如何理解和灵活应用咳嗽诊治指南

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,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,林江涛,2006-3-30 (,北京,）,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,2004,24:481492,2005:,Guideline for the management of cough.,Source Nihon,Kokyuky,Gakkai,Zasshi,2005,suppl:2-80,2005:,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（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 asthma (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: 201-207.,慢性咳嗽的主要病因构成,A,C,C,V,A,S,B,S,B,A,G,E,R,0,1,0,2,0,3,0,4,0,5,0,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,咳嗽病因,病因分布（,%,）,嗜酸细胞性支气管炎,22%,（,51,例）,鼻炎,/,鼻窦炎,17%,（,39,例）,咳嗽变异型哮喘,14%,（,31,例）,变应性咳嗽,12%,（,28,例）,胃食管反流,12%,（,27,例）,慢性咽炎,8%,（,19,例）,感冒后咳嗽,5%,（,11,例）,慢性支气管炎,4%,（,10,例）,支气管扩张症,1%,（,2,例）,左心衰竭,0.5%,（,1,例）,肺间质纤维化,0.5%,（,1,例）,病因未明,4%,（,9,例）,广州呼研所，,200,6,病因,例数,%,CVA,29,25.6,PNDS,16,19.5,GER,13,15.8,ACEI,12,14.6,EB,2,2.4,AC,2,2.4,ILD,2,2.4,病因不明,6,7.3,*慢性咳嗽定义为,8,周,中日友好医院,病因,例数,%,CVA,29,23.2,PNDS,28,22.4,PIC,23,18.4,GER,16,12.8,ACEI,15,12.0,EB,3,2.4,病因不明,11,8.5,*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,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,中华医学会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 断标准,（中华医学会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 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,0,1,0,2,0,3,0,4,0,5,0,可能,确定,可能,+,确定,双病因 其它 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 8weeks without wheezing or dyspnoea.,2,. Presence of one or more findings indicative of,an,atopic,constitution, including a,past history and/or complications of allergic diseases excluding asthma, a,peripheral blood,eosinophilia,(6% or 400cells/L), raised total,IgE,level in,the serum (200IU/,mL,), positive specific,IgE,antibody to aeroallergens and,positive allergen skin test and/or induced sputum,eosinophilia,(2.0%).,3,.,No bronchial reversibility, defined as less than a 10% increase in FEV,1,after,inhalation of 300g,salbutamol,sulphate.,4,.,Normal bronchial responsiveness,(positive responsiveness being the provocative,concentration of,methacholine,causing a 20% fall in FEV,1,(PC20)10mg/,mL,).,5,.,Increased cough reflex sensitivity,(capsaicin concentration eliciting five or more,coughs (C5)3.9M).,6,.,Cough resistant to bronchodilator therapy,(oral,clenbuterol,40g/day plus inhaled,procaterol,or,salbutamol,at bedtime and on demand for1week).,7,. No abnormal findings indicative of cough aetiology on chest X-ray.,8,. Normal FEV,1,(,80% of 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 diagnosis 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 8weeks without wheezing or dyspnoea,2. Cough resistant to bronchodilator therapy,3. Presence of one or more findings 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,慢性咳嗽病因诊断程序,慢性咳嗽诊断程序,1(immunocompetent,adults.doc,),Managing cough as a defense mechanism and as a symptom,A