대한내과학회지 : 제 72 권제 5 호 2007 의학강좌 - 개원의를위한모범처방전 쌕쌕거림의감별진단과치료 이화여자대학교의과대학내과학교실 이진화 Differential diagnosis and management of wheezing Jin Hwa Lee, M.D. Department of Internal Medicine, College of Medicine Ewha Womans University School of Medicine, Seoul, Korea 서론쌕쌕거림은 250 msec 이상지속되는연속음으로, 기도가거의닫히는시기에기도벽이떨려서나는소리이다. 고음또는저음으로음색이다양할수있으며, 숨을들이쉴때나내쉴때들릴수있고, 흉곽외상기도부터흉곽내소기도에이르기까지다양한크기의기도에서발생할수있다. 그렁거림 ( 협착음, stridor) 은주로숨을들이쉴때중심기도에서크게들리는쌕쌕거림을말한다. 원인기도를침범하는다양한질환이기도폐쇄를일으켜서숨을들이쉬거나내쉴때쌕쌕거리게된다 ( 표 1). 천식이쌕쌕거림의가장흔한원인은아니며, 실제로한연구결과쌕쌕거리는환자에게메타콜린기관지유발검사와기관지확장제반응검사를시행한결과 65% 에서기도과민성이없었다 1). 외래환자중쌕쌕거림의가장흔한원인은후비루증후군으로알려져있으며, 후비루증후군에서숨을내쉴때들리는쌕쌕거림은대부분성대주위의흉곽외기도에서비롯된다 2). 문진과신체진찰쌕쌕거리는환자를볼때쌕쌕거림이기도폐쇄를의미하지만천식이아닐수있음을명심하는것이중요하다 3). 천식의쌕쌕거림과감별되는뚜렷한특징은없다. 천식의 3대증상이쌕쌕거림, 기침, 만성적인호흡곤란이지만, 이들모두가동시에나타나는것은아니며, 각각의증상에대해천식이가장흔한원인질환은아니다. 한연구결과에따르면, 지속적인쌕쌕거림의 35%, 만성기침의 24%, 만성호흡곤란의 29% 에서만천식이원인질환이었다 1). 한가지이상증상이있으면천식일확률이높아진다. 문진을잘하면쌕쌕거림의원인질환을감별하는데도움이되는여러가지증상과징후를밝힐수있다 ( 표 2, 3). 간헐적인쌕쌕거림을호소하고기관지확장제흡입에잘반응한다면, 천식일가능성이높으며, 폐활량측정으로숨을내쉴때가역적인기류폐쇄를증명할수있다. 그러나기관지확장제후호전되었다고항상천식은아니며, 가역적인제한성폐질환도임상적으로드물게천식과감별하기어렵다 4). 쌕쌕거림이천식치료에반응하지않을때, 다른진단을고려해야한다 5). 비천식성쌕쌕거림의원인질환으로후비루, 인후통, 위식도역류, 이물질흡인, 기관지결핵또는객혈등이있다. 쌕쌕거림의음색이발생위치를짐작하게할수있는데, 다음을띠는 (polyphonic) 쌕쌕거림은주로직경이큰중심기도가역동적으로눌릴때들린다. 단음을띠는 (monophonic) 쌕쌕거림은소기도질환을시사하며, 특히여러군데서들리면천식일가능성이높다. 그러나흉곽외큰기도를침범하는질환에서도단음의쌕쌕거림이들릴수있다. - 571 -
-The Korean Journal of Medicine : Vol. 72, No. 5, 2007 - Table 1. Major causes of wheeze Extrathoracic upper airway obstruction Intrathoracic upper airway obstruction Lower airway obstruction Postnasal drip syndrome Vocal cord dysfunction Hypertrophied tonsils Epiglottitis Laryngeal edema Laryngostenosis Postextubation granuloma Retropharyngeal abscess Neoplasms Anaphylaxis Malignancy Obesity Klebsiella rhinoscleroma Mobile supraglottic soft tissue Relapsing polychondritis Laryngocele Abnormal arytenoids movement Vocal cord hematoma Bilateral vocal cord paralysis Cricoarytenoid arthritis Wegener s granulomatosis Tracheal stenosis Foreign body aspiration Benign airway tumors Malignancies Intrathoracic goiter Tracheobronchomegaly Acquired tracheomalacia Herpetic tracheobronchitis Right sided aortic arch Asthma COPD Pulmonary edema Aspiration Pulmonary embolism Bronchiolitis Carcinoid syndrome Bronchiectasis Lymphangitic carcinomatosis Parasitic infections Endobronchial tuberculosis 숨을내쉴때들리는쌕쌕거림은주로천식환자에서들리지만, 급성천식발작동안에는숨을들이쉴때도쌕쌕거리게된다. 숨을들이쉴때들리는쌕쌕거림은주로흉곽외상기도질환이나폐쇄일가능성이높으나, 일부천식환자는숨을들이쉴때만쌕쌕거리기도한다. 직경이 8 mm 미만으로상기도가폐쇄되면움직일때숨이차고, 직경이 5 mm 미만이되면협착음이들린다. 따라서협착음이들리는경우, 응급처치가필요하다. 진단쌕쌕거리는환자에서기도폐쇄의위치를찾아내는것이가장중요하다. 가장흔한원인 ( 표 1) 에대한감별진단을염두에두고, 문진, 신체진찰, 폐활량측정을한다. 문진과신체진찰로감별진단의폭을좁힌후폐활량측정을시행하면확진하는데도움이된다. 폐활량측정기도의해부학적위치에따라생리학적으로세가지기도폐쇄를볼수있다. 첫째, 흉곽외상기도로코, 입, 인후, 후두와흉곽외기관이해당되며, 둘째, 흉곽내상기도로흉곽내기관부터직경이 2 mm 이상인기도가이에해당되고, 셋째, 흉곽내소기도로직경이 2 mm 미만인기도가이에해당된다. 생리학적관점에서이세가지해부학적영역은다음과같이구별되는특징을갖는다. 흉곽외와흉곽내상기도는호흡주기에따라서로다른반대방향의압력을기도벽에받게되어, 기류-용적곡선의모양이기도가좁아진위치에따라달라진다. 기류는대기도에서는주로난류 (turbulent flow) 이고소기도에서는층류 (laminar flow) 이다. 기관분지부위에서폐쇄가일어나면기류저항이획일적으로일어나지만, 소기도가막히면다발적이고산발적인기류폐쇄가발생하게된다 ( 그림 1). 폐활량측정과기류-용적곡선의모양으로기도폐쇄위치를알아낼수있을뿐만아니라, 기관지확장제또는전신적스테로이드를투약한후폐활량을다시측정해보면천식과같은가역적인기도질환을증명할수있다. 기관지유발검사는기저폐활량이정상인환자에서천식에서보이는기도과민성을증명하는데도움이된다. - 572 -
