慢性咳嗽评估

尚缺乏诊断或排除 UACS 的确定性检查；需要结合症状、体格检查发现和治疗反应来进行诊断。[37]Pratter MR. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):63S-71. http://journal.chestnet.org/article/S0012-3692(15)52833-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/16428694?tool=bestpractice.com 若基于病史和体格检查结果怀疑存在某一 UACS 的特定病因，例如变应性鼻炎或鼻息肉，应首先针对这些疾病开展治疗。

可能使用支气管舒张剂可逆性试验，该试验能显示使用短效支气管舒张剂后气流阻塞的可逆性，通常定义为 FEV₁ 比基线增加 >12% 和 >200 mL。[10]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]. https://ginasthma.org/2023-gina-main-report [26]Louis R, Satia I, Ojanguren I, et al. European Respiratory Society guidelines for the diagnosis of asthma in adults. Eur Respir J. 2022 Feb 15:2101585. https://www.doi.org/10.1183/13993003.01585-2021 http://www.ncbi.nlm.nih.gov/pubmed/35169025?tool=bestpractice.com 部分患者肺量测定正常。[26]Louis R, Satia I, Ojanguren I, et al. European Respiratory Society guidelines for the diagnosis of asthma in adults. Eur Respir J. 2022 Feb 15:2101585. https://www.doi.org/10.1183/13993003.01585-2021 http://www.ncbi.nlm.nih.gov/pubmed/35169025?tool=bestpractice.com 若患者肺功能正常，则推荐行进一步检查，例如支气管激发试验[Figure caption and citation for the preceding image starts]: 阻塞性肺疾病（例如哮喘或 COPD）时流量-容量环（呼吸描记图）显示：呼气流量峰值可能正常，但是由于与肺容量相关的低流量，在最大流量点之后可看到凹形由 BMJ Knowledge Centre 创建 [Citation ends].

肺量测定结果正常的患者应测定 PEFR。气道梗阻的可变性可用于支持哮喘诊断。[26]Louis R, Satia I, Ojanguren I, et al. European Respiratory Society guidelines for the diagnosis of asthma in adults. Eur Respir J. 2022 Feb 15:2101585. https://www.doi.org/10.1183/13993003.01585-2021 http://www.ncbi.nlm.nih.gov/pubmed/35169025?tool=bestpractice.com [48]National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma: full report 2007. Aug 2007 [internet publication]. https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma ​​[49]Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC)., Cloutier MM, Baptist AP, et al. 2020 Focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-70. https://www.jacionline.org/article/S0091-6749(20)31404-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33280709?tool=bestpractice.com 如果 2 周内每日两次 PEFR 过度变异，则支持哮喘诊断。对于成人，PEFR 每日平均昼夜变异 >10% 则认为是过度变异。治疗 4 周后，PEFR 比基线增加 >20% 也表明过度变异。[10]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]. https://ginasthma.org/2023-gina-main-report

在未经治疗的患者中，如果 FeNO 未升高，则不太可能为哮喘。[50]Chatkin JM, Ansarin K, Silkoff PE, et al. Exhaled nitric oxide as a noninvasive assessment of chronic cough. Am J Respir Crit Care Med. 1999 Jun;159(6):1810-3. http://www.atsjournals.org/doi/full/10.1164/ajrccm.159.6.9809047 http://www.ncbi.nlm.nih.gov/pubmed/10351923?tool=bestpractice.com

吸入醋甲胆碱后气道反应性升高是哮喘的敏感特征，但并不具特异性。[10]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]. https://ginasthma.org/2023-gina-main-report [26]Louis R, Satia I, Ojanguren I, et al. European Respiratory Society guidelines for the diagnosis of asthma in adults. Eur Respir J. 2022 Feb 15:2101585. https://www.doi.org/10.1183/13993003.01585-2021 http://www.ncbi.nlm.nih.gov/pubmed/35169025?tool=bestpractice.com  在未使用吸入皮质类固醇时，乙酰甲胆碱激发试验结果呈阴性基本可排除哮喘。[10]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]. https://ginasthma.org/2023-gina-main-report [51]Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest. 2010 Aug;138(2 suppl):18S-24. http://www.ncbi.nlm.nih.gov/pubmed/20668014?tool=bestpractice.com

