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--> 00:01.501\n嗯，\n\n00:01.501 --> 00:01.901\n大家好，\n\n00:01.901 --> 00:03.151\n我是呼吸科魏医生。\n\n00:03.151 --> 00:04.875\n今天我们一起来学习一下，\n\n00:05.076 --> 00:10.475\n从2024咳嗽基层指南更新看CVA的规范化诊疗。\n\n00:14.954 --> 00:15.128\n嗯，\n\n00:15.128 --> 00:16.454\n一共分为三部分，\n\n00:16.604 --> 00:19.153\n第一部分我们介绍一下C。\n\n00:25.757 --> 00:25.906\n嗯，\n\n00:25.906 --> 00:28.607\n第三部分是CV的规范化治疗。\n\n00:31.968 --> 00:32.269\n因为，\n\n00:32.569 --> 00:32.969\n嗯，\n\n00:33.118 --> 00:34.519\n也叫咳嗽变性，\n\n00:34.519 --> 00:35.019\n哮喘，\n\n00:35.319 --> 00:37.219\n咳嗽是我们，\n\n00:37.519 --> 00:37.894\n嗯，\n\n00:37.894 --> 00:38.519\n临床。\n\n00:40.083 --> 00:42.383\n临床中最常见的一个症状，\n\n00:42.784 --> 00:43.159\n嗯，\n\n00:43.159 --> 00:44.458\n咳嗽小于三周，\n\n00:44.458 --> 00:46.409\n我们一般称为急性咳嗽，\n\n00:46.409 --> 00:47.583\n比如感冒啊，\n\n00:47.833 --> 00:49.234\n急性支气管炎。\n\n00:49.883 --> 00:52.734\n三到八周是称为亚急性咳嗽。\n\n00:52.833 --> 00:54.583\n比如感染后的咳嗽，\n\n00:54.633 --> 00:58.734\n感冒以后病人会说鼻塞流鼻涕都好了，\n\n00:58.734 --> 00:59.659\n体温也正常了，\n\n00:59.659 --> 01:00.558\n喉咙痛也好了，\n\n01:00.558 --> 01:02.359\n但是就是只剩下咳嗽了。\n\n01:02.359 --> 01:04.234\n这一般是感染后的咳嗽，\n\n01:04.234 --> 01:05.384\n叫亚急性咳嗽，\n\n01:05.384 --> 01:06.533\n一般3到八周。\n\n01:08.111 --> 01:09.861\n还有一个就是咳嗽病性哮喘，\n\n01:09.861 --> 01:10.761\n就CVA，\n\n01:10.911 --> 01:14.361\n还有嗜酸性粒细胞性支气管炎，\n\n01:14.361 --> 01:14.661\nEB,\n\n01:14.710 --> 01:16.810\n还有上气道咳嗽综合征。\n\n01:17.962 --> 01:18.063\n嗯，\n\n01:18.063 --> 01:19.087\n大于八周的话，\n\n01:19.087 --> 01:20.663\n我们一般称为慢性咳嗽。\n\n01:20.663 --> 01:22.013\n常见的病因有，\n\n01:22.362 --> 01:27.862\n咳嗽变异性哮喘、嗜酸性粒细胞性支气管炎、鼻后滴流综合征。\n\n01:28.669 --> 01:29.569\n胃食管反流。\n\n01:31.347 --> 01:32.347\n还有变异性咳嗽。\n\n01:35.928 --> 01:38.877\n我国慢性咳嗽的患病率超过有10%。\n\n01:40.127 --> 01:44.227\n咳嗽是呼吸科门诊和社区门诊最常见的症状。\n\n01:44.627 --> 01:46.053\n在社区人群中，\n\n01:46.053 --> 01:49.777\n慢性咳嗽患病率大概在10%左右，\n\n01:50.127 --> 01:52.428\n在我国呼吸专科门诊中，\n\n01:52.527 --> 01:56.678\n慢性咳嗽患者占比在1/3以上。\n\n01:59.538 --> 02:02.237\nCV是中国慢性咳嗽的首要病因。\n\n02:04.292 --> 02:08.893\n慢性咳嗽有将近1/3为咳嗽变异性哮喘。\n\n02:10.667 --> 02:13.317\n中国慢性咳嗽病因多中心研究。\n\n02:14.291 --> 02:14.966\n2013年，\n\n02:14.966 --> 02:20.891\n我国首次对慢性咳嗽进行前前瞻性、多中心的临床流行病学调查，\n\n02:21.291 --> 02:23.341\n涉及全国5大行政区，\n\n02:23.341 --> 02:26.266\n收集合格病例763例。