-Jin Hwa Lee : Differential diagnosis and management of wheezing - Table 2. Differential diagnosis of wheezing due to upper airway diseases Disease Distinguishing features Postnasal drip syndrome History of postnasal drip, throat clearing, nasal discharge; physical examination shows oropharyngeal secretions or cobblestone appearance. Epiglottitis History of sore throat out of proportion to pharyngitis; evidence of supraglottitis on endoscopy or lateral neck x-ray. Vocal cord dysfunction syndrome Lack of symptomatic response to bronchodilators, presence of stridor plus wheeze in absence of increased P(A-a)O 2; extrathoracic, variable obstruction on flow-volume loops; paradoxical inspiratory and/or early expiratory adduction of vocal cords on laryngoscopy during wheezing. This syndrome can masquerade as asthma, can be provoked by exercise and often coexists with asthma. Retropharyngeal abscess History of stiff neck, sore throat, fever, trauma to posterior pharynx; swelling noted by lateral neck x-ray or CT. Laryngotracheal injury due History of cannulation of trachea by endotracheal or tracheostomy tube; evidence of to tracheal cannulation intra or extrathoracic, variable obstruction on F-V loops, neck/chest x-ray, laryngoscopy or bronchoscopy, or all of these. Flow-volume loops with helim and air may reveal large airway obstruction superimposed on underlying small airway disease (eg, COPD). Neoplasms Carcinoid tumor is suspected when there is hemoptysis, unilateral wheezing, or evidence of lobar collapse on chest x-ray; bronchogenic carcinoma considered in the same setting in a cigarette smoker; diagnosis is confirmed by bronchoscopy. Anaphylaxis Abrupt onset of wheezing with urticaria, angioedema, nauseas, diarrhea, and hypotension, especially following insect bite or administration of drug or intravenous contrast; family history. 6 A B C D E 4 Volume, L/sec 2 0 2 4 100 0 100 0 100 0 100 0 100 0 Vital capacity, percent Figure 1. Schematic flow-volume loop configuration in a spectrum of airway lesions. (A) normal; (B) variable extrathoracic upper airway obstruction; (C) variable intrathoracic upper airway lesions; (D) fixed upper airway obstruction; and (E) lower airways obstruction. - 573 -
- 대한내과학회지 : 제 72 권제 5 호통권제 561 호 2007 - Table 3. Differential diagnosis of wheezing due to lower airway diseases Disease COPD Pulmonary edema Aspiration Pulmonary embolism Bronchiolitis Carcinoid syndrome Bronchiectasis Lymphangitic carcinomatosis Parasitic infections Distinguishing features History of dyspnea on exertion and productive cough in cigarette smoker; since productive cough is non-specific, it should only be ascribed to COPD when other cough-phlegm syndromes have been excluded; forced expiratory time > 4 sec, decreased breath-sound intensity, and unforced wheezing during auscultation; irreversible, expiratory airflow obstruction on spirometry. History and physical consistent with passive congestion of the lungs, ARDS, impaired lung lymphatics; abnormal