persistent cough
Introduction
Introduction Cough is one of the most common symptoms in the respiratory system. It is a protective measure for the body. It is beneficial to the body. When the respiratory mucosa is stimulated by foreign bodies, inflammation, secretions or allergic factors, it is caused reflexively. Cough helps to eliminate foreign bodies or secretions from the outside world and eliminate respiratory stimuli. Persistent cough is a precursor to lung disease. This cough will take two to three months to heal once it starts, and any cough medicine seems to be powerless.
Cause
Cause
(1) Infectious factors
1, upper respiratory tract disease: cold, adenovirus infection, rhinitis or paranasal [sinusitis, tonsillitis, acute and chronic pharyngitis, acute and chronic laryngitis, acute epiglottis, throat tuberculosis, etc.
2, trachea, bronchial disorders: acute and chronic bronchitis, endobronchial tuberculosis, bronchiectasis and so on.
3, lung, pleural disease: pneumonia (bacterial, viral, mycoplasma), pulmonary fungal disease, lung abscess, pulmonary cysts with infection, tuberculosis, pleurisy.
4, infectious diseases, parasitic diseases: pertussis, diphtheria, measles, influenza, paragonimiasis, pulmonary hydatid disease, hookworm disease.
(2) Physical factors
Any physical condition such as obstruction, compression, or pulling of the respiratory tract that causes the wall to be stimulated or the lumen to be distorted and narrowed can cause coughing.
1, airway obstruction: tracheal or bronchial foreign body, bronchoconstriction (common in tuberculosis), bronchial tumor, atelectasis, pulmonary edema, emphysema, alveolar proteinosis, alveolar microlithiasis, alveolar cancer.
2, respiratory tract compression: hilar or bronchial lymphadenopathy, mediastinal tumor, mediastinal lymphadenopathy, retrosternal goiter, esophageal diverticulum, esophageal tumor, lung tumor, diffuse interstitial pulmonary fibrosis, pulmonary cyst, Sarcoidosis, pneumoconiosis, pneumothorax, pleural effusion, pericardial effusion, pleural tumor, etc.
(3) Chemical factors
All toxic and harmful irritating gases in the respiratory tract stimulate the respiratory tract to cause coughing. Commonly used are smoking, drinking tobacco, stimulating industrial gases such as ammonia, chlorine, dioxide, ozone, phosgene, nitrogen oxides, etc., also seen in the volatilization of nitric acid, sulfuric acid, hydrochloric acid, formaldehyde and so on.
(4) Allergic factors
Allergic rhinitis, bronchial asthma, cotton pneumoconiosis, tropical eosinophilia, lufu syndrome, hay fever, angioedema, etc.
(5) Other factors
Infraorbital abscess, hernia, esophageal fistula, Wegener granulomatosis, leukemia, Hodgkin's disease, uremia and connective tissue disease and other lung infiltration.
Examine
an examination
First, medical history
The history of symptoms and the nature of the cough are helpful in suggesting a diagnostic clue.
1, cough with high fever: cough with high fever call patients, consider more acute infectious diseases, acute exudative pleurisy or empyema.
2, cough with chest pain: cough with invented chest pain should consider pleural disease, or lung and other organ diseases, such as lung cancer, pneumonia and pulmonary infarction.
3, cough with cough: cough with cough and jaundice more consider bronchitis, pneumonia, etc. If cough a large number of purulent patients more consider lung abscess, bronchiectasis, secondary infection of lung cysts. If you have cough with cough and jam, you should consider lung amebiasis and paragonimiasis.
4, cough accompanied by hemoptysis: hemoptysis should consider bronchiectasis or cavitary tuberculosis, a small amount of hemoptysis or blood in the sputum to consider lung cancer, tuberculosis and so on.
