Abercrombie France,Advances in diagnosis and treat

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Advances in diagnosis and treatment of chronic cough

Chronic cough (chronic persistent cough, CPC) is a respiratory disease in one of the most common complaint is defined as cough lasting more than 3 weeks, the examination failed to find significant lung disease. Because many patients only have symptoms of cough, check the etiology difficult to find objective evidence, often delay in diagnosis, since the anatomy of chronic cough Irwin proposed diagnostic procedures, and by constantly refined, CPC's cause diagnosis rate to 90%, and there have been the cause of discovery of new [1].
1 pathogenesis
The cause of the relatively consistent cough variant asthma (cough variant asthma, CVA), postnasal drip syndrome (postnasal drip syndrome, PNDS), gastroesophageal reflux (gastro-esophageal reflux, GER), eosinophils cells bronchitis (eosinophilic bronchitis, EB), also a scholar of drugs (such as angiotensin converting enzyme inhibitor) induced cough cough and psychological listed. Multi-center prospective study showed that 32% of chronic cough as a single factor to 82%, 18% to 62% for multi-factor [2]. Overseas the literature [3] Statistics of the 1258 cases showed the cause of chronic cough, chronic rhinitis related cough accounted for 34% of the first, including some, including sinusitis, followed by atypical asthma 25%, 20% of esophageal lesions.
1.1 PNDS
Usually drops after nasal and sinus secretions, repeated inhalation, local reflex stimulation of the throat caused by chronic cough, including a variety of causes, such as chronic rhinitis, allergic rhinitis, vasomotor rhinitis, sinusitis, nasal polyps and so on. Therefore, independence is not a disease, known as postnasal drip syndrome. With lower respiratory tract mucosa may have a similar inflammatory response, which contains sensory nerve endings of airway sensory nerve stimulation, increased cough reflex sensitivity, resulting in cough neuropeptides and neurotransmitters, may be apparent or potential nose, rhinitis secretion material drops choking or respiratory tract, where the cough receptors to stimulate reflex mechanisms or through sensitization of the cough reflex [4].
1.2 CVA
CVA is a chronic cough as the main clinical manifestation of a latent form of asthma, clinically mainly as persistent or recurrent cough more than 1 month, often accompanied by paroxysmal nocturnal or early morning cough, sputum less, exercise increased , no infection of clinical performance, longer antibiotic treatment or ineffective cough with bronchodilators can attack mitigation. Infection factors,[link widoczny dla zalogowanych], genetic factors, environmental and chemical factors, some of the triggering factors include a variety of allergens and physical changes, such as pollen, dust mites, chemical stimulation of smoke, cold air stimulation or movement, etc. [5,6], cough variant asthma change the performance of the airway inflammation, namely infiltration of inflammatory cells, small vascular congestion,[link widoczny dla zalogowanych], exudation and bronchial submucosal mast cell activation, causing accumulation of eosinophils and bronchial epithelial damage, epithelial cell loss after injury, some basement membrane thickening, similar to typical asthma, IgE type Ⅰ allergy described in the pathology of cough variant asthma play an important role [7]. Recent studies have found that SP nerve density in the immune neural response in asthmatic patients with cough variant asthma than the typical group and the control group, indicating that airway cough receptor nerve abnormalities may be linked to the high reactivity of the relevant receptor, which may be cough variant asthma One of the pathological features [8].
1.3 GER
More because the lower esophageal sphincter relaxation, esophageal gastric contents reflux disease caused by inhalation of the trachea, a large number of inhalation can cause pulmonary aspiration syndrome, aspiration pneumonia, lung abscess etc., long-term repeated inhalation may cause recurrent aspiration pneumonia, pulmonary fibrosis and bronchiolitis obliterans, or present only as a chronic cough. There are two theories of its mechanisms: (1) theory of aspiration, reflux of gastric contents aspirated into the larynx or tracheobronchial tree, larynx, or by direct stimulation of airway cough receptors or through the vagus nerve reflex to increase respiratory tract secretions, further stimulate cough receptors, or both produce cough. (2) acid reflux theory: hydrochloric acid, flow to the distal esophagus, the stimulation of sensory nerve endings in the esophagus, through: ① along the efferent vagal afferent cough center; ② nerve impulses along the efferent vagus nerve fibers spread from the brain under respiratory tract, causing increased mucus secretion or release of neurotransmitter receptors to stimulate coughing; ③ nerve impulses directly stimulate cough receptors passed into the airways in several ways such as cough [9].