\n\n02:26.266 --> 02:27.341\n结果显示，\n\n02:28.091 --> 02:30.740\n中国慢性咳嗽主要病因是咳嗽，\n\n02:30.740 --> 02:31.690\n变异性哮喘，\n\n02:31.940 --> 02:34.440\n占约33%。\n\n02:35.682 --> 02:35.781\n嗯，\n\n02:35.781 --> 02:42.031\n左边这张图我们可以看到上气道咳嗽综合征约占18.61%。\n\n02:42.934 --> 02:47.483\n嗜酸性粒细胞性支气管炎占17.17%，\n\n02:48.033 --> 02:50.983\n过敏性的咳嗽占13.24%。\n\n02:52.722 --> 02:55.322\n胃食管反流占比最低，\n\n02:55.322 --> 02:55.822\n4.59%，\n\n02:55.921 --> 02:58.822\n还有其他的一些病因引起的咳嗽，\n\n02:58.822 --> 03:00.572\n占13.76%。\n\n03:04.356 --> 03:06.430\n从这张表中我们可以看出CVA，\n\n03:06.430 --> 03:09.356\n它是亚急性咳嗽第三大病因。\n\n03:10.485 --> 03:20.235\n除感染后咳嗽、咳嗽变异性哮喘、嗜酸性粒细胞性支气管炎、变异性咳嗽同样是亚急性咳嗽的主要的病因。\n\n03:23.800 --> 03:25.800\n对于咳嗽大于3周的患者，\n\n03:26.000 --> 03:29.649\n在排除感染后咳嗽我们都要考虑C、Y的可能。\n\n03:30.466 --> 03:32.292\nCV有哪些临床症状呢？\n\n03:33.458 --> 03:34.958\n它的特征之一是夜咳。\n\n03:35.759 --> 03:37.184\n最新的研究证明，\n\n03:37.184 --> 03:39.408\n只有在夜间咳嗽这个特征上，\n\n03:39.408 --> 03:42.559\n是CVA相较于其他咳嗽最明显的特征。\n\n03:44.250 --> 03:46.350\n在呼吸科门诊接待的患者中，\n\n03:46.350 --> 03:50.800\n有很多患者会主诉夜里咳嗽较明显，\n\n03:50.850 --> 03:52.074\n痰不是特别多，\n\n03:52.074 --> 03:53.500\n或者少许的白痰。\n\n03:54.354 --> 04:00.005\n而且同时伴有咽痒或者是气管痒这些症状，\n\n04:00.455 --> 04:02.255\n这个就是要考虑咳嗽，\n\n04:02.255 --> 04:03.154\n变异性哮喘。\n\n04:04.261 --> 04:06.811\n咳嗽的属性可从四个维度来分判。\n\n04:07.938 --> 04:09.438\n一干咳和湿咳，\n\n04:09.537 --> 04:12.563\n如果痰量在每天大于10ml，\n\n04:12.563 --> 04:13.938\n一般是称为湿咳。\n\n04:15.033 --> 04:17.709\n还有一个就夜间咳嗽和白天咳嗽，\n\n04:17.709 --> 04:20.933\n这是门诊医生经常会问的问题。\n\n04:22.177 --> 04:22.726\n患者，\n\n04:22.976 --> 04:26.752\n是夜间咳嗽比较明显还是白天咳嗽比较明显？\n\n04:26.752 --> 04:28.076\n有痰还是没痰？\n\n04:28.915 --> 04:29.040\n嗯，\n\n04:29.040 --> 04:31.690\n其次还咳嗽的属性维度，\n\n04:31.690 --> 04:32.964\n还有饮食相关，\n\n04:33.415 --> 04:35.739\n有没有刺激性的食物，\n\n04:35.739 --> 04:37.265\n辣的凉的有没有吃？\n\n04:37.765 --> 04:38.239\n同时，\n\n04:38.239 --> 04:39.839\n这个咳嗽还跟冷空气啊，\n\n04:39.839 --> 04:40.565\n异味相关，\n\n04:40.565 --> 04:41.665\n有些病人会说。\n\n04:42.661 --> 04:42.861\n嗯，\n\n04:43.212 --> 04:47.812\n空调房间或者是早晚气温变冷的时候会咳嗽明显。\n\n04:48.839 --> 04:51.089\n还有一些病人会说闻到刺激性的味道，\n\n04:51.290 --> 04:53.515\n比如香烟味或者是香水味，\n\n04:53.515 --> 04:55.114\n他会感到咳嗽、咳痰，\n\n04:55.114 --> 04:56.690\n甚至会有一些胸闷、气喘。