恼人的慢性咳嗽怎么破 儿童慢性咳嗽治疗秘笈

秋冬季节，幼儿园和小学的教室里经常能听到小朋友们的咳嗽声此起彼伏，咳咳咳，超过一个月的慢性咳嗽并不少见。爸爸妈妈们带着医院跑了好几次，各路海淘的咳嗽药水，民间偏方也试了个遍，就是断续咳不停，一筹莫展。看来擒贼先擒王，应该找到原因，标本兼治才是王道！上次在12.3的栏目里小编和宝爸宝妈们一起学习了小儿呼吸学科专家们根据大样本多中心研究的结果所总结出来的咱们中国儿童慢性咳嗽的常见原因，今天我们就来看看怎么来标本兼治这个恼人的慢性咳嗽！想要温故知新上一篇的爸妈请戳这里链接孩子咳咳咳，咳不停怎么回事 ---- 儿童慢性咳嗽知多少

Chronic cough is a common paediatric conditions in autumns and winter seasons, especially in the kindergartens and elementary schools. The etiologies of chronic cough in children had been discussed in the last issue (Dec 3rd 2017). Today we are going to focus on the management of the chronic cough in children. The main treatment for chronic cough should be based on the underlying cause. 

让我们先从排名前三位最常见的咳嗽原因开始一一分解。各位爸妈小板凳拿拿好，瓜子茶水备备好，小编要开讲啦！

⑴ 支气管扩张剂诊断性治疗1-2周，吸入治疗或口服。比如，丙卡特罗，特布他林，沙丁胺醇等；如果咳嗽缓解则有助于诊断；

⑵ 诊断明确后，选择按照哮喘规范治疗，疗程至少8周；

--吸入糖皮质激素（比如普米克，辅舒酮），或者；

--口服白三烯受体拮抗剂（顺尔宁）；或者；

--吸入糖皮质激素及口服白三烯受体拮抗剂联合治疗，

1.Cough- variant asthma:

⑴ A trial of bronchodilator inhaler or oral given for 1 to 2 weeks (Procaterol, Terbutaline or Salbutamol). It is mostly like cough-variant asthma if the child responds well.

⑵ When the diagnosis of cough-variant asthma is established, the treatment need to be lasted at least 8 weeks.

--- Inhaled corticosteroids (Pulmicort, Flixotide ); or

---Oral leukotriene Inhibitors (Singulair); or

--- Inhaled corticosteroids and oral leukotriene Inhibitors.

根据引起慢性咳嗽的不同疾病，采用不同的治疗方案

⑴ 过敏性鼻炎：可以给予抗组胺药物（比如仙特敏，开瑞坦），鼻喷糖皮质激素（比如内舒拿，辅舒良）治疗，或联用白三烯受体拮抗剂 （顺尔宁）等。

⑵ 鼻窦炎：需要使用抗生素治疗至少2周，比如阿莫西林类或阿奇霉素；辅以鼻腔黏膜减充血剂或祛痰药。

⑶ 增殖体肥大：根据程度，轻到中度者，一般采用鼻喷糖皮质激素（比如内舒拿，辅舒良）联用白三烯受体拮抗剂 （顺尔宁）观察治疗1-3月，无效可考虑采取手术治疗。

2. Upper airway cough syndrome:

⑴Allergic rhinitis:  oral antihistamine medicines such as Zyrtec and Clarityne, corticosteroid nasal sprays such as Nasonex and Flixonase, and/or leukotriene Inhibitors singulair can be used.

⑵ Sinusitis: an antibiotic is needed for at least 2 weeks to zap the infection, such as Amoxicillin or Azithromycin. Nasal sprays can be used to ease congestion symptoms. Expectorants are applied to thin the mucus.

⑶ Adenoid hypertrophy: for mild to moderate ones, use intranasal steroids (Nasonex or Flixonase) and oral leukotriene Inhibitors (singulair) for 1 to 3 months. When medication does not correct the enlargement of the adenoid tissue, surgery is often needed.

一般来说，感染后咳嗽不需要用药治疗，会自己慢慢好转，但如果症状比较严重，影响孩子的生活学习和睡眠，可以考虑使用白三烯受体拮抗剂（顺尔宁）或吸入糖皮质激素（比如普米克，辅舒酮等）。

3. Post-infectious cough:

Generally, this condition is self-limiting and does not need treatment. If the cough cause significant impairment to sleep, meals or school, treatment is often need, such as leukotriene Inhibitors (singulair) or Inhaled corticosteroids (Pulmicort, Flixotide ).

多种病原微生物如肺炎支原体或衣原体，百日咳杆菌、结核杆菌、呼吸道合胞病毒，腺病毒等引起的呼吸道感染也可导致小儿慢性咳嗽，病程可>25天。可以根据相应的病原微生物使用敏感药物针对性治疗。

1.Respiratory infections caused by various species of microbial pathogens can lead to chronic cough in children, including Mycoplasma pneumoniae, chlamydia, Bordetella pertussis, Mycobacterium tuberculosis, Respiratory syncytial virus, and adenovirus. The duration could be more than 25 days. Treatments target choosing sensitive medicine accordingly.