5, the nature of cough: dry cough or irritating cough is more common in chronic laryngitis, laryngeal cancer, bronchitis, foreign body of the detachable tube, bronchial tumor, tracheal compression or external auditory canal stimulation, etc., more common cough is more common in bronchitis, Bronchiectasis, lung abscess, tuberculosis with hollow or pulmonary parasitic diseases; single cough is more common in tuberculosis, laryngitis, pharyngitis, bronchitis, paroxysmal cough, more common in bronchial asthma, whooping cough, respiratory foreign body inhalation, Endobronchial tuberculosis, bronchial tumors, etc. Short-term light cough or cough is often seen in dry pleurisy, pneumococcal pneumonia, chest and abdomen trauma or postoperative patients; canine-like cough is more common in throat disorders, vocal cord swelling, tracheal exhibition, tracheal tumor or tracheal compression; Deafness and cough are more common in vocal cord paralysis caused by vocal cord inflammation or mediastinal swelling.
6, occupation: miners and long-term exposure to harmful dust should consider pneumoconiosis.
Second, physical examination
First check the position of the trachea, chronic pleurisy or chronic empyema, chronic tuberculosis, atelectasis and other diseases of the trachea to the affected side, pneumothorax or a large number of pleural effusion when the trachea pushes to the healthy side, the superior vena cava syndrome prompts mediastinal swelling or Ditch tumor, supraclavicular lymph node enlargement should consider bronchial lung cancer, the occurrence of subcutaneous emphysema in the neck is often caused by tension pneumothorax or mediastinal emphysema; excessive side resuscitation on the lung side is more common in pneumothorax, excessive repercussions on both sides are more obstructive Emphysema, phlegm sounds in the upper part of the lung should pay attention to tuberculosis, turbidity in the lower part consider pleural effusion or lung consolidation, auscultation on both sides of the dry voice, consider chronic bronchitis, hear localized localized voice in any part of the lungs It is suggested that there is a lung inflammation or a hole in the lungs, and there is a possibility of a moderately humid voice in the localized lung field. The possibility of bronchial dilatation may be considered. Patients with emphysema signs and patients with obvious heartbeat should be considered for pulmonary origin. The presence of heart disease.
Third, laboratory inspection
Understanding the amount, color, smell and nature of cockroaches is diagnostic. In the sputum, bronchial tube type, lung stone, and sulfur granules were found to help pneumococcal pneumonia, tuberculosis, and pulmonary actinomycosis. Microscopic examination revealed Kusmanian spirochetes, and Xialan crystals were helpful for patients with bronchial asthma. The parasite eggs found in the sputum can be diagnosed with paragonimiasis. The head of the echinococcosis of the cysticercosis can be diagnosed with cysticercosis, and the amoebic trophozoite can be diagnosed for the diagnosis of pulmonary amebiasis. (Smear, culture, animal inoculation) is important for tuberculosis, pulmonary fungal disease, etc. It is found that cancer cells can identify the diagnosis of bronchogenic lung cancer; tuberculosis test has a certain significance for children with lymph node tuberculosis.
Fourth, equipment inspection
Because the lungs have a good natural contrast, ordinary X-ray films can detect most of the lung lesions, and sometimes the nature can be determined according to the location, extent and shape of the lesion, such as pneumonia, lung abscess, pulmonary cyst, tuberculosis, lung cancer. , pneumoconiosis, etc. For deep lesions, X-ray tomography was used. CT. MRI examination showed that the superiority of CT scan was that there was no image overlap in the cross-sectional image, and the lesions that could not be displayed by X-ray were found.
Bronchography can directly diagnose the location and shape of bronchiectasis, and can also be diagnosed with bronchial lung cancer. Patients with delirium should be diagnosed with barium meal examination. Bronchoscopy can diagnose endobronchial foreign bodies, endobronchial tuberculosis, and bronchial tumors; mediastinoscopy can help diagnose mediastinal tumors and detect mediastinal lymphadenopathy. Gallium scan is positive in lung inflammatory lesions and nodular ice, so it can not be used as a means to monitor lung cancer and pneumonia lesions and sarcoidosis.