\n\n04:57.615 --> 04:59.665\n只有在夜间咳嗽这个特征上，\n\n04:59.665 --> 05:02.816\n是CVA相较于其他咳嗽最明显的特征。\n\n05:08.397 --> 05:11.997\n约3/4的CBA患者咳嗽以夜间为主，\n\n05:12.497 --> 05:14.546\n一项国内研究中，\n\n05:14.796 --> 05:18.997\n共纳入91例大于18岁的门诊CBA患者。\n\n05:20.985 --> 05:27.885\n约74.7%的CBA患者咳嗽时以夜间或者清晨、凌晨咳嗽为主。\n\n05:28.891 --> 05:30.516\n它表现为刺激性的干咳，\n\n05:30.516 --> 05:32.242\n通常咳嗽比较剧烈，\n\n05:32.691 --> 05:35.242\n有的患者会出现恶心想吐，\n\n05:35.492 --> 05:37.641\n或者大小便小便失禁，\n\n05:38.041 --> 05:40.191\n会有的会出现肚子痛，\n\n05:40.592 --> 05:41.791\n咳的剧烈的话，\n\n05:42.191 --> 05:46.242\n有的时候可以听到夜间的喘鸣音。\n\n05:48.141 --> 05:49.691\n夜间咳嗽为主的患者，\n\n05:49.742 --> 05:52.141\n我们首先要考虑CVA的诊断。\n\n05:56.332 --> 05:58.932\nCBA临床特征二是过敏史。\n\n06:00.049 --> 06:00.250\n嗯，\n\n06:00.850 --> 06:02.100\n遇到夜里咳嗽，\n\n06:02.649 --> 06:06.549\n我们通常会问病人有没有过敏性鼻炎，\n\n06:07.000 --> 06:10.250\n或者是有没有皮肤过敏或者湿疹。\n\n06:11.381 --> 06:11.555\n嗯，\n\n06:11.555 --> 06:14.105\n本人过敏家族过敏史，\n\n06:14.105 --> 06:15.230\n过敏原的暴露，\n\n06:15.230 --> 06:19.756\n它是哮喘或者CVA发病的危险因素。\n\n06:19.756 --> 06:23.980\n60%.70%的CVA患者存在特应质变，\n\n06:23.980 --> 06:26.930\n应原皮试阳性或者血清IGE升高，\n\n06:27.281 --> 06:29.480\n这类过敏是一般会有遗传性的。\n\n06:30.174 --> 06:32.074\n比如患者是有鼻炎，\n\n06:32.074 --> 06:36.623\n你可以问问他的父亲、母亲或者是他的孩子有没有鼻炎，\n\n06:36.873 --> 06:39.074\n这个遗传性一般是比较高的。\n\n06:41.411 --> 06:43.760\n支气管哮喘防治指南2020年版。\n\n06:45.720 --> 06:58.119\n26%的吸烟、非母乳喂养、肥胖、宠物饲养、一级亲属患有哮喘、过敏性鼻炎、花粉症以及本人患有过敏性鼻炎、湿疹均为哮喘发病的危险因素。\n\n06:59.773 --> 07:02.623\n2021年的咳嗽的诊断与治疗指南上。\n\n07:03.700 --> 07:07.725\n咳嗽病原皮试和血清IG检查，\n\n07:07.725 --> 07:12.975\n用于检测患者是否存在特异质和确定病原类型，\n\n07:12.975 --> 07:19.500\n有助于变异性疾病如变异性鼻炎和变异性咳嗽的诊断。\n\n07:19.500 --> 07:23.524\n60%.70%的CVA和30%的EB患者存在特异是。\n\n07:24.835 --> 07:30.835\n在2023年轻度支气管哮喘诊断与治疗中国专家共识中，\n\n07:30.835 --> 07:34.061\nCV的概述是哮喘的CV，\n\n07:34.061 --> 07:35.985\n它是哮喘的一种特殊的类型，\n\n07:36.335 --> 07:38.960\n咳嗽是其主要或唯一的临床表现。\n\n07:38.960 --> 07:42.936\n但它的机制跟哮喘是基本类似的，\n\n07:43.335 --> 07:46.635\n它没有明显的胸闷、气喘、喘息的症状，\n\n07:46.635 --> 07:49.186\n但是存在可逆性的气流受限。\n\n07:50.281 --> 07:52.555\nCV它是慢性咳嗽常见的病因。\n\n07:52.656 --> 07:53.656\n国内中心。\n\n07:54.794 --> 07:56.044\n调查结果显示，\n\n07:56.343 --> 07:58.993\n约占慢性咳嗽病因的1/3。