Consensus Panel Report of the American College of Chest Physicians,Chest,1998;114(2,）：,166s,慢性咳嗽诊断程序,2,（,immunocompromised,adults.doc,）,Managing cough as a defense mechanism and as a symptom,A Consensus Panel Report of the American College of Chest Physicians,Chest,1998;114(2,）：,168s,成人慢性咳嗽诊断和处理,.,流程,doc,The diagnosis and management of chronic cough,Eur,Respir,J,2004;24:483,Evaluation of chronic cough in Japan,Diagnostic protocol for common causes,of prolonged or chronic cough in adults,14, 15 member,macrolides,Prolonged cough,Chronic cough,Consider SBS,Cough sensitivity,1) No abnormal findings indicative of cough aetiology on chest X-ray,2) No abnormal breath sound on auscultation,3) Normal pulmonary function,4) No systemic inflammatory reaction,Productive cough,Non-productive cough,Increased,Not increased,Cough gone,Diagnosed,Drugs tapered and stopped,Cough remained,Consider complication,of other cause (s),Cough unchanged,Consider other cause (s),Consider CVA,Bronchodilator therapy,Cough gone or decreased,CVA diagnosed,Cough,unchanged,Consider,AC,GERD,PIC,Atopic constitution,and/or,Sputum eosinophilia,Present,Consider AC,H1-antagonists,and/or,steroids,Cough gone,Diagnosed,Drugs tapered and stopped,Cough,unchanged,Consider other cause (s),Cough remained,Consider complication,of other cause (s),Cough remained,Bronchodilators,and/or,steroids,Absent,Consider,GERD,PIPC,Treatment of PIPC,Cough gone,Diagnosed,Long-term therapy (ICS),Cough remained,Consider complication,of other cause (s),Cough gone,Diagnosed,Drugs tapered and stopped,Cough unchanged,or remained,Consider GERD,PPIs,Cough gone,Diagnosed,Long-term management,Cough,unchanged,Other cause (s),SBS: sinobronchial syndrome,CVA: cough variant asthma,AC: atopic cough,GERD: gastroesophageal reflux disease,PIC: post-infectious prolonged cough,PPIs: proton pump inhibitors,ICS: inhaled corticosteroids,Diagnostic protocol for common causes of prolonged and chronic cough considering pathophysiologic features,(JRS guideline on cough 2005),Therapeutic diagnosis for common causes of prolonged or chronic cough in Japan,For general practitioners,(JRS guideline on cough 2005),慢性咳嗽病因诊断流程图,中华医学会呼吸病学分会哮喘学组,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,支气管激发试验,24h,食管,PH,值监测,诱导痰细胞学检查,24h,食管,P,H,值监测,诊断,GERC,最敏感、最特异的方法,敏感性,89%,，特异性,100%,Irwins, Am Rev,Respir,Dis,1990,同步记录胃酸反流与咳嗽事件,明确反流与咳嗽的关系,GERC,食管,PH,值监测结果,诊 断,Demeester,总评分,24h,食管,PH5min,的次数,最长反流时间,总、立、卧位食管,PH4,时间,占监测时间的百分比,反流与咳嗽症状相关概率,检查时实时记录反流相关症状如反酸、恶心、胸骨后烧灼感和咳嗽等，可以获得返流与咳嗽症状的相关概率（,symptom association probability,，,SAP,）,明确反流时相、次数与咳嗽的关系,诱导痰细胞学检查,为,EB,诊断的关键方法,但开展单位较少,技术简单，易掌握，无需复杂的设备,应广泛推广,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,加强多学科合作,呼吸内科,耳鼻咽喉科,消化内科,变态反应科,儿科,放射诊断科,加强多学科合作,知识的交流,现有设备的充分利用,儿童咳嗽,儿童与成人咳嗽有类似之处，也存在明显的临床和生理上的差异,简单从成人获得,数据,资料推演至儿童身上的做法可能不妥,目前对儿科咳嗽方面的研究相对较少，应加强儿童与成人咳嗽的异同的研究，以进一步提高儿童咳嗽的诊治水平,儿童慢性咳嗽诊断,流程,.doc,The diagnosis and