On February 5, 2020, the National Health and Wellness Committee issued the Diagnosis and Treatment Plan for Infected Pneumonia in novel coronavirus (Trial Fifth Edition) (hereinafter referred to as the Fifth Edition of the Diagnosis and Treatment Plan). The main contents are explained as follows:
Since 20 19 and 12, many cases of novel coronavirus's pneumonia have been found in Wuhan, Hubei province. With the spread of the epidemic, such cases have been found in other parts of China and abroad. At present, most of the reported cases have lived or traveled in Wuhan, and no cases have been found in some areas. The disease has been listed as a Class B infectious disease under the Law of People's Republic of China (PRC) on the Prevention and Control of Infectious Diseases, and measures have been taken to prevent and control Class A infectious diseases.
After the outbreak, National Health Commission organized relevant experts to formulate the trial, second trial, third trial and fourth trial versions of the Diagnosis and Treatment Plan for Infected Pneumonia in novel coronavirus.
The trial fifth edition includes the pathogenic characteristics, clinical characteristics, case definition, differential diagnosis, case discovery and reporting, treatment, release from isolation and discharge standards, transport principles and hospital infection control of coronavirus.
Firstly, the pathogenic characteristics of coronavirus are introduced. Coronavirus subfamily is divided into four genera: α, β, γ and δ. Together with the newly discovered coronavirus, there are 7 known coronaviruses that infect people. Most coronaviruses cause upper respiratory tract infection, while Middle East respiratory syndrome-related coronavirus, severe acute respiratory syndrome-related coronavirus and novel coronavirus this time can cause pneumonia and even severe pneumonia, and can spread from person to person.
Coronavirus is sensitive to ultraviolet rays and heat, and most disinfectants can effectively inactivate the virus, but chlorhexidine can't effectively inactivate the virus, so hand disinfectants containing chlorhexidine should be avoided.
Second, epidemiological characteristics. The source of infection is changed to "The source of infection currently seen is mainly the patients infected in novel coronavirus. Asymptomatic infected people may also become the source of infection. "
Third, clinical manifestations. The incubation period is 1~ 14 days, usually 3~7 days. The main manifestations are fever, fatigue and dry cough. A few patients have symptoms such as stuffy nose, runny nose and diarrhea. Because some severe patients have no obvious dyspnea and show hypoxemia, it is changed to "severe patients often have dyspnea and/or hypoxemia one week after onset, and severe patients quickly progress to acute respiratory distress syndrome, septic shock, metabolic acidosis and coagulation dysfunction". It is emphasized that "mild patients only show low fever and mild fatigue." And there is no pneumonia. "
Laboratory tests added, "Some patients may have elevated liver enzymes, LDH, muscle enzymes and myoglobin; Some critically ill patients can see elevated troponin "and" novel coronavirus nucleic acid can be detected in nasopharyngeal swab, sputum, lower respiratory secretions, blood, feces and other samples ".
There are many small patches and interstitial changes in the early stage of chest imaging, especially in the outer lung. Then it developed into multiple ground glass shadows and infiltration shadows in both lungs. In severe cases, lung consolidation can occur, and pleural effusion is rare.
Fourth, case diagnosis is treated differently according to Hubei Province and other provinces outside Hubei Province.
Other provinces outside Hubei are still divided into "suspected cases" and "confirmed cases". According to the confirmed cases without clear epidemiological history, "those without clear epidemiological history meet three clinical manifestations (fever and/or respiratory symptoms; Have the above imaging features of pneumonia; At the beginning of the disease, the total number of white blood cells is normal or decreased, or the lymphocyte count is decreased. ) "was also included in the suspected case for investigation.
The diagnostic criteria of confirmed cases have not changed (respiratory tract samples or blood samples need to be tested positive for novel coronavirus nucleic acid by real-time fluorescence RT-PCR; Or viral gene sequencing with high homology to known novel coronavirus).
The classification of "clinical diagnosis" was added in Hubei Province. The standard of "suspected case" is revised to: whether there is epidemiological history or not, as long as it meets the two clinical manifestations of "fever and/or respiratory symptoms" and "normal or decreased white blood cell count or decreased lymphocyte count at the initial stage of onset", it can be considered as a suspected case. It is equivalent to relaxing the standard of suspected cases. Suspected cases with imaging features of pneumonia are clinically diagnosed cases. The diagnostic criteria for confirmed cases have not changed.
Fifth, clinical classification. According to whether there are clinical symptoms, pneumonia, the severity of pneumonia, respiratory failure, shock, other organ failure, etc. , classified as mild (mild clinical symptoms, no pneumonia found in imaging); Ordinary type (imaging manifestations of fever, respiratory symptoms and pneumonia); Severe (respiratory distress, RR≥30 times/minute; At rest, the oxygen saturation is ≤ 93%; PaO _ 2/fio _ 2 ≤ 300mmhg) and critical type (respiratory failure and mechanical ventilation; Shock; Combined with other organ failure requires ICU monitoring and treatment).
