慢性咳嗽病因诊断和治疗(1)

慢性咳嗽病因诊断和治疗广州市第一人民医院呼吸内科曾军副主任医师什么是慢性咳嗽?咳嗽反射途径咳嗽会引起哪些机体不适及并发症？定义慢性咳嗽是指咳嗽症状持续3周以上，经常规治疗效果不佳且病因未明者。胸片正常咳嗽并发症urinaryincontinencefecalincontinencefrequentretchingdizzinesssweatingbrokenribs.案例A44-year-oldmanpresentedwithcoughofthreeweeks'duration.Hewasotherwisehealthyanddidnotsmokecigarettes.Thecoughhadbegunwithacoldbutpersistedafterothercoldsymptomshadresolved.Onquestioning,heacknowledgedasensationofpostnasaldrip.Achestx-rayshowednoabnormality.Acourseofbrompheniraminemaleate,6mgtwiceaday,andsustained-releasepseudoephedrinesulfate,120mgtwiceaday,wasinitiated.Oneweeklater,thepatientreportedthatthetreatmenthadbroughtpartialreliefbutthathestillcoughedandclearedhisthroatfrequently.Four-viewsinusx-rayssubsequentlyshowedevidenceofchronicsinusitis.Afive-daycourseofoxymetazolinenasalsprayanddoxycycline,100mgaday,wereaddedtohismedicalregimen.Withintwoweeks,hereportedmarkedimprovement.Bythreeweeks,thecoughwasgoneentirely.Afterfourweeks,allmedicationswerediscontinued.慢性咳嗽的病因分析慢性咳嗽不同疾病的临床表现CommoncausesPostnasaldripAsthmaGastroesophagealrefluxTransientairwayhyperresponsiveness(e.g.,afterviralupperrespiratoryinfection)Medication-related(ACEinhibitors,betablockers)ChronicbronchitisSmokingandotherenvironmentalirritantsRareCausesofChronicCoughTracheobronchialcollapseLungcancerTuberculosisOtherlunginfectionOccupationalenvironment-inducedcoughBronchiectasisSarcoidosisRareCausesofChronicCoughLeftventricularfailureInterstitiallungdiseaseMetastaticbreastcarcinomatosisHyperthyroidismCarcinoidtumorRetainedsutureHodgkin'sdiseaseZenker'sdiverticulumEtiology:0to18months支气管异物支气管异物Etiology:18monthsto6years1.5to6YearsEtiology:Adolescents6to16YearsEtiology:Adults后鼻滴流症就是鼻腔有较多分泌物,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。鼻后滴流是最常见的慢性咳嗽原因。后鼻滴流症X线或鼻窦CT可见鼻窦炎。治疗可用抗组胺药和缩血管药，也可加鼻腔激素喷剂。治疗开始五天可用血管收缩剂，不要超过5天。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。后鼻滴流症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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（40mg/日×5天）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。Insomecases,nospecificcausecanbefoundforPND.Whennocorrectablediseaseispresent,attentionisusuallydirectedtothinningsecretionssotheycanpassmoreeasily.Thisisparticularlytruefortheelderly,whooftenhaveinadequatefluidintake.Thesepatientsshoulddrinkeightglassesofwateraday,eliminatecaffeine,andavoiddiuretics(fluidpills)ifpossible.过敏性鼻炎与哮喘的关系一、哮喘（预期危险因素）:23年随访（前瞻性研究）被随访者状况总人数*新发哮喘人数%P值过敏性鼻炎16217100.002非过敏性鼻炎528193.6总数690365.2*无哮喘史或症状者Ref:Settipaneetal,AllergyProc,1994同时患AR和ASAR先于AS出现占43-64%AR与AS同时出现占21-25%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。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。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。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重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能是阳性肺功能检查表现为可逆性气流变化咳嗽变异型哮喘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。如果仍有咳嗽，加用强的松10mg3次/日，连续7-10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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，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。支气管舒张试验胃食道返流GERD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“烧心”或“返酸”史按胃食道返流治疗咳嗽可治愈。有40%GERD患者无上述典型症状，仅诉有咳嗽。胃食道返流24小时食道PH值监测采用诊断性治疗，如果按GERD治疗，咳嗽好转，停药后再复发，可证实该病存在。经验治疗GERD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。H2受体阻断剂及其它制酸药在治疗GERD引起的呼吸道症状常常无效，不宜用于经验性治疗。治疗GERD床头抬高20cm睡前2-3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可同时用降低胃酸药物。药物性咳嗽：ACEI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、赖诺普利等可出现慢性咳嗽继续服用或更换另一种ACEI药还会引起咳嗽。好发于女性，常在服药后1周内或有些甚至长达6个月后出现咳嗽。停药后4天可自行消失，部分患者需停药4周。UpperRespiratoryInfectionAirwayHyperresponsiveness上呼吸道病毒感染后可引起持续6至8周咳嗽吸入激素或气道扩张剂，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、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ACEI引起的咳嗽。UpperRespiratoryInfectionAirwayHyperresponsivenessMostpatientswillhavetotalresolutionofallsymptomswithinthreeweeks.However,asubgroupofpatientsdevelopairwayhyperresponsivenesswithapersistentcoughthatcanlasttwomonthsorso.AnEmpiricTreatmentAlgorithmSTEPONEForoneweek,giveallpatientsempirictreatmentforpostnasaldripusinganolder-generationantihistamine-decongestantcombination.Evidenceindicatesthatthenewergenerationhistamine1antagonistsareinferiorintreatingcoughcausedbypostnasaldrip,andtheiruseshouldbeavoidedunlesssedationisamajorsideeffectwiththeolderagents.STEPONEIfthecoughimproves,theantihistamine-decongestantcombinationshouldbecontinueduntilthecoughisresolvedoruntilthereisnofurtherimprovement.Nasalsteroidsshouldbeaddedinpatientswhosecoughisnotcontrolledbyantihistamine-decongestantmedications.STEPONEIfsymptomspersistafter1-2wkofnasalsteroiduse,aCTexamofthesinusesshouldbedone.Ifchronicsinusitisisidentified,thepatientshouldbetreatedwithanempirictrialofantibiotics.STEPONEsomedataindicatethatpatientsmaybenefitfromashort(three-day)courseoftreatmentwithnasaloxymetazolinedecongestantspray+antihistamine-decongestantcodrug.Whenallofthesemeasuresfail,thepatientmayrequireaspirationorirrigationofthesinuses.STEPTWOPatientswhocontinuetocoughdespitesteponeshouldbeevaluatedforasthma.Physiciansshouldbearinmindthatpatientswithasthmamaypresentwithonlyachronic,usuallynonproductivecough.STEPTWOWhentheresultsofspirometryareequivocal,abronchoprovocationtestmaybehelpfulineva