慢性咳嗽病因诊断和治疗.ppt

,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,urinaryincontinencefecalincontinencefrequentretchingdizzinesssweatingbrokenribs.,案例,A44-year-oldmanpresentedwithcoughofthreeweeksduration.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)ChronicbronchitisSmokingandotherenvironmentalirritants,RareCausesofChronicCough,TracheobronchialcollapseLungcancerTuberculosisOtherlunginfectionOccupationalenvironment-inducedcoughBronchiectasisSarcoidosis,RareCausesofChronicCough,LeftventricularfailureInterstitiallungdiseaseMetastaticbreastcarcinomatosisHyperthyroidismCarcinoidtumorRetainedsutureHodgkinsdiseaseZenkersdiverticulum,Etiology:0to18months,支气管异物,支气管异物,Etiology:18monthsto6years,1.5to6YearsEtiology:Adolescents,6to16YearsEtiology: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1621710Patientisasmoker-Purulentsputum-PatienttakinganACEI-HighriskforTBexposureWheezing-,PossiblediagnosisCongenitalmalformationsTobacco-inducedbronchitisPneumonia,bronchitisACEinhibitor-inducedcoughTuberculosisAsthma,CluestoCommonCausesofCoughbyHistory,Nocturnalwheezing-Coughisworseatwork-CoughfollowingURIorexposuretoallergenSensationofpostnasaldrip-Facialpain,toothpain-HeartburnorsourtasteinmouthHistoryofweightloss-,Asthma,congestiveheartfailureOccupationalenvironmentcausePostnasaldripPostnasaldrip,asthmaSinusitisGastroesophagealrefluxdiseaseCancer,tuberculosis,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,DiagnosticProtocolInitialEvaluationHistoryRemoveirritantPhysicalExamTreatpostnasaldrip,sinusitis,etcChestXray,Treat/furtherevaluationBronchoscopyEvaluateanatomyRemoveforeignbodyCollectspecimenforcultures,pathologyPulmonaryFunctionTestingSpirometry-TreatasthmaMICTreat-asthma,GERDTestingpHprobe-TreatGERDUpperGIseries-Treatanyanatomicabnormalit