Chapter 10. Treatment

(A) Determine the Treatment Place According to the Condition.

1. Suspected and confirmed cases should be isolated and treated in designated hospitals with effective isolation and protection conditions. Suspected cases should be treated in a single room and isolated. Multiple confirmed cases can be admitted to the same ward.
2. Critical cases should be admitted to ICU as soon as possible.

(B) General Treatment.

1. Rest in bed and strengthen supportive treatment to ensure sufficient heat; pay attention to water and electrolyte balance to maintain internal environment stability; closely monitor vital signs and oxygen saturation.
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. If possible, cytokine detection is feasible.
3. Give effective oxygen therapy in time, including nasal catheter, mask oxygen and transnasal high-flow oxygen therapy. Conditions can be treated with mixed oxygen and hydrogen inhalation (H2 / O2: 66.6% / 33.3%).
4. Antiviral therapy: try alpha-interferon (5 million U or equivalent per adult, add 2ml of sterile water for injection, 2 times daily inhalation), lopinavir / ritonavir (adult 200mg / 50mg / capsule, 2 capsules each time, 2 times a day, the course of treatment does not exceed 10 days), ribavirin (recommended application with interferon or lopinavir / ritonavir, 500mg / time for adults Intravenous infusion 2 to 3 times a day, the course of treatment does not exceed 10 days), chloroquine phosphate (18-65-year-old adults. Those who weigh more than 50 kg, 500 mg each time, twice a day for 7 days; weight less than 50 kg For patients, 500mg twice daily on the first and second days, 500mg once daily on the third to seventh days, Abidol (200mg for adults, 3 times daily, the course of treatment should not exceed 10 days) . Attention should be paid to the adverse reactions of the above drugs, contraindications (such as chloroquine disabled in patients with heart disease), and interaction with other drugs. To further evaluate the efficacy of the currently tested drugs in clinical applications. It is not recommended to use 3 or more antiviral drugs at the same time, and the use of related drugs should be stopped when there are intolerable side effects. For the treatment of pregnant women, the number of weeks of pregnancy should be considered, and as far as possible, drugs that have a small impact on the fetus, and whether to treat after termination of pregnancy should be informed and informed.
5. Antibacterial treatment: Avoid blind or inappropriate use of antibacterials, especially the combination of broad-spectrum antibacterials.

(C) Treatment of Severe and Critical Cases.

1. Treatment principle: Based on symptomatic treatment, actively prevent complications, treat basic diseases, prevent secondary infections, and provide organ function support in a timely manner.

2. Respiratory Support: -(1) Oxygen therapy: Severe patients should receive nasal cannula or mask to inhale oxygen, and promptly evaluate whether respiratory distress and / or hypoxemia is relieved. -(2) High-flow nasal catheter oxygen therapy or non-invasive mechanical ventilation: High-flow nasal catheter oxygen therapy or non-invasive ventilation can be considered when patients have respiratory distress and / or hypoxemia cannot be relieved after receiving standard oxygen therapy. If the condition does not improve or worsens within a short time (1-2 hours), tracheal intubation and invasive mechanical ventilation should be performed in time. -(3) Invasive mechanical ventilation: adopt protective lung ventilation strategy, that is, mechanical ventilation with small tidal volume (6-8mL / kg ideal weight) and low level airway platform pressure (≤30cmH2O) to reduce ventilator-related lung injury . When the airway plateau pressure is ≤35cmH2O, high PEEP can be appropriately used to keep the airway warm and humid, avoid prolonged sedation, wake up patients early and perform lung rehabilitation treatment. Many patients have human-machine synchronization, and sedation and muscle relaxants should be used in time. According to the airway secretions, closed sputum suction is selected, and if necessary, bronchoscopy is performed to take corresponding treatment. -(4) Salvage treatment: For patients with severe ARDS, lung expansion is recommended. In the case of sufficient human resources, prone ventilation should be performed for more than 12 hours per day. If prone position mechanical ventilation is not effective, if conditions permit, extracorporeal membrane pulmonary oxygenation (ECMO) should be considered as soon as possible. Relevant indications: ① When FiO2> 90%, the oxygenation index is less than 80mmHg, which lasts for more than 3-4 hours; ②The airway plateau pressure is ≥35cmH2O. For patients with simple respiratory failure, the VV-ECMO mode is preferred; if circulatory support is required, the VA-ECMO mode is used. When the underlying disease is under control and cardiopulmonary function shows signs of recovery, weaning trials can begin.

