今日の臨床サポート

急性咳嗽

著者: 吉藤歩 東京都済生会中央病院 腎臓内科

監修: 野口善令 豊田地域医療センター 総合診療科

著者校正/監修レビュー済:2019/11/08
参考ガイドライン:
  1. 日本呼吸器学会咳嗽・喀痰ガイドライン2019作成委員会:咳嗽・喀痰の診療ガイドライン2019
  1. Classification of Cough as a symptom in Adults and Management Algorithms, Chest Guideline and Expert Panel Reprot 2018
患者向け説明資料

概要・推奨   

  1. 咳嗽を主訴に診療所や病院を受診する患者数は非常に多く、その原因は多くは感染性咳嗽である。
  1. 急性咳嗽の患者が脈拍>100/分、呼吸回数>24回/分、体温>38、または聴診でラ音や浸潤影を疑う所見を認めた場合には、肺炎を除外するために胸部X線を撮影することが推奨される(推奨度2)
  1. 胸部X線が陰性であった場合には、喀痰培養を行うことは推奨されない(推奨度3)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
吉藤歩 : 未申告[2021年]
監修:野口善令 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 咳嗽・喀痰の診療ガイドライン2019および2018年のChestに掲載された咳嗽のアルゴリズムに基づき、急性咳嗽と亜急性咳嗽のフロ-チャ-トの修正を行った。
  1. マイコプラズマの迅速検査が普及してきたことからマイコプラズマの抗原検査の意義について修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 咳嗽は患者が病院を訪れる最も頻度が高い徴候である。
  1. 咳嗽は3週間未満の急性咳嗽、3週間以上8週間未満の亜急性咳嗽、8週間以上の慢性咳嗽に分類される。
  1. 急性咳嗽の頻度については不明であるが、最も頻度が高い疾患はウイルス感染による風邪症候群であり、自然軽快する場合がほとんどである。
  1. 肺血栓塞栓症や急性心不全などの重篤な疾患についても、急性咳嗽を主訴に来院するため、鑑別が重要である。
問診・診察のポイント  
 
 
 
  1. まず、症状の「持続期間」を聴取することは重要である。3週間以内の急性咳嗽、3週間から8週間以内の亜急性咳嗽、8週以上の慢性咳嗽により鑑別が異なる。

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文献 

著者: Sidney S Braman
雑誌名: Chest. 2006 Jan;129(1 Suppl):138S-146S. doi: 10.1378/chest.129.1_suppl.138S.
Abstract/Text BACKGROUND: Patients who complain of a persistent cough lasting >3 weeks after experiencing the acute symptoms of an upper respiratory tract infection may have a postinfectious cough. Such patients are considered to have a subacute cough because the condition lasts for no >8 weeks. The chest radiograph findings are normal, thus ruling out pneumonia, and the cough eventually resolves, usually on its own. The purpose of this review is to present the evidence for the diagnosis and treatment of postinfectious cough, including the most virulent form caused by Bordetella pertussis infection, and make recommendations that will be useful for clinical practice.
METHODS: Recommendations for this section of the guideline were obtained from data using a National Library of Medicine (PubMed) search dating back to 1950, which was performed in August 2004, of the literature published in the English language. The search was limited to human studies, using the search terms "cough," "postinfectious cough," "postviral cough," "Bordetella pertussis," "pertussis infection," and "whooping cough."
RESULTS: The pathogenesis of the postinfectious cough is not known, but it is thought to be due to the extensive inflammation and disruption of upper and/or lower airway epithelial integrity. When postinfectious cough emanates from the lower airway, this is often associated with the accumulation of an excessive amount of mucus hypersecretion and/or transient airway and cough receptor hyperresponsiveness; all may contribute to the subacute cough. In these patients, the optimal treatment is not known. Except for bacterial sinusitis or early on in a B pertussis infection, therapy with antibiotics has no role, as the cause is not bacterial infection. The use of inhaled ipratropium may be helpful. Other causes of postinfectious cough are persistent inflammation of the nose and paranasal sinuses, which leads to an upper airway cough syndrome (previously referred to as postnasal drip syndrome), and gastroesophageal reflux disease, which may be a complication of the vigorous coughing. One type of postinfectious cough that is particularly virulent is that caused by B pertussis infection. When the cough is accompanied by paroxysms of coughing, posttussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a B pertussis infection should be made unless another diagnosis is proven. This infection is highly contagious but responds to antibiotic coverage with an oral macrolide when administered early in the course of the disease. A safe and effective vaccine to prevent B pertussis is now available for adults as well as children. It is recommended according to CDC guidelines.
CONCLUSIONS: In patients who have a cough lasting from 3 to 8 weeks with normal chest radiograph findings, consider the diagnosis of postinfectious cough. In most patients, a specific etiologic agent will not be identified, and empiric therapy may be helpful. A high degree of suspicion for cough due to B pertussis infection will lead to earlier diagnosis, patient isolation, and antibiotic treatment.

