient who was given preoperative dexamethasone and developed hiccups before anesthesia and surgery commenced. He at no time was in distress, and the surgical procedure was completed without complication. By the second postsurgical day his hiccups were resolved completely. Although the association may be anecdotal, many clinicians consider hiccups a potential side effect of steroid therapy, especially high doses of steroids. Of interest in this case is the relatively low dose of corticosteroid used, albeit apparently linked to his hiccups. Practitioners should be aware of this potential condition.

1. Introduction

Hiccups, or singulata (hiccup is singultus), are very common and are experienced by most people at one time or another. They are usually brief and self-limiting but may become prolonged in some patients [1]. Hiccups that linger on for some time may become worrisome to the postoperative patient, thus hindering their nutritional and sleep needs [2, 3].

Hiccups are sudden, uncontrolled contractions of the diaphragm, followed by immediate inspiration and closure of the glottis over the trachea, producing the “hiccup” sound [4]. The classification of hiccups is as follows: up to 48 hours, acute or transient; longer than 48 hours, persistent; and more than a month or two, intractable [5]. The frequency of hiccups in males and females is equivalent, although intractable hiccups occur at a much higher rate in men [6, 7]. The exact etiology of the hiccup is unknown, but the neural process involves the reflex arc consisting of the afferent limb, the center, and the efferent limb [8, 9]. The afferent limb contains the phrenic and vagus nerves together with the sympathetic chain from T6 to T12. The center is linked to the afferent and efferent limbs and occupies a nonspecific location somewhere between C3 and C5. The efferent limb includes the phrenic nerve, accessory respiratory muscles, the glottis, and autonomic processes involving the medullary reticular formation and hypothalamus [4, 10]. One review proposed that the hiccup reflex arc is a myoclonic action and not a true reflex [11].

Medical conditions that have been associated with the development of hiccups include gastrointestinal, neurological, pulmonary, psychogenic, cardiovascular, metabolic, anesthesia related, and drug induced conditions [3, 4, 8, 12, 13]. Using a strict standard, drugs have not been proven to be a common cause of hiccups [7, 14]. Nevertheless, many clinicians have alluded to various medications as triggering the hiccup reflex [1, 3, 6, 13, 15–24]. The following case describes a patient who experienced transient hiccups following oral presurgical administration of dexamethasone.

2. Case Report

A 40-year-old male with an unremarkable medical history presented for surgery to place an implant. He was in excellent health, did not take any medications, and was not allergic to any drugs. The patient had taken a single prophylactic dose of 8 mg oral dexamethasone approximately 1 hour earlier. After presurgical vital signs were taken, and before any other medication (sedation, local anesthesia) was administered, the patient developed intermittent bouts of hiccups at a rate of roughly 5 to 7 per minute. He was in no distress and wanted to continue the procedure. Oral triazolam 0.50 mg was given, and by the time the surgery started, the episodic hiccups were reduced greatly allowing the implant to be placed uneventfully. By the time the patient was ready to be escorted from the clinic, the hiccups had returned at about the same rate they occurred preoperatively. He was given postoperative instructions and reassurances and followed up telephonically the next day, where he reported that by late afternoon (32 hours) the rate of hiccup episodes was reduced. The patient’s hiccups resolved completely by 42 hours after he took the dexamethasone. At the 1-week postoperative appointment, the incident was reviewed with the patient and counseling was given on the suspected drug-induced cause of the transient hiccups for his future reference/benefit.

3. Discussion

There are few reports in the literature on dexamethasone-induced hiccups and none in the dental literature [6, 15, 18, 23, 24]. Other cases of corticosteroid-induced hiccups have been reported [1, 25], and Dickerman et al. have described the first cases of anabolic steroid-induced hiccups [16, 17]. The only other adverse reaction to steroids found in the dental literature was a case of episodic psychiatric disturbance (cognitive dysfunction) in an 18-year-old female who had taken dexamethasone briefly [26]. The author would be remiss not to mention another suspected dexamethasone-induced transient hiccups case he came across years earlier, but, because other drugs were also given intravenously at the same time, it could not be confirmed.

Corticosteroids and benzodiazepines are the drug groups referenced most frequently in the literature as being associated with hiccups (see the following list), although Thompson and Landry state that there is not sufficient proof that any drug can be considered as definitely causing hiccups [14]. Souadjian and Cain reviewed 220 cases of protracted hiccups and did not mention any medication in the etiology of hiccups [7]. Garvey, who looked at postoperative cases of hiccups, came to the logical conclusion that the etiologic factor was probably drug related [3]; however, she also recounted that the intubation itself may be a contributing factor [27].

Drugs Possibly Associated with Triggering Hiccups: Steroids (dexamethasone, methylprednisolone, oxandrolone, and progesterone) Benzodiazepines (midazolam, lormetazepam, and lorazepam) Barbiturates (methohexital) Antibiotics (azithromycin) Phenothiazines (perphenazine) Opioids (hydrocodone) Alcohol.

The case described here was mild and short term and, even though somewhat inconvenient to the patient, was in practice, clinically insignificant. Hiccups that become persistent or intractable however can interfere with a patient’s daily activities and cause them to seek medical assistance. There are various reports in the literature of different treatments for protracted hiccups, including pharmacologic agents [4, 5, 8, 18, 22, 28–34]. Chlorpromazine is at present the only medication approved by the FDA for the treatment of hiccups, although many practitioners have reported less than desirable results with this drug [6, 17, 29].

Baclofen has been shown to successfully treat chronic hiccups [3, 4, 19, 30, 34], and promising results have been attained with the use of gabapentin alone [31] or as an add-on to combination therapy [5, 32].

The evidence for medication-induced hiccups may be empirical, yet for many the association is strong enough that clinicians should take notice. This is especially true for treatments involving steroids [35], drugs that are commonly used in medicine, including dental medicine. Being able to recognize the potential “drug-hiccup link” will better prepare health care practitioners manage any unexpected complications.

4. Conclusions

There are many uses for steroids in medicine and dentistry, and clinicians should be attentive to any possible side effects of medications prescribed. This paper and case explain the correlation between hiccups and steroid treatment in the perioperative setting. Although drug-induced hiccups have not been absolutely confirmed with controlled studies, the incidence is sufficient enough to raise questions by many practitioners. Fortunately, most cases of corticosteroid-related hiccups appear to be transient and usually end after the drug is withdrawn.

Conflict of Interests

The authors declare that they have no conflict of interests.

Asthma and Gastroesophageal Reflux Disease |

Asthma and Gastroesophageal Reflux Disease

People with gastroesophageal reflux disease (GERD) often suffer recurrent chest distress and commonly experience asthma symptoms.

This fact sheet provides useful information about the relationship between asthma and GERD. We hope that this material helps you better understand the nature of asthma symptoms, especially as they may relate to GERD. Please keep in mind that this information is not meant to take the place of medical advice from your physician.

After 51-year-old Percy feasted on his wife’s Thanksgiving

dinner, he popped a couple of antacid tablets to ward off the usual heartburn. But the feeling that he couldn’t quite catch his breath just wouldn’t go away. Throughout the holiday season, the frequent parties and irregular eating schedule only seemed to make his heartburn feel worse than ever before plus he developed a wheezing cough that plagued him late at night. When he visited his internist in January, the physician told him he probably had asthma- related GERD — and together they developed a plan of treatment to help Percy feel better.

What is asthma?

Asthma is a disease of increased responsiveness of the airways to various stimuli including allergens and irritants that cause obstruction of the airways. Constriction of muscles around the airway and inflammation result in swelling of the lining and increased secretion of mucous. The most common causes of an asthma flare up are infection, exercise, allergens, and air pollution (an irritant). Allergens and irritants are substances found in our everyday environment. People who have asthma may experience wheezing, cough, shortness of breath, and chest tightness. Asthma can begin at any age but with proper management and education, people with asthma can lead normal, active lives.

What is gastroesophageal reflux disease?

GERD is a digestive disorder that affects the circular band of “sphincter” muscle of the lower esophagus. The esophagus is the “food tube” that carries swallowed food to the stomach.

Normally, the lower esophageal sphincter muscle opens (relaxes) to allow food to pass into the stomach and then closes tightly (contracts) to keep stomach contents from backing up into the esophagus. Gastroesophageal reflux occurs when the lower esophageal sphincter does not close completely, allowing some semi-digested food and gastric acid to be pushed back up into the esophagus. This pushing back is known as reflux. The sensation caused by the refluxed food and acid gastric juice usually creates a burning sensation felt as “heartburn.”

People with GERD may experience reflux periodically or on a very regular basis — both upright and when lying down.

Statistical fact: According to the American College of Gastroenterology, at least 60 million Americans experience heartburn at least once a month; of these, more than 15 million experience daily heartburn symptoms. Symptoms of heartburn, popularly known as “acid indigestion,” are more common among elderly and obese persons and pregnant women; however, GERD can occur in all body types and even in infants.

What is the link between asthma and gastroesophageal reflux disease?

Researchers have discovered that GERD can trigger asthma symptoms. In addition, GERD is more common in people with asthma than in the general population. Individuals whose asthma is especially hard to treat appear to be more prone to GERD than other affected persons.

Generally speaking, reflux may cause asthma symptoms in two ways.

1)            The stomach acid that leaks back into the esophagus creates a chain reaction leading to asthma symptoms. The refluxed gastric acid irritates the nerve endings in the esophagus generating signals to the brain. Subsequently, the brain responds with impulses to the lungs that stimulate the muscle and mucus production in the airways. The small airways of the lungs then constrict, resulting in asthma symptoms.

2)            In many cases, physicians believe that the refluxed stomach contents enter the lungs directly. This situation is called aspiration. The foreign material is a potent irritant for the airways, creating wheezing, coughing, chest tightness, and other symptoms of asthma.

Some experts believe that asthma also may trigger GERD, when breathing difficulties or certain asthma medications cause the esophageal sphincter muscle to relax and allow stomach contents to reflux — completing a troublesome, potential vicious cycle.

Who develops GERD-related asthma?

Anyone — including infants, children, and teens — can develop gastroesophageal reflux. Keep in mind that people may experience GERD symptoms periodically or chronically. GERD symptoms also may be related to eating specific foods or, rarely, even to food allergies.

GERD, asthma, and children

The National Institutes of Health (NIH) reports that GERD often may be overlooked in babies and young children. Recent studies strongly suggest that GERD aggravates or may be the predominant cause of asthma symptoms in the very young.

Since small children have underdeveloped digestive systems, they are more likely to experience GERD and its consequences. Not only does GERD cause repeated regurgitation and reflux in very young children, but it also may be the cause of chronic cough or other respiratory problems. Regular burping during feedings and an upright position for at least 30 minutes after feedings can reduce reflux. Newborns and infants usually outgrow regular bouts of reflux by one year of age. Older children with reflux may benefit from dietary adjustments.

Stat fact: GERD affects as many as 89% of all patients with asthma, regardless of their age, sex, or ethnic background. (American Academy of Allergy, Asthma and Immunology)

What causes GERD?

