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进入秋冬季节，因为咳嗽来门诊就医的孩子比例大为增高，而且经常会看到反复咳嗽，迁延不愈，从而反复就诊的情况。咳嗽是呼吸道疾病的常见症状，虽然适度的咳嗽有利于清除呼吸道分泌物和有害的因子，但长期的频繁的咳嗽会影响孩子的身心健康。爸爸妈妈们找了度娘，盐蒸橙子，陈皮泡水，冰糖川贝炖梨，烤橘子等吃了不少；各款网红咳嗽药水海淘了一堆；医院也跑了好几次，但还不见好，怎么回事呢？这是不是大家所头疼的慢性咳嗽呢？
让我们来看一下医生们怎么来界定慢性咳嗽。国际上目前对慢性咳嗽通常定义为持续4周以上的咳嗽。因为大多数儿童的急性呼吸道感染引起的咳嗽能在这个时间段内消退。2013中国儿童慢性咳嗽诊断与治疗指南定义也是咳嗽为主要或惟一的临床表现，病程>4周、胸片未见明显异常者。
Chronic cough is a very common complaint in paediatric clinics throughout China, especially in autumns and winter seasons. Chronic cough in children is generally defined as a cough lasting more than four weeks. This is because most acute respiratory infections in children resolve within this interval. 2013 Guideline for Diagnosis and Treatment of Chronic Cough in Chinese Children also defined chronic cough as cough is the main or only clinical symptoms lasting more than four weeks and chest x- ray shows no significant abnormality.
那么儿童慢性咳嗽常见的原因是什么呢？
根据2009年全国19个省市29所医院联合进行的多中心研究发现，中国儿童慢性咳嗽的前三位病因分别是咳嗽变异性哮喘 (41.95%)、上气道咳嗽综合征 (24.71%) 和呼吸道感染后咳嗽 (21.73%)。这3个到底是什么鬼？让我们一起来看下面这几个病例吧：
What causes a chronic cough in children? According to prospective multicenter clinical study on the chronic cough in Chinese children in 2009, the leading three causes were cough variant asthma (41.95%), upper airway cough syndrome (24.71%), respiratory infections and post-infectious cough (21.73%).
1. 小明今年小学二年级了，虽然小时候有过湿疹，但长大就都好了，平时身体不错。但就是最近咳嗽有一个半月了，说多不多，说少也不少，也没痰，就是晚上睡觉前和早上起床时咳嗽；有时候，奔着跑着玩的疯了，或者家里炒菜的油烟闻到了，也会咳一阵，之前也没明显的感冒发烧， 其他一切也都好。但外婆担心小明咳出肺炎，带着去让医生给拍了片子，没什么异常，请医生开了头孢吃了几天没用，把家里以前吃剩下的阿奇霉素也吃了，还是咳咳咳。再去请教医生，医生给配了万托林，说是支气管舒张剂，用了三五天，明显就咳嗽少多了。复诊时医生说小明可能就是咳嗽变异型哮喘，外婆急了，我们并没有气急气喘啊，怎么回事呢？！ 别急，听小编慢慢道来：
咳嗽变异型哮喘，又称为咳嗽型哮喘，是我国是学龄前和学龄期儿童慢性咳嗽的最常见原因。这类孩子通常有以下几个特点：
(1)持续咳嗽 > 4周，通常为干咳，没有气喘，常在夜间和(或)清晨发作，运动、遇冷空气后咳嗽加重，没有发烧，正常生活学习玩耍，吃喝拉撒也不影响，医院开的抗菌素翻来覆去吃了好几种没有用；
(2)用诸如美普清，万托林，博利康尼之类的支气管扩张剂诊断性治疗，咳嗽明显好转；
(3)肺通气功能正常，支气管激发试验提示气道高反应性；
(4)有过敏性疾病病史，以及过敏性疾病阳性家族史。
(5)除外其他疾病引起的慢性咳嗽。
Cough dominant asthma: also known as cough variant asthma, is the most common cause of chronic cough in school-age and preschool children:
(1) A dry cough that lasts > 4 weeks and it is mostly at night and/or in the morning. People with cough-variant asthma generally do not have the other common symptoms of asthma, such as wheezing, shortness of breath and chest tightness. The cough also often worsens in cold air and during exercise. Apart from cough, there is no fever or other symptoms without impact on daily activities and appetite. Antibiotics have no role in the treatment of cough variant asthma.