Diagnosis
Differential diagnosis
First, upper respiratory disease
1, pharyngitis
Chronic pharyngitis is a common pharyngeal disease, and its prominent symptom is irritating dry cough. Because of the itching and discomfort in the pharynx, the patient often clears the dry cough of the pharynx, and the symptoms are more obvious when speaking. The symptoms can be alleviated after drinking water or after swallowing. Most of them are secondary to upper respiratory tract infections, or frequent smoking, alcoholics and some people who are exposed to certain harmful dust or gas.
Pharyngeal congestion can be seen in the pharyngeal examination. There are many dilated capillaries and a small amount of lymphoid follicles on the surface of the posterior pharyngeal mucosa. The mucosa of the posterior pharynx and some exposure to harmful dust or gas are more common.
Pharyngeal congestion can be seen in the pharyngeal examination. There are many dilated capillaries and a small amount of lymphoid follicles on the mucosal surface of the posterior pharyngeal wall. The mucosa and sacral arch of the posterior pharyngeal wall are slightly thickened, and the secretion is increased. Chronic simple pharyngitis generally mild symptoms, pharyngeal reaction is also easy, chronic proliferative pharyngitis clinical symptoms are more significant, pharyngeal reaction is heavier, visible pharyngeal congestion, vasodilation, soft palate congestion, county sputum congestion and edema, lymphatic filtration The proliferation of the vesicles is obvious, the nucleus is thicker, and the pharyngeal reflex is particularly sensitive. The pharyngeal dryness of chronic atrophic pharyngitis is the most prominent symptom of the patient. The pharyngeal examination shows that the pharyngeal mucosa is pale. Dry, thin, pharyngeal muscle atrophy and pharyngeal cavity is relatively wide.
2, laryngitis
The main symptoms are hoarseness, which often occurs intermittently in the early stage, and occurs every time when the pronunciation is high. If the condition is aggravated, the vocalization can be sustained, but none of them are rare. Because the patient has a dry cough to relieve symptoms.
Acoustic laryngeal mucosa examination, patients with chronic simple laryngitis often show larynx mucosal congestion, vocal cord tarnish, there are dilated blood vessels distributed, mucus secretion increased; when the disease progresses to a chronic proliferative laryngitis, The mucosa is obviously thicker and dark red, and its margin is thick and round, and the pronunciation is often closed. The throat chamber is often thickened by compensatory activities. Chronic atrophic laryngitis is rare, and yellow and green often appear after coughing. The suede has a burning or painful sensation in the throat.
3, throat tuberculosis
Often in patients with open tuberculosis, early symptoms often have dry cough and mild hoarseness. As the condition worsens, the vocalization becomes more and more serious. Until the later stage, not only the vocal increase is aggravated, but the severe punishment is like whispering because of the lack of pronunciation.
Indirect laryngoscopy in the early stage of patients with common sacral space and swelling of the posterior epiglottis, swollen mucosa was pale, vocal cord or throat room, ulcers appeared in the epiglottis, severe throat morphology may change, difficult to identify.
4, laryngeal cancer
Commonly, the coughing sound is hoarse, and as the condition worsens, the symptoms gradually become apparent, and the late stage may have aphasia and difficulty breathing.
Direct laryngoscopy or fiber laryngoscopy, early cancer occurs in the anterior and middle segments of one side of the vocal cords, and is a nodular or cauliflower-like new organism. According to the tumor occurrence, the chicken position is divided into glottic cancer, supraglottic cancer and sub-acoustic carcinoma. The location of subglottic carcinoma is not easy to find early. All suspicious tissue of the throat should be taken for pathological diagnosis of living tissue.
X-ray tomography, CT, and laryngeal dynamic microscopy are helpful for diagnosis.
Second, bronchial diseases
1. Acute tracheal-bronchitis
Acute inflammation of the tracheal-bronchial mucosa due to infection, physicochemical stimuli or allergies.
