Evaluation of the patient with chronic cough

Patients with chronic cough should avoid exposure to irritants that can trigger cough, and those who smoke should stop smoking. Patients who develop chronic cough in association with angiotensin-converting enzyme inhibitor therapy should be switched to an agent from another drug class. If cough persists, a chest radiograph should be ordered to rule out malignancy and other serious conditions. Postnasal drip syndrome, asthma, and gastroesophageal reflux disease are the most likely causes of chronic cough in adults. If postnasal drip syndrome is suspected, a trial of a decongestant and a first-generation antihistamine is warranted. Pulmonary function testing with a methacholine challenge is the preferred test for confirming the diagnosis of asthma. Gastroesophageal reflux disease usually is diagnosed based on the symptoms and after a trial of therapy. If the cause of chronic cough remains unclear, high-resolution computed tomographic scanning of the chest, bronchoscopy, and referral to a pulmonary specialist may be indicated. The approach to diagnosing chronic cough in immunocompromised patients and children is similar to the approach in immunocompetent adults. However, a CD4+ cell count can help determine the potential for opportunistic infections in immunocompromised patients. Respiratory tract infections, asthma, and gastroesophageal reflux disease are the most common causes of chronic cough in children. Foreign body aspiration should be considered in young children. Congenital conditions, cystic fibrosis, and immune disorders are possible diagnoses in children with chronic cough and recurrent infection.     

The diagnosis of wheezing in children

Wheezing in children is a common problem encountered by family physicians. Approximately 25 to 30 percent of infants will have at least one wheezing episode, and nearly one half of children have a history of wheezing by six years of age. The most common causes of wheezing in children include asthma, allergies, infections, gastroesophageal reflux disease, and obstructive sleep apnea. Less common causes include congenital abnormalities, foreign body aspiration, and cystic fibrosis. Historical data that help in the diagnosis include family history, age at onset, pattern of wheezing, seasonality, suddenness of onset, and association with feeding, cough, respiratory illnesses, and positional changes. A focused examination and targeted diagnostic testing guided by clinical suspicion also provide useful information. Children with recurrent wheezing or a single episode of unexplained wheezing that does not respond to bronchodilators should undergo chest radiography. Children whose history or physical examination findings suggest asthma should undergo diagnostic pulmonary function testing.     

The Evolving Clinical Practice of Chronic Cough

Chronic cough, defined as a cough lasting for greater than 8 weeks, accounts for a substantial number of primary care and specialist consultations in the United States. Although cough can arise from a myriad number of serious respiratory diseases, attention has traditionally focused on diagnosing and treating gastroesophageal reflux, upper airway cough syndrome, and eosinophilic airway inflammation (asthma and nonasthmatic eosinophilic bronchitis) in patients with normal chest imaging. The newly described paradigm and entity of cough hypersensitivity syndrome (CHS) becomes useful when the etiology of cough remains elusive or when the cough remains refractory despite appropriate therapy for underlying causes. We present an update on the evolving understanding of refractory chronic cough and/or unexplained chronic cough as manifestations of laryngeal hypersensitivity and CHS. This includes a focus on understanding the pathophysiology underlying current and novel therapeutics for CHS, while also ensuring that common causes of chronic cough continue to be evaluated and treated in a systematic multidisciplinary manner.     

Chronic cough: Stepwise application in primary care practice of the ACCP guidelines for diagnosis and management of cough

Purpose: To illustrate decision points encountered when using evidence-based guidelines for diagnosis and management of chronic cough by means of a composite case study based on primary care practice.
Data source: The American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines for Diagnosis and Management of Cough, and review of the scientific literature on cough and related topics.
Conclusions: The ACCP guidelines offer a systematic approach that uses trials of empirical therapies to diagnose and resolve the very common, often perplexing complaint of chronic cough. The major diagnoses reached are upper airway cough syndrome, cough-variant asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis.
Implications for practice: Cough is the most common reason that patients seek an office visit. Many coughs resolve spontaneously, but coughs that persist significantly impair the quality of life. Use of the ACCP guidelines allows a stepwise empirical approach to the problem of unexplained chronic cough. This approach greatly increases the percentage of chronic coughs that are accurately diagnosed and effectively treated, and avoids unnecessary diagnostic testing.     

