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Interpretation of pneumonia diagnosis and treatment plan for new coronavirus infection (trial version 5)
Published: 2020-02-05Source : Medical Administration and Hospital Authority
On February 5, 2020, the National Health and Health Commission issued the "Diagnosis and Treatment Plan for New Coronavirus Infected Pneumonia (Trial Fifth Edition)" (hereinafter referred to as the "Fifth Edition of the Diagnosis and Treatment Plan"). The main contents are now read as follows.
December 2019 Since then, Wuhan City, Hubei Province has successively found multiple cases of patients with pneumonitis infected by a new type of coronavirus. With the spread of the epidemic, other cases have been found in other regions of China and abroad. Most of the currently reported cases have a history of Wuhan residence or travel In some areas, no cases of travel history in Wuhan have been found. The disease has been included in the Class B infectious diseases stipulated in the Law of the People's Republic of China on the Prevention and Control of Infectious Diseases, and measures for the prevention and control of Class A infectious diseases have been taken. After the
outbreak, Relevant experts organized by the National Health and Health Committee have formulated the trial, trial second edition, trial third edition, and trial fourth edition of the New Coronavirus Infected Pneumonia Diagnosis and Treatment Plan. The
fifth edition of the trial includes the pathogenic and clinical characteristics of coronavirus . , Case definition, differential diagnosis, case discovery and reporting, treatment, release and isolation criteria, referral The principles of transport and hospital infection control.
First, the pathogenic characteristics of the coronavirus introduced the subfamily of coronavirus into four genera: α, β, γ, and δ. In addition to the newly discovered coronavirus, it is known to infect people. There are 7 types of coronaviruses. Most coronaviruses cause upper respiratory tract infections, and the Middle East respiratory syndrome-associated coronavirus, severe acute respiratory syndrome-associated coronavirus, and this new type of coronavirus can cause pneumonia, even severe pneumonia, and can It is transmitted from person to person.
Coronavirus is sensitive to ultraviolet rays and heat. Most disinfectants can effectively inactivate the virus, but chlorhexidine cannot effectively inactivate the virus. Hand disinfectants containing chlorhexidine should be avoided.
Second, epidemics The source of infection was changed to "The source of infection currently seen is mainly patients with new coronavirus infection. Asymptomatic infection may also become the source of infection."
Third, clinical manifestations. The incubation period is 1-14 days, usually 3-7 days. Main symptoms are fever, fatigue, and dry cough. A few patients have symptoms such as nasal congestion, runny nose, and diarrhea. Because some severely ill patients had no obvious dyspnea and manifested as hypoxemia, it changed to "Severely ill patients often have dyspnea and / or hypoxemia one week after the onset of illness, and the severe cases progress rapidly to acute respiratory distress syndrome, sepsis Symptomatic shock, difficult to correct metabolic acidosis, and coagulation dysfunction, etc. "emphasized that" light patients only showed low fever, mild fatigue, etc., and no pneumonia. "
Laboratory tests increased" Some patients may appear liver enzymes, LDH, Myoenzyme and myoglobin increased; troponin increased in some critically ill patients. "And" New coronavirus nucleic acids can be detected in nasopharyngeal swabs, sputum, lower respiratory secretions, blood, feces and other specimens. "
Chest imaging Multiple small patchy shadows and interstitial changes appeared early, and the extrapulmonary bands were obvious. Furthermore, it develops multiple ground glass infiltration and infiltrates in both lungs. In severe cases, pulmonary consolidation and pleural effusion are rare.
Fourth, case diagnosis is treated differently between Hubei Province and other provinces outside Hubei Province.
Other provinces outside Hubei are still divided into "suspected cases" and "confirmed cases". Based on confirmed cases that have been found to have no clear epidemiological history, "those with no clear epidemiological history are in line with 3 clinical manifestations (fever and / or respiratory symptoms; with the above-mentioned characteristics of pneumonia imaging; total white blood cells in the early stages of onset) Normal or decreased, or lymphocyte count decreased.) "Suspected cases were also included for investigation. The diagnostic criteria for confirmed cases have not changed (requires real-time fluorescent RT-PCR for respiratory or blood specimens to detect positive new-type coronavirus nucleic acid; or viral gene sequencing, which is highly homologous with known new coronaviruses.)
Hubei Province added "clinical diagnosis "classification. And the "suspected case" standard is modified to: whether with or without epidemiological history, as long as it meets the two clinical manifestations of "fever and / or respiratory symptoms" and "normal or reduced white blood cells in the early stage of onset, or decreased lymphocyte count", then Can be considered a suspected case. This is equivalent to the relaxation of suspected cases. Suspected cases with pneumonia imaging features are clinically diagnosed cases. The diagnostic criteria for confirmed cases have not changed.
Fifth, clinical typing. According to whether there are clinical symptoms, whether there is pneumonia, the severity of pneumonia, whether there is respiratory failure, shock, whether there is other organ failure, etc., it is divided into mild (clinical symptoms, no pneumonia on radiology); ordinary (fever, Respiratory symptoms such as pneumonia on imaging studies); severe (respiratory distress, RR≥30 beats / min; resting state, oxygen saturation ≤93%; arterial blood oxygen pressure (PaO [SUB]2[/SUB] ) / oxygen concentration ( FiO [SUB]2[/SUB] ) ≤ 300mmHg) and critically severe (respiratory failure occurs and requires mechanical ventilation; shock occurs; combined with other organ failure requires ICU monitoring and treatment.)
