Diagnosis and treatment of pneumonitis with a new coronavirus infection (Trial Version 4)


By Dr Greta Young Jie De

Complied and Translated by Dr. Greta Young Jie De (Ph.D)
Since December 2019, Wuhan City, Hubei Province has successively discovered multiple cases of patients with pneumonitis infected by a new type of coronavirus. With the spread of the epidemic, such cases have been found in other provinces of China and abroad.
With the deepening of disease awareness and the accumulation of diagnosis and treatment experience, the Chinese Government have revised the “Pneumonitis Diagnosis and Treatment Program for New Coronavirus Infection (Trial Version 4)”.
I. Aetiology :
The new coronavirus belongs to the new coronavirus of the genus β, which has an envelope and particles
It is round or oval, often polymorphic, with a diameter of 60-140nm. Genetic characteristics
Significantly different from SARSr-CoV and MERSr-CoV. Current research shows that with
SARS-like coronavirus (bat-SL-CoVZC45) has a homology of more than 85%.
When cultured in vitro, 2019-nCoV can be found in the human respiratory tract in about 96 hours.Epithelial cells are found, and cultured separately in Vero E6 and Huh-7 cell lines
It takes about 6 days.
Most of the understanding of the physicochemical properties of coronavirus comes from the research of SARS-CoV and MERS-CoV. The virus is sensitive to ultraviolet rays and heat. Lipid solvents such as ether, 75% ethanol, chlorine-containing disinfectant, peracetic acid, and chloroform can effectively inactivate the virus at 30 ° C for 30 minutes at 56 ° C. Chlorhexidine cannot effectively inactivate the virus.
Second, the epidemiological characteristics

2 The epidemiological characteristics:

(1) Source of infection.
The sources of infection seen so far are mainly patients with pneumonia infected by the new coronavirus.
(a) Method of transmission
Respiratory droplet transmission is the main route of transmission. It can also be transmitted through contact.
(2) Susceptible people.
Big crowd or gathering is generally susceptible. The elderly and those with underlying diseases are more severely affected; children, infants, and young children are also susceptible to COVID19.

Clinical characteristics
(3) Clinical manifestations.
Based on current epidemiological investigations, the incubation period is generally 3-7 days, with a maximum of 14 days.
Main symptoms are fever, fatigue, and dry cough. A few patients have symptoms such as nasal congestion, runny nose, and diarrhea. In severe cases, dyspnea occurs more than a week later, and severe cases progress rapidly to acute respiratory distress syndrome, septic shock, difficult to correct metabolic acidosis, and coagulopathy. It is worth noting that in the course of severe and critically ill patients, there can be moderate to low fever or no obvious fever. Some patients showed only low fever, mild fatigue, and no pneumonia. They recovered after 1 week. Judging from the current cases, most patients have a good prognosis, children with relatively mild symptoms, and a few patients are critically ill. Deaths are more common in older people and those with chronic underlying disease.

Laboratory inspection:
In the early stages of the disease, the total number of white blood cells in the peripheral blood was normal or decreased, the lymphocyte count was reduced, and some patients had increased liver enzymes, muscle enzymes, and myoglobin. Most patients have elevated C-reactive protein (CRP) and erythrocyte sedimentation rate and normal procalcitonin. Severe D-dimers increased and peripheral blood lymphocytes progressively decreased.
New coronavirus nucleic acids can be detected in throat swabs, sputum, lower respiratory tract secretions, and blood.

X-Ray imaging:
Multiple small patchy shadows and interstitial changes appeared early, and the extrapulmonary bands were obvious. Further development of multiple ground glass infiltrates and infiltrates in the lungs, severe lung consolidation may occur, and pleural effusion is rare.

Diagnostic criteria:
(1) Suspected cases.
Comprehensive analysis of the following epidemiological history and clinical manifestations:
Epidemiological history
(a) Travel history or residence history in Wuhan area or other areas with continuous transmission of local cases within 14 days before the onset of illness;
(b) Contacted from Wuhan City or other local cities within 14 days before onset
Patients with fever or respiratory symptoms in areas where the case continues to spread;
(c) Aggregative onset or epidemiological association with new coronavirus infection.