The onset of disease is more common, often with symptoms of acute upper respiratory tract infection. When inflammation involves the tracheal-bronchial mucosa, coughing and coughing occur first, followed by dry cough or a small amount of mucous sputum. After a few days, it can become mucopurulent sputum, coughing is worse, sputum is increased, occasionally sputum is bloody, and some patients are Bronchospasm can occur, the degree of shortness of breath can occur, accompanied by sternal tightness, systemic symptoms are generally light, body temperature can reach 38 degrees Celsius left, generally 3 to 5d down to normal, cough and cough can continue 2~3 Week, such as improper treatment, delay and unhealed, over time can evolve into chronic bronchitis.
During the physical examination, the lungs were found to have a rough breath sound, and they could be heard in dry and wet sounds, which were mostly reduced or disappeared after coughing.
There is no change in white blood cell test. The white blood cell count can be increased when the secondary infection is heavier. The pathogenic bacteria can be found in the sputum smear or sputum culture. Most of the X-ray chest radiographs are normal or the lung texture is thickened.
2, chronic bronchitis
Patients with bronchitis continue to cough for more than three months, or cough for more than three months each year for two consecutive years, and exclude those caused by heart, lung and other diseases, called chronic bronchitis. Chronic bronchitis refers to chronic non-specific inflammation of the trachea, bronchial mucosa and surrounding tissues. More slowly onset, longer course, coughing or wheezing. The initial symptoms are mild. When the climate changes or the cold catches cold, it causes an acute attack. The more the number of episodes, the more the symptoms become worse. The chronic infection prolongs and gradually develops into chronic bronchitis. When the summer climate warms up, the condition can be naturally relieved, and the condition in winter and spring can be exacerbated.
The most prominent symptom is cough. The severity of cough is related to the inflammation of the bronchial mucosa and the amount of sputum. It is usually more cough after the morning heart, more coughing, less cough during the day, and there is a night before going to sleep. Cough or cough, sputum is generally white mucus or serous foam, occasionally with blood, when the acute attack accompanied by bacterial infection, it becomes mucopurulent sputum, cough and sputum also increase, then there may be Micro heat or general discomfort.
There are no abnormal signs in the early stage. There are often dry and wet sounds in the acute attack period, mostly in the back and the bottom of the lungs. It may be reduced after coughing. X-ray examination showed thickening of the lung texture, and the emphysema and pulmonary heart disease often occurred in the late stage of the disorder, showing thoracic expansion, widening of the rib sound gap, and the sputum decreased and became equal signs. Diagnosis is not difficult.
3, whooping cough
It is a common acute infectious disease in children. The pathogen is Haemophilus pertussis, which is easy to be popular among children. The course of disease is longer and divided into three phases. The first is the catarrhal phase. The symptoms at the beginning of the disease are similar to those of the upper respiratory tract infection. After 1 to 2 weeks, there is a paroxysmal cough and a coughing period. It is characterized by paroxysmal spasmodic cough. It is characteristic when inhaling after coughing. High-pitched snoring, similar to murmur, chilling cough lasted for 2 to 6 weeks and gradually eased into the decline period. If the treatment is not appropriate, some patients may move to a longer date, and the elderly may be more than one year old. Some children may have traces of reflexes. If they have coughing after suffering from other respiratory diseases within one year, they may still have a pertussis-like cough.
4, bronchiectasis
Bronchiectasis is divided into primary and secondary. Primary bronchiectasis is caused by congenital bronchial dysplasia or genetic factors. Most patients have a history of pneumonia, whooping cough, measles, etc. Most of the secondary are caused by bronchial or bronchial wall obstruction due to bronchial or extraluminal obstruction. The layers of the bronchial wall cause expansion. There is not much expansion and cough. For example, the amount of co-infection increases, and fever is related to postural changes. Coughing can be aggravated in morning and bed, coughing is increased, and the amount of cough can reach hundreds of milliliters per day. The sputum is placed in the crying chamber and can be divided into three layers. The upper layer is a foamy mucus, the middle layer is a relatively clear slurry, and the lower layer is a purulent liquid and cell debris sediment. Most patients are accompanied by hemoptysis, and sometimes a large amount of hemoptysis.
