慢性咳嗽病因诊断和治疗.pptx

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 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 abnormality.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-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 discontinued.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 irritants 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 Carcinoid 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 to 6 Years Etiology:Adolescents1.5 to 6 Years Etiology:Adolescents6 to 16 Years Etiology:Adults6 to 16 Years Etiology:Adults后鼻滴流症后鼻滴流症 就就是是鼻鼻腔腔有有较较多多分分泌泌物物,咽咽后后感感有有分分泌泌物物往往下下并并常常有有清清喉喉。体体查查可可见见咽咽后后粘粘模模表表面面粗粗糙糙呈呈鹅鹅卵卵石石样样改改变变。鼻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。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，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 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、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 smoker-Purulent sputum-Patient taking an ACEI-High risk for TB exposure Wheezing-Possible diagnosisCongenital 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 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 Xray Chest Xray Treat/further evaluation Treat/further evaluation Bronchoscopy Bronchoscopy Evaluate anatomy Evaluate anatomy Remove foreign body Remove foreign body Collect specimen for cultures,pathology Collect specimen for cultures,pathology Pulmonary FunctionPulmonary FunctionTesting Spirometry -Treat asthma Testing Spirometry -Treat asthma MIC 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 Esophagoscopy-Esophagoscopy-Consider biopsy Consider biopsy Other testing Laboratory testing Other testing Laboratory testing Sinus computed tomography(CT)scan Sinus computed tomography(CT)scan Consultation:Allergy/Immunology,Consultation:Allergy/Immunology,Otolaryngology,Pulmonary,Infectious Otolaryngology,Pulmonary,Infectious Disease,CardiologyDisease,Cardiology