使用H2受体拮抗剂（比如西米替丁)，胃动力药物 ，或质子泵抑制剂(比如奥美拉唑）。改变体位，采取半卧位或俯卧前倾30度；改变食物性状，少量多餐；避免引起返流的食物,比如高脂肪，油炸，酸性食物（橙汁，番茄），巧克力，薄荷，咖啡，洋葱，大蒜及辛辣食物等，忌饱食。如果治疗8周无效，则需考虑其他原因。

2.Gastroesophageal reflux-related cough (GERD)：

Helpful therapies in children include H2 antagonists (Cimetidine), prokinetic agents, or proton pump inhibitors. Lifestyle changes are often needed. Elevate the head of the child's bed while she/he sleeps to minimize coughing. For older kids, cut back on foods that typically set off symptoms of GERD, such as fatty or fried foods, citrus fruits, tomatoes, chocolate, peppermint, garlic, onion, and anything spicy. If it is not responsive after 8 weeks treatment, then etiologies for cough need to be reassessed.

对支气管扩张剂无效，吸入或口服糖皮质激素有效（比如普米克，辅舒酮，必可酮），治疗后咳嗽很快消失或者明显减轻，每天两次，一般持续用药四周以上。

3.Nonasthmatic eosinophilic bronchitis

This cough generally does responds to bronchodilators but response to the inhaled corticosteroids (Pulmicort, Flixotide, or Becotide). The treatment is twice a day for more than 4 weeks.

去除异物

4.Foreign body

Remove the foreign body. 

行为干预或心理疗法。

5.Psychogenic cough

Behaviour modification therapies and psychological counseling are used for intervention, such as self-hypnosis, biofeedback, or suggestion therapy.

根据不同的程度，予以心理行为治疗或联用药物治疗。

6.Tic cough

Behaviour modification therapies and psychological counseling or with medications.

According to 2013 Guideline for Diagnosis and Treatment of Chronic Cough in Chinese Children, the main treatment for chronic cough should be based on the underlying cause. However, sometimes chronic cough was caused by multiple etiologies. An empiric trial of intervention can be applied and then review again. The presence of multiple cough etiologies may delay response to therapy if all causes are not treated appropriately. Additionally, one must periodically reassess therapy and discontinue it in nonresponsive patients. Further investigations may be needed for evaluation, such as chest x-ray, spirometry, allergy test, sinus CT scan etc. Doctors will adjust the management plan according to the assessment. 

1.选择一位爸爸妈妈信任的擅长儿科呼吸专业或过敏专业的医生，听从指导，进行必要的检查和治疗，要有耐心，定期随访，以便根据孩子的具体情况及时调整检查和治疗的方案。

2.提供医生详细准确的病史，检查结果，治疗经过，及用药情况。比如：

3. 不滥用抗生素和止咳药，用药须在医生的指导下进行。   

单纯的止咳是治标不治本的，而且，有些含有中枢镇咳药物的咳嗽糖浆，会抑制孩子的咳嗽反射，呼吸道中的分泌物就很容易积聚在咽部或气管里继发感染

Tips for a successful doctor visit:

1.Choose a pediatrician specialize in allergy and pulmonology.

2.Prepare for your doctor visit in advance: provide detailed medical history, keep a symptom diary, and know the results of laboratory test and what medications your child is taking.

When and how did the cough begin?

What is the cough's character or quality?

How disruptive and how frequent is it?

Is it a dry or wet cough?

At what time(s) does the cough occur? What triggers the cough?

Is it more during the day or more at the night?

Is the cough an isolated symptom; if not, what other symptoms exist?

Is there any runny nose; if any, what is the colour?

Does he snore at night?

Is the cough related to position or meals?

Is there a previous history of upper respiratory tract infections or allergic disease?

Is there a family history of respiratory, allergic, or infectious disease?

Is there evidence of environmental triggers?

Have any laboratory tests or examinations been done?

What treatments have been tried, and what were their effects?

What medications, if any, does the child take?

3.Avoid unnecessary antibiotics and cough suppressants. Take the medication as prescribed. 

