重视儿童咳嗽病因识别与用药选择

咳嗽是儿童常见临床症状,儿童急性咳嗽多与呼吸道病毒感染有关,呈自限性过程。儿童慢性咳嗽的病因有别于成人,虽然我国儿童慢性咳嗽协作组的多中心研究结果显示,咳嗽变异性哮喘、感染后咳嗽和上气道咳嗽综合征是我国儿童慢性咳嗽的主要原因,但存在明显的地域差异。由于检测手段等原因,可能存在对迁延性细菌性支气管炎等疾病的诊断不足,临床医师应加以注意。急性咳嗽一般无需使用特殊咳嗽药物治疗,慢性咳嗽应尽可能搜索病因,明确诊断,采取对因治疗。目前临床存在儿童咳嗽药物使用过度的现象,尤其应该注意避免联合使用含有相同药物成分的咳嗽药物。     

儿童慢性咳嗽与肺结核

咳嗽是儿童肺结核病的基本症状。由于肺结核是一个传染性疾病,对由结核病引起的慢性咳嗽作出早期诊断和及时治疗,对防止结核病的传播颇为重要,因此所有慢性咳嗽的患儿均不应忽视肺结核的诊断。肺结核早期症状以干咳为主;肺内病变发生干酪样坏死或形成空洞时,咳嗽多伴痰液;支气管淋巴瘘时则引起犬吠样甚至痉挛性剧烈咳嗽。     

儿童慢性咳嗽与哮喘:《儿童慢性咳嗽诊断与治疗指南》解读二

咳嗽是儿童呼吸系统疾病最常见的症状之一,儿童如持续咳嗽超过4周就要考虑诊断为慢性咳嗽[1].研究表明,哮喘特别是咳嗽变异性哮喘(cough variant asthma,CVA)及相关性疾病是导致儿童慢性咳嗽的重要原因之一.国外的研究报告CVA占儿童慢性孤立性咳嗽(我国诊疗常规称之为"非特异性咳嗽")的17%～40.1%[2-3].国内对儿童的研究显示,CVA占慢性咳嗽的34%[4],而成人的研究表明,CVA是成人慢性咳嗽的最主要原因,占62.3%[5].由于CVA缺乏明确的客观诊断指标,临床上往往存在诊断过度和误诊的情况.     

临床资料对儿童慢性咳嗽病因的诊断价值

目的 探讨临床资料对儿童慢性咳嗽病因的诊断价值.方法 选择2008年12月-2010年1月在广西医科大学第一附属医院儿科就诊的慢性咳嗽患儿117例,通过前瞻性的临床研究方法 ,获得慢性咳嗽患儿详细的临床资料和病因,分析临床资料对病因诊断的作用.结果 本组慢性咳嗽的病因为咳嗽变异性哮喘(CVA)、上呼吸道咳嗽综合征(UACS)、感染后咳嗽(PIC)、变应性咳嗽(AC)、多发性抽动(TS)和心因性咳嗽(PC)等.CVA以夜间晨起干咳为主,可伴活动后咳嗽增多;UACS以咳痰为主,多伴有鼻症状;感染后咳嗽病程多在2个月内;PC可为响亮的日间干咳;TS同时有抽动表现.性别、个人及家族过敏史、被动吸烟等在不同病因慢性咳嗽间无差异.UACS常见的上呼吸道异常为鼻窦炎、变应性鼻炎、腺样体肥大;CVA多有嗜酸性粒细胞增高或皮肤变应原阳性.结论 CVA、UACS、PIC是儿童慢性咳嗽的常见病因.临床资料对慢性咳嗽的病因诊断有较大的提示作用,年龄、病程、咳嗽特征可提供病因诊断线索;上呼吸道异常,特别是鼻窦炎患者要注意有无UACS;嗜酸性粒细胞增高或皮肤变应原阳性可提示CVA的诊断.     

