慢性咳嗽病因诊断和治疗

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1、 慢性咳嗽病因诊断和治疗慢性咳嗽病因诊断和治疗 广州市第一人民医院呼吸内科广州市第一人民医院呼吸内科 曾曾 军军 副主任医师副主任医师什么是慢性咳嗽什么是慢性咳嗽?咳嗽反射途径咳嗽反射途径咳嗽会引起哪些机体不适及并发症？咳嗽会引起哪些机体不适及并发症？定义定义 慢性咳嗽是指咳嗽症状持续慢性咳嗽是指咳嗽症状持续 3周以上周以上，经常，经常规治疗效果不佳且病因未明者。规治疗效果不佳且病因未明者。胸片正常胸片正常咳嗽并发症咳嗽并发症 urinary incontinence fecal incontinence frequent retching dizziness sweating broken

2、ribs.案例案例 A 44-year-old man presented with cough of three weeks duration.He was otherwise healthy and did not smoke cigarettes.The cough had begun with a cold but persisted after other cold symptoms had resolved.On questioning,he acknowledged a sensation of postnasal drip.A chest x-ray showed no abn

3、ormality.A course of brompheniramine maleate,6 mg twice a day,and sustained-release pseudoephedrine sulfate,120 mg twice a day,was initiated.One week later,the patient reported that the treatment had brought partial relief but that he still coughed and cleared his throat frequently.Four-view sinus x

4、-rays subsequently showed evidence of chronic sinusitis.A five-day course of oxymetazoline nasal spray and doxycycline,100 mg a day,were added to his medical regimen.Within two weeks,he reported marked improvement.By three weeks,the cough was gone entirely.After four weeks,all medications were disco

5、ntinued.慢性咳嗽的病因分析慢性咳嗽的病因分析慢性咳嗽不同疾病的临床表现慢性咳嗽不同疾病的临床表现Common causes Postnasal drip Asthma Gastroesophageal reflux Transient airway hyperresponsiveness(e.g.,after viral upper respiratory infection)Medication-related(ACE inhibitors,beta blockers)Chronic bronchitis Smoking and other environmental irritan

6、ts Rare Causes of Chronic Cough Tracheobronchial collapse Lung cancer Tuberculosis Other lung infection Occupational environment-induced cough Bronchiectasis Sarcoidosis Rare Causes of Chronic CoughLeft ventricular failure Interstitial lung disease Metastatic breast carcinomatosis Hyperthyroidism Ca

7、rcinoid tumor Retained suture Hodgkins disease Zenkers diverticulumEtiology:0 to 18 monthsEtiology:0 to 18 months支气管异物支气管异物支气管异物支气管异物Etiology:18 months to 6 yearsEtiology:18 months to 6 years1.5 1.5 to 6 Years Etiology:Adolescentsto 6 Years Etiology:Adolescents6 6 to 16 Years Etiology:Adultsto 16 Ye

8、ars Etiology:Adults后鼻滴流症后鼻滴流症 就是鼻腔有较多分泌物就是鼻腔有较多分泌物,咽后感有分泌物往下并常有清咽后感有分泌物往下并常有清喉。体查可见咽后粘模表面粗糙呈鹅卵石样改变。鼻喉。体查可见咽后粘模表面粗糙呈鹅卵石样改变。鼻后滴流是最常见的慢性咳嗽原因。后滴流是最常见的慢性咳嗽原因。后鼻滴流症后鼻滴流症 X线或鼻窦线或鼻窦CT可见鼻窦炎。可见鼻窦炎。治疗治疗 可用抗组胺药和缩血管药，也可加鼻腔激素喷可用抗组胺药和缩血管药，也可加鼻腔激素喷剂。剂。治疗开始五天可用血管收缩剂，不要超过治疗开始五天可用血管收缩剂，不要超过5天。天。治疗鼻后滴流引起的慢性咳嗽需数周到几个月时间。