The precise causes of gastroesophageal reflux disease are often unknown; however, physicians do know that a variety of factors can increase your risk for developing this problem. These factors include:

•            Excessive use of alcohol

•             Obesity

•             Pregnancy

•             Smoking

•            Hiatal hernia (in which part of the stomach rises into the chest)

In addition, some foods are known to make symptoms of reflux more likely if you already have a problem with it. These foods include:

•            Spicy foods

•            Fatty foods

•            Fried food

•            Garlic, onions

•            Citrus fruits

•             Caffeine

•            Tomato-based foods, such as pasta sauces

Asthma medications and GERD

Recent studies indicate that some asthma medications may promote gastric reflux. For example, prednisone and albuterol can possibly decrease the contracting abilities of the esophageal sphincter, thus allowing reflux. Certain other bronchodilators, which relax the smooth muscles of the esophagus, can increase the possibility for gastric reflux. Still, many patients who use those asthma medications regularly will not necessarily develop GERD or experience worsened symptoms.

What are signs and symptoms of GERD-related asthma?

You may have symptoms of both GERD and asthma, or you may only note asthma symptoms, but not both. Your physician will help you determine if your asthma may be related to gastroesophageal reflux by discussing your symptoms and possibly performing one or more useful tests. The following are of special importance:

•   You get a burning sensation — heartburn — in your lower mid-chest after eating a meal, especially a large meal that leaves you feeling really full. The burning sensation is worse when you lie down after the meal.

•            Using antacid medications often relieves your heartburn feeling.

•   You experience regurgitation after meals or awaken from sleep with sour liquid in your mouth.

•            You have bad breath regularly.

•            You have frequent hiccupping or burping.

Some people have GERD with no symptoms of heartburn. These individuals may feel chest pain, difficulty swallowing, or have the feeling that something is stuck in their throat or swallowing becomes blocked.

When asthma symptoms are related to a problem with gastroesophageal reflux, one or more of the following are common:

•            Your asthma symptoms often follow a large meal

•            Your asthma seems to get worse during sleep

•   Your asthma symptoms worsen in mid-life and do not appear to be related to allergy or seasonal infections

•            You are hoarse on a regular basis

•            You have frequent coughing

•            Your asthma does not respond well to the usual asthma medications

How is GERD-related asthma diagnosed?

A diagnosis of GERD-related asthma is not always easily made. To weigh this possibility, your physician may ask you to monitor and record your asthma symptoms in detail over a period of time.

In addition, you may be asked to undergo a 24-hour study of your esophagus with an acid-sensing indicator to determine the presence or amount of reflux. A “proton pump inhibitor” also can be used to markedly reduce stomach acid production for one or two months. If you have GERD-related asthma, this therapy should help reduce your asthma symptoms.

What is the treatment for GERD- related asthma?

The key to treating asthma symptoms related to GERD is to treat the gastroesophageal reflux and reduce the potential for damaging the lining of the esophagus from reflux. Many patients who have GERD-related asthma symptoms improve once they successfully address the gastric reflux problem.

Treating and managing GERD may be done in several ways.

1.            Medications. Several medications are available to help reduce the secretion of gastric acid. Talk with your physician about using over-the-counter-medications (such as Zantac-75®, Pepcid-AC®) before doing so.

If over-the-counter medications do not help you after two weeks, be sure to tell your physician. Prescription medications to reduce stomach acid are often necessary.

2.            Diet. Studies show that reducing your consumption of specific foods can help with GERD. Individuals vary in what foods they can tolerate, so you may have to do a little experimenting. Physicians recommend that people with reflux problems avoid fatty and fried foods; caffeinated drinks; onions; garlic; tomato-based products; citrus fruits; pepper; chocolate; peppermint; and alcoholic beverages.

3.            Eat smaller meals. Less food in your stomach may minimize the possibility of reflux. Try eating five to six “mini-meals” spaced throughout the day and early evening, instead of three larger meals.

4.            Eliminate tobacco use. Nicotine may be a factor in causing the esophageal sphincter to relax. When this happens, reflux can occur.

5.            Lose weight. Unhealthy excess body weight can increase the pressure on your stomach and esophagus, causing reflux.

6.            Avoid lying down after meals. You feel sleepy after a full meal, but lying down within three hours of eating can increase the possibility of reflux. Try keeping the head of your bed elevated, as well, to help reduce the role of gravity in causing reflux.

7.            Eat dinner early. If you eat at least three hours before going to bed, it will allow your stomach to empty more completely, and reduce the amount of acid in your stomach.

8.            Loosen your belt. You may get some relief by wearing looser clothing around your waist and lower abdomen.

Who should treat GERD-related asthma?

If you already have diagnosed asthma, talk with your asthma physician (often an allergist/immunologist or a pulmonologist) about your symptoms. Your physician may refer you to a gastroenterologist for treatment of GERD if your symptoms are severe. Those who have completed training in these specialties are usually called either board- certified or board-eligible.

If you have never been diagnosed with asthma, seek treatment first with your internist or family physician. Your internist or family physician may refer you to an asthma specialist or a physician who treats gastrointestinal disorders, depending on the nature of your symptoms.

Does health insurance cover asthma treatment?

Most health insurance plans provide some level of coverage for asthma patients. Check with your insurance carrier for details. Some things you may want to find out might include:

•            Do you need a referral to a specialist from your internist, family physician, or pediatrician?

•            Does the insurance carrier offer any patient education or specialized services related to asthma? To GERD? To asthma-related GERD?

•            What medications are not covered by your plan? (There can sometimes be a delay in approving newly released medications. Your physician may know about them, but your insurance may not cover them yet.)

What does the future hold for GERD?

The National Institutes of Health report that research is underway to explore the root causes of gastroesophageal reflux disease. Key studies are focusing on the role of hiatal hernia in GERD and the impact of the bacterium, Helicobacter pylori (H.pylori), in causing or preventing various stomach diseases. Scientists expect that application of their research results will improve treatment for GERD and related conditions.

The information provided in this fact sheet should not be a substitute for seeking responsible, professional medical care.

Reprinted with permission from “Asthma and Allergy Answers,” the patient education library developed by the Asthma and Allergy Foundation of America.

Persistent hiccups an unusual COVID-19 symptom

As the coronavirus pandemic continues to ravage worldwide, new data shows a multitude of symptoms that were not reported previously. It is well-known that the primary symptoms tied to the coronavirus disease are fever, cough, and difficulty of breathing. As time passed by, other symptoms emerged, including the loss of smell and taste, fatigue, body pains, headache, hair loss, and even a rash in the mouth.

Now, a team of researchers revealed another atypical symptom reported by patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the coronavirus disease (COVID-19) – persistent hiccups.

The case report

Published in the journal The American Journal of Emergency Medicine, a case report by researchers at Cook County Health described an incident wherein a 62-year-old patient who went to the emergency department had reported persistent hiccups for days and an unintentional weight loss over four months.

The man experienced hiccups for four days before being admitted to the hospital due to fever. Further tests revealed the patient had problems with his lung capacity, and he was later isolated and tested COVID-19 infection.

“An abnormal chest X-ray led to a CT scan of the chest with IV contrast, which demonstrated regional, peripheral ground-glass opacities of the upper lobes with small focal ground-glass opacities scattered throughout the lungs,” the authors wrote in the paper.

“He was tested for COVID-19 per admission protocol, started on hydroxychloroquine, his hiccups improved, and he was discharged to home after three days. An emergency medicine physician should keep COVID-19 on the differential and be vigilant of exposure in atypical presentations,” they added.

This is the first case report of persistent hiccups as the presenting complaint in a COVID-19 positive patient, the researchers claimed.

COVID-19 clinical characteristics

The clinical characteristics of COVID-19 are rapidly evolving as data continues to be collected across the globe. As more cases are reported, a multitude of signs and symptoms, even atypical ones, are being reported.

The case report of the man who had hiccups highlights two crucial issues, the researchers noted. First, it underscores the importance of having a detailed evaluation of those presenting with hiccups. Aside from this, it is also important for doctors to take a thorough history, conduct a physical exam, and to obtain general laboratory work and chest X-ray imaging.

Second, doctors and clinicians should keep COVID-19 infection on their differential as more cases are being discovered through atypical symptoms, which could be unexpected and bizarre. Further, doctors and the healthcare team should always maintain personal protective equipment to avoid exposure from patients who do not present with the typical symptoms of the coronavirus infection.

COVID-19 signs and symptoms

The typical signs and symptoms of coronavirus disease include coughing, fever, and shortness of breath, according to the U.S. Centers for Disease Control and Prevention (CDC). As the pandemic evolved throughout the eight months it has rippled across the globe, more signs and symptoms were reported.

These include fatigue, body pain, headache, loss of smell, loss of taste, runny nose or nasal congestion, nausea and vomiting, diarrhea, hair loss, and sore throat. Recently, a new addition has been added, which is the formation of rashes inside the mouth.

In patients with COVID-19, they are to seek medical help if they develop difficulty breathing, persistent pressure or pain in the chest, new confusion, bluish lips or face, and the inability to stay awake. Patients with severe coronavirus illness may develop many complications, including acute respiratory distress syndrome (ARDS), which is life-threatening.

Global situation

The coronavirus pandemic is actively spreading, with the United States reporting the highest number of cases, reaching more than 5 million cases and more than 163,000 deaths. Brazil and India follow with a staggering 3 million and 2 million cases, respectively.

Russia, South Africa, and Mexico report high transmission rates, with cases reaching 890,000, 563,000, and 480,000, respectively. South America has not become the new epicenter of the pandemic, with Brazil, Peru, Colombia, and Chile seeing a surge in infections.

Sources:

Journal reference:

Evaluation and Management of Coughs and Hiccups | 2012-07-30 | AHC Media: Continuing Medical Education Publishing | Relias Media

Evaluation and Management of Coughs and Hiccups

Authors:

Samuel H.F. Lam, MD, RDMS, FACEP, Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL.

Conal Roche, MD, Department of Emergency Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL.

Peer Reviewer:

John Sarko, MD, Maricopa Medical Center, Assistant Professor, Emergency Medicine, University of Arizona–Phoenix Medical School, Phoenix, AZ.

Coughs and hiccups are common emergency department complaints. While the majority of their causes are benign, patients with these symptoms can suffer from significant distress and impaired quality of life. Most patients with these symptoms can be effectively managed by understanding the pathophysiology and differential diagnosis of these symptoms and by using evidence-based therapy. It is important for the physician to be aware of the emergent conditions that may present with these seemingly benign complaints.

Cough

Cough is one of the most common chief complaints in the emergency department.^1-3 Cough is categorized as acute if it lasts less than three weeks, subacute if it lasts three to eight weeks, and chronic if it lasts more than eight weeks. Most coughing episodes are acute, but in nonsmokers, there is about a 12-14% incidence of cough lasting longer than three weeks, and the incidence of chronic cough is about 1%.⁴ Illnesses that produce cough impair the quality of life and are responsible for over 20 million lost days of work in the United States each year. ^5-6

Pathophysiology

A cough may be either a pure reflex or a volitional response. Laryngeal, or reflex cough, is often triggered by aspiration, with minimal associated inspiration. Tracheobronchial cough is initiated by receptors distal to the larynx and may occur voluntarily or by a reflex arc. Coughing is obviously protective, preventing aspiration and enhancing ciliary action and debris clearance.