management of chronic cough,Eur,Respir,J,2004;24:487,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,经验性诊断和治疗,不是盲目或习惯性的诊断和治疗,是以循证医学,（,evidence-based,）,为依据的,成人慢性咳嗽诊断和处理,.,流程,doc,The diagnosis and management of chronic cough,Eur,Respir,J,2004;24:483,14, 15 member,macrolides,Prolonged cough,Chronic cough,Consider SBS,Cough sensitivity,1) No abnormal findings indicative of cough aetiology on chest X-ray,2) No abnormal breath sound on auscultation,3) Normal pulmonary function,4) No systemic inflammatory reaction,Productive cough,Non-productive cough,Increased,Not increased,Cough gone,Diagnosed,Drugs tapered and stopped,Cough remained,Consider complication,of other cause (s),Cough unchanged,Consider other cause (s),Consider CVA,Bronchodilator therapy,Cough gone or decreased,CVA diagnosed,Cough,unchanged,Consider,AC,GERD,PIC,Atopic constitution,and/or,Sputum eosinophilia,Present,Consider AC,H1-antagonists,and/or,steroids,Cough gone,Diagnosed,Drugs tapered and stopped,Cough,unchanged,Consider other cause (s),Cough remained,Consider complication,of other cause (s),Cough remained,Bronchodilators,and/or,steroids,Absent,Consider,GERD,PIPC,Treatment of PIPC,Cough gone,Diagnosed,Long-term therapy (ICS),Cough remained,Consider complication,of other cause (s),Cough gone,Diagnosed,Drugs tapered and stopped,Cough unchanged,or remained,Consider GERD,PPIs,Cough gone,Diagnosed,Long-term management,Cough,unchanged,Other cause (s),SBS: sinobronchial syndrome,CVA: cough variant asthma,AC: atopic cough,GERD: gastroesophageal reflux disease,PIC: post-infectious prolonged cough,PPIs: proton pump inhibitors,ICS: inhaled corticosteroids,Diagnostic protocol for common causes of prolonged and chronic cough considering pathophysiologic features,(JRS guideline on cough 2005),Therapeutic diagnosis for common causes of prolonged or chronic cough in Japan,For general practitioners,(JRS guideline on cough 2005),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,病史和体格检查,胸部,X,线检查,戒烟或停用,ACEI,，,观察,4,周,肺功能,+,气道高反应性,鼻窦平片、变应评价,诱导痰检查,24,小时食道,pH,值测定,纤支镜、肺,CT,、,鼻窦,CT,或非侵入性心脏检查,美国：慢性咳嗽的病因确诊率,88,100%,。根据诊断进行特异性治疗，成功率为,84,98%,Irwin,RS.et,al. N,Engl,Med J.2000;343(23):1715-21.,回顾我国相关研究，慢性咳嗽病因确诊率,90,98%,，,治疗成功率为,80,94,马洪明等,.,中华结核和呼吸杂志,.2003;26(11):675-8.,容朝晖等,.,中国现代医学杂志,.2005;15(4):600-2.,杨忠民等,.,同济大学学报,(,医学版,).2005;26(1):62-4.,吕寒静等,.,同济大学学报,(,医学版,).2003;24(5):420-2.,掌握主要咳嗽病因的特异性治疗方案,多数慢性咳嗽与感染无关，无需使用抗菌药物治疗,咳嗽原因不明或不能除外感染时，慎用糖皮质激素,经相应治疗后咳嗽缓解，病因诊断方能确立,部分患者可同时存在多种病因,治疗后咳嗽症状部分缓解，应考虑是否同时合并其它病因,主要咳嗽病因的特异性治疗方案,CVA,吸入糖皮质激素治疗,PNDS,普通感冒,非变应性鼻炎,血管舒缩性鼻炎,常年性鼻炎,首选第一代抗组胺药（马来酸氯苯那敏）和减充血剂（盐酸伪麻黄碱）,变应性鼻炎,首选第二代抗组胺药（氯雷他定、阿斯咪唑）,鼻腔吸入糖皮质激素,;,色甘酸钠吸入、环境控制、避免变应原刺激,慢性鼻窦炎,抗生素,3W;,第一代抗组胺剂,+,减充血剂,3W;,鼻用减充血剂,1W;,鼻吸入糖皮质激素,3,个月,EB,吸入糖皮质激素,GERC,生活方式调整、抑酸药、促动力药,总 结,慢性咳嗽的病因复杂，以,CVA,、,PNDS,（鼻炎,/,鼻窦炎）、,GERC,、,NAEB,、,AC,最为常见,采用慢性咳嗽病因诊断程序可使,90%,以上患者获得病因诊断，并取得良好的治疗效果,切合实际地推广,“,咳嗽诊治指南,”,，掌握慢性咳嗽的病因诊断程序,在,推广应用过程中，加强慢性咳嗽诊治方面的研究，为指南进一步修订提供依据,