Clinical manifestations:
(1) Fever
(2) With the imaging characteristics of pneumonia
(3) The total number of white blood cells is normal or decreased, or the number of lymphocytes is decreased during the early stage of onset.
Any one of the epidemiological history matches any two of the clinical manifestations can be regarded as positive confirmed cases.

Suspected cases with one of the following pathogenic evidence:
1. Real-time fluorescent RT-PCR of respiratory specimens or blood specimens for detection of novel coronavirus nucleic acid;
2. Sequencing of viral genes in respiratory specimens or blood specimens, highly homologous to known new coronaviruses.

Clinical classifications:
(A) ordinary type:
With fever, respiratory tract and other symptoms, imaging shows pneumonia. (2) Heavy.
Meet any of the following:
1. Respiratory distress, RR≥30 times / minute;
2. In the resting state, the oxygen saturation is ≤93%;
3. Arterial blood oxygen partial pressure (PaO2) / oxygen concentration (FiO2) ≤300mmHg (1mmHg = 0.133kPa).
(B) Critical Type:
One of the following:
1. Respiratory failure occurs and requires mechanical ventilation;
2. Shock occurs;
Accompanied by other organ failures requires ICU monitoring and treatment.

Differential diagnosis:
Mainly related to influenza virus, para-influenza virus, adenovirus, respiratory syncytial disease
Virus, rhinovirus, human metapneumovirus, SARS coronavirus and other known viruses
Differentiation of pneumonia and mycoplasma pneumoniae, chlamydia pneumonia and bacterial pneumonia.
It is also linked to non-infectious diseases such as vasculitis, dermatomyositis, and organizing lungs.
Identification of inflammation.

(1) Determine the treatment location according to the severity of the disease.
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, strengthen supportive treatment to ensure sufficient water and Electrolyte balance to maintain internal environment stability; closely monitor vital signs, indicate oxygen saturation.
2. Monitor blood test routine, urine routine, CRP, biochemical indicators (liver enzyme, myocardial enzyme, renal function, etc. coagulation function according to the condition, and perform arterial blood gas analysis if necessary, and review chest imaging.
3. According to the changes in oxygen saturation, it is appropriate to provide timely effective oxygen therapies including nasal catheter, mask oxygen, transnasal high-flow oxygen therapy if necessary, non-invasive or invasive mechanical ventilation, and so on.
4. Antiviral treatment: Alpha-interferon inhalation (per adult 5 million U, add 2ml of sterile water for injection twice daily); lopinavir /Ritonavir (200 mg / 50 mg per capsule) 2 capsules each time, twice daily.
5. Antibacterial drug treatment: Avoid blind or inappropriate use of antibacterial drugs, especially the combination of broad-spectrum antibacterial drugs. In the event of secondary bacterial infection, apply antibacterial drugs accordingly.
(3) Treatment of severe and critical cases:
1. The principle of treatment: On the basis of symptomatic treatment, actively prevent complications.
Treatment of basic underlying diseases, prevention of secondary infections.
2. Respiratory support: Non-invasive mechanical ventilation for 2 hours, no improvement in the condition, or the patient cannot tolerate non-invasive ventilation, increased airway secretions, severe cough, or hemodynamic instability. Timely transition to invasive mechanical ventilation.
Invasive mechanical ventilation adopts a low tidal volume “pulmonary protective ventilation strategy” to reduce Low ventilator-related lung injury.
Prone position ventilation, lung dilatation, or extracorporeal membrane oxygenation (ECMO) if necessary
3. Circulation support: Based on adequate fluid resuscitation, improve microcirculation, use vasoactive drugs, and monitor hemodynamics if necessary.
4. Other treatment measures:
According to the patient’s dyspnea and chest imaging progress, as appropriate
Short-term (3 to 5 days) use of glucocorticoids, the recommended dose does not exceed the equivalent
Methylprednisolone 1 ~ 2mg / kg • d; blood can be given intravenously 100mL / day, each
2 treatments per day; intestinal micro-ecological regulator can be used to maintain intestinal micro-ecological level balance to prevent secondary bacterial infections; if possible, consider plasma treatment during recovery.

