儿童慢性咳嗽病因分布及误诊原因分析_张丽珍.pdf

儿童慢性咳嗽病因分布及误诊原因分析张丽珍，张钰，申永旺，田君平，梁海联基金项目:河北省 2019 年度医学科学研究课题计划项目(20191752)作者单位:073000 河北 定州，定州市人民医院儿科作者简介:张丽珍，本科，副主任医师。主要从事儿科相关疾病方向研究 摘要 目的分析儿童慢性咳嗽的病因分布，并总结发生误诊的原因。方法回顾性分析2018 年1 月2022年 2 月收治外院转诊并误诊的慢性咳嗽 86 例临床资料。结果86 例均以慢性咳嗽为主要症状就诊，其中 41 例为夜间刺激性咳嗽，24 例为日间发作性咳嗽，12 例为慢性刺激性干咳，9 例仅有干咳。15 例伴咽痒;16 例伴剑突下不适、胸骨后烧灼感、反酸、嗳气，进食后咳嗽加剧;13 例存在鼻后滴流感或日常有频繁清喉动作。86 例均多次就诊外院，误诊为支气管炎 52 例、咽炎 34 例，予对症治疗后症状改善不明显。42 例经问诊及根据咳嗽特点，加行肺功能检查、支气管激发试验及诱导痰检查后确诊为咳嗽变异性哮喘;13 例因存在鼻后滴流感或日常有频繁清喉动作，且有过敏性鼻炎、鼻窦炎病史，加行鼻咽镜检查后确诊为上气道咳嗽综合征;16 例因伴剑突下不适、胸骨后烧灼感、反酸、嗳气等症状，加行胃镜检查发现反流性食管炎表现，确诊为胃食管反流性咳嗽;15 例行变应原皮肤试验、血清特异性 IgE 测定及咳嗽敏感性检查确诊为变应性咳嗽。误诊时间为 2 16 个月。86 例确诊后予抗哮喘、抗反流、抗过敏等针对性治疗，咳嗽症状均缓解或消失，随访半年无复发。结论儿童慢性咳嗽病因繁多，涉及呼吸、消化、耳鼻咽喉、神经、心血管等多个系统，接诊医生应加强对慢性咳嗽病因特点的认知，熟知其病因诊断流程，开拓诊断思维，详细问诊、仔细查体，及时行特异性检查，以尽早明确诊断并治疗，减少延误诊治情况的发生。关键词 慢性咳嗽;咳嗽变异性哮喘;上气道咳嗽综合征;胃食管反流性咳嗽;变应性咳嗽;误诊;支气管炎;咽炎 中国图书资料分类号 725.6 文献标志码 A 文章编号 1002-3429(2023)04-0031-05 DOI 10 3969/j issn 1002-3429 2023 04 008Etiological Distribution and Causes of Misdiagnosis of Chronic Cough inChildrenZHANG Lizhen，ZHANG Yu，SHEN Yongwang，TIAN Junping，LIANG HailianDepartment of Pediatrics，the Peoples Hospital of Dingzhou City，Dingzhou，Hebei 073000，China Abstract ObjectiveTo analyze the etiological distribution of chronic cough and to summarize the causes of misdi-agnosis MethodsThe clinical data of 86 children with chronic cough who were referred to other hospitals and misdiagnosedfrom January 2018 to February 2022 were retrospectively analyzed esultsAll 86 cases presented with chronic cough as themain symptom，of whom 41 cases had irritant cough at night and 24 cases had daytime paroxysmal cough Twelve cases hadchronic irritant dry cough，9 cases only had dry cough，and 15 cases were accompanied by pharyngeal itch Sixteen cases wereaccompanied by discomfort under xiphoid process，burning sensation behind sternum，acid reflux，belching，and aggravatedcough after food consumption Thirteen patients had postnasal drip or frequent throat clearing All the 86 patients went to otherhospitals for several times，and were misdiagnosed as bronchitis in 52 cases and pharyngitis in 34 cases The symptoms did notimprove significantly after symptomatic treatment Of them，42 cases were diagnosed as cough-variant asthma after consulta-tion，pulmonary function examination，bronchial stimulation test and induced sputum examination according to cough charac-teristics Thirteen patients were diagnosed with upper airway cough syndrome after nasopharyngoscopy due to the presence ofpostnasal drip or