咳嗽变异性哮喘

咳嗽变异性哮喘（coughvariantasthma，CVA）又名咳型哮喘、隐匿型哮喘或过敏性咳嗽，是哮喘的一种潜在形式。人们都知道咳嗽和喘息是哮喘的症状，但是当咳嗽是哮喘的唯一症状而没有喘息时就不认识了，一般人以为只有出现喘息才是哮喘，这是一科。误解。慢性咳嗽是门诊医生经常遇到的问题，实际上在慢性咳嗽未明诊断或诊断为支气管炎、反复上呼吸道感染等疾病的患者中有些人就是CVA。该病早在1972年由Glauser[1]提出，并首先报道了5例成年患者，他们只有发作性的夜间干咳，没有喘息，使用支气管扩张剂或短期使用激素治疗效果很好，于是便…     

支气管舒张试验在小儿慢性咳嗽鉴别诊断中的应用

目的探讨支气管舒张试验在小儿慢性咳嗽鉴别诊断中的应用价值。方法对以干咳为主的263例慢性咳嗽患儿进行肺功能检测,其中气道阻力增高者加做支气管舒张试验,改善率>20%为阳性。结果115例支气管舒张试验中阳性共71例,支气管舒张前后呼吸阻抗各值比较差异有统计学意义。结论支气管舒张试验阳性有助于咳嗽变异型哮喘(CVA)诊断,在小儿慢性咳嗽鉴别诊断中有一定应用价值。     

小儿慢性咳嗽和/或哮鸣疾病的鉴别诊断

介绍慢性咳嗽和/或哮鸣疾病的鉴别诊断,该类疾病大体分为先天性和获得性两类,前者较少见,主要为心肺先天异常所致;后者以包括咳嗽变异性哮喘在内的支气管哮喘最常见。此外,也提到了变应性支气管肺曲菌病和心因性咳嗽反应的诊断。     

儿童慢性咳嗽的相关问题

申昆玲教授 很高兴接受<中国循证儿科杂志>编辑部的邀请,主持本次"儿童慢性咳嗽的相关问题"专家对谈.咳嗽在儿童中很常见,在成人科,对咳嗽的相关问题已经有了很多研究.以此为基础,国内外都依据循证医学方法制定了儿童慢性咳嗽诊断治疗指南.与成人不同的是,儿童慢性咳嗽与上气道疾病、哮喘及胃食管反流(GER)的关系仍不明确,这些疾病在儿童中的发生率也不确定,相关的研究较少.今天,有幸邀请到澳大利亚悉尼大学WESTMEAD儿童医院呼吸科主任Peter Van Asperen教授与大家共同探讨儿童慢性咳嗽的流行病学、诊断和治疗方面的问题.     

小儿慢性咳嗽的诊断思路

目前对慢性咳嗽诊断的时间界限尚无统一认识 ,一般是指咳嗽持续 1～ 3个月或以上。咳嗽是机体对一切引起呼吸道刺激的保护性反射动作。咳嗽的控制中枢在延髓 ,其兴奋性刺激可来源于呼吸道、中枢或肺外 ,如咽、喉、气管、支气管、胸膜以及耳等。在儿童 ,慢性咳嗽是门诊常见的疾病之一。不同的年龄 ,导致长期慢性咳嗽的病因常不一样 ,所以不同的年龄段 ,应考虑不同的病因。1　慢性咳嗽的病因1.1　婴幼儿期　该年龄阶段的小儿以感染性疾病为最常见 ,如上呼吸道感染、气管炎、支气管炎、肺炎等 ;其次为支气管异物、消化道疾病等 ;气管支气管、肺…     

儿童慢性咳嗽与鼻窦炎的相关性探讨

目的探讨儿童慢性咳嗽与慢性鼻窦炎的关系.方法对咳嗽时间1个月以上的106例2～14岁儿童作临床观察,根据鼻窦片、胸片、螨尘皮试、支气管扩张试验及疗效,将其分为鼻窦炎组21例,鼻窦炎合并咳嗽变异性哮喘(CVA)21例,CVA或哮喘44例,支气管炎等20例.同时做诱导痰细胞学检查.结果慢性咳嗽儿童中39.6%(42/106)有慢性鼻窦炎;鼻窦炎合并CVA组与CVA或哮喘组相似,螨皮试阳性率和支气管扩张试验的阳性率均达40%左右,诱导痰嗜酸粒细胞、肥大细胞含量增高,与单纯鼻窦炎组显著不同.结论上下呼吸道是一个整体,对儿童慢性咳嗽应注意鼻窦炎的伴发,而过敏原皮试阳性、支气管扩张试验阳性及诱导痰嗜酸粒细胞和(或)肥大细胞增多是CVA或哮喘的有力证据.     