The area of bronchiectasis is more common in the base of the left lower lobe. The auscultation of the lesion is attenuated by the respiratory sounds and has a fixed wet sound.
X-ray film photography is not easy to diagnose the disease, because there are few signs on the plain film, bronchography can confirm the diagnosis, and provide treatment options, especially the surgical plan.
5, endobronchial tuberculosis
Endobronchial tuberculosis is generally secondary, and is often secondary to chronic fibrovascular tuberculosis, chronic hematogenous disseminated tuberculosis, invasive pulmonary tuberculosis, and tuberculous pneumonia. The patients were young and young, more women than men, and were clinically characterized by paroxysmal irritating cough, accompanied by wheezing and paroxysmal dyspnea. Cough and hemoptysis are also common symptoms. The amount of sputum varies greatly during the day, and repeated small hemoptysis or blood in the sputum.
check, it is easy to find tuberculosis, silk chest film can find tuberculosis in the lungs, sometimes the lung lesions may be mild, and bronchoscopy can confirm the diagnosis and determine the location and extent of the lesion.
6, primary bronchial cancer
Also known as primary lung cancer, the most common malignant tumor of the respiratory system. In recent years, the incidence of lung cancer and the mortality rate of lung cancer have increased sharply in countries, and the industrialized countries have risen more significantly.
Histological classification is still inconsistent at home and abroad, but most of them are classified according to the degree of cell differentiation and morphological characteristics|: squamous cell carcinoma, small cell undifferentiated carcinoma, large cell undifferentiated carcinoma, adenocarcinoma and bronchiole-alveolar carcinoma . Squamous cell carcinoma and small cell undifferentiated carcinoma often present as central lung cancer.
Cough is the most common early symptom of lung cancer. Especially for smokers over the age of 40, irritating cough for more than a few weeks with hemoptysis should consider the possibility of lung cancer, and chest X-ray should be performed as soon as possible.
X-ray examination is the main method for finding lung cancer. According to the positive and lateral chest radiographs, the shadow of the tumor or the shadow of the suspicious mass can be found. Further, high-voltage radiography, tomography or CT tomography, bronchial or angiographic angiography can be used to confirm the mass. The shape, location, bronchial obstruction and lymph node metastasis of the hilar and mediastinum, CT scan can detect early lung cancer, the lesions in the lung, especially in the mediastinum and after the heart shadow, CT examination showed more than X-ray examination clear.
Magnetic resonance imaging (MRI) has a good natural contrast (flow effect) in observing blood vessels. Whether the masses in the hilar and mediastinum are vascular or non-vascular, MRI has its superiority and is an important early diagnosis. One of the methods.
The most simple and effective diagnostic method for sputum cytology. If the sputum is fresh, the examination is careful and the positive rate can reach 70%~80%, and the tissue cell type can be provided. The cytological examination is one of the main methods for early diagnosis of lung cancer, and the recessive lung cancer can be found.
Fiberoptic bronchoscopy is currently one of the most important methods for the diagnosis of lung cancer. It can directly see the trachea, bronchus, lung segment and sub-pulmonary bronchial lesions can also be brushed and biopsy to obtain cytological and histological diagnosis. .
7, bronchiolocarcinoma
Also known as alveolar cancer, women are more common, cancer begins to occur at the edge of the lungs, does not invade the large bronchi, symptoms develop slowly, cough, cough and shortness of breath for King Kong, more than half of patients have hemoptysis symptoms, patients often cough More sputum, easy to cause pleural effusion.
X-ray examination, the lungs generally show a circular block shadow, diffuse miliary shadow or pneumonitis-like infiltration.
Sputum smear examination is easier to find cancer cells.
