Cough (기침)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
KEYWORDS:
..기침은 병의원에 오는 환자들이 가장 많이 호소하는 증상 중 하나이다.
1. Characteristic and timing of cough
→ 야간에 심해짐 : GERD/CHF
→ 하루종일 간지러운듯 귀찮게 하는 기침 : ACE inhibitors associated cough
→ 온도변화나 운동과 연관 : Asthma
2. Sputum?
→ (+) : Pulmonary infection often, but do not always, produce a cough with
sputum (chronic bronchitis, bronchiectasis, pneumonia etc).
→ (-) : Asthma, bronchogenic carcinomas, sarcoidosis etc
1. Chest radiography : should be obtained if the history and physical examination
suggest that respiratory condition is responsible for the cough.
2. Spirometry : demonstrate obstructive changes in hyperreactive airway disease.
Chest CT / Bronchoscopy
Acute cough (< 3weeks)
i. Common cold : 첫 48시간 내 83%에서 기침이 발생
ii. Allergic rhinitis
iii. Acute bacterial sinusitis
iv. Exacerbation of COPD
v. Bordetella pertusis : Tx) Erythromycin 500mg qid × 14days
Or Trimethoprim-Sulfamethoxazole 160~800mg bid × 14days
Cough
Key questions
Key tests
Subacute cough (3~8weeks)
i. Postinfectious cough : 치료없이도 소실됨
ii. Bordetella pertussis
iii. Subacute bacterial sinusits
iv. Asthma
Chronic cough (>8weeks)
i. Postnasal drip syndrome (40%) : 부비동염, 비염에 의해 주로 발생한다. 보통 2~4회
연속으로 나타나며, 특히 누워있을 때 잘 나타나 수면중이나 이른 아침에 심해지는 경우가
많다. 문진상 목 뒤로 무엇인가가 넘어가는 것 같은 느낌, 콧물 등의 증상이 있다. 이학적 검
사상 비인두와 구인두에 분비물이 관찰되거나 인두점막이 조약돌 모양으로 관찰된다.
ii. Cough variant asthma (20~30%) : 기관지 천식과 비슷하게 야간에 악화되는 경향이
있으며 장기적으로 추적하면 일부에서 천명, 호흡 곤란 등의 전형적인 증상이 보인다.
iii. GERD (10~20%) : 식사 후 (특히 초코렛, 카페인, 술, 고지방음식) 또는 취침시 악화된다.
iv. Chronic bronchitis
v. ACE inhibitors intake : ACE inhibitors 용량과 관계가 없으며, 대개 약물을 복용한지 3주
후 길게는 1년 후 기침이 발생하고 여성 및 비흡연자에 많다. 밤에 악화되고 바로 누었을
때 심해지는 등 GERD에 의한 기침과 유사하나, 약제를 중단할 경우 대부분 4일 이내에
소실된다.
vi. Bronchiectasis/Eosinophilic bronchitis
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The Root of ambulatory care
Cough
Fig 1. 만성기침의 진단
Immunocompetent patient with chronic cough
History and physical examination
No ACE inhibitor or irritant exposure
Treat accordingly
Cough stop
Cough persists
Cough stop
Treat accordingly
Cough persists
Treat accordingly
Cough persists
Cough stop
Chest radiograph
Normal Abnormal
Abnormality may not be
related to cough
Evaluate the patient for the three
most common conditions or in combination:
PND, Asthma, GRED
Consider postinfectious cough
Evaluate the patient for uncommon conditons :
sputum tests, high-resolution CT scanning,
modified barium esophagography, bronchoscopy
Reconsider adequacy of treatment regimens before
considering habit of psychogenic
cough, Consider referral to a pulmonologist
Further testing, with order of tests based on
likely clinical possibility sputum
cytology, modified barium esophagography,
pulmonary function tests, high-resolution
CT scanning, bronchoscopy, cardiac studies
Cough stop
Cough persists Stop exposure
ACE inhibitor or irritant exposure
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The Root of ambulatory care
< Cough Therapy >
Classification Drug Dosage Remarks/Precautions
To improve cough effectiveness
Expectorant Guaifenesin(Fenatussin..) 200~400mg q Effectiveness is not
4hrs PO substantiated in clinical trials.