Afferent receptors for the “cough pathway” are located throughout the upper and larger airways. Afferent arcs are mediated by the vagus nerve. In the proximal airways, the afferent receptors are predominantly mechanoreceptors that shift primarily to chemoreceptors in the distal airways. In some individuals with variant vagus nerve innervation to the tympanic membrane, cough response can be triggered by stimulation to the external ear canal. The central and brainstem cough centers are subject to extensive and poorly understood modulation from other respiratory reflex arcs, sleep state, and voluntary initiation and suppression. The efferent pathway initiates laryngeal and respiratory muscles, as well as reflexive pelvic sphincters.

Causes of cough are often divided into upper and lower airway sources, but research has shown similarly elevated levels of inflammatory markers in the lower airways in most conditions, leading to a more unified airway theory.⁷

Pathologic states that potentially result in chronic cough may work by increased airway receptor exposure to stimulating tachykinins, upregulation or sensitization of receptors, or by central modulation of the reflex arc. More recently in the pulmonary literature, it has been suggested that, rather than fitting chronic cough into established diseases, it should be defined as a separate diagnosis of cough hypersensitivity syndrome.⁸

Etiology and Differential Diagnosis

Cough as the Chief Complaint in Life-threatening Diagnoses. Coughs are typically found in patients with tracheobronchial infections, such as pneumonia, bronchial inflammation, and chronic obstructive pulmonary disease (COPD) exacerbations. A potentially life-threatening condition, pulmonary embolism (PE) is an established mimic of community-acquired pneumonia.^9,10 Cough was also identified as an independent predictor of delay in diagnosis of PE in emergency department patients.¹¹ In a large 2008 retrospective review, cough was present in 12-43% of elderly patients with PE.¹² In addition, PE has been shown repeatedly to be present in at least 20% of patients with atypical presentations of COPD exacerbation.¹³ Therefore, the presence of cough and even sputum production does not rule out the diagnosis of PE, especially in an older population.¹⁰ This same level of caution should apply to patients known to have increased risk for thromboembolic disease when cough is not explained by infectious or post-infectious causes.¹⁴

Experienced clinicians are aware that cough can be associated with heart failure (HF).¹⁵ In patients who present with persistent non-productive cough, HF should be considered in the context of suggestive findings on history and physical exam.

Significant correlation has been found between chronic cough and myocardial infarction (MI).¹⁶ In another study, 15% of patients who subsequently were found to have anterior MI complained of cough in addition to their chest pain. Patients with inferior and lateral MI were significantly less likely to have cough (3-6% incidence).¹⁷ Cough is also commonly seen with development of cardiac shock and pulmonary edema in the infarcting patient.

Acute Cough. Acute cough is commonly caused by upper respiratory tract infection (sinusitis, rhinitis, pharyngitis, laryngitis), lower respiratory tract infections (bronchitis, pneumonia), pertussis, allergic reactions, chemical or toxic exposure, as well as exacerbation of chronic conditions such as asthma, COPD, or interstitial lung disease.

Subacute Cough. Subacute cough is most commonly attributed to postinfectious etiology. Post-infectious cough is thought to be due to excessive inflammatory and hypersecretory changes to the upper and lower airways, along with cough receptor hypersensitivity after a viral infection. ¹⁸

Chronic Cough. In a nonsmoking, immunocompetent patient with chronic cough, with no apparent infectious etiology, and not taking angiotensin-converting enzyme inhibitors (ACEI), greater than 90% will be attributed to upper airway cough syndrome, asthma, or gastroesophageal reflux disease, in this order of prevalence.^2,19,20 Many patients have more than one process involved, further complicating evaluation.

Table 1: Conditions Encompassed by Upper Airway Cough Syndrome (UACS)

• Post-nasal drip syndrome
• Acute bacterial sinusitis
• Allergic fungal sinusitis
• Allergic rhinitis
• Nonallergic rhinitis with eosinophilia (NARES)
• Occupational rhinitis
• Postinfectious rhinitis
• Rhinitis due to anatomic abnormalities
• Rhinitis due to physical or chemical irritants
• Rhinitis medicamentosa (rebound rhinitis after use of nasal decongestants)
• Rhinitis of pregnancy
• Vasomotor rhinitis

Upper Airway Cough Syndrome (UACS). UACS is the most common cause of chronic cough and is implicated in up to 85% of chronic cough in nonsmokers.^20,21 The diagnosis encompasses post-nasal drip syndrome and other common causes of rhinitis. (See Table 1.) The most commonly proposed mechanism involves draining nasal or sinus secretions into the hypopharynx and larynx causing recurrent irritation and stimulation of cough receptors.²² There is also evidence that patients diagnosed with UACS have a hypersensitive cough reflex.²³ Patients with UACS typically present with a globus sensation, nasal secretions, or frequent throat clearing. However, absence of these symptoms does not necessarily exclude the diagnosis. Physical exam findings might include a visible draining trail of mucous or clear secretion in the posterior oropharynx, or cobblestoning and inflammation to the posterior pharyngeal mucosa.

Asthma and Non-Asthmatic Eosinophilic Bronchitis (NAEB). After UACS, asthma is the second most common cause of chronic cough in adults, affecting 24-29% of patients in the outpatient setting.²⁴ Many of these patients will present with typical wheezing and asthma symptoms. In up to 57% of asthma cases, cough may be the only presenting complaint.^25,26 This cough-variant asthma may present without the expected physical exam finding of wheezing, but will invariably respond to inhaled bronchodilators.

Patients with NAEB have eosinophilic airway inflammation (like asthma) but (unlike asthma) lack airway hyperresponsiveness.²⁷ Bronchodilator therapy is typically ineffective, but they do respond to treatment with oral and inhaled corticosteroids. Diagnosis of NAEB is more suitably left to specialists. Nevertheless, it can be appropriate to initiate empiric therapy with inhaled corticosteroids in the emergency department so that an assessment of effectiveness is possible when the patient sees the specialist after discharge.

Gastroesophageal Reflux Disease (GERD). GERD is commonly thought to cause cough by microaspiration. However, numerous studies have now demonstrated an esophageal-tracheobronchial initiation of the cough reflex, elicited by lowered pH in the distal esophagus.²⁸

GERD has been considered a common cause of chronic cough, but recent literature suggests that this is rarely an isolated cause of chronic cough.^29,30 Cough caused by reflux disease was believed to be present without classic reflux symptoms up to 75% of the time.³⁰ This was largely derived from a study of coughing patients who were questioned about typical GERD symptoms after empiric therapy for GERD led to improvement in cough.²⁸ A Cochrane review in 2011 left significant doubt regarding the validity of this assumption, although significant improvement in cough scores was noted after two to three months of empiric therapy with proton pump inhibitors compared with placebo.³¹

Diagnostic Approach to the Coughing Patient

Acute Cough.^32,33 (See Figure 1.) Evaluation of acute cough should focus on diagnosis of an upper or lower respiratory infection, an exacerbation of a chronic respiratory condition, environmental or ACEI exposure, and whether the presentation could represent atypical HF, acute coronary syndrome (ACS), or PE presentation.

Figure 1: Acute Cough

Acute bronchitis is one of the most common emergency department diagnoses provided for the coughing patient, but is thought to be overused.³⁴ The diagnosis of acute bronchitis should only be considered in a patient with cough less than three weeks, in the absence of exacerbation of chronic reactive airway disease or nasal and upper respiratory tract symptoms more consistent with the common cold, and without evidence for pneumonia on chest radiography.³⁴

Subacute Cough. Similar to acute cough evaluation, subacute cough assessment should focus on identifying post-infectious or ongoing infectious sources. Suspicion for pertussis and post-viral bacterial pneumonia should be higher in these patients. If no infectious source is apparent, these patients should be evaluated as chronic cough patients.

Chronic Cough.^24,29,33,35 (See Figure 2.) Patients presenting with chronic cough should be asked about risk factors and symptoms that might suggest the presence of HIV/AIDS, tuberculosis, cancer, and any other immunocompromised status. It is appropriate to obtain a chest radiograph, primarily to assess for radiopaque foreign body, bronchogenic carcinoma, or mediastinal mass.

Figure 2: Chronic Cough

Environmental and Occupational Causes

Current data suggest that up to one in six cases of adult asthma and chronic cough can be attributed to occupational exposure.^36,37 Along with questions about smoking and ACEI use, it is reasonable to screen patients with chronic cough for occupational exposures. Questions about co-workers with similar symptoms, whether there is improvement of complaints on the weekend or vacation, or if the patient can recall a sentinel event (spill, explosion), are all appropriate in the evaluation.

At-risk groups include mine workers, farmers, painters, cleaners, bakers, and lumber industry workers, among others exposed to high levels of aerosolized substances.³⁸ The most common agents found to contribute to occupational chronic cough and asthma symptoms are: adhesives, metals, resins, flour and grain dust, latex, animals, aldehydes, and wood dust.³⁶ Farming is associated with numerous respiratory hazards and results most commonly in asthma and rhinitis. Exposure to wet winter conditions and high mold counts in stored crops can lead to fungal pneumonias and hypersensitivity syndromes. Several severe acute cough syndromes are also associated with high nitrite gas or organic dust exposure.³⁹ Symptom monitoring of 9/11 World Trade Center responders suggests a 12-fold rate of chronic cough and bronchitis symptoms in exposed individuals.⁴⁰

Patients should be informed of the risks of continued exposure to inciting toxins or triggers and referred to an occupational medicine or pulmonary clinic if available. Work restriction, personal protective measures, or appropriate trigger avoidance should be suggested.

Evaluation for Pertussis

The presence of prolonged cough and upper respiratory infectious symptoms should raise suspicion for pertussis. Studies have shown up to 20% of urban adult patients presenting for greater than two weeks of cough have positive pertussis antibody on testing.^41,42 Paroxysmal cough, inspiratory whoop, or post-tussive emesis is less likely to be present in a previously vaccinated population.

Microbial culture has been the gold standard to diagnose pertussis, but may miss more than 50% of cases (sensitivity 12-60%), especially when symptoms have been present for two weeks or more. Polymerase chain reaction (PCR) is much more sensitive (70-99%), but may return up to 14% false positives. Direct fluorescent antibody (DFA) testing gives results within minutes, but has highly variable sensitivity and specificity, and is not recommended by the Centers for Disease Control and Prevention. In general, if the patient presents in the first three weeks of disease, nasopharyngeal swabs should be sent for PCR or DFA, depending on the individual lab, along with microbial culture. If the patient presents after three weeks, serologic testing may be more appropriate, as the nasopharyngeal swabs become even less sensitive at this point. However, if the clinician has high pre-test suspicion for pertussis based on the presence of classic symptoms or known exposure in an unvaccinated individual, treatment should be initiated regardless of testing results due to limited sensitivity in all of the available tests.⁴³ Furthermore, these tests should not be used to screen patients in whom there is very low or no suspicion for pertussis, as this will result in high false-positive rates and unnecessary antibiotic use.