Chinese Medicine treatment:
The COVID10 is under the scope TCM warm epidemic disease. Different regions can refer to the following scenarios for optimum treatment according to the disease condition, local climatic factor and constitution of the patients. This is inkeeping with the Chinese medicine theory of treat according to location, seasonal climate and constitution 因地,因时,因人 三因理论. 
Clinical manifestation : Fatigue with gastrointestinal upset
Recommended Chinese patent medicine: Huo Xiang Zheng Qi Wan 藿香正气丸
• Fatigue with fever
Recommended Chinese patent medicines: Jin Hua Qing Gan granules 金花清感颗粒; Lianhua Qingwen capsules 莲花清瘟胶囊, Shu Feng Jie Du capsules 疏风解毒颗粒Fang Feng Tong Sheng Wan 防风通圣丸

2. Clinical treatment:

(1) Early stage: coldness, dampness constraint
Clinical manifestations: Aversion to cold, fever or no fever, dry hacking cough, dry throat, fatigue, chest tightness, nausea, ,sloppy stool, pale tongue with white greasy tongue coating and a soppy pulse.
Recommended prescription:
Cang Zhu 15g; Chen Pi 10g; Hou Po 10g; Huo Xiang 10g; Cao Guo 6g; Sheng Ma Huang 6g; Qiang Huo 10g; Sheng Jiang 10g; Bing Lang 10g. (This is a modified formula of Da Yuan Yin)

(2) Mid-stage: Epidemic Toxin Obstruction of the lungs
Clinical manifestations: Persistent fever or cold and fever, cough with less sputum, or yellow sputum, bloating and constipation. Chest tightness, shortness of breath, cough and wheezing when moving; red tongue, yellow greasy or yellow dry tongue coating and a slippery pulse.
Recommended prescription:
Xing Ren 10g; Sheng Shi Gao 30g; Gua Lou 30g; Sheng Da Huang 6g (to be added afterwards); Sheng and Zhi Ma Huang 6g each; Ting LI Zi 20g; Tao Ren 10g; Cao Guo 6g; Bing Lang 10g; Cao Guo 6g; Cang Zhu 10g.
(3) Critical Stage: External and internal blockage
Clinical manifestations: Dyspnea, Wheezing accompanied by fainting, irritability, cold and sweaty extremities, dark purplish tongue, thick or dry tongue coating and large, floating and rootless pulse.
Recommended prescription: Ren Shen 15g; Hei Fu Pian 10g (Decoct first); Shan Zhu Yu 15g to be taken with Su He Xiang Wan or An Gong Niu Huang Wan (The Wen Bing three treasures to resuscitate)
(4) Recovery period: Deficiency of Lung and Spleen qi
Clinical manifestations: Shortness of breath, fatigue, fatigue, anorexia, nausea, epigastric fullness, weakness to defecate, sloppy and difficult bowel movements, pale tongue body with white and greasy tongue coating.
Recommended prescription: Fa Ban Xia 9g; Chen Pi 10g; Dang Shen 15g; Zhi Huang Qi 30g; Fu Ling 15g; Huo Xiang 10g; Sha Ren 6g.

Desegregation and discharge standards:
Body temperature returned to normal for more than 3 days, respiratory symptoms improved significantly, two consecutive times of negative respiratory pathogen nucleic acid test (sampling interval of at least 1 day
Release from quarantine

About Dr Greta Young Jie De

Greta Young Jie De is a registered Chinese Medicine practitioner with the Chinese Medicine Registration Board Australia, with a focus on the treatment of emotional disorders using Chinese medicine. She is an expert in the classic literature of Chinese…Read more