(2) Empirical treatment with bronchodilator shows improvement, such as Meptin, Ventolin and Bricanyl.
(3) Spirometry is usually normal; bronchial provocation test indicates airway hyperresponsiveness.
(4) History of allergic disease and family history of allergic disease.
(5) Rule out any other causes of chronic cough.
2. 甜甜是家里的开心果，已经是大班的孩子了，爷爷奶奶最喜欢听她唱歌了，背起弟子规也是一板一眼的。可是最近甜甜开始吭吭吭地咳嗽了，就好像喉咙口有点痰要清嗓一样，说话唱歌都会有影响，鼻子有点堵，早晨起来还会打几个喷嚏，流点鼻涕，有时候还会说喉咙口不舒服或者有东西流到喉咙口，所以要咳嗽。妈妈想着这孩子是感冒了，以前也有过，就给吃了网上海淘的小绿叶止咳糖浆，一般一两周就该好了。可是转眼四周都过去了，甜甜还在咳咳咳，妈妈就开始担心是不是气管炎了，带去医院看。医生检查后告诉妈妈，引起甜甜的咳嗽不是气管炎，而是过敏性鼻炎和慢性咽炎引起的上气道咳嗽综合征，给了海盐水和内舒拿喷鼻，开瑞坦口服还有些清喉利咽的药，甜甜的咳嗽就逐渐减少了。
上气道咳嗽综合征是什么呢？这是引起中国儿童尤其是学龄前与学龄期儿童慢性咳嗽第2位主要病因，以前也叫“鼻后滴漏综合症”，是各种鼻炎(变应性及非变应性)、鼻窦炎、慢性咽炎、慢性扁桃体炎、鼻息肉、腺样体肥大等上气道疾病相关的慢性咳嗽。医生们主要是通过下面一些蛛丝马迹来揪出这个害群之马：
(1)持续咳嗽>4周，伴有白色泡沫痰(过敏性鼻炎)或黄绿色脓痰(鼻窦炎)，咳嗽以晨起或体位变化时为甚，伴有鼻塞、流涕、咽干并有异物感 和反复清咽等症状；
(2)咽后壁滤泡明显增生,有时可见鹅卵石样改变，或见黏液样或脓性分泌物附着；
(3)开瑞坦，仙特敏，顺而宁，内舒拿等对过敏性鼻炎引起的慢性咳嗽有效，化脓性鼻窦炎引起的慢性咳嗽则需要抗菌药物治疗2—4周有效；
(4)鼻咽喉镜检查或头颈部侧位片、鼻窦x线 片或CT片可有助于诊断。
Upper airway cough syndrome is the second most common cause of chronic cough in Chinese children. It is formerly known as postnasal drip syndrome. Underlying reasons for postnasal drip include rhinitis (allergic and nonallergic), sinusitis, chronic nasopharyngitis, chronic tonsillitis, and adenoid hypertrophy.
(1) Symptoms of upper airway cough syndrome include cough lasting > 4weeks with white foamy phlegm (allergic rhinitis) or yellow and greenish phlegm (sinusitis), cough more in the morning when wake up or position changes, accompany with stuffy nose,frequent nasal discharge, a sensation of liquid dripping into the back of the throat, and frequent throat clearing.
(2) Clues on physical examination are a cobblestone appearance to the nasopharyngeal mucosa and the presence of secretions in the nasopharynx.
(3) Clarityne, Zyrtec, Singulair and Nasonex show the effectiveness in the treatment of allergic rhinitis caused chronic cough. Those caused by bacterial sinusitis will benefit from antibiotics two to four weeks course.
(4) Nasal endoscopy and laryngoscopy, sinus x- ray or CT scan will help the evaluation.
