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1、如何理解和灵活应用 “咳嗽诊治指南”,卫生部中日友好医院呼吸内科,咳嗽诊治指南的发布,1998: Managing cough as a defense mechanism and as a symptom. A Consensus Panel Report of the American College of Chest Physicians.Chest,1998,114:133s181s 2004:ERS TASK FORCE.The diagnosis and Management of chronic cough.Eur Respir J,2004,24:4814922005:Guid
2、eline for the management of cough.Source Nihon Kokyuky Gakkai Zasshi,2005,suppl:2-802005:呼吸病学分会哮喘学组.咳嗽的诊断与治疗指南(草案).中华结核和呼吸杂志,2005,28(11):738744.,重视慢性咳嗽的病因诊断 充分理解和掌握慢性咳嗽的病因诊断程序 因地制宜地开展咳嗽相关检查 加强多学科合作 如何开展经验性诊断和治疗 掌握主要咳嗽病因的特异性治疗方案,咳嗽的分类,根据病程 急性:8周,急性咳嗽,普通感冒 急性气管支气管炎 急性鼻炎/鼻窦炎 变应性鼻炎 慢性支气管炎急性加重,亚急性咳嗽,感染后咳
3、嗽 上呼吸道感染后出现的咳嗽 抗菌药物治疗无效 部分病人可伴有气道高反应性 机制 气道上皮损伤,咳嗽受体对吸入刺激反应性增加 鼻后滴流,慢性咳嗽的定义,持续8周 常规X线检查阴性 肺通气功能测定正常 无吸烟史(或停止吸烟4周)或职业性有害气体或粉尘暴露史,慢性咳嗽误诊误治严重!,通常诊为“气管-支气管炎或慢性支气管炎” 重复不必要的各种检查(影像学) 大量抗菌药物使用,重视慢性咳嗽的病因诊断,病因的构成研究 病因的关联性研究 病因的多元性研究,慢性咳嗽病因的构成研究,Irwins RS, et al. Am Rev Respir Dis,1990;141(3):640-7.,慢性咳嗽的主要病因
4、构成,n=102,美 国,Fujimura M, et al. (Kanazawa Asthma Research Group). Importance of atopic cough, cough variant asthma and sinobronchial syndrome as causes of chronic cough in Hokuriku area of Japan. Respirology ,2005; 10: 201-207.,Three common causes of chronic cough in Japan CVA+ cough predominant ast
5、hma (asthmatic cough): 43.6 AC: 35.8 SBS: 25.5.,GERD: 2.4 Smokers bronchitis (chronic bronchitis): 1.8 ACE I: 1.2 Bronchogenic carcinoma: 0.6 volatile solvent-induced cough: 0.6 PNDS-induced non-productive cough was not found,Other causes of chronic cough,Fujimura M, et al.Respirology 2005; 10: 201-
6、207.,慢性咳嗽的主要病因构成,A,C,C,V,A,S,B,S,B,A,G,E,R,可能 确定 可能+确定,双病因 其它 未知,日 本,慢性咳嗽的主要病因构成,马洪明,等. 中华结核和呼吸杂志. 2003;26(11):675-8.,广州呼吸疾病研究所专科门诊 n=86,慢性咳嗽的病因构成,广州呼研所,2006,慢性咳嗽定义为8周,中日友好医院,慢性咳嗽定义为3周,天坛医院,国内外病因构成的差别,国内外关于慢性咳嗽的病因构成主要为: PNDS、CVA、GERC、EB、AC 但构成比不同 广州呼吸疾病研究所:EB22 日本:AC 35.8 美国、欧洲:PNDS占首位 国内多数资料:CVA占首位
7、,慢性咳嗽的其他病因,支气管扩张症 支气管内膜结核 肺间质病 心源性咳嗽,呼吸病学分会哮喘学组应组织一项全国的关于慢性咳嗽病因的流行病学调查(evidence-based),慢性咳嗽病因的关联性研究,Eosinophilia,Cough,wheeze,BHR,Eosinophilia,Cough,BHR,Eosinophilia,Cough,EB,CVA,Classic Asthma,Comparison of eosinophilic bronchitis, cough-variant asthma and classic asthma,变应性咳嗽(atopic cough,AC),诊 断标
8、准 (呼吸病学分会哮喘学组,2005),慢性咳嗽 肺通气功能正常 气道反应性检测阴性 具有下列特征之一:过敏物质接触史、过敏原皮试阳性、血清总IgE或特异性IgE增高 咳嗽敏感性增高 诱导痰嗜酸性粒细胞正常 排除咳嗽变异型哮喘、嗜酸细胞性支气管炎、变应性鼻炎等其它原因引起的慢性咳嗽 抗组胺药物、糖皮质激素治疗有效,Fujimura M, et al. (Kanazawa Asthma Research Group). Importance of atopic cough, cough variant asthma and sinobronchial syndrome as causes of
