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 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 2 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 urinary incontinence fecal incontinence frequent retching dizziness sweating broken ribs. 案例 A 44-year-old man presented with cough of three weeks
2、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 abnormality. A course of brompheniramine maleate, 6 mg twice a
3、 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-rays subsequently showed evidence of chronic sinus
4、itis. 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 discontinued. 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 10 慢
5、性咳嗽的病因分析 慢性咳嗽不同疾病的临床表现 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 11 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 environmenta
6、l irritants 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 12 Rare Causes of Chronic Cough Tracheobronchial collapse Lung cancer Tuberculosis Other lung infection Occupational environment-induced cough Bronchiectasis Sarcoidosis 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 13 Rare Causes of Chronic Cough Left ventricular failure Int
7、erstitial lung disease Metastatic breast carcinomatosis Hyperthyroidism Carcinoid tumor Retained suture Hodgkins disease Zenkers diverticulum Etiology: 0 to 18 months 支气管异物 支气管异物 Etiology: 18 months to 6 years 1.5 to 6 Years Etiology: Adolescents 6 to 16 Years Etiology: Adults 后鼻滴流症 就是鼻腔有较多分泌物 , 咽后感
8、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
9、感性不高，怀疑有慢性鼻窦炎时应做 CT 扫描来确诊。 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 28 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 inade
10、quate fluid intake. These patients should drink eight glasses of water a day, eliminate caffeine, and avoid diuretics (fluid pills) if possible. 过敏性鼻炎与哮喘的关系过敏性鼻炎与哮喘的关系 一、一、 哮喘（预期哮喘（预期 危险危险 因素）因素） : 23年随访（年随访（ 前瞻性前瞻性 研究研究 ） 被随访者状况被随访者状况 总人数总人数 * 新发哮喘人数新发哮喘人数 % P 值值 过敏性鼻炎过敏性鼻炎 162 17 10 Patient is a s
11、moker - Purulent sputum - Patient taking an ACEI- High risk for TB exposure Wheezing - Possible 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
12、 worse at work - Cough following URI or exposure to allergen Sensation of postnasal drip - Facial 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 Gastroesophage
13、al reflux disease Cancer, tuberculosis 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 60 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 流综合征。 经验治疗是鉴别和治疗慢性咳嗽的主要手段 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 61 Diagnostic Protocol Initial Evaluation History Remove irritant Physical Exam Treat post nasal drip,sinusi
14、tis, etc Chest Xray 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 62 Treat/further evaluation Bronchoscopy Evaluate anatomy Remove foreign body Collect specimen for cultures, pathology Pulmonary Function Testing Spirometry -Treat asthma MIC Treat - asthma 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 63 GERD Testing pH probe - Treat GERD Upper GI series - Treat any anatomic abnormalities Esophagoscopy - Consider biopsy 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 * 64 Other testing Laboratory testing Sinus computed tomography (CT) scan Consultation: Allergy/Immunology, Otolaryngology, Pulmonary, Infectious Disease, Cardiology
