Hybrid Airway Management for Neuromonitoring-guided Selective Phrenic Nerve Surgery in Intractable Hiccups: A Case...

Intractable hiccups are rare but debilitating, and may cause sleep disturbances, nutritional impairment, exhaustion, and a severe deterioration in quality of life. When pharmacological and interventional treatments fail, selected surgical procedures targeting the phrenic nerve may be considered. We report the anaesthetic management of a 32-year-old woman with idiopathic intractable hiccups who underwent right-sided selective phrenic nerve surgery guided by thoracoscopic neuromonitoring. Because thoracoscopic exposure and intraoperative neuromonitoring were required simultaneously, a hybrid airway strategy combining an electromyography endotracheal tube with a bronchial blocker was used. The patient was positioned in the left lateral decubitus position, and the bronchial blocker was placed in the right main bronchus under fiberoptic bronchoscopic guidance. One-lung ventilation was maintained for 35 minutes with FiO₂ of 0.70 to 0.80, tidal volume of 5-6 mL kg^-1, respiratory rate of 18 min^-1, and PEEP of 5 cmH₂O; the arterial blood gas analysis at 25 minutes showed pH 7.38, PaCO₂ 41 mmHg, and PaO₂ 92 mmHg. Sugammadex was administered intraoperatively to restore diaphragmatic motor responses required for branch-specific neuromonitoring. The medial and anterolateral branches of the right phrenic nerve exhibited abnormal electrophysiological responses and were treated with selective bipolar ablation and clipping. Postoperatively, the patient remained on room air, reported no intraoperative recall, and showed no clinically relevant diaphragmatic dysfunction on clinical and functional assessment. This case illustrates that established anaesthetic techniques can be carefully adapted to meet the competing requirements of lung isolation, anaesthetic depth control, and neuromonitoring in selected patients undergoing phrenic nerve surgery for intractable hiccups.