PMID 16428703  Chest. 2006 Jan;129(1 Suppl):138S-146S. doi: 10.1378/ch・・・
著者: Nam-Hee Kwon, Mi-Jung Oh, Tae-Hoon Min, Byung-Jae Lee, Dong-Chull Choi
雑誌名: Chest. 2006 May;129(5):1142-7. doi: 10.1378/chest.129.5.1142.
Abstract/Text STUDY OBJECTIVES: Cough lasting > 3 weeks has been defined as chronic cough. However, it might be more persuasive to divide cough into subacute, lasting 3 to 8 weeks, and chronic, lasting > 8 weeks. We evaluated the causes and clinical courses of subacute cough, and the value of the bronchoprovocation test and induced sputum examination (IS).
METHODS: Nonsmoking patients with cough of 3 to 8 weeks duration were enrolled into the study. Patients with dyspnea, basal FEV1 of < 70% predicted, abnormal findings on a plain chest radiograph or physical examination were excluded. We prescribed an antihistamine-decongestant for patients who were suspected to have postinfectious cough or postnasal drip. If patients had positive results on a bronchoprovocation test or IS, therapy with inhaled corticosteroids was substituted according to an algorithmic approach.
RESULTS: One hundred eighty-four patients (77 men and 107 women) were evaluated; the mean age of the study group was 47.5 years. Eighty-nine of 184 patients had postinfectious cough. Cough resolved without treatment in 62 patients. Twenty-nine of 43 patients with positive bronchoprovocation test results had cough-variant asthma.
CONCLUSIONS: Postinfectious cough was the most common cause of subacute cough. The spontaneous resolution of cough was frequent in patients with subacute cough. Unless asthma was strongly suspected, the performance of the bronchoprovocation test could be delayed until after empirical treatment had been administered.