\n\n08:01.162 --> 08:05.662\nCVA占所有哮喘患者的比例并无权威的数据，\n\n08:05.713 --> 08:06.863\n国内研究显示，\n\n08:06.863 --> 08:13.013\n儿童或成人CVA所占比例分别为9.7%和15.7%。\n\n08:13.912 --> 08:15.738\n与典型的哮喘相比，\n\n08:15.738 --> 08:17.562\nCV同样存在家族过敏，\n\n08:17.812 --> 08:18.613\n过敏原，\n\n08:18.613 --> 08:21.162\n空气污染物暴露等危险因素，\n\n08:21.463 --> 08:25.463\n具有类似的气道炎症以及蛋白组学特征。\n\n08:25.713 --> 08:30.588\n但也有研究显示CVA气道的高反应性咳嗽感性的程度。\n\n08:30.588 --> 08:31.263\n与典型的。\n\n08:31.322 --> 08:32.922\n哮喘是有差别的。\n\n08:36.107 --> 08:38.557\nCV的特征三是鼻炎，\n\n08:38.557 --> 08:40.357\nCV常伴有过敏性鼻炎，\n\n08:40.757 --> 08:44.432\n大约88.9%的CV患者合并有鼻炎病史，\n\n08:44.432 --> 08:46.833\n所以在门诊的病人当中，\n\n08:46.833 --> 08:48.458\n我们都要多问一句，\n\n08:48.458 --> 08:50.408\n他有没有鼻炎病史？\n\n08:51.874 --> 08:52.799\n有没有鼻塞，\n\n08:52.799 --> 08:53.249\n流鼻涕，\n\n08:53.249 --> 08:53.874\n打喷嚏？\n\n08:56.096 --> 08:59.372\n在2020年版的支气管哮喘的防治指南中，\n\n08:59.372 --> 09:04.447\n咳嗽变异性哮喘是指以慢性咳嗽为唯一或者主要表现，\n\n09:04.646 --> 09:06.822\n没有明显的喘息、气促等症状，\n\n09:06.822 --> 09:09.947\n但存在气道的高反应性的一种不典型的哮喘。\n\n09:10.585 --> 09:13.135\n它是成人慢性咳嗽的常见病因。\n\n09:14.200 --> 09:16.075\nCV的主要表现为刺激性的干咳，\n\n09:16.075 --> 09:17.551\n通常咳嗽较剧烈。\n\n09:17.551 --> 09:19.301\n夜间咳嗽比较。\n\n09:20.653 --> 09:21.002\n明显，\n\n09:21.153 --> 09:22.853\n部分患者有季节性，\n\n09:23.453 --> 09:29.502\n特别在3月到5月空气中有花粉和柳絮的时候，\n\n09:29.502 --> 09:32.603\nCVA的患者一般出现的比较多。\n\n09:33.052 --> 09:37.603\n在剧烈咳嗽时可伴有呼吸不畅、胸闷、呼吸困难等临床表现。\n\n09:38.002 --> 09:44.353\n常伴发有过敏性鼻炎、感冒、异味、油烟和冷空气容易诱发加重咳嗽。\n\n09:47.783 --> 09:50.833\nCV伴有AI的诊治及管理，\n\n09:50.833 --> 09:54.283\n部分CV患者合并有AI，\n\n09:54.283 --> 09:56.208\n88.9%合并有鼻炎症状。\n\n09:56.208 --> 10:00.382\n因此制定治疗方案时应联合治疗思路和方法。\n\n10:02.875 --> 10:03.224\n第二部分，\n\n10:03.224 --> 10:05.325\n我们来谈一谈如何提升C。\n\n10:07.846 --> 10:11.247\n2024中国咳嗽基层诊疗与管理指南。\n\n10:12.843 --> 10:15.393\n诊断标准包括慢性咳嗽。\n\n10:16.369 --> 10:18.469\n夜间或凌晨刺激性干咳明显，\n\n10:18.770 --> 10:21.520\n支气管激发实验阳性或者舒张实验阳性，\n\n10:21.520 --> 10:26.369\n或者呼气分流量日平均变异率大于10%，\n\n10:26.570 --> 10:28.369\n抗哮喘治疗是有效的。\n\n10:28.719 --> 10:32.219\n如果没有条件进行肺功能与支气管激发实验的检查，\n\n10:32.469 --> 10:36.145\n以干咳和一夜间咳嗽为特征的慢性咳嗽的患者，\n\n10:36.145 --> 10:41.645\n如果诱导痰嗜酸粒细胞水平升高或者非诺水平升高，\n\n10:41.645 --> 10:44.919\n可以考虑CV或嗜酸性粒细胞性支气管炎。\n\n10:46.330 --> 10:47.205\n可变气流受限，\n\n10:47.205 --> 10:49.130\n检查指标存在局限性，\n\n10:49.130 --> 10:50.729\n导致CV的诊断困难。