Patients should be isolated from unvaccinated or under-vaccinated individuals, especially infants, at least until 5-7 days of therapy are completed, but ideally for four weeks. Therapy will not decrease the duration of symptoms once patients have reached a paroxysmal cough stage, but will decrease the rate of transmission.⁴³

Management of Chronic Cough

ACEI Use and Smoking. Studies have shown that cough is present in up to 10-12% of patients taking ACEIs. Patients with chronic cough and ACEI use for less than one year should have them discontinued, preferably in conjunction with their primary physicians.^33,44 ACEI-induced cough should be expected to resolve from two days to two weeks after cessation, but may take as long as four weeks to see improvement.⁴⁴

Smokers should be offered counseling for quitting and should expect improvement in coughing within four weeks after smoking cessation.³³

Table 2: Treatment Choices for Undifferentiated Chronic Cough

UACS, Asthma, and GERD. (See Table 2.) Studies have shown that patients’ descriptions of duration of symptoms, quality of cough, and sputum production are unreliable in establishing an eventual diagnosis.⁴⁵ Therefore, these conditions are now defined by a response to therapy, rather than a classic constellation of symptoms. If one diagnosis appears most likely based on brief questioning, it is appropriate to treat this etiology first. Otherwise, therapy should be directed to each cause in order of prevalence.

UACS. In the undifferentiated patient, initial treatment should be directed at this potential cause. Therapy should involve a combination of a first-generation antihistamine and a decongestant.⁴⁶ A minimum of two weeks’ therapy is recommended, although complete symptom resolution might not be seen for several weeks or months.³³

Asthma. In a patient who has failed a trial of antihistamines and a decongestant, it is appropriate to initiate a trial of inhaled albuterol in the emergency department, even in the absence of wheeze or prolonged expiratory respiration on exam. If the patient has improvement of symptoms, he or she may be discharged with an inhaled beta-agonist and inhaled corticosteroids with the presumptive diagnosis of cough-variant asthma and a referral back to the primary care physician or a specialist for follow-up and more extensive testing as needed.^24,26 Even with normal spirometry and hyperresponsiveness testing, current recommendations allow for exclusion of cough-variant asthma as a source of chronic cough only after a trial of typical therapy has failed.²⁶

GERD. Empiric treatment in the absence of typical GERD symptoms should not be instituted unless the patient has already failed an adequate trial of therapy for UACS and asthma. It is reasonable to suggest common lifestyle modifications that have been shown to improve reflux symptoms, while initiating therapy for UACS or asthma.³⁰ If medical therapy is initiated from the emergency department, a proton pump inhibitor with or without a prokinetic agent is preferred.^30,47,48 Treatment of up to 2-3 months might be necessary for effectiveness to be seen and responsiveness determined. However, the benefit of such an approach has been called into question by two recent publications.^49,50

Role for Antibiotics in the Coughing Patient

Evidence supports antibiotic treatment for pneumonia, COPD exacerbation, and pertussis infections. (See Table 3.) Severe cases of acute sinusitis and sinusitis with symptoms lasting longer than a week may be assumed to be bacterial, and antibiotic therapy is often recommended. Severe sinusitis is characterized by high fever, exquisite tenderness to palpation of sinuses, or overlying cellulitis, in addition to the usual symptoms of nasal discharge, congestion, and sinus pain. Most other cases of sinusitis are due to viral sources that will likely resolve without antibiotic therapy.⁵¹

Table 3: Conditions Where Evidence Supports Antibiotics in the Coughing Patient⁴⁶

Acute bronchitis is a common diagnosis in the emergency department and is often associated with antibiotic prescription, contrary to recommendations of published guidelines.^34,52,53 In a 2012 study, 74% of emergency department patients with a diagnosis of acute bronchitis were prescribed antibiotics, 77% of those being broad spectrum.⁵⁴

Physicians were more likely to prescribe antibiotics if they thought the patient was expecting them. The practice of delayed antibiotic prescription has been suggested as a way to decrease unnecessary antibiotic use while preserving satisfaction scores. A Cochrane review in 2010 determined that there was little evidence to suggest improved patient satisfaction with delayed antibiotic prescribing compared with having the difficult conversation up front.⁵⁵

Role for Cough Suppressants

Despite their widespread use, studies on the effectiveness of various cough suppressants are surprisingly scant and often contradictory. (See Table 4.) A recent Cochrane review found no good evidence for or against the effectiveness of over-the-counter remedies in adults with acute cough.⁵⁶

Table 4: Choosing Suppressive Therapy⁶³

Opioids are believed to suppress cough via their action on the central nervous system. Codeine is a commonly prescribed drug in this class, yet evidence on its effectiveness is limited at best.^57-60 Hydrocodone is recommended for cancer-related cough, but its use in cough of other etiologies is mostly inferred. Dextromethorphan has a more favorable side-effect profile, although clinical studies have yielded mixed results. More recently, slow-release morphine was found to be effective in patients with chronic cough in a double-blind, crossover, placebo-controlled trial.⁶¹

In terms of peripherally acting medications, inhaled ipratropium seems to be useful in suppressing acute and chronic cough in small studies. Guaifenesin has also been found to be generally effective. In a recent study, the addition of benzonatate to guaifenesin in patients with viral cough resulted in improved cough suppression, the first new evidence on its effectiveness in more than half a century.⁶²

Disposition

Patients with cough may be discharged home from the emergency department if no serious or life-threatening pathology is found. Further outpatient workup, if indicated, should be coordinated with the patients’ primary physicians or referral specialists.

Hiccups

A hiccup, also known as a hiccough or singultus, is due to sudden inspiration followed by abrupt closure of the glottis (Latin singult = a gasp or a sob). Hiccups are more common in children than adults, more common in adult men than in women, and more common in those with co-morbid conditions.^64,65 While hiccups are often benign and self-limiting in most individuals, they can be debilitating and cause significant distress if prolonged. Hiccups are termed bouts if they last for less than 48 hours, persistent if they last for more than 48 hours, and intractable if they last for more than a month.

Pathophysiology

Hiccups are caused by involuntary, rhythmic contractions of the diaphragm and other accessory respiratory muscles. Their function is unknown, and the exact neurological pathway has yet to be elucidated. Nevertheless, they were thought to be mediated by a reflex arc with involvement of the central nervous system, the vagus nerve, and the phrenic nerve. A “hiccup center” is postulated to be located in the brainstem or the spinal cord, receiving afferent input from the vagus nerve, the phrenic nerve, and the sympathetic chain. Efferent outputs are transmitted mostly via the phrenic nerve. Multiple neuroreceptors (dopamine, serotonin, opioid, gamma-aminobutyric acid [GABA], and calcium channels) are hypothesized to be involved. Stimulation or pathology anywhere along the reflex arc can result in hiccups.

Etiology and Differential Diagnosis

Gastric distension from food, carbonated beverage, or aerophagia is a common cause of benign, self-limiting hiccups. Persistent hiccups are usually due to injury or irritation to the central nervous system, the vagus nerve, or the phrenic nerve. Since the vagus and phrenic nerves innervate or course near multiple head, neck, thoracic, and abdominal organs and structures, the differential diagnosis can be extensive. In addition, hiccups can be psychogenic, metabolic, or pharmacologic in etiology. (See Table 5.)

Table 5: Etiology of Hiccups

Central Nervous System Disorders

Ischemic/ hemorrhagic stroke

Arteriovenous malformation

Temporal arteritis

Encephalitis

Meningitis

Brain abscess

Neurosyphilis

Intracranial neoplasms

Brainstem neoplasms

Multiple sclerosis

Hydrocephalus

Syringomyelia

Head trauma

Cardiovascular Disorders

Myocardial infarction

Pericarditis

Abdominal aortic aneurysm

Gastrointestinal Disorders

Aerophagia

Gastric distension

Esophageal distension

Esophagitis

Gastritis

Hepatitis

Inflammatory bowel disease

Pancreatitis

Peptic ulcer disease

Pancreatic cancer

Gastric carcinoma

Abdominal abscess

Gallbladder disease

Peritonitis

Medications

Alpha methyldopa

Steroids

Benzodiazepines

Short-acting barbiturates

Chemotherapy agents

Post-operative

Gastric distension

General anesthesia

Intubation (stimulation of glottis)

Neck extension (stretching of phrenic nerve roots)

Traction on viscera

Psychogenic

Stress

Excitement

Conversion reaction

Malingering

Thoracic Disorders

Empyema

Pneumonia

Pleuritis

Asthma

Bronchitis

Aortic aneurysm

Mediastinitis

Chest trauma

Mediastinal and lung tumors

Thoracic adenopathy secondary to infection/neoplasm

Toxic-metabolic

Alcohol

Uremia

Hyperglycemia

Hyponatremia

Hypocalcemia

Hypocapnia

Vagus and Phrenic Nerve Irritation

Goiter

Pharyngitis

Laryngitis

Foreign body irritation of tympanic membrane

Neck cyst or tumor

Adapted from: Lembo AJ. Overview of hiccups. UptoDate. www.uptodate.com. Accessed 4/7/2012.

Diagnostic Approach in the Emergency Department

Patients with hiccups should be asked about onset, severity, and duration of symptoms, modifying factors, recent trauma or surgery, co-morbid conditions, alcohol and illicit drug use, and current medications. A concise review of systems may help uncover unsuspected causes. Associated neurologic, cardiac, respiratory, and gastrointestinal symptoms should be specifically sought. In general, hiccups that persist during sleep suggest an organic cause, while hiccups that resolve during sleep suggest a psychogenic cause, although this distinction is not absolute.

A careful physical examination should be performed in search of an underlying etiology. In particular, one should look for signs of potentially life-threatening conditions such as central nervous system pathology, myocardial injury, vascular dissection, acute surgical abdomen, and malignancy. The head and neck should be examined carefully to look for signs of trauma, infection, goiter, and other masses. An otoscopic exam should be diligently performed, since a rare but easily treatable cause of hiccups is a foreign body (usually hair) on the tympanic membrane stimulating the auricular branch of the vagus nerve.

An electrolyte and renal function panel can detect causes such as uremia, hypocalcemia, and hyponatremia. (See Figure 3.) Chest radiography may help identify intrathoracic pathology. A screening electrocardiogram (ECG) is prudent in patients with risk factors or significant co-morbidities for ischemic heart disease, since there have been case reports of hiccups as a presenting symptom in patients with myocardial infarction⁶⁶ or ischemia.^67,68

Figure 3: Diagnostic Approach to Hiccups in the Emergency Department

Management

Specific reversible causes should be treated when found. The following pertains to management of idiopathic or unrelenting cases of hiccups.

Many of the non-pharmacologic treatments suggested by various authors are based on stimulation of the vagus nerve or disruption of the normal respiratory cycle in the hope of interrupting the hiccough reflex arc. (See Table 6.) However, most of them have not been tested by rigorous scientific trials, and no one method seems to be more effective than others.

Table 6: Non-pharmacolog Treatment Options for Persistent or Intractable Hiccups

• Biting on lemon
• Breath-holding/breathing into paper bag
• Direct stimulation of nasopharynx or uvula with cotton swab/catheter
• Drinking from the opposite side of the glass
• Fright
• Ice water gargle
• Noxious odors (inhaling ammonia)
• Pulling knee to chest
• Swallowing granulated sugar/peanut butter
• Tongue traction
• Vagal maneuver (Valsalva, pressing on eyeballs, carotid sinus massage)

A myriad of pharmacologic agents have been reported to be effective in treatment of hiccups, lending support to the theory that multiple neuroreceptor types are involved in the postulated hiccough reflex arc. Chlorpromazine, a phenothiazine antipsychotic, is the only medication approved by U.S. Food and Drug Administration (FDA) for treatment of hiccups based on small case series. It is postulated to work by antagonism of central dopamine neuroreceptors. Haloperidol (non-FDA approved) likely has a similar mechanism of action.

