重视激素敏感性咳嗽的规范化诊疗

doi:10.16150/j.1671-2870.2023.06.003

摘要/Abstract

摘要：

全球成人慢性咳嗽的患病率为9.6%。2008年，《柳叶刀》咳嗽专刊上发表了按照嗜酸性粒细胞性气道炎症是否存在或激素治疗是否敏感，区分慢性咳嗽病因的诊治方案。2014年，我国赖克方教授首先提出了中文名称“激素敏感性咳嗽”（corticosteroid-responsive cough, CRC）。CRC是指糖皮质激素（corticosteroids, CS）治疗有效的慢性咳嗽，在我国占慢性咳嗽病因的63%，包括咳嗽变异性哮喘、嗜酸性粒细胞性支气管炎和变应性咳嗽这3种常见的慢性咳嗽病因，其中咳嗽变异性哮喘是我国慢性咳嗽最常见的病因，占30%~50%。慢性咳嗽病因复杂，涉及的检查众多，尤其是支气管激发试验、诱导痰细胞分析、多通道食管阻抗pH监测等这些检查在很多三级医院都未开展，而且也不是所有慢性患者都能接受相关检查后再确认诊断，进而予以治疗。CRC概念的提出对于慢性咳嗽的经验性治疗具有重要的指导意义，适合在基层医院推广，在临床实践中仅需根据患者的临床特征判断是否为CRC，而无需再进行诱导痰细胞分析、支气管激发试验等检查鉴别咳嗽变异性哮喘、嗜酸粒细胞性支气管炎和变应性咳嗽，就可以给予患者经验性治疗。但目前部分临床医师对于CRC规范化诊疗的认识不足，比如对判断是否为CRC、选用何种激素治疗、激素治疗周期等问题还缺乏统一的认识，需要进一步强调并推广CRC的相关概念及诊治方案。

关键词: 激素敏感性咳嗽, 慢性咳嗽, 糖皮质激素

Abstract:

The global prevalence of chronic cough in adults is 9.6%.In 2008, the cough special issue of Lancet published a diagnosis and treatment plan to distinguish the causes of chronic cough based on eosinophilic airway inflammation or sensitivity to glucocorticoids therapy. In 2014, Professor Lai Kefang of China first proposed the Chinese name “corticosteroid-responsive cough” (CRC). CRC refers to chronic cough that is effectively treated with glucocorticoids, accounting for 63% of the causes of chronic cough in China, including cough variant asthma, eosinophilic bronchitis, and atopic cough. Cough variant asthma is the most common cause of chronic cough in China, accounting for 30% to 50% Chronic cough has a complex etiology and involves numerous examinations, especially bronchial provocation tests, induced sputum cell analysis, multi-channel esophageal impedance pH monitoring, etc., which have not been carried out in many tertiary hospitals, and not all chronic patients can undergo relevant examinations to confirm diagnosis and receive treatment. The concept of corticosteroid-responsive cough has important guiding significance for the empirical treatment of chronic cough, and is suitable for promotion in grassroots hospitals. In clinical practice, it is only necessary to determine whether it is a CRC based on the clinical characteristics of the patient without the need for further tests, such as induced sputum cell analysis and bronchial provocation tests to distinguish cough variant asthma, eosinophilic bronchitis, and allergic cough, and then empirical treatment can be given. However, there is currently insufficient understanding of the standardized diagnosis and treatment of CRC. For example, there is still a lack of consensus on determining whether it is CRC, how to select hormone treatment and the duration of hormone treatment. It is necessary to further emphasize and promote the relevant concepts and diagnosis and treatment plans of corticosteroid-responsive cough.

Key words: Corticosteroid-responsive cough, Chronic cough, Glucocorticoids

中图分类号:

R562.25
R446

时翠芹, 余莉. 重视激素敏感性咳嗽的规范化诊疗[J]. 诊断学理论与实践, 2023, 22(06): 527-533.

SHI Cuiqin, YU Li. Pay attention to standardized diagnosis and treatment of corticosteroid-responsive cough[J]. Journal of Diagnostics Concepts & Practice, 2023, 22(06): 527-533.

