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General Office of the National Health Commission Office of the State Administration of Traditional Chinese Medicine

Guo Wei ban Yi Han

Health and Health Committee and administration of traditional Chinese medicine of all provinces, autonomous regions, municipalities directly under the central government and Xinjiang production and Construction corps:

In order to further do a good job in the diagnosis and medical treatment of pneumonia cases with  new coronavirus infection, we organized experts to revise the diagnosis and treatment plan based on the analysis, study and summary of the early medical treatment work, and formed the diagnosis and treatment work, and formed the diagnosis and treatment plan for pneumonia with the new coronavirus 

 
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General Office of the National Health Commission Office of the State Administration of traditional Chinese Medicine

Guo Wei ban Yi Han 2020103

Notice on printing and distributing the diagnosis and treatment plan for pneumonia with new coronavirus infection (trial version 5)

Health and Health Committee and administration of traditional Chinese medicine of all provinces, autonomous regions, municipalities directly under the central government and Xinjiang production and Construction Corps:

In order to further do a good job in the diagnosis and medical treatment of pneumonia cases with new coronavirus infection, we organized experts to revise the diagnosis and treatment plan based on the analysis, study and summary of the early medical treatment work, and formed the diagnosis and treatment plan for pneumonia with new coronavirus infection (trial version 5). It is hereby printed and distributed to you. Please refer to it for implementation. All relevant medical institutions should actively play the role of traditional Chinese medicine in medical treatment, strengthen the combination of traditional Chinese and Western medicine, establish the joint consultation system of traditional Chinese and Western medicine, and promote the medical treatment to achieve good results.

February 4, 2020
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Diagnosis and treatment of pneumonia with new coronavirus infection

(trial version 5)

Since December 2019, a number of new coronavirus infected pneumonia patients have been found in Wuhan, Hubei Province. With the spread of the epidemic, such cases have been found in other regions of China and abroad. As an acute respiratory infectious disease, the disease has been included in the class B infectious disease stipulated in the law of the people's Republic of China on the prevention and control of infectious diseases and is managed as class A infectious disease.

With the in-depth understanding of the disease and the accumulation of diagnosis and treatment experience, we revised the diagnosis and treatment plan for pneumonia with now coronavirus infection (trial version 4). and formed the diagnosis and treatment plan for pneumonia with new coronavirus infection (trial version 5)

Character's-TICS at catiOINPI

The new type of coronavirus belongs to the genus (3. It has a capsule, and its particles are round or oval. It is usually pleomorphic, with a diameter of 60-140nm. The genetic characteristics of SARS CoV and mersr coy were significantly different. At present, when the homology with bat-sl-covzc 45 is more than 85% in vitro, 2019-ncov can be found in human respiratory epithelial cells within 96 hours, while it takes about 6 days to isolate and culture in Vero 6 and Huh-7 cell lines.

The understanding of the physical and chemical characteristics of coronavirus is mainly from the study of SARS CoV and mers coy. The virus is sensitive to UV and heat. 56 C for 30 minutes, ether, 75% ethanol, chlorine containing disinfectant, peracetic acid and chloroform can effectively inactivate the virus, while chlorhexidine can not effectively inactivate the virus.

 
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2. Epidemiological Characteristics

(1) Source or Infection

At present, the main source of infection is patients with new coronavirus Infection. Asymptomatic Infections can also be a source of infection

(2) Transmission channels

Respiratory droplets and contact are the main routes of transmission. The transmission routes of aerosol and digestive tract are yet to be determined.

13)  Susceptible population

People are generally susceptible

3. Clinical characteristics

(1) Clinical manifestations

Based on current epidemiological survey, the incubation period is 1 -14 days, mostly 3-7 days.

Fever, fatigue and dry cough were the main manifestations. A small number of patients with nasal congestion, runny nose, sore throat and diarrhea and other symptoms. Severe patients often have dyspnea and / or hypoxemia one week after the onset of the disease, and the severe patients develop rapidly into acute respiratory distress syndrome, septic shock, metabolic acidosis and coagulation dysfunction which are difficult to correct. It should be noted that the course of severe and critical patients may be moderate to low fever, or even no obvious fever

Mild patients only showed low fever, slight fatigue, no pneumonia.