Other off-label drugs reported to be effective hiccough treatment in case series consisting of more than 10 patients include gabapentin, baclofen, and metoclopramide.^69-72 Valproic acid and nifedipine were also used to treat hiccough with some success in case series of five and seven patients, respectively.^73,74 In addition, there have been numerous case reports attesting to successful hiccough therapy with various classes of medications such as anticonvulsants (phenytoin, carbamazepine), antidepressants (amitriptyline, sertraline), central nervous system agents (methylphenidate, amantadine, olanzapine), steroids (dexamethasone), benzodiazepines (midazolam), and antiarrhythmics (quinidine, lidocaine). To date there has not been any published clinical trial comparing the effectiveness of different hiccough medications. Hence, the choice of pharmacologic therapy is somewhat empirical and clinician-dependent. Most drug treatments are prescribed for 7-10 days and may be discontinued upon cessation of symptoms. (See Table 7.) Potentially serious side effects include hypotension, arrhythmias, glaucoma, and delirium.

Table 7: Common Drug Treatment Options for Persistent or Intractable Hiccups

For refractory or debilitating hiccups, more invasive treatment options such as phrenic nerve block, controlled phrenic and vagal nerve stimulation, and phrenic nerve crushing via surgery can be considered in consultation with the appropriate specialists. Alternative medicine treatments such as hypnosis and acupuncture have also been found to be effective in some cases.^75-78

Disposition

Generally, patients with hiccups can be discharged home if no significant pathology is found during an emergency department screening examination.

In cases of failed non-pharmacologic treatment, medications such as chlorpromazine, haloperidol, metoclopramide, baclofen, among others, can be initiated. Well-appearing patients with negative emergency department screening examinations can be sent home on 7-10 days of outpatient therapy.

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41. Wright SW, Edwards KM, Decker MD, et al. Pertussis infection in adults with persistent cough. JAMA 1995;273(13): 1044-1046.

42. Nennig ME, Shinefield HR, Edwards KM, et al. Prevalence and incidence of adult pertussis in an urban population. JAMA 1996;275(21):1672-1674.

43. Centers for Disease Control and Prevention. Pertussis (whooping cough). www.cdc.gov/pertussis/clinical Accessed June 25, 2012.

44. Simon SR, Black HR, Moser M, et al. Cough and ACE inhibitors. Arch Intern Med 1992;152:1698–1700.

45. Mello CJ, Irwin RS, Curley FJ. Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause. Arch Intern Med 1996;156: 997-1003.

46. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl):1S–23S.

47. Benini L, Ferrari M, Talamini G, et al. Reflux associated cough is usually not associated with reflux: Role of reduced cough threshold. Gut 2006;55(4):583;author reply 583-584.

48. O’Hara J, Jones NS. The aetiology of chronic cough: A review of current theories for the otorhinolaryngologist. J Laryngol Otol 2005;119(7):507-514.

49. Faruqi S, Molyneux ID, Fathi H, et al. Chronic cough and esomeprazole: A double-blind placebo-controlled parallel study. Respirology 2011;16(7):1150-1156.

50. Shaheen NJ, Crockett SD, Bright SD, et al. Randomized clinical trial: High-dose acid suppression for chronic cough – a double-blind, placebo-controlled study. Aliment Pharmacol Ther 2011;33(2): 225-234.

51. Smith SR, Montgomery LG, Williams JW. Treatment of mild to moderate sinusitis. Arch Intern Med 2012;172(6):510-513.

52. Wenzel RP, Fowler AA. Clinical practice. Acute bronchitis. N Engl J Med 2006;355:2125–2133.

53. Wong DM, Blumberg DA, Lowe LG. Guidelines for the use of antibiotics in acute upper respiratory tract infections. Am Fam Physician 2006;74(6):956–966.

54. Kroening-Roche JC, Soroudi A, Castillo EM, et al. Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department. J Emerg Med 2012 Feb 16. [Epub ahead of print]

55. Spurling GK, Del Mar CB, Dooley L, et al. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev 2007 Jul 18;(3):CD004417.

56. Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2008 Jan 23; (1):CD001831.

57. Smith J, Owen E, Earis J, et al. Effect of codeine on objective measurement of cough in chronic obstructive pulmonary disease. J Allergy Clinc Immunol 2006;117(4):831-835.

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90,000 Allergies in infants treatment, allergies in newborns, allergies in infants, food allergies in infants, allergic rashes in infants ›Clinic” Forpost “

What is the risk of developing an allergy in an infant

One of the common causes of allergies in infants is formula milk. Despite the fact that manufacturers try to adapt milk formulas as much as possible, they still cannot be fully adapted for the child.

If the parents or relatives of the baby have allergies, asthma, allergic rhinitis, urticaria or atopic dermatitis, then through genes they can “reward” him with a predisposition to allergies.The risk of developing an allergy in infants to formula milk depends on the degree of the child’s predisposition, the more allergy sufferers in the family, the higher the likelihood of developing an allergy:

• 10-20% – family without allergies;
• 20-40% – 1 parent has an allergy;
• 50-80% – both parents suffer from allergic diseases.

For children with a predisposition to allergies, it is very important not to receive cow’s milk, which contains a lot of casein (there is much less of it in breast milk).Therefore, it should be noted that children prone to allergies are not supplemented with conventional mixtures in maternity hospitals, as this leads to allergization of the child from the first days, and adaptation breaks down and then such children are more likely to develop allergies.

Manifestations of infant allergy to formula milk

Signs of allergy to milk protein can manifest themselves as an immediate type (IgE-dependent), the reaction is manifested after consuming the milk mixture during the first 30 min-2 hours), and a delayed type (IgG4-dependent) – does not appear immediately, but in within one or two days.Allergy in infants to formula milk manifests itself:

• rash on the skin in the form of various dermatitis, urticaria, rash around the mouth;
• inflammation on the cheeks, buttocks, legs, back, external genitals in the form of redness, papules, accompanied by itching;
• gastrointestinal manifestations in the form of vomiting, hiccups, regurgitation, upset stools (constipation, diarrhea, bloating, intestinal colic).

Which components of infant formula cause allergies in a child? 80% of infant formula is made on the basis of cow’s milk, because cow’s milk is the most identical in composition to human milk and contains the necessary proteins and microelements for the growth and development of a child.20% of the mixtures are made on the basis of soy or goat milk.

Food allergy in infants. Allergy of children under one year old to milk

Cow’s milk contains proteins such as casein, lactalbumin and lactglobulin. All three proteins can cause allergies in a child, either individually or all at the same time. Lactalbumin and lactglobulin are thermolabile, which means that they are destroyed by boiling and can no longer cause allergies in a child. Casein, on the other hand, is thermally stable (i.e.(i.e. it is not destroyed by boiling and may cause an allergic reaction). Unfortunately, children are most often allergic to casein.

Diagnosis of allergies in infants There are tests that determine immunoglobulins (antibodies) to casein, lactalbumin, lactglobulin, i.e. you can check the baby’s allergy to all the main protein components of milk. This is possible only with the help of molecular allergy diagnostics, which determines the allergy not to the entire product, but to its individual components.

Allergic rash in infants. Allergy to cereals

Sometimes milk formulas may contain various cereals (buckwheat, oats, rice), then the child may be allergic to these cereals. Such formulas are usually intended for older children – after 6 months. Accordingly, tests are made for the respective components of the cereals. You can simply separately make IgE for wheat, rye, others. But it is best to do molecular component diagnostics → for the main (major) proteins of cereals (rPhl p1, rPhl p5b), which are included in buckwheat, wheat, rye, fescue and many other cereals, as well as minor (rPhl p7, rPhl p12) proteins, due to which cross-reactions with other foods and plants often occur.

What are hypoallergenic formulas and are they prescribed for allergies in infants If initially we know that parents are allergic and the likelihood of developing allergies in a child is high, then it is recommended to immediately start feeding with hypoallergenic mixtures, preventing the development of allergies in the child.

Hypoallergenic mixtures are hydrolysates of cow’s milk proteins (i.e.that is, the protein is split into amino acids). As a rule, there is no allergic reaction to these mixtures. But hydrolysates, due to the broken down protein, become bitter in taste. Therefore, in the beginning it happens that the child does not want to eat, and although his taste buds are not as developed as in an adult, he still feels a bitter taste, especially since his mother’s milk is sweet. Therefore, it is necessary to gradually accustom the child to the hydrolyzate, at first, in the first 3-5 days, he may refuse, and then he gets used to it. It is important that parents do not rush to cancel the mixture, as a mixture that cannot be fed to a child.

Types of hypoallergenic mixtures for allergies in an infant

There are hydrolysates depending on the degree of hydrolysis of milk protein: moderate and high hydrolysates. If the baby’s allergy is not severe, then moderate hydrolysates are recommended, since they have small amounts of allergens and thus “train” and “accustom” the baby’s immune system.

Does your child have skin rashes, gastrointestinal problems ?! This is a minimally traumatic tactic for examining infants and older children.Search for the cause of the problem, taking into account possible allergies.

Stages:

1. An analysis of feces for a coprogram is taken, which looks at the degree of food digestion, signs of inflammation in the intestines, the presence of pathogenic (iodophilic) flora, etc.
2. Ultrasound of the abdominal organs, which allows you to identify possible developmental anomalies (atresia, underdevelopment of the bile ducts, deformation of the gallbladder, etc.)
3. Blood test to determine the level of total immunoglobulin E and / or Phadiatop Infant.Fadiatop Infant is an allergy screening test that contains all staple foods – milk, eggs, wheat, etc., as well as inhaled allergens. If this test is positive, then component allergy diagnostics is necessary. If negative, go to paragraph
4. Component diagnostics of allergy to casein, lactalbumin, lactglobulin (if the child consumes only milk formula). If the child is more than 6 months old and he consumes various cereals, then component diagnostics for cereals is necessary.
5. In case of negative results of allergy tests, tests for lactase deficiency and celiac disease are carried out.

Prevention of allergy in newborns and older children

Breastfeeding helps to strengthen the baby’s immunity. Even though the parents are allergic, it is desirable that the mother breastfeed her baby. Through breast milk, the child gets acquainted with all the proteins of the surrounding world and, along with an allergic reaction, is produced in it – an antiallergic reaction, an adaptive one.Thus, the child quickly adapts and outgrows this increased sensitivity to various substances and proteins of the surrounding world.

Memo ECS »GBUZ SK” Regional Clinical Cardiology Dispensary “

1633

Life with a pacemaker

A pacemaker (Pacemaker) is a device designed for people whose heart beats too slowly or irregularly.It is a substitute for the natural pacemaker and restores one of the most important rhythms of life. Since the first pacemaker was successfully implanted, more than two million people have benefited from this invention.

Heart rate

Heart rate is individual and depends on age, nationality, constitution, lifestyle and profession. In a newborn, the heart beats at a rate of 140–180 beats per minute. With age, the frequency decreases, and in adults, values ​​from 60 to 100 beats per minute are considered normal.Conditions in which the heart rate is less than 60 beats per minute are called bradycardia, above 100 – tachycardia.