9、治疗鼻后滴流引起的慢性咳嗽需数周到几个月时间。如伴有鼻窦炎则需用抗生素治疗。如伴有鼻窦炎则需用抗生素治疗。后鼻滴流症后鼻滴流症过敏性鼻炎和慢性鼻窦炎：过敏性鼻炎和慢性鼻窦炎：过敏性鼻炎引起慢性咳嗽主要通过后鼻滴流过敏性鼻炎引起慢性咳嗽主要通过后鼻滴流 对抗组胺药与鼻腔激素反应好。对抗组胺药与鼻腔激素反应好。如果伴有慢性鼻窦炎应使用能覆盖厌氧菌的广谱抗生素如果伴有慢性鼻窦炎应使用能覆盖厌氧菌的广谱抗生素至少三周同时加用鼻腔激素及血管收缩剂。至少三周同时加用鼻腔激素及血管收缩剂。在抗生素使用同时，短时间口服强的松（在抗生素使用同时，短时间口服强的松（40mg/日日5天）天）鼻窦炎的诊断敏感性不高，

10、怀疑有慢性鼻窦炎时应做鼻窦炎的诊断敏感性不高，怀疑有慢性鼻窦炎时应做CT扫描来确诊。扫描来确诊。In some cases,no specific cause can be found for PND.When no correctable disease is present,attention is usually directed to thinning secretions so they can pass more easily.This is particularly true for the elderly,who often have inadequate fluid inta

11、ke.These patients should drink eight glasses of water a day,eliminate caffeine,and avoid diuretics(fluid pills)if possible.*无哮喘史或症状者无哮喘史或症状者 咳嗽变异型哮喘：咳嗽变异型哮喘：又称咳嗽型哮喘，是一种潜在或非典型性哮喘。又称咳嗽型哮喘，是一种潜在或非典型性哮喘。慢咳常为其唯一表现，所以很容易被误诊、误治。慢咳常为其唯一表现，所以很容易被误诊、误治。患者可见于任何年龄，成年发病者较多。患者可见于任何年龄，成年发病者较多。咳嗽持续发作或反复发作，时间长达一个月或更

12、长，以咳嗽持续发作或反复发作，时间长达一个月或更长，以干咳为主，多在清晨或夜间发生干咳为主，多在清晨或夜间发生。咳嗽变异型哮喘咳嗽变异型哮喘：冷空气、冷风、运动或病毒感染等因素诱发或加冷空气、冷风、运动或病毒感染等因素诱发或加重重 可常年持续或呈季节性发作。可常年持续或呈季节性发作。多有家族和个人过敏史，做皮肤的过敏源试验可多有家族和个人过敏史，做皮肤的过敏源试验可能是阳性能是阳性 肺功能检查表现为可逆性气流变化肺功能检查表现为可逆性气流变化 咳嗽变异型哮喘咳嗽变异型哮喘 抗过敏或短期用激素治疗可使症状缓解抗过敏或短期用激素治疗可使症状缓解 对于联合使用抗组胺药及血管收缩剂而无后鼻滴对于联合使

13、用抗组胺药及血管收缩剂而无后鼻滴流及支气管哮喘典型症状，组胺激发试验阳性患流及支气管哮喘典型症状，组胺激发试验阳性患者用喘乐宁气雾剂治疗。者用喘乐宁气雾剂治疗。如果仍有咳嗽，加用强的松如果仍有咳嗽，加用强的松10mg3次次/日，连续日，连续7-10天，如果有效改用糖皮质激素，然后减量或吸入天，如果有效改用糖皮质激素，然后减量或吸入激素，或加长效支气管扩张剂激素，或加长效支气管扩张剂 如果组胺激发阴性，不应考虑咳嗽变异型哮喘。如果组胺激发阴性，不应考虑咳嗽变异型哮喘。支气管哮喘常合并有后鼻滴流，如果治疗哮喘不佳，支气管哮喘常合并有后鼻滴流，如果治疗哮喘不佳，要考虑有无后鼻滴流并予适当的治疗，可改

14、善症状，要考虑有无后鼻滴流并予适当的治疗，可改善症状，因后鼻滴流可加重支气管哮喘症状。因后鼻滴流可加重支气管哮喘症状。支气管舒张试验支气管舒张试验 胃食道返流胃食道返流 GERD是引起慢性咳嗽第三常见原因。是引起慢性咳嗽第三常见原因。诊断常常靠病史，病人常有典型的诊断常常靠病史，病人常有典型的“烧心烧心”或或“返酸返酸”史史 按胃食道返流治疗咳嗽可治愈。按胃食道返流治疗咳嗽可治愈。有有40%GERD患者无上述典型症状，仅诉有咳嗽。患者无上述典型症状，仅诉有咳嗽。胃食道返流胃食道返流 24小时食道小时食道PH值监测值监测 采用诊断性治疗，如果按采用诊断性治疗，如果按GERD治疗，咳嗽好转，治疗，

