咳嗽为啥老不好?1 表总结 5 种常见情况!

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咳嗽是呼吸科门诊最常见的主诉,按病程可分为急性咳嗽,亚急性咳嗽和慢性咳嗽,特别是慢性咳嗽,病因复杂,容易误诊,普通成人慢性咳嗽在社区和呼吸科门诊统计的患病率在全球高达 10%,目前相关病因诊断和治疗仍具有巨大挑战。
慢性咳嗽的基本定义

通常将以咳嗽为唯一或者主要症状,病程 > 8 周,且 X 线胸片无明显异常者称为慢性咳嗽。
常见慢性咳嗽病因的诊断及治疗

1. 咳嗽变异性哮喘(cough variant asthma,CVA)

CVA 是哮喘的一种特殊类型,是慢性咳嗽的常见病

诊断标准:

(1) 慢性咳嗽,常伴有明显的夜间刺激性咳嗽。
(2) 支气管激发试验阳性,或 PEF 平均昼夜变异率 > 10%,或支气管舒张试验阳性。
(3) 抗哮喘治疗有效。

治疗方案

(1) 吸入 ICS 联合支气管舒张剂:治疗首选推荐,如长效 β2 受体激动剂(long acting beta-agonists,LABA)或单用 ICS 治疗,治疗时间 8 周以上。
(2) 口服糖皮质激素:如果患者症状或气道炎症较重,或对 ICS 治疗反应不佳时,可以短期口服糖皮质激素治疗(10 ~ 20 mg/d,3 ~ 5 d)或使用超微颗粒的吸入制剂。不推荐长期口服糖皮质激素治疗。
(3) 白三烯受体拮抗剂:如孟鲁司特,能够减轻患者咳嗽症状、改善生活质量并减缓气道炎症。
(4) 中医药治疗:如苏黄止咳胶囊

2.上气道咳嗽综合征(upper airway cough syndrome,UACS)[鼻后滴流综合征(postnasal drip syndrome,PNDS)]

诊断标准:

(1) 慢性咳嗽,以白天或体位转变后咳嗽为主,入睡后较少;
(2) 有鼻部和(或)咽喉疾病的临床表现和病史;
(3) 辅助检查支持鼻部和(或)咽喉疾病的诊断;
(4) 针对基础疾病病因治疗后咳嗽缓解。

治疗原则:

(1) 病因治疗:
① 非变应性鼻炎以及普通感冒:推荐首选口服第一代抗组胺药和减充血剂治疗。
② 变应性鼻炎:推荐首选鼻腔吸入鼻用糖皮质激素和口服第二代抗组胺药治疗。
③ 慢性鼻窦炎:
细菌性鼻窦炎:抗感染是重要治疗措施。建议抗菌谱应覆盖革兰阳性菌、阴性菌及厌氧菌,急性发作者应用 ≥ 2 周,慢性者酌情延长使用时间。常用药物为阿莫西林/克拉维酸、头孢类或喹诺酮类。
伴有鼻息肉的慢性鼻窦炎:推荐联合鼻腔吸入鼻用糖皮质激素,疗程 3 个月以上,口服激素序贯局部鼻吸入激素的治疗效果优于单用鼻吸入激素治疗。
(2) 对症治疗:
① 鼻用减充血剂:疗程一般 < 1 周。建议联合应用第一代口服抗组胺药和鼻用减充血剂,疗程 2 ~ 3 周;
② 黏液溶解剂(羧甲司坦/厄多司坦);
③ 生理盐水鼻腔冲洗:对慢性鼻窦炎治疗有效。
④ 治疗效果不佳,必要时可经鼻内镜手术治疗。

3.嗜酸粒细胞性支气管炎(eosinophilic bronchitis,EB)

诊断:符合以下全部标准可确诊 EB:
(1) 慢性咳嗽,表现为刺激性干咳或伴少量黏痰。
(2) 肺通气功能正常,无气道高反应性,PEF 变异率正常。
(3) 痰细胞学检查嗜酸粒细胞比例 ≥ 2.5%。
(4) 排除其他嗜酸粒细胞增多性疾病。
(5) 口服或吸入糖皮质激素有效。
治疗:首选 ICS 治疗,持续应用 8 周以上。初始治疗可联合口服泼尼松 10 ~ 20 mg/d,持续 3 ~ 5 d。

4.食管反流性咳嗽(gastroesophageal reflux-related cough,GERC)

诊断标准

(1) 慢性咳嗽,以白天咳嗽常见,少数患者可有夜间咳嗽。
(2) 食管反流监测 AET > 6% 和 SAP ≥ 95%。
(3) 抗反流治疗后咳嗽明显减轻或消失。