3. 小伟今年4岁，十一假期和爸爸妈妈出门玩了10天，假期结束去了幼儿园没几天就发烧咳嗽，去看了医生，说是病毒性感冒，过个3-5天就好了。果然过了3天烧就退了，过了一周多咳嗽和痰见少了，接下来的2周咳嗽的次数和强度虽然也在慢慢减少，可是就是零零星星一直有点咳。不知不觉已经咳了一个月了。尽管小伟照常吃饭，照常蹦蹦跳跳去上幼儿园，奶奶坐不住了，心想小孩的肺很嫩的，会不会咳出肺炎来，就带去医院。医生详细问了病史做了体检后，初步考虑是（呼吸道）感染后咳嗽，问题不大，不用吃药，最多再有几周慢慢就好了。奶奶半信半疑，还是坚持要拍个胸片，结果是无异常。奶奶纳闷了，这到底是怎么回事呢？
其实(呼吸道)感染后咳嗽也是引起幼儿和学龄前儿童慢性咳嗽的常见原因。研究发现，可能是呼吸道感染导致气道粘膜上皮损伤后修复较慢，持续的气道炎症伴有暂时性的气道高反应性。这类慢性咳嗽的特征是：
(1)近期有明确的呼吸道感染病史；
(2)咳嗽持续>4周，呈刺激性干咳或伴有少许白色黏痰；
(3)胸部x线片检查无异常或仅显示双肺纹理增多；
(4)肺通气功能正常，或呈现一过性气道高反应；
(5)咳嗽通常有自限性，如果咳嗽时间超过8周，应考虑其他诊断；
(6)除外其他原因引起的慢性咳嗽。
Post-infectious cough is also a common cause of chronic cough in toddler and preschooler. Research showed that it may due to the disruption of upper and/or lower airway epithelial integrity, extensive airway inflammation and temporarily airway hyperresponsiveness.
(1) A recent history of respiratory tract infection.
(2) A persistent cough lasting >4 weeks, dry cough or with white sticky phlegm.
(3) The chest radiograph findings are normal or increased lung markings.
(4) Spirometry is usually normal or transient airway hyperresponsiveness.
(5) Cough is self limiting. Other diagnoses should be considered if cough lasting > 8 weeks.
(6) Rule out any other causes of chronic cough.
除了以上3个引起儿童慢性咳嗽的前三位病因之外，那么还有哪些常见的情况会引起呢？让我们一起来看一看：
Apart from the above three leading causes of chronic cough, is there any other common causes? Let's take a look at the following conditions:
1.特定病原体引起的呼吸道感染
多种病原微生物如肺炎支原体或衣原体，百日咳杆菌、结核杆菌、呼吸道合胞病毒，腺病毒等引起的呼吸道感染也可导致小儿慢性咳嗽，病程可>25天。因为感冒使得气道粘液清除速率降低，需要两个月左右恢复到正常水平；损伤的纤毛上皮细胞也需要一个月左右再生至正常水平。
Respiratory infections caused by various species of microbial pathogens can lead to chronic cough in children, including Mycoplasma pneumoniae, chlamydia, Bordetella pertussis, Mycobacterium tuberculosis, Respiratory syncytial virus, and adenovirus. The duration could be more than 25 days due to disruption of airway epithelial integrity, poor mucus clearance, and secretion pooling.
2.胃食管反流性咳嗽
(1)阵发性咳嗽，最好发的时相在夜间；
(2)咳嗽也可在进食后加剧；
(3)24小时食管下端pH监测呈阳性；
(4)除外其他原因引起的慢 性咳嗽。
2. Gastroesophageal reflux-related cough
(1) Coughing episodes occur mostly at night.
(2) Cough can be worse after a meal;
(3) 24-h esophageal pH monitoring shown positive.
(4) Rule out any other causes of chronic cough.
3.非哮喘性嗜酸粒细胞性支气管炎：
(1)刺激性咳嗽持续>4 周；
(2)胸部x线片正常；
(3)肺通气功能正常，且无气道高反应性；
(4)痰液中嗜酸粒细胞相对百分数>3％；
(5)支气管舒张 剂治疗无效，口服或吸入糖皮质激素治疗有效；
(6)除外其他原因引起的慢性咳嗽。
3. Nonasthmatic eosinophilic bronchitis
(1) An irritating cough lasting > 4weeks.
(2) The chest radiograph findings are normal.
(3) Spirometry is normal with the absence of airway hyperresponsiveness.
(4) Percentage of Eos in induced sputum test> 3%
(5) Respond well to inhaled glucocorticoids but does not respond to bronchodilators.
(6) Rule out any other causes of chronic cough.
