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 345 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 347 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. 349 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