Mucolytic Acetylcysteine(Muteran..) 200mg bid~tid May increase airway
irritation and broncospasm
and should be administered
with a bronchodilator.
Cough suppressing
Afferent receptor Benzonatate(Zicol..) 100mg q Must be swallowed whole to
4~6hrs PO avoid oral and pharyngeal
anesthesia ; similarity to
tetracaine causes toxicity
in overdose.
Cough center Non-narcotic
Dextromethorphan 10~30mg q Contraindicated in patients
4~8hrs PO on MAOIs ; reduced
alertness in some cases.
Narcotic
Codeine 15~30mg q Sleepiness and constipation
4~6hrs PO are occasional side effects.
Hydrocodone/homatropine 5mg q 4~6hrs Greater addiction potential
PO than codeine
For Postnasal drip
Sympathomimetic Pseudoephedrine(Sudafed..) 60mg q Lower doses are less likely
decongestant 4~6hrs PO to produce hypertension.
Oxymetazoline(Respiben..) 2~3 nasal May cause rebound nasal
sprays bid congestion if used for more
than 3days.
Phenylephrine((Phenephrine..) 2~3 nasal May cause rebound nasal
sprays q congestion if used for more
3~4hrs than 3days.
H1 antagonist
First generation Chlorpheniramine(Pheniramine..) 2~6mg May produce sleepiness.
bid~qid
Second generation Fexofenadine(Allegra..) 60mg bid PO Also available with
pseudoephedrine (allegra-D..)
for combined
Key treatments
Cough
decongestant effect.
Loratadine(Clarityne..) 10mg qd PO
Cetrizine(Zyrtec..) 5~10mg qd
PO
Nasal Fluticasone(Flixonase..) 2 nasal
corticosteroids sprays qd
For airway hyperreactivity
Aerosol Albuterol(Ventolin..) 2 puffs by Tremor and tachycardia
bronchodilator metered-dose with overuse.
inhaler as
needed up to
4 times a day
Inhalded Fluticasone 2 puffs by Followed by oral rinsing to
corticosteroids (Flixotide Inh..) metered-dose reduce risk of yeast
inhaler twice pharyngitis.
a day using
spacer
Budesonide(Pulmicort..) 2 inhalation Followed by oral rinsing to
bid reduce risk of
yeast pharyngitis.
..Bronchogenic carcinoma환자에서 기침을 호소할 수 있는데, 이는 afferent
trigger site가 많은 larger airway에 병변이 있는 경우가 많다.
..첫 방문 후 통상적으로 2~4주 후 추후 방문이 필요하다.
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The Root of ambulatory care
참고 문헌
ROBERT L. HOLMES, D.O., PH.D., CLARE T. FADDEN, M.D., S. : Evaluation of the patient with chronic
cough, A journal of the American Family Physicains 2004 ; 69(9) : 2159-2169
Daniel McNally, M.D : Cough, in Conn's Current Therapy 2004, Robert E. Rakel(ed), Edward T.
Bope(ed). Philadelphia, Saunders, 2004, P 28-34
가톨릭의과대학 내과학교실 : 만성 기침. in Current Principles and Clinical Practice of Internal Medicine.
서울, 군자출판사, 2005, P 242-246
Jae-Hyoung Cho, Ji-Hyeon Ju, Jeoung-Won Jang : Cough, in Clinical Road Map of Internal Medicine.
Seoul, Panmun Book, 2005, P 45
William J. Hueston : Chronic cough, in Saunders Manual of Medical Practice, 2nd ed, Robert E.
Rakel(ed). Philadelphia, Saunders, 2000, P 148-150
조경환: 기침, in 가정의학 임상편. 서울, 계측문화사, 2002, P 717-723
David Holmes, M.D. : Cough, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention,
4th ed, Mark B. Mengel,M.D.,L. Peter Schwiebert M.D. (ed). United States of America, The
McGrwa-Hill Companies, Inc., 2005, P 72-81