Sixth, differential diagnosis. There are more than 100 species of pathogens that cause community-acquired pneumonia, of which viruses account for about 30%, and pneumonia caused by other viruses and common influenza viruses, parainfluenza viruses, adenoviruses, respiratory syncytial virus, rhinoviruses, human metapneumoviruses Viruses, SARS coronaviruses, etc. have similarities. It is difficult to distinguish from clinical manifestations and chest imaging alone, and they need to be distinguished by pathogenic testing.
Seventh, case detection, reporting and exclusion. Hubei Province is different from other provinces outside Hubei.
In other provinces outside Hubei, the case detection was the same as the defendant's procedure and the fourth edition. There was no change in the case. It was stressed that the transfer should ensure that the suspected patient was transferred to the designated hospital as soon as possible under the premise of ensuring the safety of the transfer.
For Hubei Province, medical staff at all levels and types of medical institutions are required to immediately isolate and treat suspected and clinically diagnosed cases that meet the definition of the case. Suspected and clinically diagnosed cases should be isolated in a single room. Suspected and clinically diagnosed cases should be isolated. Specimens should be collected for pathogenic testing as soon as possible.
Suspected cases should be tested negative for two consecutive consecutive respiratory pathogenic nucleic acid tests (sampling interval of at least 1 day).
Eighth, treatment includes isolation, symptomatic support, and close monitoring of changes in the condition, especially respiratory rate, finger saturation, etc.
Suspected cases should be treated in isolation in a single room, and confirmed cases can be admitted to the same ward.
Critical cases should be admitted to ICU as soon as possible.
Antibacterial use: Avoid blind or inappropriate use of antibacterials, especially the combination of broad-spectrum antibacterials.
Antiviral treatment: Add "No effective antiviral treatment is currently confirmed." On the basis of alpha-interferon nebulization inhalation, lopinavir / ritonavir may be added, "or ribavirin may be added ". At the same time, pay attention to adverse reactions related to lopinavir / ritonavir, diarrhea, nausea, vomiting, liver damage, and interaction with other drugs.
Successful treatment of severe and critical cases is the key to reducing mortality. It is necessary to actively prevent complications, treat underlying diseases, prevent secondary infections, and provide organ function support in a timely manner. Patients often have anxiety and fear, and psychological counseling should be strengthened.
Condition monitoring, adding "conditionally feasible cytokine testing."
Respiratory support: (1) Oxygen therapy: Severe patients should receive nasal cannula or mask to inhale oxygen, and timely evaluate whether respiratory distress and / or hypoxemia is relieved . (2) High-flow nasal catheter oxygen therapy or non-invasive mechanical ventilation: When patients with respiratory distress and / or hypoxemia cannot be relieved after receiving standard oxygen therapy, high-flow nasal catheter oxygen therapy or non-invasive ventilation can be considered. Emphasis "if the condition does not improve or worsen within a short period of time (1-2 hours), tracheal intubation and invasive mechanical ventilation should be performed in a timely manner." (3) Invasive mechanical ventilation: lung protective ventilation strategy, that is, small tidal volume ( 4-8ml / kg ideal body weight) and low inspiratory pressure (platform pressure <30cmH [SUB]2[/SUB] O) for mechanical ventilation to reduce ventilator-related lung injury. (4) Salvage treatment: For patients with severe ARDS, it is recommended to perform lung expansion. In the case of sufficient human resources, prone ventilation should be performed for more than 12 hours per day. If the prone position does not respond well, ECMO should be considered as soon as possible if conditions permit.
Circulation support: Based on adequate fluid resuscitation, improve microcirculation, use vasoactive drugs, and perform hemodynamic monitoring if necessary.
Other treatment measures: According to the patient's dyspnea and chest imaging progress, glucocorticoids can be used within a short period (3 to 5 days) as appropriate. The recommended dose does not exceed 1 to 2 mg / kg / day of methylprednisolone. It should be noted that Large doses of glucocorticoids will delay the removal of coronavirus due to immunosuppressive effects; Xuebijing 100ml / time can be administered intravenously, twice daily treatment; intestinal microecological regulators can be used to maintain intestinal microecological balance , To prevent secondary bacterial infections; plasma treatment can be used in recovery period; for critically ill patients with high inflammatory response, conditions can consider using extracorporeal blood purification technology.
About Chinese medicine treatment. The disease belongs to the category of traditional Chinese medicine epidemic. The disease is caused by the epidemic qi, and the disease is located in the lungs. The basic pathogenesis is "wet, hot, poisonous, and stasis." Refer to the recommended scheme for dialectical treatment.
Ninth, lift the isolation and discharge standards. On the basis of "the body temperature returned to normal for more than 3 days and the respiratory symptoms improved significantly", the "pulmonary imaging showed obvious absorption of inflammation" was added, and the nucleic acid test for respiratory pathogens was negative for two consecutive times (sampling interval at least 1 day), which could be released from isolation and discharged. Or transfer to the appropriate department according to the condition to treat other diseases.
Tenth, the principle of transshipment. In order to ensure the safety of transport, patients should be transported in special vehicles, and personal protection and vehicle disinfection of transport personnel should be done.
Related Links:
Notice on Printing and Distributing Pneumonia Diagnosis and Treatment Plan for New Coronavirus Infection (Trial Version 5)
http://www.nhc.gov.cn/yzygj/s7652m/2...e4db22ea.shtml
Roger Dow, president and CEO of the U.S. Travel Association, prefaced his state of the travel industry address Wednesday with an update on the virus and said, “while visitation from China will be temporarily affected, all of the current expert advice indicates that business and leisure travel in the U.S. can and should continue as normal.”