Central airways stenosis in school-aged children: differential diagnosis from asthma

This study assessed the value of spirometry and chest X-rays in the diagnosis of airways stenosis in the tracheal or laryngeal regions at school age. A series of 14 patients was studied. Six of them had vascular ring anomalies, four subglottic stenosis, two aberrant innominate artery, one tracheal stenosis and one a laryngeal web. Four patients were suffering from chronic cough and ten from dyspnoea, noisy breathing and cough upon physical exercise. Two had had their symptoms since infancy and five since 3-6 y of age, whereas seven had had their first symptoms at school age. Nine patients had previously been suspected of having asthma, and five of them had been using inhaled corticosteroids, one inhaled sodium cromoglycate and one peroral terbutaline without any effect. The ratio of forced expiratory volume in 1 s (FEV 1 ) to peak expiratory flow (PEF) was abnormally high in most of the patients. All six children with vascular ring anomalies also had an abnormal aortic configuration on a chest X-ray, and narrowing of the trachea was seen in two of the four with subglottic stenosis. Two children had both chest X-rays and spirometry values within the normal limits.

Conclusion: The results show that children with stenosis in the laryngeal or tracheal region may not have their first symptoms until school age. Many patients are falsely suspected of having asthma. Simple spirometry and chest X-rays will help the physician to make the correct diagnosis in these patients.     

Persistent cough in children and the overuse of medications

OBJECTIVE: Children referred for persistent cough were evaluated for the referring and final diagnosis, and the extent of the use of medications prior to referral and the side effects encountered. METHODS: Data on children seen by respiratory paediatricians for persistent cough (> or =4 weeks) in a tertiary respiratory setting were collected prospectively over 12 months. RESULTS: Of the 49 children, 61.2% were diagnosed with asthma at referral, with similar referral rates from general practitioners and paediatricians. Children with isolated cough were just as likely to have been diagnosed with asthma as children with cough and wheeze. Medication use (asthma, gastro-oesophageal reflux and antibiotics) prior to referral was high, asthma medications were most common, and of these 12.9% had significant steroid side effects. The most common abnormality found (46.9%) was a bronchoscopically defined airway lesion, and in 56.5% of these children, another diagnosis (aspiration, achalasia, gastro-oesophageal reflux) existed. No children had a sole final diagnosis of asthma and pre-referral medications were weaned in all children. CONCLUSION: Over diagnosis of asthma and the overuse of asthma treatments with significant side effects is common in children with persistent cough referred to a tertiary respiratory clinic. Children with persistent cough deserve careful evaluation to minimize the use of unnecessary medications and, if medications are used, assessment of response to treatment is important.     

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??Cough is a common clinical symptom in children. Acute cough in children is frequently associated with viral respiratory tract infection. It is usually self-limited. The causes of chronic cough in children differ from those in the adults. Although Chinese cooperative multicenter study of chronic cough has shown that the leading causes for chronic cough in children are cough variant asthma??post-infection cough and the upper airway cough syndrome in China??there are obvious regional differences. Due to reason of lack of detection means??there may be the possibility of underdiagnosis of protracted bacterial bronchitis and other diseases??so pediatricians should pay enough attention to the issue. Generally no special medications are needed for acute cough in children. As for chronic cough??possible etiology should be studied to make a confirmed diagnosis??and then therapy should be based on the etiology. It appears that there is overuse of cough medicines in pediatric practice. Special attention should be paid to avoid combined use of cough medicines that contain the same ingredients.     