frequent throat clearing and history of allergic rhinitis and sinusitis Sixteen cases were diagnosed with gas-troesophageal reflux cough due to symptoms including subxiphoid discomfort，retrosternal burning sensation，acid regurgitationand belching Fifteen patients were diagnosed with allergic cough by allergen skin test，serum specific IgE determination andcough sensitivity test Misdiagnosis lasted from 2 to 16 months After 86 cases were treated with anti-asthma，anti-reflux，anti-allergy and other targeted treatments after diagnosis，the cough symptoms were relieved or disappeared，and no recurrence wasobserved during six months of follow-up ConclusionThere are many causes of chronic cough in children，with system in-volvement including respiratory，digestive，otorhinolaryngeal，neural，cardiovascular diseases The receiving doctor should13strengthen the understanding of the etiological characteristics of chronic cough，be familiar with the etiological diagnosisprocess，develop the diagnostic thinking，make detailed consultation，perform careful physical examination，and timely con-duct specific examination，so as to make clear diagnosis and treatment as early as possible and reduce the occurrence of de-layed diagnosis and treatment Key words Chronic cough;Cough variant asthma;Upper airway cough syndrome;Gastroesophageal reflux cough;Allergic cough;Misdiagnosis;Bronchitis;Pharyngitis咳嗽是临床常见的呼吸系统症状，也是一种重要的人体保护性反射，可有效清除气道内分泌物、防止误吸。儿童慢性咳嗽为 4 周的持续性咳嗽，咳嗽为主要或唯一症状，且胸部 X 线检查常阴性1。全球荟萃分析指出，目前世界上约有 10%的成年人患有慢性咳嗽，且不同人群和国家流行程度不同，欧洲发 病 率 为 12 7%2，而 在 我 国 其 患 病 率 为10.2%3，且在呼吸科就诊患者中占 20%30%甚至更高，严重影响患者正常工作、生活和学习，大幅降低其生活质量。对胸部影像学存在异常的慢性咳嗽患者而言，病因诊断不难，但对部分胸部影像学无明显异常的患者而言，病因诊断就显得十分困难。然而慢性咳嗽病因较为复杂，涉及多个学科，咳嗽变异性哮喘(CVA)、慢性咽炎、反流性食管炎等多种疾病均能引起，且不同地区、不同种族间慢性咳嗽病因分布存在差异。故对慢性咳嗽的常见病因进行研究，有助于临床更好地诊断与治疗。慢性咳嗽临床表现常不典型，无发热、咯血等伴随症状，且病因多不明确，再加上基层医院硬件条件差、部分接诊医生经验不足，使得接诊此类患者时极易误诊为气管炎、慢性支气管炎、慢性咽炎等，进而造成各种抗生素滥用。文 献 报 道 慢 性 咳 嗽 临 床 初 诊 误 诊 率 高 达64%4。现回顾性分析 2018 年 1 月2022 年 2 月我院收治外院转诊并误诊的儿童慢性咳嗽 86 例临床资料，探讨儿童慢性咳嗽的常见病因及发生误诊原因，以期提高该病的病因诊断水平，减少临床误诊的发生。1临床资料1.1一般资料本组男 56 例(65.12%)，女 30 例(34.88%)，男女性别比为 1.86 1;年龄 4 14(9.25 3.46)岁;病程 4 48(21.32 7.95)个月;就诊我院前均复诊 2 次以上并多次使用多种抗生素治疗;均无咯血史;有过敏性鼻炎、鼻窦炎史 13 例(15.12%)，有哮喘家族史 10 例(11.63%)，有慢性胃炎史 16 例(18.60%)。本组均符合中国儿童慢性咳嗽诊断与治疗指南(2013 年修订5 相关标准，咳嗽时间4 周，且 X 线检查肺部无明显病变，近 4 周内无急慢性呼吸道感染。1.2症状与体征86 例均以慢性咳嗽为主要症状就诊，41 例(47.67%)为明显夜间刺激性咳嗽;24 例(27.91%)主要为日间发作性咳嗽;12 例(13.95%)为慢性刺激性干咳，油烟、粉尘、说话、异味或冷空气均可诱发咳嗽;9 例(10.47%)仅有干咳。15 例(17.44%)伴咽痒，41 例(47.67%)伴 咳 白 色 泡 沫 痰;16 例(18.60%)伴剑突下不适、胸骨后烧灼感、反酸、嗳气，进 食 后 咳 嗽 加 剧;8