感染后顽固性咳嗽,抗菌药物治疗无效怎么办?

2019-01-20 华武星 医学界呼吸频道

缘何一般感染后咳嗽抗菌药物治疗无效?什么是感染后咳嗽,如何治疗?

感冒后咳嗽:在介绍感染后咳嗽这个概念之前,首先介绍下感冒后咳嗽。当感冒本身的急性期症状(比如鼻塞、流涕、咽痛、咳嗽等)消失后,咳嗽仍然迁延不愈,临床上则称为感冒后咳嗽。

感染后咳嗽:感染后咳嗽,就是感染后遗留的咳嗽。因为除了常规“感冒病毒”以外,肺炎支原体、衣原体等也可导致此类咳嗽,而这些感染算不上感冒,所以现在统称为感染后咳嗽。患者多表现为刺激性干咳或咳少量白黏痰,一般持续3-8周,胸片正常,该病有一定自限性,能自行缓解,抗菌药物治疗无效。

感染后咳嗽非常常见,很多患者说咳嗽了一段时间(3-8周),一直没好,如果进一步询问,或许会发现有部分患者说咳嗽之前有感冒,此后感冒好了而咳嗽没好,一直咳到现在,这时候你就要考虑是否有感染后咳嗽的可能了。虽然这个咳嗽的病程还没达到慢性咳嗽的诊断标准(>8周),但常规排除慢性咳嗽最常见的几个疾病还是有必要的,可以先从病史入手。

所以,诊断感染后咳嗽是第一步。感染后咳嗽的诊断是排除性临床诊断,具体为:
 
1、发病初期有明确呼吸道感染史,比如流清鼻涕、打喷嚏、流泪、咽痛、发热等感冒症状。

2、感染急性症状消退以后,咳嗽仍然迁延不愈甚至加剧,表现为刺激性干咳或咳少量白色黏液痰,通常持续3-8周,或者更长时间。

3、胸片正常。

4、肺通气功能正常,气道反应性正常。

5、诱导痰细胞学嗜酸性粒细胞比例正常。

6、排除其他引起咳嗽的病因。

这个诊断标准只是理想标准而已,实际上没有几个患者是真的都做了胸片、肺功能、诱导痰检查等,个人认为最重要的诊断条件是第一条(有明确感染史),这应该也是公认的,也是该病的定义所在。上述检查只是为了排除肺部感染、咳嗽变异性哮喘、嗜酸性粒细胞性支气管炎等常见病因,毕竟该病诊断是排除性诊断过程。当如果患者没有感冒病史,或者咳嗽时间超过了8周,并且胸片正常,就要按照慢性咳嗽的诊断程序来处理了,该做的检查就应该做,并且充分做好与患者的病情沟通工作。

如果已经确立了诊断,或者说高度怀疑是本病,接下来就应该考虑如何治疗。

上文已经说到,感染后咳嗽是一种自限性疾病,即使不治疗,一般也会症状消失,但是过程可能痛苦,而且可能影响工作和生活,那就得进行对症处理,也就是止咳。

考虑到该病咳嗽的原因可能与呼吸道黏膜损伤、炎症、气道反应性增高等有关,治疗首选第一代抗组胺H1受体拮抗剂(比如扑尔敏、酮替芬等)和中枢镇咳药物(比如右美沙芬、喷托维林、可待因等)缓解症状。个人临床经验及很多文献都认为酮替芬等药物效果不错,必要时可以联合用药,比如酮替芬+右美沙芬,或者用复方制剂,比如阿斯美。

