宵枚： 他山之石---也談冠狀病毒肺炎

我一直擔心的事兒終於發生了。美國也出現了多起新冠病毒肺炎的病例，並且在華盛頓州已經有人死亡。

今天在網上看到下麵這篇文章，覺著這可能是“他山之石”，轉在這裏，供大家參考。西藥，美國不缺，中藥，美國沒有中國城的城市可能買不到。但是美國是多民族的聚集地，從來就不缺少各民族的抗炎症草藥。比如說印度人用來燒菜的Turmeric，現在就是美國人推崇的抗炎神藥。中國人的生薑，也是抗炎神藥呀。現在明白了老祖宗讓我們喝薑湯的意思了吧？抗病毒呀。當然，大病隻喝薑湯是不行的。大病要去醫院。但是輕症，薑湯可以清毒安神。你最怕在大難來臨時，亂了手腳。如果做點事情，也許可以安神、免驚、增加抵抗力。自新冠肺炎爆發以來，我一直在看各種文章，直覺這篇文章的可信度高，也是中國對世界做了貢獻吧。這個貢獻是由成千上萬的中國醫務人員殊死奮戰而來，由成千上萬的中國義務人員日夜奮戰而來，總結了近三千位死亡的同胞的病程而來。這近三千名同胞就包括了李文亮、李醫生。現在“眼睛充血”成了冠狀病毒肺炎的症狀之一。李醫生生前是眼科醫生，他是在為一位攜帶病毒的老人看眼病時感染的。閑話少說，看看幹貨是怎麽說的吧。

 

Novel Coronavirus Pneumonia Diagnosis and Treatment Plan (Provisional 6th Edition)

2020/02/19 China Law Translate Uncategorized 1

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III. Clinical Characteristics

(1) Clinical presentation. Based on the current epidemiological investigation, the incubation period is 1-14 days, and most often between 3-7 days.

The primary presentations are fever, dry cough, and fatigue. A minority of patients have symptoms such as nasal congestion, nasal discharge, sore throat, muscle pain, and diarrhea. Severe patients often suffer from dyspnea and/or hypoxemia one week after onset, and severe patients can rapidly progress to acute respiratory distress syndrome, septic shock, difficult to correct metabolic acidosis, coagulation dysfunction and multiple organ failure. It is worth noting that severe and critical patients may have moderate to low fever or even no obvious fever during the course of the disease.

Patients with the mild form of the disease present only as low fever, slight fatigue, and so forth, with no lung inflammation.

Judging from the current cases, most patients have a good prognosis and a minority are in critical condition. The prognosis of the elderly and those with chronic underlying diseases is more poor. The symptoms of child cases are relatively mild.

(2) Laboratory examination.

In the early stage of the disease, the total number of peripheral blood leukocytes is normal or decreased, and the lymphocyte count was decreased, and some patients may have increased liver enzyme, lactate dehydrogenase (LDH), myoenzyme and myoglobin, and some critically ill patients may have elevated troponin. C-reactive protein (CRP) and erythrocyte sedimentation rate increased in most patients, and procalcitonin was normal. In severe cases, D- dimer increased and peripheral blood lymphocytes progressively decreased. Inflammatory cytokines often increase in severe and critical patients.

Novel coronavirus nucleic acid can be detected in nasopharyngeal swabs, sputum and other lower respiratory tract secretions, blood, feces and other samples.

In order to improve the positive rate of nucleic acid detection, it is suggested that sputum be collected as much as possible, collecting secretions from the lower respiratory tract of patients undergoing tracheal intubation, and sending samples for examination as soon as possible after collection.

(3) Chest Imaging.

In the early stage, there are multiple small patches and interstitial changes, most notably in the outer lung. It further develops into multiple ground-glass opacity and infiltration shadows in both lungs; and in severe cases, consolidation of the lungs may occur, and pleural effusion is rare.

VIII. Treatment

(1) Determine the place of treatment based on the patients' conditions.

1. Suspected and confirmed cases should be treated in quarantine, in designated hospitals with effective isolation and disease control capacity. Suspected cases should be treated in individual isolation. Confirmed cases can be treated with multiple patients in the same isolation room.
2. Critical cases shall be put in ICU treatment as soon as possible.

(2) Regular treatment.