图/表 2

参考文献 39

[1]	SONG W J, CHANG Y S, FARUQI S, et al. The global epidemiology of chronic cough in adults: a systematic review and meta-analysis[J]. Eur Respir J, 2015, 45(5):1479-1481. doi: 10.1183/09031936.00218714 URL
[2]	DENG H Y, LUO W, ZHANG M, et al. Initial empirical treatment based on clinical feature of chronic cough[J]. Clin Respir J, 2016, 10(5):622-630. doi: 10.1111/crj.2016.10.issue-5 URL
[3]	中华医学会呼吸病学分会哮喘学组. 咳嗽的诊断与治疗指南(2021)[J]. 中华结核和呼吸杂志, 2022, 45(01):13-46.
	Asthma Group of Chinese Thoracic Society. Chinese national guideline on diagnosis and management of cough(2021)[J]. Chin J Tuberc Respir Dis, 2022, 45(1):13-46.
[4]	PAVORD I D, CHUNG K F. Management of chronic cough[J]. Lancet, 2008, 371(9621):1375-1384. doi: 10.1016/S0140-6736(08)60596-6 pmid: 18424326
[5]	LAI K, CHEN R, LIN J, et al. A prospective, multicenter survey on causes of chronic cough in China[J]. Chest, 2013, 143(3):613-620. doi: S0012-3692(13)60138-5 pmid: 23238526
[6]	KASTELIK J A, AZIZ I, OJOO J C, et al. Investigation and management of chronic cough using a probability-based algorithm[J]. Eur Respir J, 2005, 25(2):235-243. pmid: 15684286
[7]	LAI K, PAN J, CHEN R, et al. Epidemiology of cough in relation to China[J]. Cough, 2013, 9(1):18. doi: 10.1186/1745-9974-9-18 pmid: 23835047
[8]	BRIGHTLING C E, WARD R, GOH K L, et al. Eosinophilic bronchitis is an important cause of chronic cough[J]. Am J Respir Crit Care Med, 1999, 160(2):406-410. doi: 10.1164/ajrccm.160.2.9810100 URL
[9]	IRWIN R S, CURLEY F J, FRENCH C L. Chronic cough. The spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy[J]. Am Rev Respir Dis, 1990, 141(3):640-647. doi: 10.1164/ajrccm/141.3.640 URL
[10]	MELLO C J, IRWIN R S, CURLEY F J. Predictive values of the character, timing, and complications of chronic cough in diagnosing its cause[J]. Arch Intern Med, 1996, 156(9):997-1003. pmid: 8624180
[11]	FUJIMURA M, ABO M, OGAWA H, et al. Importance of atopic cough, cough variant asthma and sinobronchial syndrome as causes of chronic cough in the Hokuriku area of Japan[J]. Respirology, 2005, 10(2):201-207. pmid: 15823186
[12]	DING H, XU X, WEN S, et al. Changing etiological frequency of chronic cough in a tertiary hospital in Shanghai, China[J]. J Thorac Dis, 2019, 11(8):3482-3489. doi: 10.21037/jtd.2019.07.86 pmid: 31559054
[13]	NIIMI A, OHBAYASHI H, SAGARA H, et al. Cough variant and cough-predominant asthma are major causes of persistent cough: a multicenter study in Japan[J]. J Asthma, 2013, 50(9):932-937. doi: 10.3109/02770903.2013.823444 pmid: 23841529
[14]	AN T J, KIM J W, CHOI E Y, et al. Clinical Characteristics of Chronic Cough in Korea[J]. Tuberc Respir Dis (Seoul), 2020, 83(1):31-41. doi: 10.4046/trd.2019.0018 URL
[15]	中华医学会呼吸病学分会哮喘学组. 支气管哮喘防治指南(2020年版)[J]. 中华结核和呼吸杂志, 2020, 43(12): 1023-1048.
	Asthma group of Chinese Throacic Society. Guidelines for bronchial asthma prevent and management(2020 edition)[J]. Chin J Tuberc Respir Dis, 2020, 43(12): 1023-1048.
[16]	LONG L, LAI K. Characteristics of Chinese chronic cough patients[J]. Pulm Pharmacol Ther, 2019, 57:101811. doi: 10.1016/j.pupt.2019.101811 URL
[17]	LAI K, SHEN H, ZHOU X, et al. Clinical Practice Guidelines for Diagnosis and Management of Cough-Chinese Thoracic Society (CTS) Asthma Consortium[J]. J Thorac Dis, 2018, 10(11):6314-6351. doi: 10.21037/jtd.2018.09.153 pmid: 30622806
[18]	MCGARVEY L, MORICE A H. Atopic cough: little evidence to support a new clinical entity[J]. Thorax, 2003, 58(8):736-738. pmid: 12886002
[19]	GIBSON P G. Atopic cough[J]. Thorax, 2004, 59(5):449. pmid: 15115881
[20]	时翠芹, 邱忠民. 气道炎症在慢性咳嗽中的作用[J]. 国际呼吸杂志, 2007, 27(10):773-776.
	SHI C Q, QIU Z M. Effect of airway inflammation on chronic cough[J]. Int J Respir, 2007, 27(10) :773-776.