15、咳嗽好转，停药后再复发，可证实该病存在。停药后再复发，可证实该病存在。经验治疗经验治疗GERD采用足够剂量质子泵阻滞剂至少采用足够剂量质子泵阻滞剂至少6周，症状好转可减少剂量。周，症状好转可减少剂量。H2受体阻断剂及其它制酸药在治疗受体阻断剂及其它制酸药在治疗GERD引起的引起的呼吸道症状常常无效，不宜用于经验性治疗。呼吸道症状常常无效，不宜用于经验性治疗。治疗治疗GERD 床头抬高床头抬高20cm 睡前睡前2-3小时避免吃或喝，不吃肥腻食物，巧克力、小时避免吃或喝，不吃肥腻食物，巧克力、饮汤、橙汁及含咖啡因的饮料饮汤、橙汁及含咖啡因的饮料 可同时用降低胃酸药物。可同时用降低胃酸药物。药物性咳

16、嗽：药物性咳嗽：ACEI引起咳嗽发生率达引起咳嗽发生率达5-20%。血管紧张素转换酶抑制剂如卡托普利、依那普利、血管紧张素转换酶抑制剂如卡托普利、依那普利、赖诺普利等可出现慢性咳嗽赖诺普利等可出现慢性咳嗽 继续服用或更换另一种继续服用或更换另一种ACEI药还会引起咳嗽。药还会引起咳嗽。好发于女性，常在服药后好发于女性，常在服药后1周周内或有些甚至长达内或有些甚至长达6个月个月后出现咳嗽。后出现咳嗽。停药后停药后4天可自行消失，部分患者需停药天可自行消失，部分患者需停药4周。周。Upper Respiratory Infection Airway Hyperresponsiveness 上呼吸道

17、病毒感染后可引起持续上呼吸道病毒感染后可引起持续6至至8周咳嗽周咳嗽 吸入激素或吸入激素或 气道扩张剂，咳嗽很快好转。气道扩张剂，咳嗽很快好转。诊断病毒感染后咳嗽，首先要排除慢性呼吸道疾病，如结核、诊断病毒感染后咳嗽，首先要排除慢性呼吸道疾病，如结核、支气管扩张、间质性肺病、吸烟、支气管腔内病变、充血性支气管扩张、间质性肺病、吸烟、支气管腔内病变、充血性心力衰竭或心力衰竭或ACEI引起的咳嗽。引起的咳嗽。Upper Respiratory Infection Airway Hyperresponsiveness Most patients will have total resolution

18、of all symptoms within three weeks.However,a subgroup of patients develop airway hyperresponsiveness with a persistent cough that can last two months or so.An Empiric Treatment Algorithm STEP ONE For one week,give all patients empiric treatment for postnasal drip using an older-generation antihistam

19、ine-decongestant combination.Evidence indicates that the newer generation histamine1 antagonists are inferior in treating cough caused by postnasal drip,and their use should be avoided unless sedation is a major side effect with the older agents.STEP ONEIf the cough improves,the antihistamine-decong

20、estant combination should be continued until the cough is resolved or until there is no further improvement.Nasal steroids should be added in patients whose cough is not controlled by antihistamine-decongestant medications.STEP ONEIf symptoms persist after 1-2 wk of nasal steroid use,a CT exam of th

21、e sinuses should be done.If chronic sinusitis is identified,the patient should be treated with an empiric trial of antibiotics .STEP ONE some data indicate that patients may benefit from a short(three-day)course of treatment with nasal oxymetazoline decongestant spray +antihistamine-decongestant co

22、drug.When all of these measures fail,the patient may require aspiration or irrigation of the sinuses .STEP TWO Patients who continue to cough despite step one should be evaluated for asthma.Physicians should bear in mind that patients with asthma may present with only a chronic,usually nonproductive

23、 cough.STEP TWOWhen the results of spirometry are equivocal,a bronchoprovocation test may be helpful in evaluating airway hyperresponsiveness.Patients diagnosed with asthma should be counseled about avoidance of allergens,treated prophylactically with intranasal and inhaled cromolyn ,and with beta-a