1. Treatment for mild cases includes bed rest, supportive treatments, and maintenance of caloric intake. Pay attention to fluid and electrolyte balance and maintain homeostasis. Closely monitor the patient's vitals and oxygen saturation.
2. As indicated by clinical presentations, monitor the hematology panel, routine urinalysis, CRP, biochemistry (liver enzymes, cardiac enzymes, kidney function), coagulation, arterial blood gas analysis, chest radiography, and so on. Cytokines can be tested if possible.
3. Administer effective oxygenation measures promptly, including nasal catheter, oxygen mask, and high flow nasal cannula.
4. Antiviral therapies: Interferon-alpha (adult: 5 million units or equivalent can be added to 2ml sterile water for injection and delivered with a nebulizer twice daily), lopinavir/ritonavir (adult: 200mg/50mg/tablet, 2 tablets twice daily; the length of treatment should not exceed 10 days), ribavirin (recommended in combination with interferon or lopinavir/ritonavir, adult: 500mg twice or three times daily via IV, the length of treatment should not exceed 10 days), chloroquine phosphate (adult: 500mg twice daily; the length of treatment should not exceed 10 days), umifenovir (adult: 200mg three times daily; the length of treatment should not exceed 10 days). Pay attention to the adverse effects associated with lopinavir/ritonavir, such as diarrhea, nausea, vomiting and liver dysfunction, as well as interactions with other medications. The efficacy of the current medications in use will be evaluated in clinical application. Using 3 or more antiviral drugs is not recommended. Corresponding medication should be discontinued should intolerable side effects are present.
5. Antibiotic therapies: avoid unjustifiable or inappropriate usage of antibiotics, especially combinatory use of broad-spectrum antibiotics.

(3) Treatment of severe and critical cases.

1. Treatment principles: on the basis of symptom management, proactively prevent and manage complications, treat underlying diseases, prevent secondary infections, and prompt organ function support.
2. Respiratory support:

(1) Oxygen therapy: patients with severe symptoms should be receiving oxygenation through nasal cannulas or oxygen masks. Assess the patient timely to determine whether dyspnea and/or hypoxemia have been alleviated.

(2) High flow nasal cannula or non-invasive ventilation: when patients with dyspnea and/or hypoxemia do not respond to regular oxygen therapy, consider using high flow nasal cannula or non-invasive ventilation. If the symptoms do not improve or worsen within a short period of time (1-2 hours), tracheal intubation and invasive mechanical ventilation should be used.

(3) Invasive mechanical ventilation: using lung-protective ventilation strategy (LPVS), i.e. low tidal volume of 4-8ml/kg ideal body weight, and low inspiratory pressure (plateau pressure < 30cm H2O) for mechanical ventilation in order to reduce ventilation-associated lung injury. Patient-ventilator asynchrony is common. Sedation and muscle relaxant should be used appropriately.

(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is recommended. When resources allow, prone ventilation should be carried out for 12 hours per day. If prone ventilation is ineffective, extracorporeal membrane oxygenation (ECMO) should be considered if conditions allow.

1. Circulatory support: starting with sufficient fluid resuscitation and improve microcirculation. Use vasoactive drugs, and monitor hemodynamics when necessary.
2. Use of convalescent plasma collected from recovered patients: indicated for patients with rapid disease progression, and severe or critical cases For usage and dosage, see "The Diagnosis and Treatment Plan for COVID-19 (Provisional 1st edition)".
3. Other treatment measures

For patients with progressively deteriorating oxygenation index, rapid imaging progression, and overactive inflammatory responses, short-term (3-5 days) glucocorticoid treatment may be used at the clinician's discretion. It's recommended that the dosage should not exceed the equivalence of methylprednisolone at 1-2mg/kg/day, since the immunosuppressive function of high-dose glucocorticoid may delay the clearance of coronavirus from the system. Xuebijing may be given intravenously at 100ml twice a day. Probiotics can be given to maintain intestinal microbiome balance and to prevent secondary bacterial infection. For severe and critical cases with hyper-inflammation, extracorporeal blood purification techniques such as plasma exchange, plasma absorption, plasma perfusion, and hemofiltration may be considered.

Patients often have anxiety and fear, and psychological counseling should be strengthened.

(4) Treatment by Chinese Medicine.

本病屬於中醫“疫”病範疇,病因為感受“疫民”之氣,各地可根據病情、當地氣候特點以及不同體質等情況,參照下列方案進行辨證論治。 涉及到超藥典劑量,應當在醫師指導下使用。

1. Period of Medical Observation

Clinical manifestation 1: lack of energy accompanied by gastrointestinal discomfort

推薦中成藥:藿香正氣膠囊(丸、水、口服液)

Clinical Manifestation 2: Fatigue with Fever

推薦中成藥:金花清感顆粒、連花清瘟膠囊(顆粒)、疏風解毒膠囊(顆粒)

1. Clinical treatment period (confirmed cases)

2.1清肺排毒湯

適用範圍:適用於輕型、普通型、重型患者,在危重型患者救治中可結合患者實際情況合理使用。

基礎方劑:麻黃9g、炙甘草6g、杏仁9g、生石膏15~30g(先煎)、桂枝9g、澤瀉9g、豬苓9g、白術9g、茯苓15g、柴胡16g、黃芩6g、薑半夏9g、生薑、紫菀9g、冬花9g、射千9g、細辛6g、山藥12g、枳實6g、陳皮68、藿香9g。