PMID 16685003  Chest. 2006 May;129(5):1142-7. doi: 10.1378/chest.129.5・・・
著者: Akira Yamasaki, Keichi Hanaki, Katsuyuki Tomita, Masanari Watanabe, Yasuyuki Hasagawa, Ryota Okazaki, Miki Yamamura, Kouji Fukutani, Yuji Sugimoto, Kazuhiro Kato, Masahiro Kodani, Toshikazu Ikeda, Tatsuya Konishi, Yuji Kawasaki, Hirokazu Tokuyasu, Hiroki Yajima, Hitoshi Sejima, Takeshi Isobe, Eiji Shimizu
雑誌名: Int J Gen Med. 2010 Apr 8;3:101-7. Epub 2010 Apr 8.
Abstract/Text BACKGROUND: Cough is one of the most common reasons for visiting a clinic. The causes of cough differ according to the duration of cough. Infectious disease is commonly observed in acute cough while noninfectious disease is commonly observed in chronic cough. On the other hand, cough is frequently observed in patients with asthma/cough variant asthma (CVA).
OBJECTIVE: In this study, we investigated the causes of cough in a rural region in Japan and the clinical examination and treatment for the patients diagnosed as asthma/CVA.
METHODS: We analyzed 124 patients who complained of cough.
RESULTS: The most common reason for acute cough was respiratory tract infection while asthma/CVA is the most common reason for subacute and chronic cough. The diagnostic procedure for asthma/CVA depends on clinical symptoms in asthmatic patients with acute cough. While in asthmatic patients with subacute and chronic cough, diagnosis of asthma depends on clinical examinations including chest radiogram, immunoglobulin E, white blood cells counts, sputum examination or spirometry as well as symptoms. For the treatment of asthma, the use of long-acting beta(2)-stimulant was dominant in asthmatic patients with acute cough while the use of leukotriene receptor and inhaled corticosteroid were dominant in asthmatic patients with subacute or chronic cough.
CONCLUSIONS: Diagnosis and treatment for asthma differs according to the duration of cough. Simple guidelines for asthma/CVA according to the duration of cough might be necessary for diagnosis and treatment of asthma/CVA for general physicians especially in rural areas.

PMID 20463827  Int J Gen Med. 2010 Apr 8;3:101-7. Epub 2010 Apr 8.
著者: R S Irwin, F J Curley, C L French
雑誌名: Am Rev Respir Dis. 1990 Mar;141(3):640-7. doi: 10.1164/ajrccm/141.3.640.
Abstract/Text A successful, systematic, anatomic, diagnostic protocol for evaluating patients with chronic cough was presented in 1981. To determine whether it was still valid, we prospectively evaluated, over a 22-month interval, 102 consecutive and unselected immunocompetent patients complaining of cough an average of 53 +/- 97 months (range, 3 wk to 50 yr). Utilizing the anatomic, diagnostic protocol modified to include prolonged esophageal pH monitoring (EPM), the causes of cough were determined in 101 of 102 (99%) patients, leading to specific therapy that was successful in 98%. Cough was due to one condition in 73%, two in 23%, and three in 3%. Postnasal drip syndrome was a cause 41% of the time, asthma 24%, gastroesophageal reflux (GER) 21%, chronic bronchitis 5%, bronchiectasis 4%, and miscellaneous conditions 5%. Cough was the sole presenting manifestation of asthma and GER 28 and 43% of the time, respectively. While history, physical examination, methacholine inhalational challenge (MIC), and EPM yielded the most frequent true positive results, MIC was falsely positive 22% of the time in predicting that asthma was the cause of cough. Laboratory testing was particularly useful in ruling out suspected possibilities. We conclude that the anatomic diagnostic protocol is still valid and that it has well-defined strengths and limitations.

PMID 2178528  Am Rev Respir Dis. 1990 Mar;141(3):640-7. doi: 10.1164/・・・
著者: J D Klausner, D Passaro, J Rosenberg, W L Thacker, D F Talkington, S B Werner, D J Vugia
雑誌名: J Infect Dis. 1998 Jan;177(1):161-6.
Abstract/Text There are currently no recommended epidemic-control measures for Mycoplasma pneumoniae pneumonia outbreaks in closed communities. Previous studies have suggested the usefulness of chemoprophylaxis administered to close contacts of case-patients. To evaluate the effectiveness of various epidemic-control measures during an institutional outbreak, an observational study was undertaken during a very large outbreak of M. pneumoniae pneumonia at a facility for developmentally disabled residents (n = 142 cases). Control measures evaluated included no control, standard epidemic-control measures, and targeted azithromycin prophylaxis (500 mg on day 1, 250 mg/day on days 2-5) plus standard epidemic-control measures. The combined use of azithromycin prophylaxis and standard epidemic-control measures was associated with a significant reduction in the secondary attack rate. This study suggests that the addition of antibiotic prophylaxis to standard epidemic-control measures can be useful during institutional outbreaks of M. pneumoniae pneumonia.