对于疑似与工作相关的哮喘，在暴露前、后进行检测，即在正常工作周结束时和休假后进行。[15]Tarlo SM, Altman KW, Oppenheimer J, et al. Occupational and environmental contributions to chronic cough in adults: chest expert panel report. Chest. 2016 Oct;150(4):894-907. http://www.ncbi.nlm.nih.gov/pubmed/27521735?tool=bestpractice.com

可用于支持诊断和衡量治疗。

症状缓解可能需要给予 8 周 PPI 治疗，故在 8 周之前不应认为试验“无效”。罕见情况下，可能需要长达 3 个月才能有所改善。[39]Chen JW, Vela MF, Peterson KA, et al. AGA clinical practice update on the diagnosis and management of extraesophageal gastroesophageal reflux disease: expert review. Clin Gastroenterol Hepatol. 2023 Jun;21(6):1414-21.e3. https://www.cghjournal.org/article/S1542-3565(23)00143-X/fulltext http://www.ncbi.nlm.nih.gov/pubmed/37061897?tool=bestpractice.com [41]Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022 Jan 1;117(1):27-56. http://www.ncbi.nlm.nih.gov/pubmed/34807007?tool=bestpractice.com [42]Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest. 2016 Dec;150(6):1341-60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026249 http://www.ncbi.nlm.nih.gov/pubmed/27614002?tool=bestpractice.com ​​​

75% 的反流性疾病无临床症状，在常规检查前即可开始 PPI 经验性治疗。[38]Irwin RS, French CL, Curley FJ, et al. Chronic cough due to gastroesophageal reflux. Clinical, diagnostic, and pathogenetic aspects. Chest. 1993 Nov;104(5):1511-7. http://journal.chestnet.org/article/S0012-3692(15)42301-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/8222816?tool=bestpractice.com [42]Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest. 2016 Dec;150(6):1341-60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026249 http://www.ncbi.nlm.nih.gov/pubmed/27614002?tool=bestpractice.com 若患者超重或肥胖，应建议其减重，垫高床头，并在睡前 3 小时内避免进食。[42]Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest. 2016 Dec;150(6):1341-60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026249 http://www.ncbi.nlm.nih.gov/pubmed/27614002?tool=bestpractice.com

最敏感和特异性最高的反流性疾病相关性咳嗽检测手段。可考虑作为 PPI 尝试性治疗替代的首选检查。不过关于这一点尚存争议。[42]Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest. 2016 Dec;150(6):1341-60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026249 http://www.ncbi.nlm.nih.gov/pubmed/27614002?tool=bestpractice.com 如果 PPI 尝试性治疗后症状并未缓解，但仍考虑可能为 GORD，则应进行 24 小时食道 pH 值监测。仔细评估与反流事件相关的症状对诊断的支持作用最大。[42]Kahrilas PJ, Altman KW, Chang AB, et al. Chronic cough due to gastroesophageal reflux in adults: CHEST guideline and expert panel report. Chest. 2016 Dec;150(6):1341-60. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026249 http://www.ncbi.nlm.nih.gov/pubmed/27614002?tool=bestpractice.com

敏感性低。

如果痰或支气管肺泡灌洗液中的嗜酸性粒细胞增高，而肺量测定法显示无梗阻，并且支气管激发试验未显示峰流速可变性或高反应性，则提示 NAEB。[52]Brightling CE. Chronic cough due to nonasthmatic eosinophilic bronchitis: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):116S-21. http://journal.chestnet.org/article/S0012-3692(15)52839-0/fulltext http://www.ncbi.nlm.nih.gov/pubmed/16428700?tool=bestpractice.com

对于未使用吸入皮质类固醇的患者是敏感的。[53]Berlyne GS, Parameswaran K, Kamada D, et al. A comparison of exhaled nitric oxide and induced sputum as markers of airway inflammation. J Allergy Clin Immunol. 2000 Oct;106(4):638-44. http://www.ncbi.nlm.nih.gov/pubmed/11031333?tool=bestpractice.com

NAEB 引起的咳嗽可在 4-6 周（一个疗程）的激素治疗后改善。

2023 年慢性阻塞性肺疾病全球倡议（GOLD）指南建议，如果 FEV1/FVC 比值介于 0.6 和 0.8 之间，则应重复进行肺量测定。[54]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report. 2022 [internet publication]. https://goldcopd.org/2023-gold-report-2

依据临床表现，选择肺量测定法、肺容量及弥散功能检测等不同的检测方法组合。[Figure caption and citation for the preceding image starts]: 阻塞性肺疾病（例如哮喘或 COPD）时流量-容量环（呼吸描记图）显示：呼气流量峰值可能正常，但是由于与肺容量相关的低流量，在最大流量点之后可看到凹形由 BMJ Knowledge Centre 创建 [Citation ends].