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease is the most common and expensive digestive disease with complex and multi-factorial pathophysiologic mechanisms. Transient inappropriate relaxation of the lower esophageal sphincter is the predominant mechanism in the majority of patients with mild to moderate disease. Hiatal hernias and a reduced lower esophageal sphincter pressure have a significant role in patients with moderate to severe disease. Typical manifestations of gastroesophageal reflux disease include heartburn, regurgitation, and dysphagia. Atypical symptoms, such as noncardiac chest pain, pulmonary manifestations of asthma, cough, aspiration pneumonia, or ENT manifestations of globus and laryngitis, can be seen in patients with or without typical symptoms of gastroesophageal reflux disease. Endoscopy and ambulatory pH tests are best to evaluate the anatomic and physiologic impact ofgastroesophageal reflux disease. Complications of chronic gastroesophageal reflux disease include peptic strictures and Barrett metaplasia. Barrett esophagus is a major risk factor for esophageal adenocarcinoma, and upper endoscopy with surveillance biopsies is recommended for patients with Barrett esophagus. Medical therapy with anti-secretory agents (H2 blockers and proton pump inhibitors) is effective for most patients with gastroesophageal reflux disease. Surgical fundoplications and endoscopic treatment modalities are mechanical treatment options for patients with gastroesophageal reflux disease.     

老年患者慢性咳嗽病因构成及咳嗽严重程度分析

目的探讨老年与非老年组患者慢性咳嗽病因构成及咳嗽严重程度。方法 58例老年和82例非老年不明原因慢性咳嗽患者,按照慢性咳嗽的解剖学诊断程序,根据病史、体格检查、实验室检查及相关辅助检查明确病因,咳嗽积分评价咳嗽严重程度。结果老年组常见病因依次为：咳嗽变异性哮喘（CVA）23例,上气道咳嗽综合征（UACS）16例,胃食管反流性咳嗽（GERC）8例;非老年组常见病因依次为：CVA 31例,UACS 26例,GERC 10例。两组主要病因构成比较差异无统计学意义（P〉0.05）。两组患者各病因间的日间咳嗽积分比较差异无统计学意义（P〉0.05）,CVA的夜间积分明显高于其他病因（P均〈0.01）。结论与非老年组类似,CVA、UACS、GERC也是老年不明原因慢性咳嗽的常见病因,不同病因慢性咳嗽的日间咳嗽程度类似,但CAV夜间咳嗽程度显著高于其他病因的咳嗽。     

慢性咳嗽患者的呼吸道嗜酸性粒细胞性炎性反应特征

目的探讨慢性咳嗽患者的呼吸道嗜酸性粒细胞炎性反应特征。方法使用诱导痰嗜酸性粒细胞计数检查123例慢性咳嗽患者的呼吸道嗜酸性粒细胞性炎性反应情况,其中咳嗽变异型哮喘(CVA)44例、嗜酸性粒细胞性支气管炎(EB)27例、上气道咳嗽综合征(UACS)26例、变应性咳嗽(AC)17例和胃食管反流相关性咳嗽(GERC)9例。收集56例典型哮喘(CA)患者和25例健康者的诱导痰嗜酸性粒细胞计数结果进行统计学比较。结果慢性咳嗽患者呼吸道嗜酸性粒细胞炎性反应的阳性率为0.487 8(60/123),其中,CVA组和EB组分别为0.750 0(33/44)和1.000 0(27/27),其他病因组均为0.000 0。CVA组与EB组之间的差异具有统计学意义(P=0.005),CVA组与CA组[0.821 4(46/56)]之间的差异无统计学意义(P=0.507),EB组与CA组之间差异具有统计学意义(P=0.019),CVA组、EB组分别与UACS组、AC组、GERC组、健康对照组比较,差异具有统计学意义(P值均为0.000)。呼吸道嗜酸性粒细胞炎性反应患者的诱导痰嗜酸性粒细胞比值,EB组低于CVA组(Z=-2.551,P=0.011)和CA组(Z=-3.190,P=0.001),CVA组与CA组之间差异无统计学意义(Z=-0.801,P=0.423)。结论嗜酸性粒细胞性炎性反应是慢性咳嗽患者的一种主要的呼吸道炎性反应类型,主要见于CVA和EB患者。CVA和EB的呼吸道嗜酸性粒细胞性炎性反应程度不同。     