PMID 9419183  J Infect Dis. 1998 Jan;177(1):161-6.
著者: Lorne A Becker, Jeffrey Hom, Miguel Villasis-Keever, Johannes C van der Wouden
雑誌名: Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001726. doi: 10.1002/14651858.CD001726.pub4. Epub 2011 Jul 6.
Abstract/Text BACKGROUND: There are no clearly effective treatments for the cough of acute bronchitis. Beta2-agonists are often prescribed, perhaps because clinicians suspect many patients also have reversible airflow restriction contributing to the symptoms.
OBJECTIVES: To determine whether beta2-agonists improve acute bronchitis symptoms in patients with no underlying pulmonary disease.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, issue 1 which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1966 to February week 1, 2011) and EMBASE (1974 to February 2011).
SELECTION CRITERIA: Randomised controlled trials (RCTs) in which patients (adults, or children over two years of age) with acute bronchitis or acute cough and without known pulmonary disease were allocated to beta2-agonist versus placebo, no treatment or alternative treatment.
DATA COLLECTION AND ANALYSIS: Three review authors independently selected outcomes and extracted data while blinded to study results. Two review authors independently assessed each trial for risk of bias. We analysed trials in children and adults separately.
MAIN RESULTS: Two trials in children (n = 109) with no evidence of airway obstruction did not find any benefits from oral beta2-agonists. Five trials in adults (n = 418) had mixed results but overall summary statistics did not reveal any significant benefits from oral (three trials) nor inhaled (two trials) beta2-agonists. There were no significant differences in daily cough scores nor in the percentage of adults still coughing after seven days (control group 73%; risk ratio (RR) 0.77, 95% confidence interval (CI) 0.54 to 1.09). in one trial, subgroups with evidence of airflow limitation had lower symptom scores if given beta2-agonists. The trials that noted quicker resolution of cough with beta2-agonists were those with a higher proportion of wheezing patients at baseline. Adults given beta2-agonists were more likely to report tremor, shakiness or nervousness (RR 7.94, 95% CI 1.17 to 53.94; number needed to treat to harm (NNTH) 2.3).
AUTHORS' CONCLUSIONS: There is no evidence to support the use of beta2-agonists in children with acute cough who do not have evidence of airflow obstruction. There is also little evidence that the routine use of beta2-agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in people with evidence of airflow obstruction. However, this potential benefit is not well-supported by the available data and must be weighed against the adverse effects associated with their use.

PMID 21735384  Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001726. do・・・
著者: D N MacKay
雑誌名: J Gen Intern Med. 1996 Sep;11(9):557-62.
Abstract/Text OBJECTIVE: To determine whether antibiotic and bronchodilator treatment of acute bronchitis in patients without lung disease is efficacious.
DESIGN: A MEDLINE search of the literature from 1966 to 1995 was done, using "Bronchitis" as the key word. Papers addressing acute bronchitis in adults were used as well as several citations emphasizing pediatric infections. A manual search of papers addressing the microorganisms causing acute bronchitis was also done. Data were extracted manually from relevant publications.
SETTING: All published reports were reviewed. Papers dealing with exacerbations of chronic bronchitis were excluded in this review.
RESULTS: Although acute bronchitis has multiple causes, the large majority of cases are of viral etiology. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Bordetella pertussis are the only bacteria identified as contributing to the cause of acute bronchitis in otherwise healthy adults. Nine double-blind, placebo-controlled trials were reviewed. Four studies showed no advantage for doxycycline and one study showed no advantage for erythromycin. One study using erythromycin and one study using trimethoprim and sulfamethoxazole showed that these antibiotics were slightly better than placebo. Two other studies showed an impressive superiority for liquid or inhaled albuterol when compared with erythromycin.
CONCLUSIONS: Most studies showed no significant difference between drug and placebo, and the two studies that did showed only small clinical differences. Albuterol had an impressive advantage over erythromycin. Antibiotics should not be used in the treatment of acute bronchitis in healthy persons unless convincing evidence of a bacterial infection is present.