chest X-ray, echocardiogram, radionuclide ventriculography, cardiac catheterization, or combinations of these. History of risk for pharyngeal dysfunction or gastroesophageal reflux disease; modified barium swallow, 24 hour esophageal ph monitoring. History of risk for thromboembolic diseases. History of respiratory infection, connective tissue disease, transplantation, ulcerative colitis, development of chronic airflow obstruction over months to few years rather than over many years in a non smoker; mixed obstructive and restrictive pattern on pulmonary function tests and hyperinflation and fine nodular infiltrates on chest X-ray. History of episodes of flushing and watery diarrhea; elevated 5-hydroxyindoleacetic acid level in a 24-hour urine specimen. History of episodes of productive cough, fever, or recurrent pneumonias; suggestive chest X-ray or typical chest CT findings; allergic bronchopulmonary aspergillosis should be considered when bronchiectasis is central. History of dyspnea or prior malignancy; reticulonodular infiltrates with or without pleural effusions; suggestive high resoulution chest CT scan; bronchoscpoy with biopsies. Consider in a non-asthmatic who has traveled to an endemic area and complains of fatigue, weight loss, fever; peripheral blood eosinophilia; infiltrates on chest X-ray; stools for ova and parasites for non-filarial causes; blood serologic studies for filarial causes. 상기도폐쇄의위치는기류-용적곡선에서가장잘확인할수있다. 보통기관과같은상기도가좁아지는경우기류-용적곡선중최대호기또는최대흡기의가운데부분에서기류속도가일정해진다 ( 그림 1). 상기도폐쇄병변이고정되어있다면, 기도벽을통해전달되는정상적인압력변화에기도벽이움직이지않기때문에기류-용적곡선모양으로흉곽외또는흉곽내인지감별하기어렵다 ( 그림 1D). 그렇지만기류-용적곡선을통해기도폐쇄의위치가소기도가아니라는것을알수있으며, 숨을들이쉬거나내쉴때동일한기류저항을받게된다. 기도폐쇄가고정된병변이아닌경우정상적인기도벽의압력변화를반영하게되어흉곽외와흉곽내병변을구별할수있다. 흉곽외폐쇄는최대흡기시저항을보 이고, 호기시흉곽외기도가이완되기때문에최대호기시기류-용적곡선은정상모양이다 ( 그림 1B). 반대로, 흉곽내고정되지않은기도폐쇄는최대호기시호기류가일정하게된다 ( 그림 1C). 결론쌕쌕거림의진단에서문진과신체진찰을통해감별진단의폭을줄이는것이가장중요하다. 곧호흡부전에빠질것같은환자가아니라면, 다음과같은순서로접근하는것을권고한다. 첫째, 문진과신체진찰에서나타나는특징을통해서가능한원인을알아낸다. 둘째, 구별되는특징이없을때, 쌕쌕거림의흔한원인부터고려해서평가해야한다. 셋째, 감별되는특징이없을때, salbutamol, ipratropium - 574 -
- 이진화 : 쌕쌕거림의감별진단과치료 - 등과같은속효성흡입용기관지확장제약물치료를시도해본다. 넷째, 흔한원인으로증상이설명되지않으면서천식치료에반응하지않을때, 생리학적관점에서덜흔한원인을고려해본다. 마지막으로, 협착음은기도폐쇄를시사하는위험한임상징후이므로조속한진단과처치를해야한다. Key Words : Wheezing, Spirometry, Asthma 중심단어 : 쌕쌕거림, 폐활량측정법, 천식 REFERENCES 1) Pratter MR, Hingston DM, Irwin RS. Diagnosis of bronchial asthma by clinical evaluation. An unreliable method. Chest 84:42-47, 1983 2) Irwin RS, Pratter MR, Holland PS, Corwin RW, Hughes JP. Postnasal drip causes cough and is associated with reversible upper airway obstruction. Chest 85:346-352, 1984 3) Boushey HA, Corry DB, Fahy JV, Burchard EG, Woodruff PG. Asthma. In: Mason RJ, Broaddus VC, Murray JF, Nadel JA, eds. Murray and Nadel's textbook of respiratory medicine. 4 th ed. p. 1190-1191, Philadelphia, Elsevier Inc., 2005 4) Kaminsky DA, Irvin CG. Anatomic correlates of reversible restrictive lung disease. Chest 103:928-931, 1993 5) Bahrainwala AH, Simon MR. Wheezing and vocal cord dysfunction mimicking asthma. Curr Opin Pulm Med 7:8-13, 2001 게재목록 2007년 6월 : 고프로락틴혈증의임상적접근및치료 2007년 7월 : 식중독 - 575 -