4.异物吸入
异物吸入是小年龄儿童尤其是l～3岁儿童慢性咳嗽的重要原因。如果幼儿慢性咳嗽之前曾经有呛到后发生咳嗽(即使时间较久远)或在进食或玩耍时突然发生咳嗽的病史，则有异物吸入的可能。咳嗽是气道异物吸入最常见的症状，研究发现有70％的气道异物吸入患者表现为咳嗽，其他症状还有呼吸音降低、喘鸣等。咳嗽通常表现为阵发性剧烈呛咳，也可仅表现为慢性咳嗽伴阻塞性肺气肿或肺不张。需要听诊和胸片评估了解有无通气不对称和/或局灶性附加音(最常为低音调哮鸣音)以及是否存在提示异物阻塞的单侧肺过度充气，必要时应进行支气管镜评估。
4. Foreign body
Foreign body aspiration is an important cause of chronic cough in young children especially toddlers aged 1 to 3 years. A history of onset of the cough after an episode of choking, even if remote in time, or sudden onset of the cough in a young child while eating or playing, raises the possibility of a foreign body. Cough is the most common symptom of foreign body aspiration and it generally presented as episodes of paroxysmal coughing. Other symptoms include decreased breathing sound and wheezing. An auscultatory assessment and chest radiographs are needed to assess for asymmetry in aeration and/or focal adventitious sounds, most commonly low-pitched wheeze. Bronchoscopy may also be performed for evaluation if need.
5.心因性咳嗽
(1)年长学龄和青春期儿童多见；
(2)日间咳嗽为主，专注于某件事情或夜间休息咳嗽消失，可呈雁鸣样高调的咳嗽；
(3)常伴有焦虑症状，但不伴有器质性疾病；
(4)除外其他原因引起的慢性咳嗽，经过行为干预或心理 治疗后咳嗽能得到改善时才能诊断
5. Psychogenic cough
(1) Common in older school aged children and adolescents.
(2) Cough mostly during the daytime; cough is absent when focusing on some activities, exercise or night time sleep; cough with a barking or honking character.
(3) Often accompany with anxiety but without organic disorders.
(4) Rule out any other causes of chronic cough. Cough improves with specific therapy such as behavior modification or psychiatric therapy.
6.抽搐性咳嗽
抽搐性咳嗽，即多发性抽动的表现之一，又称为习惯性咳嗽，这个也很常见。国外文献有数据显示它在儿童或青少年原因不明的慢性咳嗽中所占比例高达10%。这种咳嗽通常很有特色：可为短促的单声干咳(抽动)，或与急性喉炎的咳嗽相似(短时间吸气后出现犬吠声或雁鸣声)，咳嗽通常在就诊时比较明显，但在夜间无咳嗽，并且很少影响正常的生活学习玩耍。孩子有时会说咽喉发痒，而咳嗽模式的确也支持咳嗽源于喉部。这种咳嗽常开始于上呼吸道感染时，并且不会消退。常用的止咳药或哮喘药物治疗无效，而心理暗示疗法有效。抽搐性咳嗽虽然较常见，但它是一个排除性诊断，也是需要考虑排除其他可能的原因。
6. Tic cough
Tic cough (previously referred to as habit cough) is common in a pediatric practice. Literature reported that it can represent up to 10 of children and adolescents with chronic cough of unknown origin. Tic cough is often quite distinctive. It may consist of short, single dry coughs (tics) or may be similar to the cough heard in croup (a barking or honking sound after a short inhalation). The cough usually is prominent during visits to the clinic, but is absent at night and rarely interrupts play, speech, or eating. Patients sometimes report a “tickle” in the throat and the pattern of the cough supports a laryngeal origin. Tic cough is often preceded by an upper respiratory tract infection and fails to resolve. There is no response to commonly used antitussive or asthma medications. Suggestion therapy has been demonstrated to be effective. Tic cough is also a diagnosis of exclusion, and the label should not be applied until all other possible causes have been considered.
说了这么多，那么怎么对付咳嗽呢？欲知后事如何,各位看官，且听下回分解！
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孩子五岁时经常咳嗽，一咳就是一个多月。起因是着凉感冒，医生诊断都说是过敏性咳嗽，用了很多抗生素，后来发现家里是靠着两条大马路，灰尘太多，也是很大的一个因素。现在每天睡前擦灰，情况好转很多。
2017-12-05 20:57
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