不适用于诊断，但可能有助于排除其他疾病或诊断合并症。[54]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2023 report. 2022 [internet publication]. https://goldcopd.org/2023-gold-report-2

停用 ACEI 药物后，咳嗽会在 1-12 周内缓解，通常在 1-4 周内缓解。[40]Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):169S-73. http://journal.chestnet.org/article/S0012-3692(15)52845-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/16428706?tool=bestpractice.com

CRP >10 mg/L 对于诊断社区获得性肺炎的敏感性为 90%，特异性为 48%。[57]Ebell MH, Bentivegna M, Cai X, et al. Accuracy of biomarkers for the diagnosis of adult community-acquired pneumonia: a meta-analysis. Acad Emerg Med. 2020 Mar;27(3):195-206. https://www.doi.org/10.1111/acem.13889 http://www.ncbi.nlm.nih.gov/pubmed/32100377?tool=bestpractice.com

对存在症状的患者，除非证实其他诊断，否则应通过可用的恰当检查诊断百日咳。[58]Braman SS. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 suppl):138S-46. http://journal.chestnet.org/article/S0012-3692(15)52842-0/fulltext http://www.ncbi.nlm.nih.gov/pubmed/16428703?tool=bestpractice.com 应对患者进行 5 天的隔离，并将病例报告给公共卫生部门。培养需使用加富培养基。

在胸部 X 线检查中，多达 26% 的肺实质不能充分显像。[55]Chotas HG, Ravin CE. Chest radiography: estimated lung volume and projected area obscured by heart, mediastinum and diaphragm. Radiology. 1994 Nov;193(2):403-4. http://www.ncbi.nlm.nih.gov/pubmed/7972752?tool=bestpractice.com

允许直视地观察肿瘤边界，以及收集活检标本。

结果具有敏感性但无特异性。如果无法行 HRCT，则仍首选普通 X 线检查。

如果可用，应该作为首选方法。

呼气流量峰值可能正常，但在流速最大值这一点之后由于有肺容量相关低流速，会形成凹形曲线。[Figure caption and citation for the preceding image starts]: 阻塞性肺疾病（例如哮喘或 COPD）时流量-容量环（呼吸描记图）显示：呼气流量峰值可能正常，但是由于与肺容量相关的低流量，在最大流量点之后可看到凹形由 BMJ Knowledge Centre 创建 [Citation ends].

如果不能行 HRCT，则首选胸部 X 线。

确诊手段，具有敏感性及特异性。不同的间质病理分型，表现不同。间质性肺炎是最常见的表现。

限制性肺病（例如，肺间质纤维化）中的流量-容积环（呼吸描记图）。[Figure caption and citation for the preceding image starts]: 限制性肺病（例如，间质性肺纤维化）时的流量-容量环（呼吸描记图）：呼气流量峰值可能正常或偏低。曲线形状一般正常，但由于肺容量减少，导致环变窄，用力肺活量降低。由 BMJ Knowledge Centre 创建 [Citation ends].

肺部影像学所示病灶严重程度与疾病严重程度可能并不一致。

对识别此病的敏感性或特异性不高，但一旦结合临床和放射影像学资料，结果可能影响治疗选择。

如果肺部受累，则活检有较高的敏感性。

可见尚未被识别的肺结核证据或陈旧已经痊愈的结核证据（如上叶的纤维化）；如有这些异常，需要留取痰样行涂片、培养和核酸扩增检测。

许多国家建议取 3 份样本（取样至少间隔 8 小时，包括至少一份清晨样本）；请参考当地指导意见。[59]Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan 15;64(2):e1-33. https://academic.oup.com/cid/article/64/2/e1/2629583?login=false http://www.ncbi.nlm.nih.gov/pubmed/27932390?tool=bestpractice.com