\n\n10:52.447 --> 10:54.947\n支气管激发实验应注意不良反应。\n\n10:56.140 --> 10:59.116\n激发引起激发剂引起的副反应，\n\n10:59.116 --> 10:59.616\n咳嗽，\n\n10:59.616 --> 11:00.015\n声嘶，\n\n11:00.015 --> 11:00.440\n咽痛，\n\n11:00.440 --> 11:03.041\n急性哮喘发作，\n\n11:03.041 --> 11:04.716\n急性喉水肿，\n\n11:04.716 --> 11:06.140\n过敏性休克，\n\n11:06.690 --> 11:11.440\n支气管舒张实验存在假阴性气度的轻度的气道狭窄，\n\n11:11.491 --> 11:12.940\n肺功能接近正常。\n\n11:12.940 --> 11:16.690\n重症哮喘患者较多的分泌物堵塞气道，\n\n11:16.690 --> 11:19.690\n影响药物在气中气道中的沉积和作用。\n\n11:20.250 --> 11:21.375\n药物吸入方法不当，\n\n11:21.375 --> 11:22.049\n剂量不足，\n\n11:22.049 --> 11:22.541\n不敏感。\n\n11:22.541 --> 11:26.591\nP、F检查依赖于受试者的正确操作。\n\n11:26.591 --> 11:34.599\nP、F受正确操作体位、气道通畅、肺内气体容量、呼吸肌肉力量等影响，\n\n11:34.750 --> 11:37.049\n需自行连续数日监测。\n\n11:37.299 --> 11:39.400\n建议每天有消毒药口，\n\n11:39.400 --> 11:40.849\n每周冲洗消毒。\n\n11:43.679 --> 11:47.304\n在2024的CVA患者的肺功能正常。\n\n11:47.304 --> 11:50.379\nCVA的临床表现在某些儿童和成人哮喘中，\n\n11:50.379 --> 11:53.429\n咳嗽可能是唯一的或者最为突出的症状。\n\n11:53.679 --> 11:56.929\n他的咳嗽症状可在夜间或者运动时加重。\n\n11:56.929 --> 11:58.679\n部分患者可伴有咳痰，\n\n11:58.828 --> 12:01.703\n但是一般痰量比是比较少的。\n\n12:01.703 --> 12:03.653\nCBA患者的肺功能通常是正常的，\n\n12:03.653 --> 12:08.254\n但仅能通过支气管激发实验发现存在可变的气流受限，\n\n12:08.254 --> 12:08.778\n因此，\n\n12:09.078 --> 12:09.578\n此外，\n\n12:09.578 --> 12:13.328\n一些患者随疾病进展可出现喘息和气道高反应。\n\n12:13.971 --> 12:17.745\n大多数的CVA的都有痰液嗜酸性粒细胞增多，\n\n12:17.745 --> 12:21.120\n也有可能也可能有非no的升高。\n\n12:24.783 --> 12:27.408\nCV患者肺功能指标高于典型哮喘患者，\n\n12:27.408 --> 12:29.208\n且舒张实验存在假阴性。\n\n12:30.499 --> 12:30.698\n嗯。\n\n12:32.374 --> 12:33.973\n中国的咳嗽指南指出，\n\n12:34.174 --> 12:39.323\n有30%.40%的CVA患者对支气管舒张治疗是反应是不佳的。\n\n12:45.888 --> 12:48.237\n激发试验不可及或不及时，\n\n12:48.487 --> 12:50.538\n如何在早期识别CVA？\n\n12:53.127 --> 12:59.427\n2024中国咳嗽基层诊疗与管理指南病因诊断客观条件有限，\n\n12:59.577 --> 13:02.327\n经验性的治疗可作为替代措施。\n\n13:04.429 --> 13:08.379\n病因诊断是慢性咳嗽诊治成功的基础，\n\n13:08.679 --> 13:12.129\n但基层医疗卫生机构或者经济条件有限的患者，\n\n13:12.129 --> 13:15.229\n往往无法进行特定的检查而明确。\n\n13:15.679 --> 13:18.278\n比如在一些社区他没有肺功能检查，\n\n13:18.679 --> 13:22.328\n或者有一些二级甲等或者乙等的医院他没有。\n\n13:23.211 --> 13:24.861\n支气管激发实验的检查。\n\n13:25.992 --> 13:28.767\n这个就是存在一定的局限性。