1.4 EB
Diagnosed it as an independent raised only near, its etiology and pathogenesis is not clear, although it is often accompanied by upper airway symptoms, but on the upper airway inflammation and airway hyperresponsiveness is not its main features and pathogenesis, and its eosinophilic airway inflammation and cytokine mechanisms and asthma are similar, but why do so will lead to different pathophysiological changes, difficulties in the current study.
1.5 angiotensin converting enzyme inhibitor (ACEI)
The exact mechanism of cough unclear. ACEI may prevent the degradation of endogenous bradykinin. ACEI stimulated prostaglandin synthesis, ACEI prevent tachykinin degradation, which can accumulate in the airways of inflammatory mediators that stimulate the production cough cough receptors. ACEI-induced cough addition there is a certain genetic susceptibility.
2 diagnosis
CPC is not strictly defined [10], usually uncommon cause of chronic lung disease, chest cough, general requirements meet the following conditions: (1) symptoms of dry cough as the sole, or main symptoms; (2) cough lasting 3 weeks or more; (3) chest radiographic findings significantly,[link widoczny dla zalogowanych], except lung disease; (4) except for smoking related cough can; (5) non-angiotensin converting enzyme inhibitor induced by ACEI, ACEI drugs with or without more than 4 weeks has been disabled who still have a cough; (6) no recent upper respiratory tract infection, or more than 8 weeks is still cough who meet the above conditions, the establishment of CPC diagnosis. Further asked the medical history, around the CVA, PNDS, EB, GRE and other common methods for selection for further examination. There are many diagnostic techniques [11], can be selected according to the disease, such as sputum examination, spirometry examination, HRCT scan, endoscopy and so on. In recent years, a number of assessments they conducted the inspection method of airway inflammation, such as guide sputum cytokines and inflammatory mediators were repeated in the inspection, examination exhaled NO, and assessment of airway hyperresponsiveness and airway challenge test and so on. Provide clues in the clinical history data, based on the empirical treatment of rational examination and combination of methods, is the best treatment strategy, if too much emphasis on a comprehensive examination, and treatment, although targeted, but they are costly and patients often get early treatment. However, if only from the empirical therapy, and gradually explore the diagnosis,[link widoczny dla zalogowanych],[link widoczny dla zalogowanych], it may delay the diagnosis of certain diseases.
2.1 PNDS diagnosis
Described based mainly on patients with symptoms such as throat felt something trickle need to clear throat, itchy throat, nasal congestion and runny nose, the patient sometimes complained of hoarseness, speech can cause coughing, with nasopharyngeal examination and X ray signs make the diagnosis and treatment effects [2].
2.2 CVA diagnostic criteria [12]
(1) repeated episodes of cough lasting> 1 month, often at night and (or) early morning attack, increased after exercise; (2) normal lung function, and X-ray, physical examination no positive signs; (3) airway hyperresponsiveness and reversible airway obstruction; (4) ineffective antibiotics and cough medicines, bronchodilators or corticosteroids effective in the short term relapse after treatment; (5) have a personal or family history of allergic hypersensitivity history, allergen test positive; (6) other causes other than chronic cough.
2.3 GER
GER is often caused by chronic cough or chest under the xiphoid accompanied by burning sensation, throat discomfort, acid reflux, mouth pain, and even spit up food, with the typical symptoms, clinical diagnosis, use of proton pump inhibitor agent treatment is effective and provides the basis for further diagnosis, 24h esophageal pH value of the test (OPHM) is the most sensitive diagnostic methods, the methods are: Lee pH gradient two-electrode through the nose into the esophagus, esophageal sphincter are located above the upper edge of 5cm and 20cm at the continuous record of 24h esophageal pH 5min number of times, the longest reflux time, upright, supine pH 14.72 as GER; total sub <14.72, but the upper and lower electrodes have a cough associated with reflux as a ≥ 75% probability of CPC with GER-related [13]. The determination of GER have a higher sensitivity and specificity of diagnosis, many patients with GER without CPC [14], its mechanism needs further study.

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