服法:傳統中藥飲片,水煎服。 每天一付,早晚兩次(飯後四十分鍾),溫服,三付一個療程。

如有條件,每次服完藥可加服大米湯半碗,舌幹津液虧虛者可多服至一碗。 (注:如患者不發熱則生石膏的用量要小,發熱或壯熱可加大生石膏用量)。 若症狀好轉而未痊愈則服用第二個療程,若患者有特殊情況或其他基礎病,第二療程可以根據實際情況修改處方,症狀消失則停藥。

處方來源:國家衛生健康委辦公廳國家中醫藥管理局辦公室《關於推薦在中西醫結合救治新型冠狀病毒感染的肺炎中使用“清肺排毒湯”的通知》(國中醫藥辦醫政函〔2020)22號)。

2.2 Mild Form

(1)寒濕鬱肺證

臨床表現:發熱,乏力,周身酸痛,咳嗽,咯痰,胸緊整氣,納呆,惡心,嘔吐,大便粘膩不爽。 舌質淡胖齒痕或淡紅,苔白厚腐膩或白膩,脈濡或滑。

推薦處方:生麻黃6g、生石膏15g、杏仁9g、羌活15g、尊勞子15g、貫眾9g、地龍15g、徐長卿15g、藿香15g、佩蘭9g、蒼術15g、雲苓45g、生白術30g、焦三仙各9g、厚樸15g、焦檳榔9g、喂草果9g、生薑15g。

服法:每日1劑,水煎600ml,分3次服用,早中晚各1次,飯前服用。

(2)濕熱蘊肺證

臨床表現:低熱或不發熱,微惡寒,乏力,頭身困重,肌肉酸痛,幹咳痰少,咽痛,口幹不欲多飲,或伴有胸悶脘痞,無汗或汗出不暢,或見嘔惡納呆,便溏或大便粘滯不爽。 舌淡紅,苔白厚膩或薄黃,脈滑數或需。

推薦處方:檳榔10g、草果10g、厚樸10g、知母10g、黃夢10g、柴胡10g、赤芍10g、連翹15g、青蒿10g(後下)、蒼術10g、大青葉10g、生甘草5g。

服法:每日1劑,水煎400ml,分2次服用,早晚各1次。

2.3普通型

(1)濕毒鬱肺證

臨床表現:發熱,咳嗽痰少,或有黃痰,憋悶氣促,腹脹,便秘不暢。 舌質暗紅,舌體胖,苔黃膩或黃燥,脈滑數或弦滑。

推薦處方:生麻黃6g、苦杏仁15g、生石膏30g、生薏苡仁30g、茅蒼術10g、廣藿香15g、青蒿草12g、虎杖20g、馬鞭草30g、幹蘆根30g、孝子15g、化橘紅15g、生甘草10g。

服法:每日1劑,水煎400ml,分2次服用,早晚各1次。

(2)寒濕阻肺證

臨床表現:低熱,身熱不揚,或未熱,幹咳,少痰,倦怠乏力,胸悶,脘痞,或嘔惡,便溏。 舌質淡或淡紅,苔白或白膩,脈濡。

推薦處方:蒼術15g、陳皮10g、厚樸10g、藿香10g、草果6g、生麻黃6g、羌活10g、生薑10g、檳榔10g。

服法:每日1劑,水煎400ml,分2次服用,早晚各1次。

2.4 Serious Form

(1)疫毒閉肺證

臨床表現:發熱麵紅,咳嗽,痰黃粘少,或痰中帶血,喘憋氣促,疲乏倦怠,口幹苦粘,惡心不食,大便不暢,小便短赤。 舌紅,苔黃膩,脈滑數。

推薦處方:生麻黃6g、杏仁9g、生石膏15g、甘草3g、灌香10g(後下)、厚樸10g、蒼術15g、草果10g、法半夏9g、獲苓15g、生大黃58(後下)、生黃芪10g、夢芹子10g、赤芍10g。

服法:每日1~2劑,水煎服,每次100ml~200ml,一日2~4次,口服或鼻飼。

(2)氣營兩燔證

臨床表現:大熱煩渴,喘憋氣促,擔語神昏,視物錯督,或發斑疹,或吐血、衄血,或四肢抽搐。 舌絳少苔或無苔,脈沉細數,或浮大而數。

推薦處方:生石膏30~60g(先煎)、知母30g、生地30~60g、水牛角30g(先煎)、赤芍30g、玄參30g、連翹15g、丹皮15g、黃連6g、竹葉12g、夢勞子15g、生甘草6g。

