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1、Chronic CoughA Practical ApproachDefinitionnCough lasting more than 8 weeks in a nonsmoking,immunocompetent patient who has a normal chest radiograph,is not receiving therapy with an ACE inhibitor,and has not been exposed to an environmental irritant.ACCP consensus.CHEST 1998;114:133-181ERS Task For
2、ce.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.Chronic CoughnFifth most common symptom for which outpatient care is sought.n24,263,000 visits in the US in 1991nPrevalence among non-smoking:14 to 23%n38%out
3、patient pulmonary practicenCost exceeds$1 billion dollarsACCP consensus.CHEST 1998;114:133-181Evaluation of chronic cough.UPTODATE 2005Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284The Cough ReflexComplications nIntrathoracic pre
4、ssures of up to 300mmHGnExpiratory velocity:500 miles/hrTextbook of Respiratory Disease.Murray-Nadel.Chapter 24.ACCP consensus.CHEST 1998;114:133-181ComplicationsnMost common complaints:nSomething is wrong:98%nExhaustion:57%nFeeling self-conscious:55%nInsomnia:45%nLife style change:45%nMusculoskelet
5、al pain:45%nHoarseness:45%nUrinary incontinence:39%Textbook of Respiratory Disease.Murray-Nadel.Chapter 24.ACCP consensus.CHEST 1998;114:133-181ComplicationsnLost of consciousnessnBrady and tachyarrhytmiasnSyncopenCerebral embolismnSeizuresnStroke due to vertebral arteries dissection.Evaluation of c
6、hronic cough.UPTODATE 2005ComplicationsnGERDnSplenic rupturenInguinal hernianIncrease CPKnPulmonary&subcutaneous emphysemanPneumothoraxnLung herniationEvaluation of chronic cough.UPTODATE 2005EtiologiesnPostnasal dripnAsthmanGERDnEosinophilic bronchitisnChronic bronchitisnBronchiectasisACCP consensu
7、s.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284EtiologiesnPostinfectious coughnBronchogenic carcinomanACE inhibitorsnVocal cord dysfunctionnSingle cause:38 to 82%nMultip
8、le cause:18 to 62%ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Chronic Cough Practical Consideration.CHEST 1998;1213:639-660Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005Grading of EvidencenI-Properly randomized controll
9、ed trialsnII-Well-designed control trials.No randomization.nII-2 Prospective observationalnII-3 Retrospective observationalnIII-Experts opinion,clinical experience,descriptive studiesACCP consensus.CHEST 1998;114:133-181Postnasal Drip(PNDS)nSingle most common causenPrevalence:8 to 87%nPathogenesisnM
10、echanical stimulation of the afferent limb in the upper airwaysACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005Postnasal DripnClinical PresentationnDripping sensationnTickle in
11、the throatnNasal congestionnMucus in the oropharynxnCobblestone appearance of oropharynxACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005DiagnosisnSymptoms and signs are nonspeci
12、ficn4 views sinus radiographs:nTiming and use not fully definednProductive cough,purulent nasal discharge,failure of empiric therapy for chronic rhinitis.(grade II-2)nChronic cough&excess sputum production.PPV&NPV:81&95%nChronic cough only:57&100%ACCP consensus.CHEST 1998;114:133-181ERS Task Force.E
13、RS Journal;24:553-566Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005DiagnosisnImportant information:nPreceding URTInLegal or illegal nasal drugsnEnvironmental historynResponse to specific therapy&the absence of another cause of coughACCP consensus.CH
14、EST 1998;114:133-181Pathogenic Triad in Chronic Cough.CHEST 1999;116:279-284Evaluation of chronic cough.UPTODATE 2005TherapynAllergic Rhinitis:nEnvironmental controlnNasal steroidsnFirst line of treatmentnConsider other therapies as possible alternatives.nConsider saline sprays to facilitate cleanin
15、gnNonsedating antihistaminesnCromolyn ACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Management of allergic rhinitis.Uptodate.2005TherapynNasal decongestant not recommendednLeukotriene inhibitorsnNasal congestion and LTC4 levelsnLess effective than intranasal steroidsnPati
16、ents experiencing epistaxis with nasal sprays.nAllergen immunotherapyACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Management of allergic rhinitis.Uptodate.2005TherapynPerennial Non-Allergic RhinitisnOften difficult to control with traditional therapynIntranasal steroidsnTopical antihistamines with or without oral medications.nOlder generation antihistaminesACCP consensus.CHEST 1998;114:133-181ERS Task Force.ERS Journal;24:553-566Evaluation of chronic cough.UPTODATE 2