24、gonist and/or steroid inhalers and oral corticosteroids,as requiredSTEP THREE Chest and sinus radiographs Any clinically significant abnormality should be evaluated and treated.STEP FOUR empiric gastric-acid suppression test antireflux measures for treatment of possible GERD.STEP FOUR GERD can be ru

25、led out in most patients if symptoms do not improve during a limited period of gastric-acid suppression therapy.High doses of proton-pump inhibitors(e.g.,omeprazole,in a dosage of 80 mg per day)are used to ensure complete suppression.This test has a sensitivity of 83 to 90 percent.STEP FOUR Disconti

26、nuing certain medications that can exacerbate GERD(e.g.,anticholinergic drugs,calcium channel blockers,theophylline,other smooth muscle relaxants)may be necessary.STEP FOUR A protective agent,such as sucralfate(Carafate),in a dosage of 1 g taken one hour before meals,may be helpful,as may the additi

27、on of a prokinetic agent,such as metoclopramide(Reglan)or cisapride(Propulsid),before meals and at bedtime.STEP FOUR Nonresponding patients should be further evaluated using 24-hour esophageal pH monitoring,which is the most sensitive and specific test for the diagnosis of GERD.Patients with abnorma

28、l results should receive aggressive therapy with a proton-pump inhibitor for at least eight weeks.STEP FIVE Patients who still continue to cough at this stage should receive bronchoscopic examination.If this procedure does not produce a diagnosis,a repeat course of antiasthmatic therapy with a beta

29、agonist and steroids should be tried.STEP FIVE If no pathology can be found,psychogenic cough must be considered.attention-seeking symptom.the cough is a nervous tic,occurring when they become upset or nervous.We recommend that evaluation and treatment progress side by side as an effective method of

30、 managing patients with chronic cough.The use of nonspecific antitussives is avoided and invasive procedures are reduced to a minimum.Clues to Common Causes of Cough by History Finding Infant with cough-Patient is a smoker-Purulent sputum-Patient taking an ACEI-High risk for TB exposure Wheezing-Pos

31、sible diagnosis Congenital malformations Tobacco-induced bronchitis Pneumonia,bronchitis ACE inhibitor-induced cough Tuberculosis Asthma Clues to Common Causes of Cough by History Nocturnal wheezing-Cough is worse at work-Cough following URI or exposure to allergen Sensation of postnasal drip-Facial

32、 pain,tooth pain-Heartburn or sour taste in mouth History of weight loss-Asthma,congestive heart failure Occupational environment cause Postnasal drip Postnasal drip,asthma Sinusitis Gastroesophageal reflux disease Cancer,tuberculosis 总结总结慢性咳嗽是呼吸科门诊最常见就诊的症状引起慢性咳嗽的病因有多种，但最常见的疾病有三种，分别是后鼻滴溜综合征、哮喘、胃食道返流

33、综合征。经验治疗是鉴别和治疗慢性咳嗽的主要手段Diagnostic Protocol InitialDiagnostic Protocol InitialEvaluation History Evaluation History Remove irritant Remove irritant Physical Exam Physical Exam Treat post nasal drip,sinusitis,etc Treat post nasal drip,sinusitis,etc Chest XrayChest Xray Treat/further evaluation Treat/f

34、urther evaluation BronchoscopyBronchoscopy Evaluate anatomy Evaluate anatomy Remove foreign body Remove foreign body Collect specimen for cultures,pathology Collect specimen for cultures,pathology Pulmonary FunctionPulmonary FunctionTesting SpirometryTesting Spirometry -Treat asthma -Treat asthma MI

35、C Treat-MIC Treat-asthma asthma GERDGERDTesting pH probe-Testing pH probe-Treat GERD Treat GERD Upper GI series -Upper GI series -Treat any anatomic Treat any anatomic abnormalities abnormalities EsophagoscopyEsophagoscopy-Consider biopsyConsider biopsy Other testing Laboratory testing Other testing Laboratory testing Sinus computed tomographySinus computed tomography(CT)scan (CT)scan Consultation:Allergy/Immunology,Consultation:Allergy/Immunology,Otolaryngology,Pulmonary,Infectious Otolaryngology,Pulmonary,Infectious Disease,CardiologyDisease,Cardiology