[21]	PADEM N, SALTOUN C. Classification of asthma[J]. Allergy Asthma Proc, 2019, 40(6):385-388. doi: 10.2500/aap.2019.40.4253 pmid: 31690376
[22]	ANDO A, SMALLWOOD D, MCMAHON M, et al, Neural correlates of cough hypersensitivity in humans: evidence for central sensitisation and dysfunctional inhibitory control[J]. Thorax, 2016, 71(4):323-329. doi: 10.1136/thoraxjnl-2015-207425 pmid: 26860344
[23]	LAI K, ZHAN W, LI H, et al. The Predicative Clinical Features Associated with Chronic Cough That Has a Single Underlying Cause[J]. J Allergy Clin Immunol Pract, 2021, 9(1):426-432.e2. doi: 10.1016/j.jaip.2020.06.066 pmid: 32693212
[24]	上海市医学会呼吸病学专科分会哮喘学组. 激素敏感性咳嗽诊治上海专家共识[J]. 上海医学, 2022 ;45(6):373-379.
	Group of Asthma, Society of Respiratory Medicine, Shanghai Medical Association. Management of corticosteroid-responsive cough:Shanghai consensus[J]. Shanghai Med, 2022, 45(6):373-379.
[25]	YU L, XU X H, CHEN Q, et al. Gastro-esophageal reflux induced cough with airway hyperresponsiveness[J]. Int J Clin Exp Med, 2014, 7(3):728-735. pmid: 24753770
[26]	MATUCCI A, VULTAGGIO A, MAGGI E, et al. Is IgE or eosinophils the key player in allergic asthma pathogenesis? Are we asking the right question?[J]. Respir Res, 2018, 19(1):113. doi: 10.1186/s12931-018-0813-0
[27]	PAVLIDIS S, TAKAHASHI K, NG KEE KWONG F, et al. "T2-high" in severe asthma related to blood eosinophil, exhaled nitric oxide and serum periostin[J]. Eur Respir J, 2019, 53(1):1800938. doi: 10.1183/13993003.00938-2018 URL
[28]	Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease (2023 Report)[R/OL]. [2023-10-05]. https://goldcopd.org/2023-gold-report-2/.
[29]	GAO J, WU F, WU S, et al. Inflammatory Subtypes in Classic Asthma and Cough Variant Asthma[J]. J Inflamm Res, 2020, 13:1167-1173. doi: 10.2147/JIR.S269795 pmid: 33376381
[30]	BRIGHTLING C E. Clinical applications of induced sputum[J]. Chest, 2006, 129(5):1344-1348. pmid: 16685028
[31]	LAI K, LIN L, LIU B, et al. Eosinophilic airway inflammation is common in subacute cough following acute upper respiratory tract infection[J]. Respirology, 2016, 21(4):683-688. doi: 10.1111/resp.12748 pmid: 26969485
[32]	YI F, CHEN R, LUO W, et al. Validity of Fractional Exhaled Nitric Oxide in Diagnosis of Corticosteroid-Responsive Cough[J]. Chest, 2016, 149(4):1042-1051. doi: 10.1016/j.chest.2016.01.006 pmid: 26836931
[33]	DIVER S, RUSSELL R J, BRIGHTLING C E. Cough and Eosinophilia[J]. J Allergy Clin Immunol Pract, 2019, 7(6):1740-1747. doi: S2213-2198(19)30457-X pmid: 31279462
[34]	GRAHAM B L, STEENBRUGGEN I, MILLER M R, et al. Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement[J]. Am J Respir Crit Care Med, 2019, 200(8):e70-e88. doi: 10.1164/rccm.201908-1590ST URL
[35]	YI F, JIANG Z, LI H, et al. Small Airway Dysfunction in Cough Variant Asthma: Prevalence, Clinical, and Pathophysiological Features[J]. Front Physiol, 2022, 12:761622. doi: 10.3389/fphys.2021.761622 URL
[36]	BAO W, ZHANG X, LV C, et al. The Value of Fractional Exhaled Nitric Oxide and Forced Mid-Expiratory Flow as Predictive Markers of Bronchial Hyperresponsiveness in Adults with Chronic Cough[J]. J Allergy Clin Immunol Pract, 2018, 6(4):1313-1320. doi: S2213-2198(17)30786-9 pmid: 29128336
[37]	BAI H, SHI C, YU S, et al. A comparative study on the value of lower airway exhaled nitric oxide combined with small airway parameters for diagnosing cough-variant asthma[J]. Ther Adv Respir Dis, 2023, 17:17534666231181259.
[38]	FUJIMURA M, HARA J, MYOU S. Change in bronchial responsiveness and cough reflex sensitivity in patients with cough variant asthma: effect of inhaled corticosteroids[J]. Cough, 2005, 1:5. pmid: 16270932
[39]	LAI K, LIU B, XU D, et al. Will nonasthmatic eosinophilic bronchitis develop into chronic airway obstruction?: a prospective, observational study[J]. Chest, 2015, 148(4):887-894. doi: S0012-3692(15)50276-6 pmid: 25905627