3. Circulation Support: Based on adequate fluid resuscitation, improve microcirculation, use vasoactive drugs, closely monitor changes in patients’ blood pressure, heart rate, and urine output, and lactic acid and alkali residuals in arterial blood gas analysis. Invasive hemodynamic monitoring, such as echo Doppler, echocardiography, invasive blood pressure or continuous cardiac output (P1CCO) monitoring. In the treatment process, pay attention to the liquid balance strategy to avoid overdose and underdose. If it is found that the patient’s sudden increase in heart rate is greater than 20% of the baseline value or that the blood pressure is reduced by more than 20% of the baseline value, if accompanied by symptoms such as poor skin perfusion and decreased urine output, the patient should be closely observed for septic shock, digestion Road bleeding or heart failure.

4. Renal Failure and Renal Replacement Therapy: Renal impairment in critically ill patients should actively look for the causes of renal impairment, such as hypoperfusion and drugs. For the treatment of patients with renal failure, attention should be paid to body fluid balance, acid-base balance and electrolyte balance, and nutritional support treatment should pay attention to nitrogen balance, calories and trace elements supplement. Severe patients can choose continuous renal replacement therapy (CRRT). The indications include: ① hyperkalemia; ② acidosis; ③ pulmonary edema or excessive water load; ④ fluid management in the case of multiple organ dysfunction.

5. Plasma Therapy for Recoverers: It is suitable for patients with rapid disease progression, severe and critically ill patients. For usage and dosage, please refer to “Clinical Treatment Plan for Recovery Period of New Coronary Pneumonia Rehabilitation Patients (Trial Version 2)”.

6. Blood Purification Treatment: The blood purification system includes plasma exchange, adsorption, perfusion, blood / plasma filtration, etc., which can remove inflammatory factors and block the “cytokine storm”, thereby reducing the damage of the inflammatory response to the body. It can be used for heavy, Early and Mid-term Treatment of Cytokine Storms in Critical Patients.

7. Immunotherapy: For patients with extensive lung disease and severe patients, and laboratory testing of elevated IL-6 levels, tocilizumab treatment can be tried. The first dose is 4-8mg / kg, the recommended dose is 400mg, 0.9% physiological saline is diluted to 100ml, and the infusion time is more than 1 hour; if the first medication is not effective, it can be applied once more after 12 hours (dose is the same as before), cumulative The maximum number of administrations is 2 times, and the maximum single dose does not exceed 800 mg. Pay attention to allergic reactions, and those with active infection such as tuberculosis are prohibited.

8. Other Treatments For patients with progressive deterioration of oxygenation indicators, rapid imaging progress, and excessive activation of the body’s inflammatory response, use glucocorticoids as appropriate in the short term (3 to 5 days). The recommended dose is not to exceed 1-2 mg / kg of methylprednisolone. / Day, it should be noted that larger 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 prevents secondary bacterial infections.

In children with severe and critical cases, intravenous drip of gamma globulin may be considered as appropriate. Pregnant women with severe or critically severe new coronavirus pneumonia should actively terminate their pregnancy, and a cesarean delivery is preferred. Patients often have anxiety and fear, and psychological counseling should be strengthened.

(D) Chinese Medicine Treatment.

This disease belongs to the category of “epidemic” disease in traditional Chinese medicine. The cause of the disease is “epidemic celebration”. According to the disease, local climate characteristics and different physical conditions, the disease can be treated according to the following schemes. Involving over-pharmacopoeia doses should be used under the guidance of a physician.

1. Medical Observation Period

Clinical manifestation 1: fatigue with gastrointestinal upset

Recommended Chinese patent medicine: Huoxiangzhengqi capsules (pills, water, oral liquid)

Clinical manifestation 2: fatigue with fever

Recommended Chinese patent medicines: Jinhua Qinggan Granules, Lianhua Qingwen Capsules (granules), Shufeng Jiedu Capsules (granules)

2. Clinical Treatment Period (Confirmed Cases)

2.1 Qingfei Detox Soup

Scope of application: Combined with the clinical observations of doctors in various places, it is suitable for light, ordinary and heavy patients. It can be used reasonably in combination with the actual situation of patients in the treatment of critically ill patients.

Basic formulas: Ephedra 9g, Zhigancao 6g, Almond 9g, Gypsum 15 ~ 30g (fried first), Guizhi 9g, Alisma 9g, Zhuling 9g, Atractylodes 9g, Poria 15g, Bupleurum 16g, Scutellaria baicalensis 6g , Ginger pinellia 9g, ginger 9g, aster 9g, winter flower 9g, shoot dry 9g, asarum 6g, yam 12g, coriander fruit 6g, tangerine peel 6g, aquila 9g

Method of administration: Traditional Chinese medicine decoction pieces, decoction. Pay once a day, once in the morning and evening (forty minutes after a meal). Warm clothes, three pay one course.

