咳嗽咳嗽咳痰咳痰的诊断的诊断 北京协和医院呼吸科 韩江娜 Cough spreads infection! 咳嗽会传染疾病 We learn a lot in SARS A very dangerous cough! Appropriate cough! Cough can be a symptoms of hundreds of diseases. With a systematic approach, it should be possible to diagnose successfully in the great majority of cases. 咳嗽可能是上百种疾病的症状 咳嗽反射：迷走神经介导的 主要分布咽喉部、呼吸道、心 血管、消化道 咳嗽有中枢神经系统的参与 When does it occur? Is it new or more chronic? How frequent is it? Is it worse at night? Is it seasonal? Is it dry or productive? Anatomic Diagnostic Protocol Review the patients history 诊断的第一步是问病史 有些患者是持续咳；有的可 能是持续多年但最近加重 In case it is productive, ask The volume of the sputum Its color Mucoid: translucent, white, grey Purulent: yellowish, greenish Mucopurulent Its odor Review the patients history Anatomic Diagnostic Protocol 咳嗽有痰 厌氧菌感染有恶臭味 Fever Smoking ACE-I Nasal discharge Frequently clear throat Heart burn or regurgitation Wheezing: whistling while breathing Additional questions in reviewing patients Anatomic Diagnostic Protocol 清嗓子 烧心、胃酸反流 喘息：这个词不要轻易用 鼻后滴漏综合症，如鼻炎、鼻窦炎 剑突下烧灼感、反流胃食管返流GERD，还可导致吸入性肺炎 Concentrating on the anatomy of the afferent limb of the cough reflex Anatomic Diagnostic Protocol Physical Examination Nose 鼻子 Sinus鼻窦 Lungs双肺 Heart 心脏 Abdomen 剑下有无压痛，考虑有无反流 集中于上腹部 The chest x-ray is extremely useful for initially ranking differential diagnostic possibilities. If the chest x-ray is abnormal, we should evaluate the possibility of the diseases suggested by the radiographic findings. 胸片检查非常重要 Normal chest x-ray Most common causes: pneumonia 很可能是大叶性肺炎，在查个血常规，若是白细胞升高则诊断为肺炎 73 y/o male smoker presenting cough for several months Lung cancer 吸烟的患者需要特别注意 Tuberculosis Bronchiectasis HRCT scan showing bronchiectasis 之前都是国内常见的咳嗽原因 Sarcoidosis 结节病 双侧肺门对称性淋巴结肿大 Interstitial Lung Diseases 间质性肺炎 Cough can be divided into 3 categories: Acute ( 8 weeks) Estimating the duration of cough is the 1ststep in narrowing the list of potential causes. Irwin RS et al. The new England Journal of Medicine 2000; 343:1715-1721 若是胸片正常，将咳嗽进行分期 Most Common Causes of Acute Cough URT Infections Common Cold Acute Bacterial Sinusitis Exacerbations of Chronic Bronchitis Allergic Rhinitis 上呼吸道感染 急性细菌性鼻窦炎 慢支的急性加重 过敏性鼻炎 Common cold Acute onset Rhinorrhea, sneezing, nasal obstruction With or without fever Lacrimation, irritation of throat Normal chest examination congestion 嗓子不舒服、流泪 一般胸部体检正常 自限性疾病，一般7-10天自行消失，若是未消失考虑找胸片 Commonest Causes of Subacute Cough After a Respiratory Infection Postinfectious Cough B. pertussis infection Bacterial sinusitis Exacerbation of a pre-existing disease Asthma Chronic Bronchitis Helpful Hints: Pertussis is likely with cough-vomit syndrome with or without whoop COPD更合适 百日咳：咳得都要呕吐了 Proportion of Cases of Pertussis Reported among Persons of Different Ages in the US 散发的百日咳 未打百白破 Causes of chronic cough (95%) UACS/PNDS Asthma GERD NAEB Smoking ACE-I Endobronchial tuberculosis Irwin RS et al. CHEST 2006,129:1S-23S; The new England Journal of Medicine 2000; 343:1715-1721 95%慢性咳嗽的原因 高血压、心衰常用，内 分泌科以此保护糖尿病 患者的肾脏 反流性食管炎 非哮喘性的嗜酸性支气管炎 支气管内结核（中国蛮多见的） Stop smoking for 4 weeks to see whether cough is partially or entirely due to this factor. Smoking 持续戒烟4周以上看是否有明显改善 While smokers have a cough, they have not been the group of patients who most commonly seek medical attention complaining of cough. Smoking In patients with a normal chest x-ray, withhold ordering additional laboratory studies in patients takinganACE-Iuntiltheresponseto discontinuation of the drug for 4 weeks can be assessed. Cough due to this etiology should substantially improve or disappear during this period of abstinence. ACE-I 用的时间越久出现咳嗽的比例越高，2个月以上的都见过的，至少要停药4、5周才可 Diagnostic Evaluation of Chronic Cough From prospective studies in adults, chronic cough is likely due to upper airway cough syndrome (UACS), asthma, eosinophilic bronchitis, 343:1715-1721 Commonest Causes of Subacute Cough After a Respiratory Infection Postinfectious Cough B. pertussis infection Bacterial sinusitis Exacerbation of a pre-existing disease Asthma Chronic Bronchitis Helpful Hints: Pertussis is likely with cough-vomit syndrome with or without whoop Tulobuterol patch 2mg QN Compound methoxyphenamine 2 caps. tid Substantial improvement at 14-day follow-up Pulmicort turbuhaler 400ug qd initiated Complete remission at 3-month follow-up Case 1 Common pitfalls in treating patients with cough variant asthma Not considering that inhaled medications for asthma may be making the cough worse. Take home message Gastroesophageal reflux disease (GERD) is caused when contents from the stomach reflux (back up) into the esophagus. 反流性食管炎：胃内容物返回到食管，尤其是食管下段，有些患者可能完全没有消化道的症状 剑突下烧灼感和反酸 Heartburn, sour taste, regurgitation 24-h esophageal pH monitoring Response to specific therapy 39 y/o male, with cough of several months and normal chest X-ray. Case 2 Case 2 24-h esophageal pH monitoring pH低于4才算有酸 Chronic cough Normal ra