PMID 8905509  J Gen Intern Med. 1996 Sep;11(9):557-62.
著者: R Gonzales, M Sande
雑誌名: Lancet. 1995 Mar 18;345(8951):665-6.
Abstract/Text
PMID 7885119  Lancet. 1995 Mar 18;345(8951):665-6.
著者: J Smucny, T Fahey, L Becker, R Glazier
雑誌名: Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000245. doi: 10.1002/14651858.CD000245.pub2. Epub 2004 Oct 18.
Abstract/Text BACKGROUND: Antibiotic treatment of acute bronchitis, which is one of the most common illnesses seen in primary care, is controversial. Most clinicians prescribe antibiotics in spite of expert recommendations against this practice.
OBJECTIVES: The objective of this review was to assess the effects of antibiotic treatment for patients with a clinical diagnosis of acute bronchitis.
SEARCH STRATEGY: In this updated review, we searched the Cochrane Central Register of Controlled trials (CENTRAL) (The Cochrane Library Issue 2, 2004); MEDLINE (January 1966 to March 2004); EMBASE (January 2000 to December 2003); SciSearch from 1989 to 2004; reference lists of articles and the authors' personal collections up to 1996, and also wrote to study authors and drug manufacturers. EMBASE has previously been searched from 1974 to 2000).
SELECTION CRITERIA: Randomised controlled trials comparing any antibiotic therapy with placebo in acute bronchitis or acute productive cough without other obvious cause in patients without underlying pulmonary disease.
DATA COLLECTION AND ANALYSIS: At least two reviewers extracted data and assessed trial quality. Authors were contacted for missing data.
MAIN RESULTS: Nine trials involving over 750 patients aged eight to over 65 and including smokers and non-smokers were included in the primary analysis. The quality of the trials was variable. A variety of outcome measures were assessed. Overall, patients receiving antibiotics had better outcomes than did those receiving placebo. At a follow-up visit, they were less likely to have a cough (relative risk (RR) 0.64, 95% confidence interval (CI) 0.49 to 0.85; number-needed-to-treat (NNT) 5; 95% CI 3 to 14), show no improvement on physician assessment (RR 0.52; 95% CI 0.31 to 0.87; NNT 14; 95% CI 8 to 50), or have abnormal lung findings (RR 0.48; 95% CI 0.26 to 0.89; NNT 11; 95% CI 6 to 50); and had shorter durations of cough (weighted mean difference 0.58 days; 95% CI 0.01 to 1.16 days), productive cough (weighted mean difference (WMD) 0.52 days; 95% CI 0.01 to 1.03 days), and feeling ill (WMD 0.58 days; 95% CI 0.00 to 1.16 days). There were no significant differences regarding the presence of night cough, productive cough, or activity limitations at follow up, or in the mean duration of activity limitations. The benefits of antibiotics were less apparent in a sensitivity analysis that included data from two other studies of patients with upper respiratory tract infections with productive cough. There was a non significant trend towards an increase in adverse effects in the antibiotic group, relative risk (RR) 1.22 (95% CI 0.94 to 1.58).
REVIEWERS' CONCLUSIONS: Overall, antibiotics appear to have a modest beneficial effect in patients who are diagnosed with acute bronchitis. The magnitude of this benefit, however, is similar to that of the detriment from potential adverse effects.

PMID 15494994  Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000245. d・・・
著者: Toni Tan, Paul Little, Tim Stokes, Guideline Development Group
雑誌名: BMJ. 2008 Jul 23;337:a437. doi: 10.1136/bmj.a437. Epub 2008 Jul 23.
Abstract/Text
PMID 18650239  BMJ. 2008 Jul 23;337:a437. doi: 10.1136/bmj.a437. Epub ・・・

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