If conditions permit, you can take half a bowl of rice soup each time you take the medicine, and you can take up to one bowl if you have a dry tongue and fluid. (Note: If the patient does not have a fever, the amount of gypsum should be small. Fever or strong heat can increase the amount of gypsum). If the symptoms improve but do not heal, then take the second course of treatment. If the patient has special conditions or other underlying diseases, the prescription can be modified according to the actual situation, and the medicine should be discontinued.

Source of prescription: Notice on recommending the use of “Qingfei Detoxification Decoction” in pneumonia of new type of coronavirus infection in combination of traditional Chinese and western medicine by the Office of the State Administration of Traditional Chinese Medicine of the General Office of the National Health and Health Commission. Political Letter (2020) No. 22).

2.2 Lightweight

(1) Cold and Dampness Lung Syndrome

Clinical manifestations: Fever, fatigue, sore body, cough, expectoration, chest tightness, suffocation, nausea, nausea, vomiting, sticky stools. The tongue is pale, with thick tooth marks or red, moss white, thick, rotten or greasy, and the pulses are slippery or slippery.

Recommended prescriptions: Raw ephedra 6g, raw gypsum 15g, almond 9g, Zhihuo 15g, Zongzi 15g, Guanzhong 9g, Dilong 15g, Xu Changqing 15g, Huoxiang 15g, Pei Lan 9g, Cangzhu 15g, Yunling 45g, raw 30g of Atractylodes, 9g each of Jiaosanxian, 15g of Magnolia officinalis, 9g of betel nut, 9g of yarrow fruit, 15g of ginger.

Method of administration: 1 dose daily, 600ml decoction, divided into 3 times, once in the morning, evening and evening, before meals.

(2) Damp Heat Syndrome

Clinical manifestations: Low or no fever, slight chills, fatigue, heavy head and body, muscle aches, less dry sputum, sore throat, dry mouth, do not want to drink more, or with chest tightness, no sweat or Poor sweating, or seeing vomiting and appetite, diarrhea or sticky stool. The tongue is reddish, the white fur is thick and greasy or thin yellow, and the pulse is slippery or sloppy.

Recommended prescription: Betel nut 10g, grass fruit 10g, Magnolia officinalis 10g, Zhimu 10g, Scutellaria baicalensis 10g, Bupleurum 10g, red peony 10g, forsythia 15g, barberry 10g (back), atractylodes 10g, daqing Leaves 10g, raw licorice 5g.

Method of administration: 1 dose daily, 400ml decoction, divided into 2 doses, one morning and one evening.

2.3 Ordinary

(1) Damp Poisoning Stagnation Syndrome

Clinical manifestations: Fever, less cough and sputum, or yellow sputum, suffocation, shortness of breath, bloating, and constipation. The tongue is dark red, the tongue is fat, the coating is greasy or yellow, and the pulse is slippery or stringy.

Recommended prescription: Raw ephedra 6g, bitter almond 15g, raw gypsum 30g, raw coix seed 30g, grass root 10g, patchouli 15g, barnyardgrass 12g, Polygonum cuspidatum 20g, verbena 30g, dried reed root 30g, loquat 15g of gardenia, 15g of tangerine red and 10g of raw licorice.

Method of administration: 1 dose daily, 400ml decoction, divided into 2 doses, one morning and one evening.

(2) Cold Dampness Lung Syndrome

Clinical manifestations: Low fever, not hot or not, dry cough, less sputum, fatigue, fatigue, chest tightness, nausea, or nausea. The tongue is pale or red, the fur is white or greasy, and the veins are pulsating.

Recommended prescriptions: Atractylodes rhizome 15g, Chenpi 10g, Magnolia officinalis 10g, Huoxiang 10g, grass fruit 6g, raw ephedra 6g, Zhihuo 10g, ginger 10g, betel nut 10g.

Method of administration: 1 dose daily, 400ml decoction, divided into 2 doses, one morning and one evening.

2.4 Heavy

(1) Epidemic Lung Closure Certificate

Clinical manifestations: Fever redness, cough, yellowish phlegm stickiness, or blood in sputum, wheezing, shortness of breath, tiredness, tiredness, dry mouth, sticky mouth, nausea, lack of food, poor stool, short urine. Red tongue, yellow greasy fur, slippery pulses.

Recommended Prescription: Hua Shi Ba Du Fang Basic formulas: Raw Ephedra 6g, Almond 9g, Raw Gypsum 15g, Licorice 3g, Agastache 10g (below), Magnolia 10g, Atractylodes 15g, Herbal Fruit 10g, Pinellia 9g, Poria 15g, Raw Rhubarb 5g (Below), raw astragalus 10g, gardenia 10g, red scallion 10g.