Chronic Cough: An Update

Cough persisting beyond 8 weeks (ie, chronic cough) is one of the most common reasons for an outpatient visit. A protracted cough can negatively affect one’s quality of life by causing anxiety, physical discomfort, social isolation, and personal embarrassment. Herein, the anatomy and physiology of the cough reflex are reviewed. Upper airway cough syndrome, asthma, eosinophilic bronchitis, and gastroesophageal reflux disease account for most chronic cough after excluding smoking, angiotensin-converting enzyme inhibitor use, and chronic bronchitis. Many patients have more than one reason for chronic cough. Treating the underlying cause(s) resolves cough in most instances. There are some coughs that seem refractory despite an extensive work-up. The possibility of a hypersensitive cough reflex response has been proposed to explain these cases. Several clinical algorithms to evaluate chronic cough are presented.     

常见慢性咳嗽病因及其诊断探讨

目的 探讨常见慢性咳嗽的病因及疾病表现的临床意义,为经验性治疗提供依据.方法 按慢性咳嗽的病因诊断流程对160例患者的病因构成进行分析,比较常见病因慢性咳嗽患者的咳嗽时相、性质、诱发因素及相关伴随症状,统计方法采用U检验,计算P值.结果 共入选160例2009年1月至12月宜昌市中心人民医院呼吸科门诊慢性咳嗽患者,其中常见病因分布依次为咳嗽变异性哮喘(CVA) 72例占45.00％、上气道咳嗽综合征(UACS) 54例占33.75％、嗜酸性粒细胞性支气管炎(EB) 14例占8.75％、胃食管反流性咳嗽(GERC)9例占5.63％,其他病因共11例、占6.87％.不同病因组临床表现有差异.CVA患者夜间咳嗽构成比为52.8(38/72),明显高于其他病因;UACS患者以白天咳嗽为主,70.2％伴有鼻后滴流症状,且绝大部分伴有鼻炎相关症状或有鼻炎病史,高于其他各组;GERC患者饮食相关咳嗽占66.7％,77.8％伴有反流症状明显高于其他病因组;上述症状差异均有统计学意义.但EB患者临床症状无特异性.结论 各种病因的慢性咳嗽具有一定的临床特征,慢性咳嗽病因构成及咳嗽时相、部分伴随症状对病因诊断具有一定的参考价值.     

以食管外表现为主的老年胃食管反流病15例误诊分析

目的 探讨老年胃食管反流病(gastroesophageal reflux disease,GERD)误诊原因,以减少误诊误治.方法 对我院2009年1月～2011年6月收治176例老年GERD中15例误诊病例资料进行回顾性分析.结果 本组均无明显反酸、胃灼热症状,咳嗽、咽痒、咽部异物感9例,胸痛、胸闷4例,呼吸困难2例.本组误诊率8.5％ (15/176),误诊为慢性支气管炎6例、冠心病心绞痛4例、慢性咽炎3例、哮喘2例,误诊时间20 d～13个月.后结合症状及电子胃镜检查诊断为GERD,予奥美拉唑、多潘立酮等治疗,症状均明显改善.结论 应重视老年GERD患者的食管外表现,对表现为胸痛、吞咽困难、咽喉痛、牙龈炎、气管炎、哮喘、夜间呛咳老年患者在按照专科疾病治疗效果不佳时,应考虑GERD,尽早行胃镜及相关检查确诊.     

儿童慢性咳嗽134例病因分析及随访观察

目的：了解儿童慢性咳嗽的病因及随访情况,做出准确诊断。方法对汕头市澄海区人民医院134例慢性咳嗽患儿按《儿童慢性咳嗽诊断与治疗指南》的诊断流程询问病史,行体格检查,在初步确定病因后,针对病因进行特异性治疗并进行随访,根据辅助检查及疗效做出最终诊断,并进行病因分析。结果1）134例慢性咳嗽患儿病因依次为咳嗽变异性哮喘（CVA）52例（38.81%）,呼吸道感染和感染后咳嗽（PIC）39例（29.10%）,上气道咳嗽综合征（UACS）30例（22.39%）,胃食道反流性咳嗽（GERC）3例（2.24%）,气管异物2例（1.49%）,不明原因8例（5.97%）。2）不同年龄组病因构成比不同：≤3岁组中,主要病因为PIC（28例,49.12%）,＞3～6岁组中,主要病因为CVA （29例,59.18%）,＞6～14岁组中,主要病因为UACS（15例,53.57%）。3）总诊断修正率为8.96%（12/134）。结论汕头市澄海区人民医院儿童慢性咳嗽的病因前3名依次为CVA、PIC、UACS;不同年龄组病因构成比不同;儿童慢性咳嗽的诊治的过程要遵循观察、等待、随访的原则。     