Heart electrical system

The heart has its own electrical system that makes it beat and controls the frequency of its contractions. It includes two nodes and many paths. Special tissues generate electrical signals that travel along a kind of “electrical wires” of the heart every time it beats.The pacemaker in a healthy person is the sinus node. After an impulse is born here, it is conducted on the atria, forcing them to contract and push blood into the ventricles. Then the impulse is delivered to the ventricles. On the way to them, it lingers in the second node, atrioventricular, and only then spreads along the conducting system of the ventricles: the branches of the His bundle and the Purkinje fibers. This delay is necessary for the synchronous operation of the heart chambers: atrial contraction → expulsion of blood from the atria to the ventricles → contraction of the ventricles → expulsion of blood into the great vessels (aorta and pulmonary artery).

Causes of bradycardia

1) Sick sinus syndrome. This is a disease in which the sinus node, the natural driver of the heart rate, becomes “lazy” and generates electrical impulses too slowly. Sometimes he just “forgets” about his work. And then there is a pause, during which the heart stops. The first organ that responds to a lack of blood is the brain. Due to an inadequate supply of oxygen, severe weakness, dizziness, darkening of the eyes and loss of consciousness for a few seconds occur.

These episodes in medicine are called Morgagni-Adams-Stokes attacks, after the doctors who described them 200 years ago.

With prolonged chronic bradycardia, all organs, including the heart, experience a constant lack of blood flow. As a consequence, both heart disease and non-heart disease progress.

2) Atrioventricular block. Electrical impulses in this disease are blocked on the way from the atria to the ventricles. However, the heart is protected from such an unexpected error of nature; otherwise it would stop beating.In this case, another part of the ventricle takes over the function of a pacemaker and makes the heart work, but with less efficiency. Thus, the chambers of the heart have different pacemakers and contract independently of each other: the atria are frequent, the ventricles are rare (30–60 per minute).

3) The combination of both forms of bradycardia. Bradycardia is a consequence of heart disease, myocardial infarction, cardiac surgery, or the aging process. The exact cause may not be known.

4) Condition after some arrhythmological operations.In some cases, with tachycardia, an operation is required to eliminate this arrhythmogenic focus. For this, the surgeon passes several electrodes into the heart cavity through the main vessels and processes the zone of the atrioventricular node with radiofrequency energy, stopping the conduction from the atria to the ventricles. After this operation, the ventricles begin to contract rhythmically, but slowly, and this requires the installation of a pacemaker.

5) Other causes of fainting. Fainting can have more than twenty causes of both cardiac and non-cardiac origin.Fainting that occurs due to cardiac pauses is the most dangerous and portends a cardiac catastrophe due to a longer cardiac arrest.

6) Severe heart failure. In patients with severe dyspnea, low cardiac contractility and lagging of the left ventricle from the right, which is manifested on the ECG by a complete blockade of the left bundle branch, a resynchronizing (or three-chamber) pacemaker is installed. Its task is to synchronize the contraction of all four chambers of the heart, which increases the pumping function of the left ventricle and improves the functional state of the heart and exercise tolerance.

Pacemaker device

A pacemaker, also called a pulse generator, is a small device weighing 22–45 g and measuring no more than 55 mm. It contains a battery and a microcircuit enclosed in a titanium case, which allows the pacemaker to stay in the human body for a long time without a negative reaction from the body. The pacemaker has three main components:

1. The battery provides electrical energy for the ECS.This is a small, sealed lithium iodine battery that usually lasts for many years.
2. The electronic circuit is like a mini-computer inside the ECS. It converts the energy from the battery into tiny electrical signals that the patient cannot perceive. The circuit controls the timing of the pulses directed to the heart.
3. Electrode – an insulated wire connected to the pacemaker, which carries an electrical impulse from the device to the heart and transmits information regarding the natural activity of the heart back to the pacemaker.The electrodes are extremely flexible to resist twisting and bending that results from heart contractions or body movements. One end of the electrode is connected to the pacemaker, the other end is placed in the right ventricle or right atrium of the heart. One or two electrodes are used depending on the type of pacemaker prescribed by your doctor. The manufacturer of pacemakers checks each component individually and the entire system as a whole at each stage of production.

Types of pacemakers

Currently there are over 300 ECS models. The type of pacemaker that will be implanted in you depends on the disease, comorbidity, physical properties of the heart and the activity of your lifestyle. You can be absolutely sure that the doctor is familiar with all the existing possibilities and will be able to choose the most suitable model.

Doctors recommend pacemaker to relieve the patient from bradycardia or prolonged pauses in the work of the heart.Because of these rhythm disturbances, the heart is unable to satisfy the body’s demands, which is reflected in symptoms such as dizziness, weakness, severe fatigue, shortness of breath or fainting.

Preparation for operation

After you are admitted to the hospital, you will have a preoperative diagnosis. Your doctor will give you special instructions before surgery. Some of them will be as follows:

1. You must stop eating and drinking after midnight the night before your surgery.
2. The evening before your implantation procedure and 30 minutes before you leave the room and go to the operating room, you will receive some sedatives and anesthetics (drugs that relieve pain).

Operation progress

The pacemaker can be implanted in endocardial or myocardial variants. The first method is most often used. Endocardial implantation is performed under local anesthesia (pain relief). General anesthesia (anesthesia) is used only in children.The surgeon will process the operating field and anesthetize it by several injections with an anesthetic – novocaine or lidocaine. If you have an allergic reaction to local anesthetics, such as those used by your dentist, be sure to tell your doctor. During the operation, you may not experience any sensations or feel that the doctor is performing some action in the subclavian region. During surgery, you may be napping or tempted to sleep. In this case, your sleep will be superficial and you can easily answer any question of the surgeon.

Most of the operations have the following sequence. A small incision 6–7 cm long is made under the collarbone (parallel to it). The location of the area where the pacemaker is placed (right or left) depends on the patient’s disease, age and lifestyle. The surgeon will then locate the subclavian vein and pass an electrode through it into the heart. The electrode will be advanced under X-ray control until it reaches the desired heart chamber.

Single-chamber pacemaker implantation requires only one lead.The patient’s illness determines which chamber the electrode is placed in (atrium or ventricle).

When implanting a two-chamber pacemaker, two electrodes are used, a three-chamber (resynchronizing) pacemaker – three electrodes. In this case, one electrode is passed into the right ventricle, the second electrode – into the right atrial appendage, the third – into the coronary sinus (a small vein of the heart that is adjacent to the left ventricle). After passing the electrode into the corresponding chamber of the heart, the doctor will measure the electrical parameters of several areas of the heart muscle and place the tip of the electrode at the point with the lowest electrical resistance.Then the outer end of the electrode will be docked with the pacemaker unit, which is immersed in the subcutaneous fatty tissue here in the subclavian region. The operation ends with suturing the incision, usually a cosmetic suture is applied. The total duration of the operation, as a rule, does not exceed 1.0–1.5 hours.

Myocardial implantation

If you have a heart disease for which a cardiac surgery is planned, then, perhaps, at the same time, you will be implanted with a pacemaker in the myocardial version, with the electrode attached to the heart from the outside.Then the operation takes place under anesthesia, the surgical access is carried out through the sternum or the left intercostal space, and the pacemaker is located in the abdominal muscle or in the abdominal cavity. The same method can be recommended by the doctor if it is impossible to install the electrode in the usual transvascular way. Immediately after implantation, the pacemaker begins to generate electrical impulses that cause the heart muscle to contract after stimulation. However, this impulse is born only if there is a long pause in the work of the heart.The rest of the time, the pacemaker works in a “standby” mode, carefully monitoring all signals of the natural heart rate. Thus, it is wrong to imagine the ECS only as an artificial pacemaker, completely replacing its own conducting system. Rather, he is a helper for the heart in situations that can be life-threatening.

Post-transaction period

From the operating room you will be transferred to the anesthesiology-intensive care unit. Hospital staff will monitor your heart by monitoring your ECG and heart rate to make sure the pacemaker is functioning properly.Therefore, you can get up and walk around the department only in the morning the next day.

For the first few days, you will feel mild discomfort in the incision area. Therefore, after surgery, the doctor usually prescribes pain relievers and antibiotics.

There may be a feeling of heaviness in the beginning. You will be aware that you have a pacemaker and will want to touch it. But soon you will get used to it and it will seem that the pacemaker is part of your body.Tell your doctor or nurse if you experience severe discomfort.

Be sure to tell your doctor about the following symptoms:

• muscle twitching in the area of ​​the pacemaker,
• unpleasant sensation of jolts and pulsations in the area of ​​
• stomach or liver,
• episodes of severe hiccups,
• feeling the beat of your EKS,
• return of preoperative episodes of dizziness and loss of consciousness.

Dressings will be performed daily.As a rule, stitches do not need to be removed after surgery. The length of hospital stay depends on the disease and the type of intervention performed.

Follow doctor’s advice

You, your healthcare professional and other professionals play an important role in monitoring your pacemaker to provide you with the most effective follow-up treatment. The attending physician will give advice on nutrition, medications and actions to be taken or, conversely, avoided.The doctor may prescribe some foods that benefit the heart and refuse others. He may also prescribe medications that will work along with a pacemaker to help your heart beat properly.

If you have any of the following symptoms, contact your doctor immediately:

• sudden shortness of breath,
• dizziness,
• fainting,
• persistent weakness or fatigue,
• chest pain,
• constant hiccups,
• edema on the legs, arms,
• sudden or persistent heartbeat,
• redness or blue discoloration of the skin in the area of ​​the stimulator, or the appearance of a skin defect (ulcer) above it.

The doctor will tell you about the next schedule of appointments with him to check the apparatus. Before you leave the clinic, you will be shown how to measure your heart rate correctly and will be scheduled for the day of your first regular check-up. Follow-up attendance is usually required 3 months after discharge, then 6 months later, and thereafter once a year. Of course, as the expiration date of the pacemaker approaches, appointments with a doctor will become more frequent.

Programming procedure

All modern pacemakers are multi-programmable.This means that most of their parameters can be changed if necessary. Thus, it is possible to simulate the natural rhythm of the heart.

Programming is carried out without surgical intervention by introducing a pacemaker into a magnetic field through the head of the programmer (the device that performs programming), which is applied to the skin above the pacemaker.

During the sessions of checking the pacemaker, the doctor will extract all the diagnostic information that the device has accumulated, assess its interaction with the heart, check the condition of the electrodes and the battery, and optimize the pacemaker parameters for the heart.All this will ensure that the pacemaker fully meets the needs of your body. The doctor himself will try to make the programming procedure as comfortable as possible. However, during the session, you may feel intermittent interruptions in the work of the heart, pauses, sudden palpitations. These sensations are the result of testing the device, do not pose any danger and will completely disappear after the programming procedure is completed.

Pacemaker life

All pacemakers need to be replaced.The exact replacement time depends on the type of device and the rate of depletion of the battery, which is determined by the following factors:

• the pulse amplitude is the voltage acting on the myocardium,
• the duration of the impulse is the time of exposure of the stimulating impulse to the myocardium,
• frequency of activation of the pacemaker during the day, for example, several times a day during pauses or
• continuous work during the day,
• additional diagnostic and therapeutic functions (the more these functions are enabled, the more the power consumption of the pacemaker increases).