需要注意的是糖皮质激素、白三烯受体拮抗剂(比如孟鲁司特)等疗效不肯定,且价格相对昂贵,一般不建议使用。

抗生素通常是没必要的,因为本病不是细菌感染所致,但如果明确是由肺炎支原体等引起的咳嗽,则应尽早使用大环内酯类抗生素(比如红霉素、罗红霉素、阿奇霉素等)。

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    2019-02-20 jyzxjiangqin

    顽固性咳嗽的治疗。

    0

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    2019-02-15 jyzxjiangqin

    感染后顽固性咳嗽的治疗。

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1632889, encodeId=652c1632889db, content=<a href='/topic/show?id=5e1110013180' target=_blank style='color:#2F92EE;'>#顽固性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100131, encryptionId=5e1110013180, topicName=顽固性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5e4121955726, createdName=limedical1981, createdTime=Sun Oct 13 01:40:00 CST 2019, time=2019-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=361076, encodeId=f5003610e65e, content=顽固性咳嗽的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Wed Feb 20 06:55:14 CST 2019, time=2019-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=360656, encodeId=32b13606563b, content=感染后顽固性咳嗽的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Fri Feb 15 06:52:26 CST 2019, time=2019-02-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=359929, encodeId=d1dc359929c0, content=顽固性咳嗽抗菌药物治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Feb 04 10:35:21 CST 2019, time=2019-02-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=359205, encodeId=ed8935920510, content=认真学习,不断进步,把经验分享给同好。点赞了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=ebe61630855, createdName=1dd8a7c5m95(暂无匿称), createdTime=Fri Jan 25 12:05:45 CST 2019, time=2019-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358977, encodeId=52843589e7ca, content=感染后顽固性咳嗽的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Wed Jan 23 07:02:02 CST 2019, time=2019-01-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1330791, encodeId=eac91330e9148, content=<a href='/topic/show?id=c6b455688d1' target=_blank style='color:#2F92EE;'>#抗菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55688, encryptionId=c6b455688d1, topicName=抗菌)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdqq.qlogo.cn/qqapp/1103841572/2898B09F0DA89357D0D54A725E611AC7/100, createdBy=fdd32500040, createdName=ms7899726347904398, createdTime=Tue Jan 22 01:40:00 CST 2019, time=2019-01-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1373102, encodeId=05f513e3102e7, content=<a href='/topic/show?id=eb2555e176c' target=_blank style='color:#2F92EE;'>#抗菌药#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55717, encryptionId=eb2555e176c, topicName=抗菌药)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7e12358, createdName=lhlxtx, createdTime=Tue Jan 22 01:40:00 CST 2019, time=2019-01-22, status=1, ipAttribution=)]
    2019-02-04 jyzxjiangqin

    顽固性咳嗽抗菌药物治疗。

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1632889, encodeId=652c1632889db, content=<a href='/topic/show?id=5e1110013180' target=_blank style='color:#2F92EE;'>#顽固性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100131, encryptionId=5e1110013180, topicName=顽固性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5e4121955726, createdName=limedical1981, createdTime=Sun Oct 13 01:40:00 CST 2019, time=2019-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=361076, encodeId=f5003610e65e, content=顽固性咳嗽的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Wed Feb 20 06:55:14 CST 2019, time=2019-02-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=360656, encodeId=32b13606563b, content=感染后顽固性咳嗽的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Fri Feb 15 06:52:26 CST 2019, time=2019-02-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=359929, encodeId=d1dc359929c0, content=顽固性咳嗽抗菌药物治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Feb 04 10:35:21 CST 2019, time=2019-02-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=359205, encodeId=ed8935920510, content=认真学习,不断进步,把经验分享给同好。点赞了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRuUXgacXpPeW0x8Z3Qr9c3I2kTic4ZIpR29iaftYgkjRcbv982icYMtqANBPYBgPnOia6mVtX76qMXuc/0, createdBy=ebe61630855, createdName=1dd8a7c5m95(暂无匿称), createdTime=Fri Jan 25 12:05:45 CST 2019, time=2019-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358977, encodeId=52843589e7ca, content=感染后顽固性咳嗽的治疗。, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Wed Jan 23 07:02:02 CST 2019, time=2019-01-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1330791, encodeId=eac91330e9148, content=<a href='/topic/show?id=c6b455688d1' target=_blank style='color:#2F92EE;'>#抗菌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55688, encryptionId=c6b455688d1, topicName=抗菌)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdqq.qlogo.cn/qqapp/1103841572/2898B09F0DA89357D0D54A725E611AC7/100, createdBy=fdd32500040, createdName=ms7899726347904398, createdTime=Tue Jan 22 01:40:00 CST 2019, time=2019-01-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1373102, encodeId=05f513e3102e7, content=<a href='/topic/show?id=eb2555e176c' target=_blank style='color:#2F92EE;'>#抗菌药#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55717, encryptionId=eb2555e176c, topicName=抗菌药)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7e12358, createdName=lhlxtx, createdTime=Tue Jan 22 01:40:00 CST 2019, time=2019-01-22, status=1, ipAttribution=)]
    2019-01-25 1dd8a7c5m95(暂无匿称)

    认真学习,不断进步,把经验分享给同好。点赞了!

    0

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    2019-01-23 jyzxjiangqin

    感染后顽固性咳嗽的治疗。

    0

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    2019-01-22 lhlxtx

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