白三烯受体拮抗剂在慢性咳嗽治疗中的临床价值

目的 探讨白三烯受体拮抗剂在慢性咳嗽临床治疗中的意义.方法 选择81例慢性咳嗽患者(根据慢性咳嗽诊断流程诊断),所有患者均符合咳嗽时间≥8周,不吸烟或戒烟4周以上,无服用血管紧张素转换酶抑制剂类药物史,服用者停药观察4周,X线胸片检查未见异常,并除外胃食管反流性咳嗽、除变应性鼻炎的其他上气道咳嗽综合征、支气管内膜结核等其他慢性咳嗽病因.对诊断为咳嗽变异性哮喘、变应性鼻炎、嗜酸粒细胞性支气管炎及感染后咳嗽的患者给予孟鲁司特钠10 mg,每晚1次进行治疗4周并观察疗效.结果 81例入选患者中咳嗽变异性哮喘36例,变应性鼻炎30例,嗜酸粒细胞性支气管炎5例,感染后咳嗽10例.经孟鲁司特钠治疗后,67例患者咳嗽症状临床控制,12例患者显效,2例无效,有效率97.5%(79/81).结论 气道炎症是慢性咳嗽患者常见的病理特征,白三烯受体拮抗剂孟鲁司特钠有显著的抗炎作用,能明显改善咳嗽变异性哮喘、嗜酸粒细胞性支气管炎、感染后咳嗽、变应性鼻炎等慢性咳嗽患者的气道炎症,减轻咳嗽症状,是治疗慢性咳嗽的重要药物.     

Aspiration Pneumonia and Related Syndromes

Aspiration is a syndrome with variable respiratory manifestations that span acute, life-threatening illnesses, such as acute respiratory distress syndrome, to chronic, sometimes insidious, respiratory disorders such as aspiration bronchiolitis. Diagnostic testing is limited by the insensitivity of histologic testing, and although gastric biomarkers for aspiration are increasingly available, none have been clinically validated. The leading mechanism for microaspiration is thought to be gastroesophageal reflux disease, largely driven by the increased prevalence of gastroesophageal reflux across a variety of respiratory disorders, including chronic obstructive pulmonary disease, asthma, idiopathic pulmonary fibrosis, and chronic cough. Failure of therapies targeting gastric acidity in clinical trials, in addition to increasing concerns about both the overuse of and adverse events associated with proton pump inhibitors, raise questions about the precise mechanism and causal link between gastroesophageal reflux and respiratory disease. Our review summarizes key aspiration syndromes with a focus on reflux-mediated aspiration and highlights the need for additional mechanistic studies to find more effective therapies for aspiration syndromes.     

儿童慢性上气道咳嗽综合征病因及诊断方法探讨

目的探讨儿童慢性上气道咳嗽综合征（UACS）的病因及诊断方法。方法对135例诊断为UACS患儿的病因、临床特点及对治疗反应进行分析。结果135例UACS患儿中3例失访,132例慢性上气道咳嗽综合征患儿病因明确（97.78%）,其中慢性鼻炎67例（49.63%）,鼻窦炎42例（31.11%）,变应性鼻炎22例（16.30%）,腺样体肥大7例（5.19%）,解剖结构异常所致鼻炎1例（0.74%）。主要临床特点是咳嗽135例（100%）,抠鼻孔102例（75.56%）,清喉94例（69.63%）、流涕89例（65.93%）,鼻塞或打鼾78例（57.78%）,打喷嚏71例（52.59%）、咽痒68例（50.37%）、咽部感分泌物下流或异物感63例（46.67%）,张口呼吸45例（33.33%）。治疗12周症状基本消失128例（94.81%）,显效3例（2.22%）,总有效率97.04%（131/135）。结论儿童UACS最常见的三个病因是慢性鼻炎、鼻窦炎及变应性鼻炎,咳嗽是其主要症状,通过详细询问咳嗽特点及其伴随症状,尤其是鼻部症状、检查鼻咽部,97.78%都能明确诊断,经特异积极治疗,绝大部分疗效好。     