The lower the amplitude, pulse duration, frequency of the pacemaker activation and additionally introduced functions, the lower the power consumption, the slower the battery is depleted and the longer the service life of the device. The doctor will determine the need for a new pacemaker replacement at regular follow-up visits. Most of the devices are more than 7 years old. Thanks to programming, the device can work effectively for much longer than without it. This is one of the reasons for regular visits to the doctor.To select the optimal amplitude and pulse duration, the doctor will focus on the value of the stimulation threshold.

The electrical stimulation threshold is the smallest stimulating impulse force that can excite the heart muscle. Why is it necessary to strictly follow the schedule of visits to the arrhythmologist?

1. During life, the functional and electrical state of the heart changes. Accordingly, an annual adjustment of the pacemaker is required.
2. The doctor needs to make sure that the pacemaker does not perform unnecessary work and is turned on only when necessary, that is, when bradycardia or a pause in the work of the heart occurs, which will significantly extend the life of the device. This result is achieved through sequential multiple “adjustments”.
3. In the process of timely visits, the doctor will be able to determine the time of the required pacemaker replacement 1-2 years before the depletion of energy.
4. Any significant disturbances in the operation of the pacemaker begin with precursors that are not recorded by a conventional electrocardiogram (ECG) and are not felt by the patients themselves.During the next examination, the doctor will promptly identify this problem and eliminate it, thereby preventing a cardiac catastrophe.

Pacemaker replacement

When the battery runs out, the rhythm of the apparatus will decrease. The pacemaker must be replaced before significant changes in pacing frequency are made. When the doctor tells you about the need to replace the pacemaker (reimplantation), the device will continue to work for several more months.This will allow you and your doctor to schedule a convenient time for your surgery.

Pacemaker reimplantation takes much less time than the initial installation of the device (approximately 1 hour). The incision is made in the same place as for the first time, along the scar. The bed of the apparatus is opened (its capsule, formed by the tissues of the body over several years), and the device is removed. During the operation, the doctor will also check the performance of the electrostimulation lead to determine if new leads are needed.If the electrodes function well, the existing electrodes will remain in the heart and will mate with the new pacemaker unit.

Travel Tips

You can use any type of transport and travel by train, plane, yacht. It is not recommended to go through magnetic detectors at airports, train stations, stadiums, metro stations – your device can trigger an “alarm”.

Just show the dispatcher or customs officer a document certifying that you have a pacemaker and they will let you bypass the magnetic device or turn it off and examine you with a handheld metal detector.

In some large cities, special detection devices are installed in supermarkets and libraries. These devices react only to the magnetic code of the product and cannot damage the ECS in any way.

Always carry a document certifying that you have a pacemaker

You will receive a pacemaker certificate from the doctor who operated or programmed the pacemaker before you leave the hospital. If you ever find yourself in a medical emergency, this document will tell your companions that you have a pacemaker.

Physical activity

For 10 days after the operation, try not to make active movements of the hand on the side of which the device is implanted. This is necessary so that the electrode is not stretched. Then the tip of the electrode will reliably “grow” to the heart, and a capsule will form around the apparatus. After these days, you will be able to do any work with your hands. At the same time, it is not recommended to make active rotational movements with the hand on the side of which the pacemaker is implanted.It is undesirable to crawl, play tennis, basketball and volleyball with this hand, hang or rotate on the horizontal bar.

After talking with your doctor, you should gradually return to your normal lifestyle without fear of harming the pacemaker. It is completely wrong to think that you can avoid possible complications or prolong the service of a pacemaker by immersing yourself in “greenhouse” conditions. Only unfounded fear or anxiety can make you unhappy.

Live the way people of your age live and, if possible, the way you used to live.Work in the garden, swim, dance, travel, do household chores, sports. Most owners of pacemakers do not have any problems with their device. Do not be afraid to injure or break the pacemaker: its metal body can withstand 10 times more stress than the ribs of the chest.

Household appliances

The pacemaker has a special filter in order to exclude the influence of external influences. Therefore, properly operated household and household electrical appliances are unlikely to hinder its work.You can safely use any serviceable electrical appliance (washing machine, vacuum cleaner, microwave oven, sewing machine, remote control TV, VCR, heating devices), work on a computer. When using devices with vibration (impact drill, vibration massager, etc.), the frequency of the pacemaker may increase, leading to tachycardia and discomfort. In this case, stay away from this device and consult your doctor.It is not recommended to use welding yourself.

Medical procedures

Of course, there may be cases when you need to consult a specialist doctor on health issues that are not directly related to the pacemaker. At a doctor’s appointment, when visiting a physiotherapy room, a dentist or calling an ambulance, always inform the medical staff that you have a pacemaker. With proper preventive measures, the most common medical procedures (dental procedures, electrocardiography and 24-hour ECG and blood pressure monitoring, radiography, fluoroscopy, computed tomography, laser, ultrasound) are safe and will not affect the pacemaker.However, some medical procedures create high levels of electromagnetic fields that can temporarily interfere with the functioning of the pacemaker. It is not recommended to perform magnetic resonance imaging (but multispiral computed tomography is possible), diathermy, lithotripsy. Check with your doctor to weigh the risks and benefits of these procedures. Do not perform other physical therapy directly on the pacemaker area.

The pacemaker is protected from defibrillator discharge by a titanium case, but after this procedure, the device must be checked by a specialist.

90,000 Dog sneezes: causes, treatment and prevention

Contents of article

When a pet sneezes, it looks very funny and cute, but in fact it can mean that the dog is sick. By paying attention to the symptoms in time, you can prevent the development of the most dangerous complications and even the death of your pet.

Causes of sneezing in dogs

Most often, the dog sneezes due to dust or some substances irritating the mucous membrane.It can be aerosols, perfumes and cosmetics, household chemicals, even food – for example, flour, if the dog sniffed it out of curiosity.

Some breeds with a short snout and snub nose sneeze more often than others, as this condition is due to their anatomy. It is much more serious if the animal sneezes often, and the process is accompanied by a rise in temperature, lethargy, apathy, refusal to eat, aggression, and heavy breathing. In this case, only an urgent visit to the veterinarian can save the pet.

Main causes of sneezing:

• respiratory tract infections;
• colds due to hypothermia;
• allergic reactions;
• entry of a foreign body into the nose or nasopharynx;
• injuries of the respiratory tract, damage to the mucous membranes;
• neoplasms in the nasopharynx;
• cardiovascular diseases.

Any of these diseases can cause serious harm to the dog, therefore a mandatory diagnosis by a veterinarian is required.

Coping with illness

First of all, you need to make the correct diagnosis and the cause of the disease. Without this, treating a dog is useless and even harmful, because sneezing is just a symptom, a sign of a disease. The dog will stop sneezing as soon as the root cause is eliminated.

Amateur activities here can seriously harm the animal, especially if you immediately grab for antibiotics. They are not a panacea, and for allergies, heart problems, cancer or polyps, they turn out to be absolutely useless and even harmful.

Once the diagnosis is made, the veterinarian will prescribe treatment. You can go through it on an outpatient basis or take care of your pet at home, strictly following the doctor’s instructions. In severe cases, a sick dog can be hospitalized in a hospital.

Preventive measures

It is much easier and easier to prevent a disease than to treat a sick animal later.

Preventive measures against sneezing:

1. Cleanliness. This applies to both the content of the animal itself and the place where it lives.Carefulness and attention to the condition of the dog’s coat, to what it sleeps on, what it eats and drinks from, can prevent the development of many diseases accompanied by sneezing, including allergic reactions, infections and colds.
2. Warm and cozy place to sleep. It is important to make sure that the dog does not sleep in a draft, in a damp and cold place.
3. Providing the dog with warm overalls for walking in the cold season. This is especially important for dogs with short plush hair and hairless breeds.
4. Proper nutrition and hardening strengthens the immune system, the dog will be less susceptible to various diseases.

If signs of illness or behavioral abnormalities are found, you should immediately contact your veterinarian for diagnosis and treatment.

Interesting topics

90,000 Milk formula allergy symptoms

Infants who are formula-fed may be diagnosed with food allergies. This is due to the intolerance of the immune system to proteins (most often – lactose) contained in powdered cow’s milk.If you find allergy symptoms in a newborn, you should see a doctor. Pediatricians help solve the problem and recommend changing the diet.

Employees of the Dochki-Sinochki online store will acquaint parents with the range of lactose-free baby food products.

How does milk formula allergy manifest

Symptoms of food allergy to infant formula can be traced on the skin, as well as in violation of the digestive and respiratory systems.One of the clearest signs of an allergic reaction in the body is the appearance of a red rash on the baby’s face, tummy, buttocks and shoulders. Profuse regurgitation and the appearance of excess mucus in the child’s nose and throat are secondary symptoms.

Allergy to formula milk is diagnosed in the following cases:

• on the skin, rashes and peeling are observed, accompanied by itching;
• there is a constant violation of the stool (constipation, diarrhea) for more than 2 days;
• lack of appetite, abdominal pain;
• shortness of breath, runny nose, bronchial spasms appear at normal body temperature.

Allergy manifests itself 2-3 hours after the end of the liquid food intake. In some cases, the reaction makes itself felt after 1-2 days. After feeding with an allergenic mixture, you can observe abundant (up to 7 times) regurgitation and hiccups. Skin rashes are also accompanied by prolonged intestinal dysfunction with colic.

Important!

Allergy to formula milk is prone to 75-80% of infants whose parents are themselves allergic. At risk are up to 40% of children in whom at least one of the parents suffers from milk intolerance, and up to 20% with healthy dad and mom.

What to do if a newborn is allergic to formula

When the main signs of food allergy are found in a baby, the first step is to consult a pediatrician. The doctor will help determine the allergen component and offer a special hypoallergenic food that does not contain an irritant.

It is possible to replace baby food based on allergenic cow’s milk with the following mixtures:

• hypoallergenic;
• on goat milk;
• soy-based;
• lactose-free.

Hypoallergenic mixtures are made according to a special technology – complete or partial splitting (hydrolysis) of cow’s milk protein. Medicinal products include products with complete hydrolysis (Friso Frisopep, Hipp HA Combiotik and Nutrilak Peptidi MCT). Lactose-free food is indicated for infants with milk sugar intolerance.

Expert opinion

“Our online store offers all types of hypoallergenic mixtures represented by the brands Nutrilon, Similac, Hipp, Babushkino Lukoshko, Nutrilak, Bellakt and others.The best nutrition for treating cow’s milk allergy is a hypoallergenic formula made using the

complete protein breakdown technology

When choosing between blends based on soy protein and goat milk, the latter is preferred. Soy formula is not suitable for toddlers from polyvalent food allergies. In addition, soybeans are significantly inferior to goat milk protein in terms of nutritional value ”.

Specialist of the online store “Dochki-Sinochki”
Antonova Ekaterina

Conclusions

In a child, an allergy to formula milk manifests itself in the form of clearly visible red skin rashes on the face, abdomen, shoulders and buttocks.Associated symptoms are the appearance of a runny nose and shortness of breath, colic, prolonged diarrhea or constipation. In case of an allergic reaction in a newborn, regurgitation increases at times, hiccups are possible.

A pediatrician should diagnose food allergies, identify the allergen and prescribe an alternative mixture. Unsuitable nutrition can be replaced with a therapeutic hypoallergenic or lactose-free formula, as well as baby food based on soy protein or goat milk.