Third, lung disease
Bacterial pneumonia: Bacterial pneumonia accounts for more than 50% of pneumonia. Most of the pathogenic bacteria are pneumococci, mainly Staphylococcus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Haemophilus influenzae and so on.
1. Pneumococcal pneumonia: caused by Streptococcus pneumoniae (Pneumococci), showing acute inflammatory mutations in the lung or lung. Most of the patients are healthy young adults. Men often have more onset of illness, chills, high fever (39~40 degrees), chest pain on the affected side, increased cough or deep breathing, cough with bloodshot or rust.
At the time of examination, most of them found simple herpes on the lips. When the lungs were solid, they were diagnosed with dullness, increased vocal fibrillation and bronchial breath sounds, and the dissipated period could smell wet sounds.
Laboratory examination, elevated white blood cells, neutrophils accounted for more than 0.08, and in the left or visible cytoplasmic toxic particles, sputum smear or sputum culture can be found pathogens.
In the early stage of X-ray examination, only the lung texture weight gain or the lung leaf boat blur can be seen. When the lung is solid, the lung segment or the lung leaf is solidly shadowed, and the bronchial airway sign is visible in the shadow.
2, staphylococcal pneumonia: is an acute lung infection caused by staphylococcus, the onset of more rapid, high fever, chills, chest pain cough, cough is purulent, the amount of bloodshot or red milky.
Experimental examination of hemorrhage increased white blood cells, increased proportion of neutrophils, nuclear left shift and toxic particles, sputum bacteriological examination and cytosolic acid antibody determination for pathogenic diagnosis.
X-rays show flaky shadows with voids and liquid levels.
3, pneumonia bacillus pneumonia: is an acute lung inflammation caused by Klebsiella pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, Escherichia coli, etc., more common in the elderly and elderly patients with frail and sick, their body immunity is low , accounting for more than 50% of nosocomial infections.
Most of the onset is sharp, high fever, chest pain, cough, cough, sticky, purulent, bloody, different pathogen infections, can show different colors of color, such as Klebsiella pneumonia, grayish green or red brick Color, Pseudomonas aeruginosa is emerald green purpura or yellow purulent.
Laboratory tests, sputum or blood culture can be diagnosed as pathogens, serum antibody determination is helpful for diagnosis, and Pseudomonas aeruginosa pneumonia serum agglutination test can be positive.
X-ray examination showed that most of the fire-fighting lungs or lobular consolidation, multiple honeycomb lung abscess, generally bilateral lower lobe is more affected.
4. Legionella pneumonia: is a pneumonia-based systemic disease caused by Legion Ella pneumophila. It was confirmed in 1976 from US military patients. The bacteria are present in water and In the soil, it is generally inhaled by the water supply system, air conditioning and atomized inhalation, causing respiratory infections, and may also be a small outbreak. Middle-aged and elderly people, as well as chronic diseases, people with low immunity are susceptible to this disease, such as mixed infection with Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Candida, and Cryptococcus neoformans, becoming "refractory pneumonia" The rate is higher.
The patient was slow onset and had a sudden onset of sputum after 2 to 10 days of incubation. Patients generally have fatigue, myalgia, headache, high fever accompanied by this battle, cough, cough, sputum may not be much, viscous is generally not purulent, some people with blood, about 10% of patients appear relatively slow pulse There may also be gastrointestinal symptoms such as nausea, vomiting and diarrhea, and severe symptoms such as mental symptoms, respiratory failure or circulatory failure.
Laboratory tests, sputum, inflammatory exudate or lung biopsy prints can be visualized by direct immunofluorescent antibody staining, or bacteria can be diagnosed from sputum, pleural fluid and lung tissue biopsy, indirect immunofluorescent antibody titers It can be diagnosed up to 1:256.
X-ray examination, early pneumonia showed peripheral plaque-like lung infiltration in the lung field, followed by development of lung consolidation, unilateral or bilateral, mostly in the lower lobe, severe cases with pleural effusion.