80例慢性咳嗽的病因分析

目的探讨慢性咳嗽的病因分布特点。方法对80例慢性咳嗽患者,按照慢性咳嗽的解剖学诊断程序,根据病史、体格检查、实验室检查及特异性治疗反应,判定病因。结果 80例患者慢性咳嗽的病因为咳嗽变异性哮喘（CVA）20例（25.0%）,鼻后滴漏综合征（PNDS）14例（17.5%）,胃食管反流性疾病（GERC）11例（13.7%）,嗜酸粒细胞支气管炎（EB）9例（11.2%）,ACEI诱发的咳嗽8例（10.0%）,其他病因18例（22.5%）。结论 CVA、PNDS和GERC是慢性咳嗽的常见病因。     

儿童咳嗽变异性哮喘50例误诊分析

目的：探讨儿童咳嗽变异性哮喘(CVA)的病因、诊断及误诊。方法：对50例 CVA 患儿的临床资料进行回顾性分析。结果：男 性35例，女性15例。发作诱因：上呼吸道感染39例，气候变化15例，运动后6例，吸入冷空气后21例，同时具备2种以上诱因21 例。误诊为气管或支气管炎36例，上呼吸道感染25例，支原体感染18例，慢性咽炎10例，百日咳或类百日咳综合征4例，免疫功能 低下9例。抗生素治疗无效。结论：CVA 以慢性持续性干咳为其临床表现，运动、冷空气或上呼吸道感染可使咳嗽加重，支气管舒张 剂治疗有效。仔细询问病史，减少误诊。     

Gastroesophageal reflux disease as a cause of chest pain

Patients with recurrent chest pain free of significant coronary artery disease account for 10% to 30% of patients undergoing coronary angiography. Recent studies suggest that gastroesophageal reflux disease may be very common in these patients. The cause of this chest pain seems to be related primarily to an acid-sensitive mucosa regardless of the presence of esophagitis. Unfortunately, a careful history will not distinguish chest pain arising from a cardiac versus an esophageal source. Therefore, all patients must undergo a thorough cardiac evaluation before assuming that acid reflux is the cause of their complaints. Initial gastroenterology evaluation will usually include upper GI endoscopy or barium studies, possibly with acid perfusion (Bernstein) testing, or both. However, the more sensitive and specific test for acid-related disease is prolonged esophageal pH monitoring. This study quantifies the amount of acid reflux but, more importantly, identifies the relationship between chest pain and acid reflux episodes. Patients should be studied in the outpatient setting with emphasis placed on performing activities that replicate their chest pain. Although we presume that acid-induced chest pain responds as well as heartburn to vigorous antireflux regimens, there are few studies to address this issue. Nevertheless, I have had great success in treating these patients with either high-dose H2 blockers or omeprazole therapy.     

Chronic respiratory disease and gastroesophageal reflux

Both GERD(gastroesophageal reflux disease) and chronic respiratory disease are common disease in old and the association between GERD and chronic respiratory disease are recently proved in many reports. Patient with GERD have a higher prevalence of asthma and chronic cough. Aggressive antireflux therapy in patient with asthma and GERD results in improvement in asthma outcome. In our study, endoscopic examination revealed that the prevalence of esophageal mucosal disease in patient with asthma was about 83%. In this paper, I review the role of GERD in chronic respiratory disease, especially asthma.     

Sleep apnea in infancy and childhood

Episodic apnea leading to asphyxia is a relatively common disorder of young children. Important apnea syndromes include apnea of prematurity, "narrow upper airway syndrome," congenital hypoventilation syndrome, breath-holding spells, and "near-miss" sudden infant death syndrome. More recently described syndromes include apnea associated with feedings, regurgitation or gastroesophageal reflux, and apnea initiated by epileptic seizures. Apnea occurring during wakefulness is common and may be related to that occurring during sleep. Knowledge of the clinical features and pathophysiology of these various kinds of apnea is important in their management.