Hiccups: causes, symptoms and drugs for treatment

Hiccup

According to the International Classification of Diseases, hiccups are abnormal breathing.It arises from the convulsive contraction of the intercostal muscles and the diaphragm, which obeys the nervous structures of the brain. As a result, a short breath occurs, a sharp movement of air irritates the nerve endings and closes the glottis – this process is accompanied by a specific sound, which we call hiccups.

Classification

Conventionally, the anomaly is divided into three types:

1. Short-term (episodic) – usually lasts no more than 15 minutes.
2. Persistent – occurs daily for several days or weeks in a row, can persist for several hours or even days.
3. Undidable – persistent, lasting for months.

Persistent and intractable hiccups are a reason to see a doctor. In most cases, they indicate the presence of traumatic injury or disease, which causes sharp jerky contractions of the diaphragm.

Persistent and intractable hiccups, depending on the localization of the pathological focus, are divided into:

• peripheral – due to lesions of the phrenic or sympathetic nerves against the background of cardiovascular and gastrointestinal diseases;
• central – occurs in case of damage to the spinal cord and / or brain;
• toxic – develops as a result of metabolic disorders, exposure to certain drugs, smoking, alcohol abuse.

Causes of hiccups

An episodic disorder is a natural reaction to irritation of the vagus nerve – this is how excess air is forced out of the stomach. And the accumulation of excess air can be caused by the use of dry food (cookies, bagels, crackers), thirst, hasty food, overeating or hunger, hypothermia, severe stress.

The causes of hiccups in children and adults are similar.

In newborns, hiccups are a frequent phenomenon, since in the first months of life the mechanisms regulating the contractile function of the diaphragm are extremely excitable.This is due to the fact that babies adapt to the world around them. Most often, babies have a problem due to excessive stretching of the stomach walls with air trapped during feeding, or with food when overeating. Hypothermia and severe fright can also be the reasons.

If a child’s hiccups go away on their own and do not last long, do not worry. But if it occurs regularly or persists for a long time, you need to consult a doctor to rule out the presence of a serious illness.

Possible causes of persistent hiccups of central origin:

• encephalitis;
• meningitis;
• circulatory disorders;
• neoplasms or brain trauma;
• cerebral artery aneurysm;
• multiple sclerosis, etc.

Peripheral hiccups are a frequent “companion” of patients with:

• diaphragmatic hernia;
• tumors of the esophagus or stomach;
• diseases and formations of the pancreas;
• gastric ulcer and duodenal ulcer;
• gallstone disease;
• gastroesophageal reflux;
• cardiac arrhythmias requiring the installation of a pacemaker;
• myocardial infarction;
• diseases of the respiratory organs (especially laryngitis, pneumonia and mediastinal tumors), etc.

Prolonged toxic hiccups in an adult

is due to metabolic disorders. These include diabetic neuropathy against the background of diabetes mellitus, hypokalemia (including due to diarrhea, vomiting), hypocalcemia, uremia, etc.

The reason may be medication, for example, morphine, azithromycin, tranquilizers, barbiturates, chemotherapy drugs.

Diagnosis of abnormal breathing

The disease “hiccups” requires a thorough diagnosis of the whole organism in order to establish the cause of this pathological condition.First of all, consultations with a cardiologist and a neurologist are prescribed in order to exclude myocardial infarction and cerebral stroke. For examination, an electrocardiogram and magnetic resonance imaging, respectively, are usually performed.

Depending on the clinical picture, the following studies may be required: X-ray, computed tomography, gastroscopy, spirography, electroencephalography, bronchoscopy, esophagomanometry, as well as tests for the level of calcium in the blood serum, for creatinine, the functional state of the liver, etc.d.

Hiccups in newborns: what to do?

If the room is cool, the baby needs to be wrapped up and held in your arms in order to warm with your warmth.

If the baby begins to hiccup while eating or immediately after feeding, you should vilify the baby in an upright position, stroking the back. This will speed up the release of excess air from the stomach.

If the child’s hiccups are prolonged, you need to see a doctor.

Treatment in adults

Prolonged hiccups are never a separate disease, it is a symptom of a serious pathology, so the treatment regimen will depend solely on the underlying health problem.

Tablets for hiccups of central origin, used exclusively as symptomatic therapy (so that a person stops hiccupping): haloperidol, chlorpromazine, sodium valproate, gabapentin, pregabalin, nifedipine, methylphenidate. They stop irritation of the diaphragm and normalize the functioning of the central nervous system.

For concomitant gastrointestinal disturbances, a remedy for hiccups in adults that normalizes digestion, for example, domperidone, metoclopramide, simethicone, or a drug from the group of proton pump inhibitors, may be recommended.

Complications

Prolonged hiccups significantly impair the quality of human life, cause insomnia, stress, nervous exhaustion. The absorption of food in the gastrointestinal tract is impaired, leading to weight loss. There is a risk of developing esophagitis, dehydration.

Prevention

There are only two ways to prevent an attack:

• eat right – do not overeat, chew food thoroughly, do not eat too dry, hot or cold food;
• avoid hypothermia.

References

1. Shtulman D.R., Levin O.S. Neurology: A Practical Physician’s Handbook. – 6th ed. – 2008 .– 1024 p.
2. References MSD.

Frequently Asked Questions About Hiccups

How to stop hiccups?

To get rid of it, you can slowly drink a glass of cool water, eat something sour (a slice of lemon, for example) or sweet (a spoonful of honey), do breathing exercises.

Which drug is effective?

Unfortunately, there is still no cure that will help in the shortest possible period of time.You can take an over-the-counter digestion aid.

Which organ is responsible for the hiccups?

The mechanism of this disorder involves the diaphragm and intercostal muscles.

How long can the hiccups last?

Episodic – up to 15 minutes (sometimes a little longer), persistent – several hours or days.

Attention! Symptom chart is for educational purposes only. Do not self-medicate; for all questions regarding the definition of the disease and methods of treatment, contact your doctor.Our site is not responsible for the consequences caused by the use of information posted on the portal.

Food allergy. Doctor’s advice. | Ministry of Health of the Chuvash Republic

New Year is coming, the most favorite holiday of children and adults. New Year is a merry round dances, delicious gifts. But, unfortunately, often, our adults, carried away by the feast, leave the children unattended, and then the holiday turns into a nightmare.

Traditionally, on holidays, the number of patients with signs of food allergies and food intolerances (urticaria, Quincke’s edema, allergic dermatitis) and with exacerbation of bronchial asthma, allergic rhinitis, and atopic dermatitis increases.

1. What is food allergy.

Food allergy is an increased sensitivity of the body to food, which develops when the immune system is impaired.

More often, allergies are observed in children, adults, as a rule, suffer from it from childhood.

Among people with diseases of the gastrointestinal tract, liver, biliary tract, the prevalence of allergy to food is wider than among people without this pathology, and ranges from 5 to 50%.

Food allergy is also common in patients with other allergic diseases, in particular, with hay fever.

Food allergy should be distinguished from another very similar condition – food intolerance.

2. What are the differences between “food allergies” and “food intolerances”?

In case of food intolerance, unlike food allergies, there are no changes in the immune system, and the reasons for the development of intolerance reactions are often associated with the presence of various concomitant diseases in a person, for example, the stomach, intestines, liver, nervous and endocrine systems.

In addition, food allergy persists throughout a person’s life, and food intolerance can disappear after the causes that caused it are eliminated.

3. What are the symptoms of food allergy?

The most common clinical manifestations of food allergy with a predominant lesion of the gastrointestinal tract include: vomiting, colic with lack of appetite, refusal to eat, constipation, loose stools, itching in the mouth or throat.

Skin manifestations of food allergies, or allergic dermatoses, are among the most common in both adults and children. In children under 1 year old, one of the first signs of food allergy may be diaper rash, symptoms of skin irritation, itching that occur after feeding.

Manifestations of food allergy from the respiratory tract (allergic rhinitis, laryngitis). Allergic rhinitis with food allergies is characterized by the appearance of profuse, mucous nasal discharge, sometimes stuffiness, sneezing, itching of the skin around the nose or in the nose.

Changes in the nervous system in case of food allergies – headache, migraine.

4. What foods are more likely to cause food allergies?

Food allergy can develop after ingestion of almost any food product, however, there are food products with pronounced allergenic properties and special allergenic activity:

– fish, especially sea fish

– seafood (oysters, crustaceans, shellfish, etc.)etc.)

– nuts (peanuts, hazelnuts)

– eggs

– milk

– stone fruits (apricots, red apple varieties, etc.)

– vegetables (carrots, tomatoes)

– food grains (wheat, oats, etc.)

Most often, when eating foods rich in biologically active substances (histamine, tyramine), food intolerance develops. This is after eating cheese, wine, sauerkraut, spinach, tomatoes, ham, sausages, canned foods, smoked meats, pickles, avocados.Often, the reason for the development of food intolerance is not the product itself, but various chemical additives (dyes, flavorings, anoxidants, emulsifiers, enzymes)

If you do not know exactly (the culprit of the allergy), it is recommended to adhere to a general hypoallergenic diet on holidays.

General non-specific hypoallergenic diet.

Recommended to be excluded from the diet

1. Citrus fruits (oranges, tangerines, lemons, grapefruits, etc.)
2. Nuts (hazelnuts, almonds, peanuts, etc.).
3. Fish and fish products (fresh and salted fish, fish broths, canned fish, caviar, etc.).
4. Poultry (goose, duck, turkey, chicken, etc.) and products from them.
5. Chocolate and chocolate products.
6. Coffee.
7. Smoked products.
8. Vinegar, mustard, mayonnaise and other spices.
9. Horseradish, radish, radish.
10. Tomatoes, eggplants.
11. Mushrooms.
12. Eggs.
13. Fresh milk.
14. Strawberry, strawberry, melon, pineapple.
15. Butter dough.
16. Honey.
17. It is strictly forbidden to consume all alcoholic beverages.

Can be eaten

1. Boiled lean beef meat.
2. Soups: cereals, vegetables:
3. On secondary beef broth
4. Vegetarian
5. Butter, olive, sunflower.
6. Boiled potatoes.
7. Porridge: buckwheat, oatmeal, rice.
8. One-day lactic acid products (cottage cheese, yogurt).
9. Fresh cucumbers, parsley, dill.
10. Baked apples, watermelon.
11. Tea, sugar.
12. Compotes from apples, plums, currants, cherries, dried fruits.

5. What kind of help parents should give in case of symptoms of food allergy.

1. Elimination (elimination) of the food allergen, presumably causing the reaction.

2. Enterosorbents (activated carbon, smectite, polyphepan, enterosgel, lactofiltrum)

3.Cleansing enema.

4. Antihistamines.

5. In case of worsening symptoms, consult a pediatrician.

6. Practical advice.

In order for the New Year to remain the most beloved holiday, carefully read the labels on imported and domestic food products, containing basic information about the quantitative and qualitative composition.

Patients suffering from food allergies or food intolerances should not use genetically processed foods in their diet.

Care should be taken in advance to ensure that the correct diet is kept out of “culpable” food allergens when dining, visiting, or traveling on vacation.

If, while at a restaurant or at a party, you are offered a dish whose composition is not known, it is better to refuse it.

Head of Allergy Department

City Children’s Clinical Hospital

Lukanova Irina Gennadievna

Emergency Protection and Safety Recommendations