\n\n13:30.987 --> 13:31.112\n嗯，\n\n13:31.112 --> 13:32.338\n经验性的治疗，\n\n13:32.638 --> 13:36.987\n在慢性咳嗽的经验性治疗是指病因诊断不明确的情况下，\n\n13:37.288 --> 13:40.463\n根据患者的临床特征和可能的诊断，\n\n13:40.463 --> 13:42.187\n给予相应的治疗措施，\n\n13:42.538 --> 13:46.138\n通过治疗反应来确立或者排除诊断。\n\n13:46.487 --> 13:48.288\n当客观条件有限时，\n\n13:48.288 --> 13:51.138\n经验性治疗可以作为一种替代的措施。\n\n13:51.437 --> 13:52.763\n比如在门诊的时候，\n\n13:52.763 --> 13:55.737\n患者说他咳嗽咳痰大概有三个多月了，\n\n13:55.737 --> 13:57.013\n每天是夜里为主，\n\n13:57.013 --> 13:58.388\n可以听到传鸣音。\n\n13:58.687 --> 13:59.687\n但是患者。\n\n14:00.763 --> 14:00.963\n嗯，\n\n14:00.963 --> 14:02.487\n夜里的痰不是很多，\n\n14:02.487 --> 14:06.737\n有气管痒或者是咽痒患者拒绝进一步的肺功能，\n\n14:06.737 --> 14:08.163\n或者是因为经济原因，\n\n14:08.362 --> 14:12.612\n一些自费的患者可能他觉得肺功能检查比较昂贵，\n\n14:12.612 --> 14:14.213\n他是拒绝，\n\n14:15.062 --> 14:17.263\n拒绝去进一步的去检查。\n\n14:17.463 --> 14:18.112\n这个时候，\n\n14:18.112 --> 14:22.763\n我们可以经验性的给他一些按照哮喘的那类去给他治疗。\n\n14:23.440 --> 14:23.640\n嗯，\n\n14:24.491 --> 14:27.890\n治疗以后可以让他过个一周再来复诊。\n\n14:28.780 --> 14:29.929\n问问他治疗的情况。\n\n14:31.705 --> 14:32.729\n大多数的情况下，\n\n14:32.729 --> 14:36.554\n经验性治疗后患者的症状是比较明显改善的。\n\n14:36.705 --> 14:40.080\n因为你经验性治疗可能问的问题相对要多一点，\n\n14:40.080 --> 14:41.804\n比如他的家族史啊，\n\n14:41.854 --> 14:42.905\n无名史啊，\n\n14:42.905 --> 14:45.054\n有没有鼻炎之类的。\n\n14:45.682 --> 14:45.932\n嗯。\n\n14:49.721 --> 14:51.221\n经验适应治疗的原则，\n\n14:51.221 --> 14:53.096\n针对慢性咳嗽常见的病因，\n\n14:53.096 --> 14:57.471\n针对慢性咳嗽的常见病因进行经验性的治疗成功比较大，\n\n14:57.620 --> 15:01.671\n有利于尽快解除患者的痛苦和提高其对治疗的依从性。\n\n15:01.971 --> 15:03.471\n根据临床的特征，\n\n15:03.471 --> 15:05.270\n选择经验性治疗的方案。\n\n15:05.671 --> 15:05.995\n嗯，\n\n15:05.995 --> 15:08.921\n它并非是漫无目标的对症治疗，\n\n15:09.120 --> 15:10.945\n而是根据患者的临床特征，\n\n15:10.945 --> 15:14.171\n针对目前最可能的慢性咳嗽的病因进行治疗，\n\n15:14.171 --> 15:16.596\n比如你像C、B考虑是咳嗽变异性哮喘，\n\n15:16.596 --> 15:19.721\n就按照咳嗽变异性哮喘的治疗去给他一个诊治。\n\n15:19.919 --> 15:20.919\n给他一个诊断，\n\n15:21.218 --> 15:22.119\n慢性咳嗽，\n\n15:22.119 --> 15:24.568\n咳痰特点以及伴随症状，\n\n15:24.669 --> 15:25.643\n提示病因，\n\n15:25.643 --> 15:26.818\n有一定的治疗价值。\n\n15:27.750 --> 15:28.151\n是。\n\n15:29.206 --> 15:30.706\n避免滥用抗菌药物，\n\n15:30.757 --> 15:33.581\n大多数患者有慢性咳嗽的病因与感染无关，\n\n15:33.581 --> 15:34.731\n不需要抗感染治疗。