9、chronic cough in Hokuriku area of Japan. Respirology ,2005; 10: 201-207.,Three common causes of chronic cough in Japan CVA+ cough predominant asthma (asthmatic cough): 43.6 AC: 35.8 SBS: 25.5.,Fujimura M, et al.Respirology, 2005; 10: 201-207.,慢性咳嗽的主要病因构成,A,C,C,V,A,S,B,S,B,A,G,E,R,可能 确定 可能+确定,双病因 其它
10、未知,日 本,Criteria for definite diagnosis of atopic cough: for clinical researchers (Japanese Cough Research Society)1. Non-productive cough lasting more than 8 weeks without wheezing or dyspnoea. 2. Presence of one or more findings indicative of an atopic constitution, including a past history and/or
11、complications of allergic diseases excluding asthma, a peripheral blood eosinophilia ( 6 or 400 cells/L), raised total IgE level in the serum ( 200 IU/mL), positive specific IgE antibody to aeroallergens and positive allergen skin test and/or induced sputum eosinophilia ( 2.0). 3. No bronchial rever
12、sibility, defined as less than a 10 increase in FEV1 after inhalation of 300 g salbutamol sulphate. 4. Normal bronchial responsiveness (positive responsiveness being the provocative concentration of methacholine causing a 20 fall in FEV1 (PC20) 10 mg/mL). 5. Increased cough reflex sensitivity (capsa
13、icin concentration eliciting five or more coughs (C5) 3.9 M). 6. Cough resistant to bronchodilator therapy (oral clenbuterol 40 g/day plus inhaled procaterol or salbutamol at bedtime and on demand for 1 week). 7. No abnormal findings indicative of cough aetiology on chest X-ray. 8. Normal FEV1 (80 o
14、f predicted value), FVC (80 of predicted value), and FEV1/FVC ratio (70).When all criteria were satisfied, a definite diagnosis of atopic cough is made.,Criteria for probable diagnosis of atopic cough: for general practitioners (Japanese Cough Research Society)If one or more criteria for definite di
15、agnosis of atopic cough are not satisfied (or assessed), a diagnosis of probable atopic cough was made when all of the followings were present: 1. Non-productive cough lasting more than 8 weeks without wheezing or dyspnoea2. Cough resistant to bronchodilator therapy3. Presence of one or more finding
16、s indicative of atopic constitution as a global feature described above and/or induced sputum eosinophilia ( 2.0)4. Complete relief of cough after treatment with histamine H1-antagonists and/or corticosteroid therapy.,慢性咳嗽病因的多元性 AR和CVA CVA和GER AR和PNDS 4-20,重视慢性咳嗽的病因诊断 充分理解和掌握慢性咳嗽的病因诊断程序 因地制宜地开展咳嗽相关检查 加强多学科合作 经验性诊断和治疗 掌握主要咳嗽病因的特异性治疗方案,重视病史,包括服药史,耳鼻咽喉和消化系统检查 根据病史选择有关检查,检查由简单到复杂,先常见病,后少见病 条件不具备时,根据临床特征和发病比例进行诊断性治疗 根据治疗反应确定咳嗽病因,治疗无效时再选择有关检查 部分有效应考虑咳嗽病因的多元性,