From the current situation of the cases, most patients have a good prognosis, and a few patients are in critical condition. The prognosis of the elderly and those with chronic basic diseases is poor. The symptoms of children were relatively mild.

(2) Laboratory Examination
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In the early stage of the disease, the total number of leukocytes in peripheral blood was normal or decreased, the lymphocyte count was decreased, some patients could have the increase of liver enzyme, lactate dehydrogenase (LDH), muscle enzyme and myoglobin, and some critical patients could see the Increase of troponin. CRP and ESR increased in most patients, and procalcitonin was normal. In severe cases, D-dimer increased and peripheral blood lymphocyte decreased progressively.

The new coronavirus nucleic acid can be detected in the samples of nasopharynx swab, sputum, lower respiratory tract secretion, blood, feces. etc.

(3) Chest imaging

In the early stage, there were multiple small patch shadows and interstitial changes, especially in the extrapulmonary zone. In severe cases, lung consolidation may occur, and pleural effusion is rare

4, Diagnostic criteria

Provinces outside Hubei:

1. Suspected cases.Combined witht he comprehensive analysis of the follwing epidemioligcal history and clinical identifications:

Epidemiological history

1) Within 14 days of the onset of the disease, there was Wuhan and surrounding areas, or other diseases.

Report the travel or residence history of the community:

(2) Within 14 days before the onset of the disease, they had contact history with new coronavirus infected persons (those with positive nucleic acid test):

(3) Within 14 days before the onset of the disease, the patients from Wuhan city and surrounding areas, or from the community with case reports of fever or respiratory symptoms were contacted;

(4) Aggregation.

2. Clinical manifestations

 
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(1) Fever and / or respiratory symptoms;

(2) It has the above-mullioned image characteristics of pneumonia:

(3) In the early stage of the disease, the total number of leukocytes was normal or decreased, or the lymphocyte count was decreased

There Is any one in the epidemiological history, and it is consistent with any two in the clinical manifestations. If there is no clear epidemiological history, it is in line with 3 of the clinical manifestations.

(2)Confirmed cases.

Suspected cases with one of the following pathogenic evidences:

1. Real time RT-PCR detection of new crown in respiratory or blood samples

The nucleic acid of the virus was positive;

2. The virus gene sequencing of respiratory or blood samples is highly homologous with the known new coronavirus.

Hubei Province:

1. Suspected cases.

Combined with the comprehensive analysis of the following epidemiological history and clinical manifestations

1. Epidemiological history

(1) Within 14 days before the onset of the disease, there were travel or residence histories of Wuhan and its surrounding areas, or other communities with case reports;

(2) Within 14 days before the onset of the disease, they had contact history with new coronavirus infected persons (those with positive nucleic acid test);

(3) Within 14 days before the onset of the disease, the patients from Wuhan city and surrounding areas, or from the community with case reports of fever or respiratory symptoms were contacted;

(4) Agglomerative disease

2. Clinical manifestations

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(1) Fever and / or respiratory symptoms;

(2) In the early stage of the disease, the total number of leukocytes was normal or decreased, or the lymphocyte count was decreased.

There is any one or no epidemiological history, and at the same time, there are 2 clinical manifestations.

()clinically diagnosed cases.

 Suspected cases with Imaging characteristics of pneumonia

(2) Confirmed cases.

Clinically diagnosed or suspected cases with one of the following epidemiological evidences

Who:

1. Real time RT-PCR was used to detect the new coronavirus in respiratory or blood samples;

2. Virus gene sequencing of respiratory or blood samples, and new known Coronavirus is highly homologous.

5, Clinical typing

(1) Light duty,

The clinical symptoms were mild, and there was no sign of pneumonia on imaging.

(2)Common type. It has fever, respiratory tract and other symptoms, and Its imaging shows pneumonia

(3)Heavy duty.

 Comply with any of the following:

1. Respiratory distress, RR > 30 times / min;

2. In the resting state, the oxygen saturation is < 93%;

3. Pa02 / Fi02 < 300MMHG
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( 1mmHg=0.133kPa )

(4)Severe.