治疗方案

(1) 调整生活方式:控制饮食、减重、抬高床头及避免睡前进食等有利于缓解症状。另外,需避免过饱,避免进食酸性、辛辣和油腻食物,避免饮用咖啡、酸性饮料及吸烟,避免剧烈运动
(2) 抑酸药物:包括 PPI 和钾离子竞争性酸阻断剂作为 GERC 的首选治疗方法;
(3) 促胃动力药:建议对于 GERC 患者,可在抑酸基础上联用促胃动力药。抗反流治疗疗程至少 8 周,逐步减量。

5.变应性咳嗽(atopic cough,AC)

符合下述标准 (1)、(2)、(3)、(5) 及(4)中的一条可确诊 AC:

(1) 慢性咳嗽,多为刺激性干咳。
(2) 肺通气功能正常,支气管激发试验阴性。
(3) 诱导痰嗜酸粒细胞不增高。
(4) 具有下列指征之一:① 有变应性疾病史或变应原接触史;② 变应原皮试阳性;③ 血清总 IgE 或特异性 IgE 增高。
(5) 糖皮质激素或抗组胺药治疗有效。
治疗:吸入 ICS 和(或)口服抗组胺药物治疗 4 周以上,初期可短期口服小剂量糖皮质激素 3 ~ 5 d。
总结以上 5 种常见慢性咳嗽病因的诊断及治疗,见下表:
咳嗽为啥老不好?1 表总结 5 种常见情况!
其他慢性咳嗽病因的诊断及治疗

1. 慢性支气管炎:咳嗽、咳痰连续 2 年以上,每年累积或持续至少 3 个月,并排除其他引起慢性咳嗽的病因。治疗包括戒烟、消除环境危险因素暴露、选择相应的抗生素抗感染治疗。
2. 支气管扩张症:最佳诊断方法为行胸部高分辨率 CT,治疗包括抗感染、减少急性加重因素、体位引流等。
3. 气管-支气管结核:诊断方法包括痰涂片找抗酸杆菌、胸部 CT、气管镜等检查,治疗原则参考结核相关指南进行抗结核规范化治疗。
4. 支气管肺癌:诊断方法包括影像学、气管镜等检查,明确诊断后,治疗以原发灶治疗为主。
5. 药物性咳嗽:特别是血管紧张素转换酶抑制剂(ACEI)类降压药最常见的副作用,典型表现为干咳。治疗最有效的方法是停用 ACEI 药物。
6. 心因性咳嗽:是非器质性疾病引起的慢性咳嗽,多见于儿童青少年,暗示治疗是主要的治疗方法。
7. 其他少见或罕见疾病:
包括咽喉疾病,如声门下腺瘤、喉癌、扁桃体肥大、悬雍垂过长等;少见气管疾病如气管支气管软化症;少见肺部疾病如肺泡微结石症;纵膈疾病如胸腺瘤等;心血管疾病如心功能不全等;其他如颈椎病、外耳道耵聍等均可引起慢性咳嗽。
慢性咳嗽诊疗的注意事项

慢性咳嗽的诊断首先需要重视病史询问,重点包括耳鼻咽喉和消化系统疾病病史、职业和环境因素暴露史、吸烟史、用药史;
其次要做详细体格检查,包括体型、鼻、咽、喉、气管、肺部等检查;
第三、要根据病史选择有关检查,包括影像学检查、诱导痰细胞学检查、肺通气功能和气道反应性检查、FeNO 检测、食管反流监测、变应原检测等,由简单到复杂,先考虑常见病,后考虑少见病;
第四、诊断和治疗应同步或顺序进行。如检查条件不具备时,可以根据临床特征进行诊断性治疗,并根据治疗反应确定咳嗽病因,治疗无效时再选择有关检查,并需要评估是否诊断错误、治疗强度和时间是否足够、有无影响疗效的因素,如职业或环境暴露因素。
慢性咳嗽的治疗可根据常见病因进行经验性治疗,主要根据病史推测可能的病因并进行相应的治疗,经验性治疗 4 周无效者,建议及时到有条件的医院进行相关检查明确病因。
题图:站酷海洛

参考文献

1 中华医学会呼吸病学分会哮喘学组. 咳嗽的诊断与治疗指南(2021)[J] . 中华结核和呼吸杂志, 2022, 45(1) : 13-46. DOI: 10.3760/cma.j.cn112147-20211101-00759.
2. 张亦南, 王涛, 刘德行, 等. 慢性咳嗽的研究进展 [J] . 中华结核和呼吸杂志, 2021, 44(7) : 645-650. DOI: 10.3760/cma.j.cn112147-20201201-01137.
3. 赖克方, 易芳, 邱忠民, 等. 中国慢性咳嗽研究进展与展望 [J] . 中华结核和呼吸杂志, 2022, 45(1) : 1-5. DOI: 10.3760/cma.j.cn112147-20210930-00690.
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葵花妈妈小儿止咳贴咳嗽咳喘远红外宝宝药化痰神器非日本婴幼儿童 券后价¥9.90 天猫 优惠券¥25.00 立即领券
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