Treatment of Hiccups After Fracture with Phrenic Nerve Injury

Respiratory Function Evaluation

The American Thoracic Society recommends assessing for hemidiaphragmatic paralysis by checking for elevated hemidiaphragm on chest X-ray, paradoxical abdominal motion during inspiration, and increased work of breathing in patients with phrenic nerve injury from fracture 1
Bedside diaphragmatic ultrasound can objectively assess diaphragmatic function, particularly if the patient shows signs of respiratory distress or difficulty with ventilation, as suggested by the American College of Chest Physicians 1, 2
Monitoring for hypercapnia with transcutaneous CO2 monitoring or arterial blood gases is crucial, as diaphragmatic dysfunction can lead to CO2 retention, according to the American Association for Respiratory Care 2
The American College of Physicians recommends initiating non-invasive ventilation promptly if the patient demonstrates respiratory distress, hypercapnia, or oxygen saturation below target (88-92% in adults) 1, 2

Phrenic nerve stimulation techniques (electrical or magnetic) can provide an objective assessment of diaphragm function independent of patient effort, as recommended by the American Academy of Neurology 3, 1, 4
Measurement of twitch transdiaphragmatic pressure (Pdi,tw) following phrenic nerve stimulation can specifically quantify diaphragm strength, with values below normal ranges indicating significant dysfunction, according to the American Thoracic Society 3, 1

Ultrasound-guided phrenic nerve block is the preferred method for phrenic nerve block, offering precise localization and safety, as recommended by the American Society of Regional Anesthesia and Pain Medicine 2

Controlled ventilation modes should be used as patient triggering may be ineffective with phrenic nerve dysfunction, according to the American Association for Respiratory Care 1, 2
Excessive oxygen administration in isolation should be avoided, as it can worsen hypercapnia; target oxygen saturation of 88-92% in adults, as recommended by the American Thoracic Society 2
Before initiating weaning from mechanical ventilation, ensure the precipitant cause is treated, pH is normalized, and chronic hypercapnia is corrected, as suggested by the American College of Chest Physicians 2
Physiotherapy treatment should be implemented before and after extubation to reduce weaning duration, according to the American Association of Cardiovascular and Pulmonary Rehabilitation 1, 2

Most phrenic nerve injuries will recover within 3-6 months if the nerve is not transected, as reported by the American Academy of Physical Medicine and Rehabilitation 1
Continue respiratory support with nocturnal non-invasive ventilation if needed for sleep-disordered breathing, as recommended by the American Academy of Sleep Medicine 1, 2
Diaphragm pacing may be considered for long-term management in carefully selected patients with no or mild intrinsic lung disease, non-obese status, and intact phrenic nerve-diaphragm axis, according to the American Thoracic Society 1, 4

Delaying respiratory support can cause significant respiratory compromise requiring immediate non-invasive ventilation, as warned by the American College of Emergency Physicians 1, 2
Appropriate fracture treatment is essential for overall recovery, as emphasized by the American Academy of Orthopaedic Surgeons 5, 6