One of the following:

1. Respiratory failure occurs and mechanical ventilation is required;

2. Shock;

3. Patients with other organ failure need ICU monitoring and treatment.

6. Differential diagnosis

It is mainly differentiated from influenza virus, parainfluenza virus, adenovirus, respiratory syncytial virus, rhinovirus, human metapneumovirus, SARS coronavirus and other known viral pneumonia, Mycoplasma pneumoniae, Chlamydia pneumoniae and bacterial pneumonia. In addition, it should be differentiated from non infectious diseases, such as vasculitis, dermatomyositis and organic pneumonia.

7, Case finding and report

Provinces outside Hubei:

After finding suspected cases that meet the definition of cases, medical staff of all kinds of medical institutions at all levels shall immediately carry out isolation treatment. Experts or chief physicians in the hospital shall consult with each other, and the suspected cases shall still be considered. Within 2 hours, the network direct report shall be carried out, and samples shall be collected for new coronary viral nucleic acid detection. At the same time, the suspected patients shall be transferred to the designated hospital immediately on the premise of ensuring the safety of transfer. For patients who have close contact with new coronavirus infection, even if the common respiratory tract pathogens are positive, it is recommended to carry out the new coronavirus etiology test in time.

The suspected cases can only be excluded if the respiratory pathogenic nucleic acid test is negative twice in a row (the sampling time is at least one day apart).

Hubei Province:

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Medical staff of all kinds of medical institutions at all levels shall immediately conduct isolation treatment after finding suspected and clinically diagnosed cases that meet the definition of cases. Suspected and clinically diagnosed cases shall be isolated separately. Samples of suspected and clinically diagnosed cases shall be collected as soon as possible for etiological test.

Eight, treatment

(1) Determine the treatment site according to the condition.

1. Suspected and confirmed cases shall be isolated and treated in designated hospitals with effective isolation conditions and protection conditions. Suspected cases shall be isolated and treated in a single room. Confirmed cases can be admitted to the same ward by multiple people.

2. Severe cases should be treated In ICU as soon as possible.

(2) General treatment.

1. Rest in bed, strengthen support treatment, ensure sufficient heat; pay attention to the balance of water and electrolyte, maintain the stability of internal environment; closely monitor vital signs, finger oxygen saturation, etc.

2. Monitor blood routine, urine routine, CRP, biochemical indicators (liver enzyme, myocardial enzyme, renal function, etc.) coagulation function, arterial blood gas analysis, chest imaging, etc. according to the condition. Cytokine detection is feasible if conditions permit.

3. Give effective oxygen therapy measures in time, including nasal catheter, mask and high flow oxygen therapy through nose.

4. Antiviral therapy: there is no confirmed effective antiviral therapy. It can be used to inhale interferon a (5 million U or equivalent dose for adults, 2M1 sterile water for injection, twice a day) twice a time for lopinavir / ritonavir (200mg / 50mg, twice a day), or add ribavirin (4G for adults, 1.2g every 8 hours the next day, or 8mg / kgiv)
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Every 8 hours). Attention should be paid to the adverse reactions of lopinavir / ritonavir related diarrhea, nausea, vomiting, liver function damage, and the interaction with other drugs

5. Antibiotic treatment: avoid blind or inappropriate use of antibiotics, especially the combination of broad-spectrum antibiotics.

(3) Treatment of severe and critical cases. (3) Treatment of severe and critical cases

1. Treatment principle: on the basis of symptomatic treatment, actively prevent and treat complications, treat basic diseases, prevent secondary infection, and timely support organ function

2. Respiratory support:

() oxygen therapy: severe patients should receive nasal catheter or face mask oxygen inhalation, and timely assess whether respiratory distress and / or hypoxemia are relieved.

(2) High flow oxygen therapy or noninvasive mechanical ventilation: when the respiratory distress and / or hypoxemia cannot be alleviated after standard oxygen therapy, high flow oxygen therapy or noninvasive ventilation can be considered. If the condition does not improve or even worsen in a short period of time (1-2 hours), intubation and invasive mechanical ventilation should be carried out in time.