Sixth, differential diagnosis. There are more than 100 pathogens causing community-acquired pneumonia, of which viruses account for about 30%. Pneumonia caused by other viruses is similar to common influenza virus, parainfluenza virus, adenovirus, respiratory syncytial virus, rhinovirus, human metapneumovirus and SARS coronavirus. It is difficult to distinguish between clinical manifestations and chest imaging only, and it needs to be distinguished by pathogen detection.
Seventh, the discovery, reporting and elimination of cases. Hubei province is different from other provinces outside Hubei.
In other provinces outside Hubei, the procedure of finding cases is the same as that of the defendant and the fourth edition, emphasizing that suspected patients should be transferred to designated hospitals as soon as possible on the premise of ensuring the safety of transfer.
In view of Hubei province's requirement that medical staff at all levels and types of medical institutions immediately isolate suspected diseases and clinically diagnosed cases that meet the definition of cases. Suspected cases and clinically diagnosed cases should be isolated in a single room, and samples should be collected as soon as possible for pathogen detection.
Suspected cases can only be excluded if the respiratory pathogenic nucleic acid test is negative for two consecutive times (the sampling interval is at least 1 day).
Eighth, the treatment includes isolation and symptomatic support, while closely monitoring the changes of the disease, especially the respiratory rate and finger oxygen saturation.
Suspected cases should be treated in isolation in a single room, and confirmed cases can be treated in the same ward.
Critical cases should be sent to ICU for treatment as soon as possible.
Antibacterial drug use: Avoid blind or improper use of antibiotics, especially the combined use of broad-spectrum antibiotics.
Antiviral treatment: add "There is no effective antiviral treatment at present." ? Add "or ribavirin" on the basis of trying interferon-α aerosol inhalation and lopinavir/ritonavir. At the same time, we should pay attention to the adverse reactions related to lopinavir/ritonavir, such as diarrhea, nausea, vomiting, liver function damage, and the interaction with other drugs.
Successful treatment of severe and critical cases is the key to reduce mortality. It is necessary to actively prevent and treat complications, treat basic diseases, prevent secondary infection, and provide organ function support in time. Patients often have anxiety and fear, so psychological counseling should be strengthened.
For disease surveillance, add "cytokine detection is feasible if conditions permit."
Respiratory support: (1) oxygen therapy: critically ill patients should receive nasal catheter or mask for oxygen inhalation, and timely assess whether respiratory distress and/or hypoxemia are relieved. (2) High-flow nasal catheter oxygen therapy or noninvasive mechanical ventilation: When the patient's respiratory distress and/or hypoxemia cannot be relieved after receiving standard oxygen therapy, high-flow nasal catheter oxygen therapy or noninvasive ventilation can be considered. It is emphasized that "if the condition does not improve or even worsen within a short time (1~2 hours), tracheal intubation and invasive mechanical ventilation should be carried out in time".
(3) Invasive mechanical ventilation: lung protective ventilation strategy is adopted, that is, low tidal volume (4~8mL/kg ideal body weight) and low inspiratory pressure (platform pressure)
Circulation support: on the basis of adequate fluid resuscitation, improve microcirculation, use vasoactive drugs, and monitor hemodynamics when necessary.
Other treatment measures: according to the degree of dyspnea and the progress of chest imaging, glucocorticoid can be used for a short time (3 ~ 5 days), and the recommended dose should not exceed the equivalent of methylprednisolone 1 ~ 2mg/kg/ day. It should be noted that high-dose glucocorticoid will delay the clearance of coronavirus due to immunosuppression; Xuebijing 100mL/ can be administered intravenously twice a day; Intestinal microecological regulator can be used to maintain intestinal microecological balance and prevent secondary bacterial infection; Recovery plasma treatment can be used; For critically ill patients with high inflammatory reaction, extracorporeal blood purification technology can be considered if conditions permit.
About Chinese medicine treatment. The disease belongs to the category of TCM epidemic. The etiology lies in the lung, and its basic pathogenesis is "damp-heat and toxic blood stasis". According to the condition, local climate characteristics and different physique, all localities can treat according to the recommended scheme.
Ninth, lift the isolation and discharge standards. On the basis of "body temperature returned to normal for more than 3 days, respiratory symptoms were obviously improved", "lung imaging showed obvious absorption of inflammation" was added, and respiratory pathogenic nucleic acid was negative for two consecutive times (sampling interval was at least 1 day), and patients could be released from isolation or transferred to corresponding departments for treatment of other diseases according to their illness.
Tenth, the principle of transshipment. In order to ensure the safety of transshipment, patients should be transported by special vehicles, and personal protection and vehicle disinfection should be done.