咳嗽是一种症状，是机体重要的自我清洁和保护机制，有利于清除呼吸道的分泌物、过敏原和异物，并且具有清除呼吸道刺激因子、抵御感染的作用。总的原则是如果宝宝的咳嗽不影响饮食、睡眠，以及其他日常活动，就不需要给他吃止咳药。但如果咳嗽较多，影响孩子的学习，进食，运动，和睡眠，这时候就要考虑在医生的指导下适当选用止咳药物和家庭疗法。

★ 有痰的湿咳

咳嗽可以帮助痰液排出并防止痰液滞留呼吸道所引起的继发感染，所以有痰的咳嗽应该以祛痰为主而不是单纯止咳，可以选用能让痰液稀释从而容易排出的药物并且多喝水。过多的咳嗽也会影响睡眠并刺激呼吸道粘膜使痰液增多，在这种情况下可以酌情谨慎地使用止咳药。

★ 无痰的干咳

多喝水，保持气道湿润。如果有剧烈、阵发性的干咳，并影响孩子睡眠进食和学习的，建议在医生的指导下选用止咳糖浆。一般来说，6岁以下的孩子要慎用复方的感冒咳嗽糖浆，因为如果有其他药物同时服用的话，会增加重复服用相同药物成分和过量服药的风险；再者中枢镇咳药物的成分会抑制孩子的咳嗽反射，一旦有痰液就会积聚粘滞在咽部或气管引起症状加重或继发感染。另外，国家食品药品监督管理局也明确规定在12岁以下的儿童中禁用含有可待因等易引起成瘾性的止咳药水。

★多饮水

小口多饮水，对干咳和湿咳都有帮助，稀释咽喉部的痰液，使之易于排出。

3个月~1岁：咳嗽时给予温的液体口服 （比如温白开水，温苹果汁），一天4次，每次5~15毫升。注意不要用蜂蜜水以防肉毒杆菌中毒的风险。

1岁以上的儿童：需要时可以口服2~5毫升的蜂蜜水，可以帮助稀释痰液减轻咳嗽。有研究发现蜂蜜水可以帮助减少晚间咳嗽的频率和严重度。

★ 湿化空气

打开浴室的淋浴龙头，帮助宝宝吸入温暖的水蒸气，或者生理盐水雾化吸入对减轻阵发性干咳和稀释痰液有帮助。

★ 饮食

建议清淡饮食，规避油炸，甜腻，辛辣的食物。多吃蔬菜水果，特别是对润肺止咳和理气化痰有帮助的，比如梨，银耳，百合， 莲子，杏仁，薏苡仁，莲藕， 萝卜，山药，冬瓜，丝瓜，桔子， 枇杷等等。

★ 规避过敏原

如果是过敏性疾病引起的咳嗽，则要先明确过敏原，然后日常生活中避免接触这些致敏物质，比如前文提到的雾霾，粉尘，尘螨，霉菌，花粉，烟雾，油烟，猫，狗，油漆味，海鲜等等。

It's important to know that a cough is a symptom, not a disease. A cough protects child's body by removing mucus, irritating substances and infections from the respiratory tract. It helps prevent bacterial infections. Generally, cough suppressants is not needed unless it disturbs child's sleep, interrupt meals, or affects school.

★ Wet cough: Coughing is useful because it brings up mucus from the lungs and helps prevent bacterial infections. Expectorants are used for a productive cough rather than cough suppressants. An expectorant helps thin the mucus and make it easier to cough mucus up. Drink plenty of water also helps. Use cough suppressants wisely when the cough keeps the child from getting enough rest and increased mucus production and secretion.

★ Dry cough: Drink plenty of fluid to keep airway clean and moist. If there is dry, hacking cough that disturbing the child's sleep and meals, choose cough syrup according to doctor's advice. Avoid multi-symptom cold and cough preparations; if you combine them with other medicines, it may increase the risk of overdose from overlapping ingredients. The American Academy of Pediatrics does not recommend cough and cold medications for kids under 6. Cough suppressants act on the center in the brain that controls the cough reflex. Suppressing the urge to cough can create an excess amount of infected phlegm in the airways, which in turn will cause the symptoms to last longer or secondary infections. In addition, China Food and Drug Administration ban cough syrup with codeine in children under the age of 12.

★ Drink plenty of fluid: It helps both dry and wet cough. Fluids keep the secretions thin and soothe an irritated throat.

For children 3 Months to 1 year of age: Give warm, clear fluids (eg, warm water, apple juice). Dosage is 5 to 15 mL 4 times per day when coughing. Avoid honey because it can cause infantile botulism.

For Children 1 Year and Older: Use honey, 2 to 5 mL, as needed. It thins secretions and loosens the cough. Recent research has shown that honey is better than drugstore cough syrups at reducing the frequency and severity of nighttime coughing.

★ Humidify the air: Expose the child to warm mist from a shower or try a normal saline nebulisation can help with coughing spasms and loosen the phlegm.

★ Diet: Eat lightly and avoid fried, fatty or spicy food. Plenty of vegetables and fruits, including pears, white jelly mushroom, lotus seed, almond, coix seed, lotus root, mooli, yam, white gourd, towel gourd, mandarin, loquat etc.

★ Avoid exposure to allergens: If the etiology of cough is allergic disease, then identify the allergens first and avoid exposure to allergens, such as haze, dust, dust mite, mold, pollen, smoke, fume, pets, dust mites, paint taste, and seafood etc.