\n\n15:34.731 --> 15:36.206\n很多患者就说我咳嗽了，\n\n15:36.206 --> 15:37.057\n给我点消炎药，\n\n15:37.057 --> 15:40.132\n但是不是说每次咳嗽都是感染引起的，\n\n15:40.132 --> 15:41.831\n有的是可能是病毒引起的，\n\n15:41.831 --> 15:43.382\n有的时候可能是过敏引起的，\n\n15:43.382 --> 15:45.257\n所以它治疗方案是不一样的，\n\n15:45.757 --> 15:50.557\n少数伴浓痰或者浓浓鼻涕的慢性咳嗽患者，\n\n15:50.807 --> 15:53.057\n需要考虑可能是细菌感染。\n\n15:53.106 --> 15:54.882\n支气管炎或者鼻窦炎引起，\n\n15:54.882 --> 15:56.856\n这个时候是可以用抗生素的，\n\n15:56.856 --> 15:59.307\n所以是黄痰黄鼻涕。\n\n16:01.065 --> 16:03.690\n血白细胞炎症指标比较高的情况下，\n\n16:03.690 --> 16:05.215\n我们才使用抗生素。\n\n16:05.315 --> 16:06.265\n其他的情况，\n\n16:06.565 --> 16:08.039\n白痰或者是干咳，\n\n16:08.039 --> 16:15.414\n我们一般不是抗生素使用的指针限制经限制经验性治疗的疗程。\n\n16:15.414 --> 16:17.515\n经验性治疗有一定的盲目性，\n\n16:17.515 --> 16:24.164\n应注意排除支气管恶性肿瘤、结核和其他的肺部疾病常见病因的经验性治疗疗程。\n\n16:25.971 --> 16:28.346\nCVAEBAC一般为1.2周，\n\n16:28.645 --> 16:30.570\n嗯，\n\n16:30.570 --> 16:31.596\nGRC为2到四周。\n\n16:31.596 --> 16:32.796\n经验性治疗无效，\n\n16:33.245 --> 16:38.046\n应该及时转诊到有条件的医院进行相关检查，\n\n16:38.046 --> 16:38.995\n明确病因。\n\n16:41.789 --> 16:45.090\n慢性咳嗽的经验性治疗的策略啊，\n\n16:45.340 --> 16:49.039\n临床线索导向策略从临床实用的角度，\n\n16:49.039 --> 16:51.164\n可以根据病史和典型的临床症状，\n\n16:51.164 --> 16:57.640\n将慢性咳嗽分为激素敏感性咳嗽、上气道咳嗽综合征和胃食管反流咳嗽进行管理，\n\n16:57.640 --> 17:00.039\n有利于减少经验治疗的盲目性。\n\n17:00.289 --> 17:01.164\n其中，\n\n17:01.164 --> 17:05.040\nCVA诊断患者可以使用糖皮质激素进行诊断性的治疗。\n\n17:05.290 --> 17:05.765\n第二，\n\n17:05.765 --> 17:07.390\n常见病因导向策略，\n\n17:07.390 --> 17:11.015\n对于无任何潜在病因提示线索的慢性咳嗽患者。\n\n17:11.015 --> 17:11.890\n可以根据本。\n\n17:12.077 --> 17:15.276\n一、常见慢性咳嗽病因的分布频率，\n\n17:15.276 --> 17:16.901\n确定经验性治疗的顺序，\n\n17:16.901 --> 17:19.052\n首先治疗最常见的慢性咳嗽病，\n\n17:19.052 --> 17:23.302\n然后依次治疗次常见的病因，\n\n17:23.302 --> 17:25.227\n直到取得了疗效。\n\n17:27.577 --> 17:28.901\n定性治疗的三步疗法，\n\n17:28.901 --> 17:30.552\n快速缓解咳嗽症状，\n\n17:30.552 --> 17:33.427\n总体受获益率超过80%。\n\n17:36.837 --> 17:38.837\nCVA的规范化治疗，\n\n17:38.837 --> 17:43.161\n2024年中国咳嗽基层诊疗与管理指南指出，\n\n17:43.161 --> 17:45.261\nCVA的治疗原则与典型哮喘相同，\n\n17:45.261 --> 17:48.386\n推荐使用ICS拉巴进行治疗，\n\n17:48.536 --> 17:51.437\n推荐使用吸入糖皮质激素和支气管舒张剂，\n\n17:51.536 --> 17:55.411\n如布丁奈德福、莫特洛、氟替卡、松沙美特洛啊。\n\n17:55.411 --> 17:57.487\n建议治疗时间至少在8周以上，\n\n17:57.487 --> 17:59.036\n部分患者治疗反应不佳，\n\n17:59.036 --> 18:00.737\n需要更长期的治疗。