Method of administration: 1 to 2 doses daily, decoction, 100ml to 200ml each time, 2 to 4 times a day, orally or nasally.

(2) Two Certificates of Air Camp

Clinical manifestations: Fever, thirst, shortness of breath, shortness of breath, dizziness, blurred vision, or spotted rash, or vomiting blood, bleeding, or convulsions in the limbs. Tongue ridges have few or no moss, the pulse sinks finely, or floats large and counts.

Recommended prescription: 30 ~ 60g of raw gypsum (fried first), 30g of Zhimu, 30 ~ 60g of raw land, 30g of buffalo horn (fried first), 30g of red peony, 30g of black ginseng, 15g of forsythia, 15g of paeonia 6g, bamboo leaves 12g, gardenia 15g, raw licorice 6g.

Method of administration: 1 dose per day, decoction, decoction of gypsum, buffalo horn first, and then various drugs, 100ml ~ 200ml each time, 2 ~ 4 times daily, orally or nasally.

Recommended Chinese patent medicines: Xiyanping injection, Xuebijing injection, Reduning injection, Tanreqing injection, Xingnaojing injection. Drugs with similar efficacy can be selected according to individual conditions, or can be used in combination according to clinical symptoms. Traditional Chinese medicine injection can be used in combination with traditional Chinese medicine decoction.

2.5 Critical

Closed and Closed

Clinical manifestations: Dyspnea, dyspnea, or mechanical ventilation, accompanied by faintness, irritability, cold sweaty limbs, dark purple tongue, thick greasy or dry fur, and large pulses without roots.

Recommended prescription: Ginseng 15g, Heishun tablets 10g (fried first), dogwood 15g, delivered with Suhexiang pills or Angong niuhuang pills.

For those who have mechanical ventilation with abdominal distension, constipation or poor stool, 5 ~ 10g of raw rhubarb can be used. Human-machine out-of-sync situation occurs. In the case of sedation and muscle relaxant, 5 to 10 g of raw rhubarb and 5 to 10 g of thenardite can be used.

Recommended Chinese patent medicines: Xuebijing injection, Reduning injection, Tanreqing injection, Xingnaojing injection, Shenfu injection, Shengmai injection, Shenmai injection. Drugs with similar efficacy can be selected according to individual conditions, or can be used in combination according to clinical symptoms. Traditional Chinese medicine injection can be used in combination with traditional Chinese medicine decoction.

Note: Recommended usage for heavy and critical Chinese medicine injections The use of traditional Chinese medicine injections follows the principle of starting from a small dose and gradually adjusting the symptoms according to the instructions of the drug. The recommended usage is as follows:

Viral infection or mild bacterial infection: 0.9% sodium chloride injection 250ml plus Xiyanping injection 100mg bid, or 0.9% sodium chloride injection 250ml heated Duning injection 20ml, or 0.9% sodium chloride injection 250ml plus Tanreqing injection 40ml bid.

High fever with disturbance of consciousness: 250% of 0.9% sodium chloride injection and 20ml bid of Xingnaojing injection.

Systemic inflammatory response syndrome or / and multiple organ failure: 250% 0.9% sodium chloride injection plus 100ml bid of Xuebijing injection.

Immunosuppression: 250ml glucose injection plus 100ml Shenmai injection or 20 ~ 60ml bid of Shengmai injection.

2.6 Recovery Period

(1) Lung and Spleen Qi Deficiency Syndrome Clinical manifestations: shortness of breath, fatigue, fatigue, anorexia, nausea, fullness, weak stool, and uneasiness. The tongue is pale and greasy.

Recommended prescriptions: French Pinellia 9g, Chenpi 10g, Codonopsis 15g, Sunburn Astragalus 30g, Fried Atractylodes 10g, Poria 15g, Huoxiang 10g, Amomum 6g (later), and Licorice 6g.

Dosage: 1 dose daily, 400ml decoction, divided into 2 doses, one each morning and evening.

(2) Qi and Yin Deficiency Syndrome Clinical manifestations: fatigue, shortness of breath, dry mouth, thirst, palpitations, excessive sweating, poor appetite, low or no fever, dry cough and less phlegm. Dry tongue, little pulse, thin pulse or weakness.

Recommended prescription: 10g each of North and South American ginseng, 15g Ophiopogon ginseng, 6g American sage, 6g Schisandra, 15g gypsum, 10g light bamboo leaf, 10g mulberry leaf, 15g reed root, 15g salvia, 6g raw licorice.

Dosage: 1 dose daily, 400ml decoction, divided into 2 doses, one each morning and evening.