服法:每日1劑,水煎服,先煎石膏、水牛角後下諸藥,每次100ml~200ml,每日2~4次,口服或鼻飼。

推薦中成藥:喜炎平注射液、血必淨注射液、熱毒寧注射液、痰熱清注射液、醒腦靜注射液。 功效相近的藥物根據個體情況可選擇一種,也可根據臨床症狀聯合使用兩種。 中藥注射劑可與中藥湯劑聯合使用。

2.5危重型(內閉外脫證)

臨床表現:呼吸困難、動輒氣喘或需要機械通氣,伴神昏,煩躁,汗出肢冷,舌質紫暗,苔厚膩或燥,脈浮大無根。

推薦處方:人參15g、黑順片10g(先煎)、山茱萸15g,送服蘇合香丸或安宮牛黃丸。

推薦中成藥:血必淨注射液、熱毒寧注射液、痰熱清注射液、醒腦靜注射液、參附注射液、生脈注射液、參麥注射液。 功效相近的藥物根據個體情況可選擇一種,也可根據臨床症狀聯合使用兩種。 中藥注射劑可與中藥湯劑聯合使用。

注：重型和危重型中藥注射劑推薦用法

中藥注射劑的使用遵照藥品說明書從小劑量開始、逐步辨證調整的原則,推薦用法如下:

病毒感染或合並輕度細菌感染:0.9%氯化鈉注射液250ml加喜炎平注射液100mgbid,或0.9%氯化鈉注射液250ml加熱毒寧注射液20ml,或0.9%氯化鈉注射液250ml加痰熱清注射液40mlbid。

高熱伴意識障礙:0.9%氯化鈉注射液250ml加醒腦靜注射液20mlbid。

全身炎症反應綜合征或/和多髒器功能衰竭:0.9%氯化鈉注射液250ml加血必淨注射液100mlbid。

免疫抑製:0.9%氯化鈉注射液250ml加參麥注射液100mlbid.

休克:0.9%氯化鈉注射液250ml加參附注射液100mlbid。

2.6 Recovery Period

(1)肺脾氣虛證

臨床表現:氣短,倦怠乏力,納差嘔惡,痞滿,大便無力,便溏不爽。 舌淡胖,苔白膩。

推薦處方:法半夏9g、陳皮10g、黨參15g、炙黃芪30g、1炒白術10g、茯苓15g、藿香10g、砂仁6g(後下)、甘草6g。

服法:每日1劑,水煎400ml,分2次服用,早晚各1次。

(2)氣陰兩虛證臨床表現:乏力,氣短,口幹,口渴,心悸,汗多,納差,低熱或不熱,幹咳少痰。 舌幹少津,脈細或虛無力。

推薦處方:南北沙參各10g、麥冬15g、西洋參6g,五味子6g、生石膏15g、淡竹葉10g、桑葉10g、蘆根15g、丹參15g、生甘草6g。

服法:每日1劑,水煎400ml,分2次服用,早晚各1次。

IX. Matters for attention after release from isolation or hospital.

(1) Criteria for release from isolation and hospital discharge

1. Temperature returned to normal for 3 days or more;

1. Respiratory symptoms have a clear turn for the better;
2. Chest radiology findings show substantial improvement of acute exudative lesions.
3. Two consecutive negative nucleic acid tests using respiratory tract samples (taken at least 24 hours apart).

Those meeting the requirements above may be released from isolation or hospital.

(2) Matters for attention after hospital discharge.

1. Designated hospitals should communicate with primary care facilities at the patient's place of residence and share medical records. Information on the discharged patients should be forwarded to the relevant neighbourhood committees and primary care facilities in a timely manner.
2. Discharged patients are at increased risk of acquiring other pathogens due to their reduced immune functions during recovery. It's recommended that the patients: continue to self-monitor for 14 days, wear masks, live in well-ventilated individual suites if possible, reduce close contact with family members, eat separately, practice good hand hygiene, and avoid going outside.
3. Follow-up visits are recommended at 2 and 4 weeks after discharge.

X. Transport Priniciples

Implement in accordance with the "Work Plan for Transport of Novel Coronavirus Pneumonia Cases (Provisional)" released by our Commission.

XI. Prevention and Control of Infection in Medical Establishments

嚴格按照我委《醫療機構內新型冠狀病毒感染預防與控製技術指南(第一版)》、《新型冠狀病毒感染的肺炎防護中常見醫用防護用品使用範圍指引(試行)》的要求執行。

抄送;各省、自治區、直轄市及新疆生產建設兵團應對新型冠狀病毒肺炎疫情聯防聯控機製(領導小組、指揮部)。

General Office of the National Health Commission

Released February 18, 2020

校對:杜青陽

 

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應該也有中文版。