小儿慢性咳嗽诊断与鉴别诊断

慢性咳嗽是指咳嗽症状至少持续3周,以咳嗽为主要表现,胸部X线检查无明显病变。通过临床表现和相关检查可对慢性咳嗽进行诊断和鉴别诊断。引起小儿慢性咳嗽的三大病因是咳嗽变异性哮喘(CVA)、鼻窦炎及鼻后滴流综合征(PNDs)和胃食管反流(GER)性疾病,而在小儿还须注意呼吸道感染因素和先天性肺发育畸形。近年来国内外研究表明,嗜酸细胞性支气管炎(EB)亦是慢性咳嗽的重要原因。此外,还应注意支气管扩张、支气管异物、药物性咳嗽及精神性咳嗽。     

福建省福州地区儿童慢性咳嗽病因分析

目的 探讨福建省福州地区儿童慢性咳嗽的病因.方法 根据中华医学会儿科学分会呼吸学组与<中华儿科杂志>编辑委员会2008年制定的<儿童慢性咳嗽诊断与治疗指南>的标准,对福建省福州儿童医院哮喘专科门诊诊断的364例慢性咳嗽患儿,按照指南的诊断流程询问病史,进行体检、辅助检查,初步确定病因后,并针对病因进行特异性治疗,分别在初诊后半个月、1个月、3个月对患儿进行随访,根据辅助检查及疗效判定病因诊断,进而分析病因构成比.结果 364例慢性咳嗽患儿病因依次为:咳嗽变异性哮喘171例(47.0%),上气道咳嗽综合征104例(28.6%),呼吸道感染和感染后咳嗽58例(15.9%),胃食管反流17例(4.7%),支气管异物3例(0.8%);引起慢性咳嗽只有单一病因的299例(82.1%),同时有2种病因的56例(15.4%),同时有3种病因的9例(2.5%).结论 福建省福州地区儿童慢性咳嗽的病因依次为咳嗽变异性哮喘、上气道咳嗽综合征、呼吸道感染和感染后咳嗽、胃食管反流、支气管异物;不同年龄组儿童慢性咳嗽病因构成比不同;部分患儿合并有2或3种病因,表明儿童慢性咳嗽病因呈多因素.

Abstract：

Objective Chronic cough in children is a common pediatric symptom with complex causes and its diagnosis is difficult; chronic cough affects the life of children in both physical and mental health and also learning. Therefore this study aimed to investigate the causes of chronic cough in children in Fuzhou area of Fujian province. Method Data were collected from 364 children with chronic cough who visited the asthma specialist clinic of Children's Hospital of Fuzhou, Fujian Province from March 2009 to April 2010. The diagnosis was made according to Guideline for Diagnosis and Treatment of Chronic Cough in Pediatrics published in 2008. Among the patients, 241 were boys and 123 girls. The patients were divided into 3 age groups: group 1, 1 to 3 years old ( infants and young children group, n =75); group 2, 4 to 6years old (pre-school group, n =215 ); and group 3, over 7 years (school-age group, n = 74), the mean age was (4.8 ± 1.1) years (3 months to 14 years), course of the illness was (4.5 ± 1.8) months (4 weeks to 38 months ). Mycoplasma pneumoniae was detected by Enzyme-linked immunosorbent assay (ELISA). Result The causes of chronic cough were as follows: 171 cases (46. 98% ) had cough variant asthma; 104 cases ( 28.57% ) had upper airway cough syndrome; 58 cases ( 15.93% ) had respiratory infections; 17 cases (4.67% ) had gastroesophageal reflux; 3 cases (0.82% ) had foreign bodies. Totally 9 cases (2.47% ) had chronic cough associated with 3 causes; 56 cases ( 15.38% ) had 2 causes and 299cases ( 82.14% ) had single cause. The main causes of cough in the group of pre-school children were cough variant asthma and upper airway cough syndrome. The proportion of the upper airway cough syndrome in school-age children group was the highest among the 3 age groups, which is flowed by cough variant asthma.Conclusion The causes of chronic cough in children were cough variant asthma, upper airway cough syndrome, respiratory infections, cough after infection, gastroesophageal reflux and foreign bodies in Fuzhou area of Fujian province. Children with chronic cough in different age groups had different etiology, in about 18% of the children the etiology of chronic cough was associated with 3 or 2 causes, indicating that the causes of chronic cough in children are multifactorial.     

