Niimi Akio, Matsumoto Hisako, Mishima Michiaki
Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
Pulm Pharmacol Ther. 2009 Apr;22(2):114-20. doi: 10.1016/j.pupt.2008.12.001. Epub 2008 Dec 16.
Chronic cough is a major clinical problem. The causes of chronic cough can be categorized into eosinophilic and noneosinophilic disorders, the former being comprised of asthma, cough variant asthma (CVA), atopic cough (AC) and non-asthmatic eosinophilic bronchitis (NAEB). Cough is one of the major symptoms of asthma. Cough in asthma can be classified into three categories; 1) CVA: asthma presenting solely with coughing, 2) cough-predominant asthma: asthma predominantly presenting with coughing but also with dyspnea and/or wheezing, and 3) cough remaining after treatment with inhaled corticosteroid (ICS) and beta2-agonists in patients with classical asthma, despite control of other symptoms. There may be two subtypes in the last category; one is cough responsive to anti-mediator drugs such as leukotriene receptor antagonists and histamine H1 receptor antagonists, and the other is cough due to co-morbid conditions such as gastroesophageal reflux. CVA is one of the commonest causes of chronic isolated cough. It shares a number of pathophysiological features with classical asthma with wheezing such as atopy, airway hyperresponsiveness (AHR), eosinophilic airway inflammation and various features of airway remodeling. One third of adult patients may develop wheezing and progress to classical asthma. As established in classical asthma, ICS is considered the first-line treatment, which improves cough and may also reduce the risk of progression to classical asthma. AC proposed by Fujimura et al. presents with bronchodilator-resistant dry cough associated with an atopic constitution. It involves eosinophilic tracheobronchitis and cough hypersensitivity and responds to ICS treatment, while lacking in AHR and variable airflow obstruction. These features are shared by non-asthmatic eosinophilic bronchitis (NAEB). However, atopic cough does not involve bronchoalveolar eosinophilia, has no evidence of airway remodeling, and rarely progresses to classical asthma, unlike CVA and NAEB. Histamine H1 antagonists are effective in atopic cough, but their efficacy in NAEB is unknown. AHR of NAEB may improve with ICS within the normal range. Taken together, NAEB significantly overlaps with atopic cough, but might also include milder cases of CVA with very modest AHR. The similarity and difference of these related entities presenting with chronic cough and characterized by airway eosinophilia will be discussed.
慢性咳嗽是一个主要的临床问题。慢性咳嗽的病因可分为嗜酸性粒细胞性和非嗜酸性粒细胞性疾病,前者包括哮喘、咳嗽变异性哮喘(CVA)、特应性咳嗽(AC)和非哮喘性嗜酸性粒细胞性支气管炎(NAEB)。咳嗽是哮喘的主要症状之一。哮喘中的咳嗽可分为三类:1)CVA:仅以咳嗽为表现的哮喘;2)以咳嗽为主的哮喘:主要以咳嗽为表现,但也伴有呼吸困难和/或喘息的哮喘;3)在经典哮喘患者中,尽管其他症状得到控制,但在吸入糖皮质激素(ICS)和β2受体激动剂治疗后仍有咳嗽。最后一类可能有两个亚型;一种是对白细胞三烯受体拮抗剂和组胺H1受体拮抗剂等抗介质药物有反应的咳嗽,另一种是由胃食管反流等合并症引起的咳嗽。CVA是慢性孤立性咳嗽最常见的病因之一。它与伴有喘息的经典哮喘有许多病理生理特征相同,如特应性、气道高反应性(AHR)、嗜酸性粒细胞性气道炎症和气道重塑的各种特征。三分之一的成年患者可能会出现喘息并进展为经典哮喘。正如在经典哮喘中所确立的,ICS被认为是一线治疗药物,它可以改善咳嗽,还可能降低进展为经典哮喘的风险。Fujimura等人提出的AC表现为与特应性体质相关的支气管扩张剂抵抗性干咳。它涉及嗜酸性粒细胞性气管支气管炎和咳嗽高敏反应,对ICS治疗有反应,同时缺乏AHR和可变气流受限。这些特征与非哮喘性嗜酸性粒细胞性支气管炎(NAEB)相同。然而,与CVA和NAEB不同,特应性咳嗽不涉及支气管肺泡嗜酸性粒细胞增多,没有气道重塑的证据,很少进展为经典哮喘。组胺H1拮抗剂对特应性咳嗽有效,但其对NAEB的疗效尚不清楚。NAEB的AHR可能会在正常范围内随着ICS治疗而改善。综上所述,NAEB与特应性咳嗽有显著重叠,但也可能包括AHR非常轻微的较轻CVA病例。将讨论这些以慢性咳嗽为表现且以气道嗜酸性粒细胞增多为特征的相关实体的异同。
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