\n\n18:02.401 --> 18:04.177\nCVA的药物推荐级别，\n\n18:04.526 --> 18:04.927\n嗯，\n\n18:04.977 --> 18:09.327\n我们一般是强烈推荐吸入治疗，\n\n18:09.526 --> 18:13.927\n就是刚才说的有性必咳或者舒利迭这类，\n\n18:13.927 --> 18:16.876\n因为这个直接药物直接到达气管，\n\n18:17.077 --> 18:20.077\n它的效果是很明显的。\n\n18:20.177 --> 18:21.927\n口服啊，\n\n18:22.477 --> 18:25.401\n二B类的推荐口服有白三烯受体拮抗剂，\n\n18:25.401 --> 18:26.227\n有莫鲁斯特。\n\n18:26.376 --> 18:28.327\n如果患者咳嗽特别明显，\n\n18:28.327 --> 18:30.327\n我们可以给他吃一点舒黄止咳胶囊。\n\n18:33.980 --> 18:36.730\n布地奈德抗炎优势明显，\n\n18:36.730 --> 18:39.331\nICS多靶点阻断气道的炎症的进展。\n\n18:42.050 --> 18:43.974\nICS急性发作风险更低。\n\n18:45.870 --> 18:46.120\n嗯。\n\n18:50.998 --> 18:52.498\nFDA于2020年3月，\n\n18:52.498 --> 18:57.047\n对孟鲁斯特做出了关于严重精神事件发生风险的黑框警告，\n\n18:57.047 --> 18:59.123\n成年和青少年患者的自杀事件，\n\n18:59.123 --> 19:01.647\n儿童患者可能出现噩梦或者行为异常，\n\n19:01.848 --> 19:03.373\n在使用孟鲁斯特之前，\n\n19:03.373 --> 19:05.848\n医护人员应当考虑其为的风险。\n\n19:05.848 --> 19:09.248\n患者应知晓该药的精神事件发生风险。\n\n19:11.991 --> 19:14.342\n中外指南均推荐ICS福莫特罗，\n\n19:14.342 --> 19:19.291\n作为所有级别哮喘患者优选控制以及缓解的药物。\n\n19:21.323 --> 19:23.573\n规范吸入ICH治疗三个月以上，\n\n19:23.624 --> 19:29.874\n我们可以想降阶梯的CV进展为典型哮喘患者的比例26.3%。\n\n19:30.223 --> 19:30.548\n嗯，\n\n19:30.548 --> 19:34.274\n哮喘咳嗽变性哮喘一般我们是三个月评估一次，\n\n19:34.524 --> 19:34.999\n然后，\n\n19:34.999 --> 19:38.874\n如果患者在三个月内都没有急性发作的风险，\n\n19:38.874 --> 19:40.573\n我们可以降阶梯两天，\n\n19:40.774 --> 19:44.673\n一天两次改为一天一次来给患者降阶梯的治疗。\n\n19:49.130 --> 19:50.405\n总结一下CVA，\n\n19:50.405 --> 19:51.905\n它是慢性咳嗽的首要病因，\n\n19:51.905 --> 19:54.555\n也是亚急性咳嗽的第三大病因。\n\n19:54.555 --> 19:56.680\nCV的典型症状为夜咳过敏史，\n\n19:56.680 --> 19:58.454\n合并有鼻炎。\n\n19:58.454 --> 20:00.479\nCVA患者的肺功能通常是正常的，\n\n20:00.479 --> 20:05.255\n仅在支气管激发实验才可以发现存在可变的气流受限。\n\n20:05.454 --> 20:06.555\n当条件不足时，\n\n20:06.555 --> 20:10.055\n经验性治疗可快速缓解咳嗽并明确诊断。\n\n20:10.255 --> 20:13.229\n它的治疗原则与哮典型的哮喘相同，\n\n20:13.229 --> 20:16.204\n推荐使用吸入糖皮质激素和支气管舒张剂。\n\n20:16.505 --> 20:18.354\n比如心必咳和。\n\n20:19.272 --> 20:19.373\n嗯，\n\n20:19.373 --> 20:20.572\n苏丽丽啊，\n\n20:20.572 --> 20:21.322\n谢谢大家。\n\n","v0247cg10004d61hpc2ljhtfc6s47eig",1222,824,0,"2026-01-25 02:51:33","2024咳嗽基层指南更新解读：CVA规范化诊疗新进展  \n","2024咳嗽指南,CVA诊疗,咳嗽变异性哮喘,基层医疗指南,慢性咳嗽管理,哮喘规范化治疗  \n","本文深入解读2024年最新咳嗽基层指南更新要点，聚焦咳嗽变异性哮喘(CVA)的规范化诊疗策略，涵盖诊断标准、治疗方案及基层实践建议，助力临床医生提升慢性咳嗽管理水平。","2026-04-10 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