Vocal cord dysfunction in children

Vocal cord dysfunction is characterised by paradoxical vocal cord adduction that occurs during inspiration, resulting in symptoms of dyspnoea, wheeze, chest or throat tightness and cough. Although the condition is well described in children and adults, confusion with asthma often triggers the use of an aggressive treatment regimen directed against asthma. The laryngoscopic demonstration of vocal cord adduction during inspiration has been considered the gold standard for the diagnosis of vocal cord dysfunction, but historical factors and pulmonary function findings may provide adequate clues to the correct diagnosis. Speech therapy, and in some cases psychological counselling, is often beneficial in this disorder. The natural course and prognosis of vocal cord dysfunction are still not well described in adults or children.     

儿童迁延性细菌性支气管炎诊治进展

迁延性细菌性支气管炎(protracted bacterial bronchitis,PBB)是幼儿及学龄前儿童慢性咳嗽的常见原因.其以湿性咳嗽＞4周为主要临床表现,但缺乏提示其它慢性咳嗽病因的特异性症状及体征,胸部影像学一般缺乏特异性改变,支气管镜下可见气道内膜呈慢性化脓性炎症改变,支气管肺泡灌洗液中中性粒细胞比例明显升高,通常2周合理口服抗感染治疗(常为阿莫西林克拉维酸钾)咳嗽可缓解.目前国内外儿科医师对PBB认识尚不足,常将其误诊为哮喘.该文就其病原学、发病机制、临床表现及诊治、预后作一综述.     

Respiratory Symptoms and Asthma in Primary School Children in Kuala Lumpur

In a Cross-sectional Study of 7 to 12-year-old primary school children in Kuala Lumpur, the prevalence of chronic cough and/or phlegm, persistent wheeze, and doctor-diagnosed asthma were 8.0%, 8.0% and 8.7%, respectively. The prevalence of asthma (defined as persistent wheeze and/or doctor-diagnosed asthma) was 13.8%, 4.3% experienced at least one episode of chest illness that resulted in inactivity for at least 3 days in the previous year. The mean age of commencement of symptoms in the doctor-diagnosed asthma group was 2.75 years. The prevalence of chronic cough and/or phlegm and persistent wheeze were highest among Indian children (p<0.05). More Malays had been diagnosed as having asthma than the other ethnic groups but the differences were not statistically significant. The patients' fathers' low levels of education were associated with chronic cough and/or phelgm (p<0.05) but not with other complaints. Asthma was significantly more common among boys than girls. No age differences were noted. Further analysis showed that persistent wheeze and doctor-diagnosed asthma were associated with increased likelihood of other respiratory illnesses or doctor-diagnosed allergy before the age of 2 years.     

儿童不同呼吸系统疾病气道反应性特点及其临床价值

目的探讨儿童支气管哮喘、咳嗽变异性哮喘(CVA)和支气管炎等不同呼吸系统疾病气道反应性特点及其临床价值。方法应用Astograph法气道反应性测定技术,对42例哮喘患儿、38例咳嗽变异性哮喘(CVA)患儿、36例支气管炎患儿及30例健康儿童进行气道反应性测定;分别对反映气道敏感性和气道反应性的Dmin、SGrs、PD35等各指标进行统计学分析和评估。结果哮喘组、CVA组和支气管炎组患儿的Dmin、SGrs、PD35等指标均低于健康对照组,差异有统计学意义(P<0.05),哮喘组、CVA组与支气管炎组患儿之间比较,差异也有统计学意义(P<0.05),而哮喘组与CVA组患儿比较,差异无统计学意义(P>0.05)。结论哮喘病、CVA和支气管炎等不同呼吸系统疾病患儿的气道反应性及气道敏感性均高于健康儿童,而不同呼吸系统疾病患儿的气道反应性、气道敏感性变化也各不相同,以此可为鉴别诊断提供依据。     

Cough, wheezing and asthma in children: lesson from the past

Recurrent cough is an important medical and sometimes frustrating problem encountered by pediatricians, especially if it is not associated with wheeze or other evidence of systemic disease. In the past, many children with chronic cough have been diagnosed as asthmatic. However, epidemiological, clinical and laboratory studies conducted over the last ten years elucidated many aspects of the relationship between cough and bronchoconstriction. It is difficult to make a diagnosis of asthma on cough alone, but the setting in which the patient is seen (i.e., in a primary care setting or ain a specialistic clinic) may address doctors to the right diagnosis. A prudent 'wait and see' approach may be useful in many occasions.