对于疑似肺外结核患者，应检测痰液样本，因为活动性肺结核见于 15%-20% 的肺外结核患者。[60]Geldmacher H, Taube C, Kroeger C, et al. Assessment of lymph node tuberculosis in northern Germany: a clinical review. Chest. 2002 Apr;121(4):1177-82. http://www.ncbi.nlm.nih.gov/pubmed/11948050?tool=bestpractice.com [61]Weir MR, Thornton GF. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature. Am J Med. 1985 Oct;79(4):467-78. http://www.ncbi.nlm.nih.gov/pubmed/4050833?tool=bestpractice.com [62]Baydur A. The spectrum of extrapulmonary tuberculosis. West J Med. 1977 Apr;126(4):253-62. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1237539/pdf/westjmed00272-0024.pdf http://www.ncbi.nlm.nih.gov/pubmed/855317?tool=bestpractice.com

培养结核分枝杆菌通常需要数周（最长达 8 周）；在培养结果明确之前，往往已经制定治疗决策。

在考虑肺结核诊断时，应至少对一份呼吸道样本进行 NAAT。NAAT 可能加速涂片阴性病例的诊断，并且可能有助于鉴别非结核分支杆菌感染（痰液的 AFB 涂片呈阳性而 NAAT 呈阴性时）。[63]Centers for Disease Control and Prevention. Updated guidelines for the use of nucleic acid amplification tests in the diagnosis of tuberculosis. Jan 2009 [internet publication]. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5801a3.htm

TB 暴发时，基因分型被认为可能有助于识别 TB 传播，尤其是在流行病学调查过程中尚未对人际接触史进行评估时。现有数种快速 NAAT 可用于诊断 TB，部分还能够检测编码结核药物耐药性的基因。[64]World Health Organization. WHO consolidated guidelines on tuberculosis Module 3: Diagnosis - Rapid diagnostics for tuberculosis detection. Jul 2021 [internet publication]. https://www.who.int/publications/i/item/who-consolidated-guidelines-on-tuberculosis-module-3-diagnosis---rapid-diagnostics-for-tuberculosis-detection ​​​

支气管肺泡灌洗可用于诱导痰失败或涂片及 NAAT 阴性的患者。支气管镜检查可用于强烈考虑其他诊断时或经其他方法仍不能诊断但仍怀疑肺结核的患者。

经支气管镜肺活检有助于粟粒性结核的诊断，因为有可能发现肉芽肿。

一项 Cochrane 评价发现，对于有 TB 症状的 HIV 阳性个体，采用尿液侧流脂阿拉伯甘露聚糖（lateral flow lipoarabinomannan, LF-LAM）测定法诊断 TB 的灵敏度为 42%，而对于未接受 TB 症状评估的 HIV 阳性个体，灵敏度为 35%。​[65]Bjerrum S, Schiller I, Dendukuri N, et al. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev. 2019 Oct 21;10(10):CD011420. https://www.doi.org/10.1002/14651858.CD011420.pub3 http://www.ncbi.nlm.nih.gov/pubmed/31633805?tool=bestpractice.com [ ] What is the accuracy of lateral flow urine lipoarabinomannan (LF‐LAM) for detecting tuberculosis (TB) in symptomatic HIV‐positive adults?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2824/full展示答案 [ ] What is the accuracy of lateral flow urine lipoarabinomannan (LF‐LAM) for detecting tuberculosis (TB) in unselected HIV‐positive adults (symptomatic or asymptomatic)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2825/full展示答案​ WHO 建议，LF-LAM 可用于辅助诊断 HIV 阳性成人、青少年和儿童的活动性 TB。[64]World Health Organization. WHO consolidated guidelines on tuberculosis Module 3: Diagnosis - Rapid diagnostics for tuberculosis detection. Jul 2021 [internet publication]. https://www.who.int/publications/i/item/who-consolidated-guidelines-on-tuberculosis-module-3-diagnosis---rapid-diagnostics-for-tuberculosis-detection ​

药敏试验仍然需要进行培养。

支气管扩张可见于慢性病例。咯血通常源于支气管动脉，但来源于临近空洞的肺动脉的拉斯穆森动脉瘤可能是出血源。

陈旧性肺结核残留的支气管扩张可引起咯血。

很少有助于制定治疗策略。

应将患者转诊至语言病理学家处进行该评估。