(3) Invasive mechanical ventilation: adopt lung protective ventilation strategy, that is, low tidal volume (4-8M / kg ideal body weight) and low inspiratory pressure (platform pressure < 30cmh20) for mechanical ventilation to reduce ventilator-related lung injury. Many patients have man-machine asynchrony, so sedation and muscle relaxant should be used in time.

(4) Rescue treatment: for patients with severe ARDS, it is recommended to carry out lung atelectasis in a prone position with sufficient human resources for more than 12 hours every day. If the ventilation effect of prone position is not good, ECMO should be considered as soon as possible
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3. Circulation support: on the basis of full fluid resuscitation, improve microcirculation, use vasoactive microcirculation, use vasoactive drugs, and conduct hemodynamic monitoring if necessary

4. Other treatment measures

According to the degree of dyspnea and the progress of chest imaging, glucocorticoids can be used in a short time (3-5 days) as appropriate. It is suggested that the dosage should not exceed 1-2mg / kg / day of methylprednisolone. It should be noted that the larger dose of glucocorticoids will delay the removal of coronavirus due to immunosuppression. Xuebijing 100m1 / time can be given intravenously, twice a day. Intestinal microecological regulators can be used, To maintain the intestinal microecology balance and prevent the secondary bacterial infection, the recovery plasma therapy can be used, and for the critical patients with high inflammatory reaction, the in vitro blood purification technology can be considered if conditions permit.

Patients often have anxiety and fear, so we should strengthen psychological counseling

(4) TCM treatment.

This disease belongs to the category of epidemic disease in traditional Chinese medicine. Due to the feeling of the disease, all regions can treat it according to the following schemes according to the conditions, local climate characteristics and different physical conditions.

1. Medical observation period

Clinical manifestation 1: asthenia with gastrointestinal miscomfort

Recommended Chinese patent medicine: Huoxiang Zhenggi Capsule (pill. water. oral liquid)

 Clinical manifestation 2: asthenia with fever

Recommended Chinese patent medicine: Jinhua Qinggan granules, Lianhua Qingwen capsules (granules). Shufeng Jiedu capsules (granules), Fangfeng Tongsheng pills (granules)

2. Clinical treatment period

(1) Early stage: cold, damp and depressed lung
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Clinical manifestations: cold, fever or no fever, dry cough, dry throat, fatigue and fatigue.

Chest tightness. (unclear), or nausea, loose stools. The tongue is light or reddish. the moss is white and greasy. and the pulse Is moistening

Recommended prescription: Atractylodes lanceolata 15g, tangerine peel 10g, Magnolia officinails 10g. Huoxiang 10g

In the middle stage: epidemic virus and lung arrest

Clinical manifestations: body heat does not subside or flow between cold and heat, cough less phlegm, or yellow phlegm, abdominal distension and constipation. Chest tightness and shortness of breath, coughing and suffocating, movement leads to asthma. Red tongue, yellow greasy or dry fur, smooth pulse.

Recommended prescription: Almond 10g, raw gypsum 30g, Trichosanthes 30g, raw rhubarb 6G (later), raw ephedra 6G, Tingli 10g, peach 10g, grass 6G, betel 10g, Atractylodes 10g

Recommended Chinese patent medicine: Xiyanping injection, Xuebijing Injection

(3) Severe stage: internal closure and external detachment

Clinical manifestations: dyspnea, wheezing frequently or requiring auxiliary ventilation, accompanied by spirit

Faint, fidgety, cold sweating limbs, dark purple tongue, thick and greasy or dry moss, large and rootless pulse floating. Recommended prescription: Ginseng 15g, heishun tablet lOg (Pan Fried first), Cornus 15g,

Take Suhexiang pill or Angong Niuhuang Pill as a gift

Recommended Chinese patent medicine: Xuebijing injection, Shenfu injection, Shengmai Injection (4) recovery period: deficiency of lung and spleen qi

Clinical manifestations: shortness of breath, fatigue, nausea, fullness of ruffian, weakness of stool, loose stools, fat tongue, white and greasy fur.

Recommended prescription: Rhizoma Pinelliae 9g, tangerine peel 10g, dangshen 15g, roasted Astragalus 30g, Poria 15g, Huoxiang 10g, Amomum 6G (later)

9, De isolation and discharge criteria.