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【醫學新知】 新型冠狀病毒(2019-nCoV)感染的肺炎 診斷和治療的快速建議指引 (標準版) (論文)　A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). REFERENCE: Mil Med Res. 2020 Feb 6;7(1):4

　

　

題目：A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)　新型冠狀病毒(2019-nCoV)感染的肺炎 診斷和治療的快速建議指引 (標準版)

雜誌：Military Medical Research　軍事醫學研究

編號：Mil Med Res. 2020 Feb 6;7(1):4.

出版：2020年2月

作者：Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, Fang C, Huang D, Huang LQ, Huang Q, Han Y, Hu B, Hu F, Li BH, Li YR, Liang K, Lin LK, Luo LS, Ma J, Ma LL, Peng ZY, Pan YB, Pan ZY, Ren XQ, Sun HM, Wang Y, Wang YY, Weng H, Wei CJ, Wu DF, Xia J, Xiong Y, Xu HB, Yao XM, Yuan YF, Ye TS, Zhang XC, Zhang YW, Zhang YG, Zhang HM, Zhao Y, Zhao MJ, Zi H, Zeng XT, Wang YY, Wang XH.

單位：Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China. Institute of Hospital Management, Wuhan University, Wuhan, 430071, China.

(Free PMC Article)

　

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Abstract
In December 2019, a new type viral pneumonia cases occurred in Wuhan, Hubei Province; and then named “2019 novel coronavirus (2019-nCoV)” by the World Health Organization (WHO) on 12 January 2020. For it is a never been experienced respiratory disease before and with infection ability widely and quickly, it attracted the world’s attention but without treatment and control manual. For the request from frontline clinicians and public health professionals of 2019-nCoV infected pneumonia management, an evidence-based guideline urgently needs to be developed. Therefore, we drafted this guideline according to the rapid advice guidelines methodology and general rules of WHO guideline development; we also added the first-hand management data of Zhongnan Hospital of Wuhan University. This guideline includes the guideline methodology, epidemiological characteristics, disease screening and population prevention, diagnosis, treatment and control (including traditional Chinese Medicine), nosocomial infection prevention and control, and disease nursing of the 2019-nCoV. Moreover, we also provide a whole process of a successful treatment case of the severe 2019-nCoV infected pneumonia and experience and lessons of hospital rescue for 2019-nCoV infections. This rapid advice guideline is suitable for the first frontline doctors and nurses, managers of hospitals and healthcare sections, community residents, public health persons, relevant researchers, and all person who are interested in the 2019-nCoV.

Keywords: 2019 novel coronavirus, 2019-nCoV, Respiratory disease, Pneumonia, Infectious diseases, Rapid advice guideline, Clinical practice guideline, Evidence-based medicine

　

摘要
2019年12月，湖北省武漢市發生新型病毒性肺炎病例;並於2020年1月12日被世界衛生組織（WHO）命名為“ 2019新型冠狀病毒（2019-nCoV）”。由於它是一種從未經歷過的呼吸道疾病，而且具有廣泛而迅速的感染能力，因此引起了全世界的關注，但未經處理和控製手冊。應一線臨床醫生和公共衛生專業人員的要求，對2019-nCoV感染的肺炎進行管理，急需制定循證指引。因此，我們根據快速諮詢指引方法論和WHO指引制定的一般規則起草了該指引。我們還添加了武漢大學中南醫院的第一手管理數據。該指引包括2019-nCoV的指引方法，流行病學特徵，疾病篩查和人群預防，診斷，治療和控制（包括中藥），醫院感染的預防和控制以及疾病護理。此外，我們還提供了成功治療2019-nCoV嚴重肺炎的完整過程以及2019-nCoV感染的醫院搶救經驗和教訓。此快速建議指引適用於第一線的醫生和護士，醫院和醫療部門的經理，社區居民，公共衛生人員，相關研究人員以及對2019-nCoV感興趣的所有人員。

關鍵詞：2019新型冠狀病毒，2019-nCoV，呼吸系統疾病，肺炎，傳染病，快速諮詢指引，臨床實踐指引，循證醫學

　

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1 Background
In December 2019, the 2019 novel coronavirus (2019-nCoV) was discovered and identified in the viral pneumonia cases that occurred in Wuhan, Hubei Province, China; And then was named by the World Health Organization (WHO) on 12 January 2020. In the following month, the 2019-nCoV quickly spreading inside and outside of Hubei Province and even other countries. What’s more, the sharp increase of the case number caused widespread panic among the people. Medical professionals require an up-to-date guideline to follow when an urgent healthcare problem emerging. In response to the requests for reliable advice from frontline clinicians and public healthcare professionals managing 2019-nCoV pandemics, we developed this rapid advance guideline, involving disease epidemiology, etiology, diagnosis, treatment, nursing, and hospital infection control for clinicians, and also for public health workers and community residents.

　

1背景
2019年12月，在湖北省武漢市發生的病毒性肺炎病例中發現並鑑定了2019年新型冠狀病毒（2019-nCoV）;然後在2020年1月12日被世界衛生組織（WHO）命名。在接下來的一個月中，2019-nCoV在湖北省乃至其他國家內外迅速傳播。而且，案件數量的急劇增加引起了人們的普遍恐慌。當緊急醫療保健問題出現時，醫療專業人員需要遵循最新的指引。為響應一線臨床醫生和管理2019-nCoV大流行的公共衛生保健專業人員提供可靠建議的要求，我們制定了此快速進展指引，涉及疾病流行病學，病因學，診斷，治療，護理和醫院感染控制，以及對臨床醫生的控制公共衛生工作者和社區居民。

　

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2 Guideline methodology
This guideline was prepared in accordance with the methodology and general rules of WHO Guideline Development and the WHO Rapid Advice Guidelines [1, 2].

2.1 Composition of the guideline development group
This guideline development group is multidisciplinary and composed of individuals from health professionals and methodologists. Health professionals included frontline clinical doctors, nurses who work in departments of respiratory medicine, fever clinic, critical medicine, emergency, infectious disease, and experts of respiratory infectious disease and hospital management board. The methodologists included methodologists of guideline development, systematic review, and literature searching professionals.

2.2 The end-user of the guideline
This guideline is suitable for frontline doctors and nurses, managers of hospitals and healthcare sections, healthy community residents, personnel in public healthcare, relevant researchers, and all persons who are interested in the 2019-nCoV management.

2.3 The target population of the guideline
This guideline is aimed to serve the healthcare professionals to tackle the suspected 2019-nCoV infected cases, confirmed 2019-nCoV infected cases, clustered 2019-nCoV infected cases, and those with close contacts or suspicious exposure to 2019-nCoV infected cases. 2.4 A survey of conflict of interests Oral inquiry for financial interests of relevant personal was conducted at the first meeting while to start this guideline. Relevant financial as well as nonfinancial interests were surveyed and disclosed and subsequently assessed in consensus conference in order to minimize potential bias in guideline development. Finally, there is no conflict of interests for all the personnel participating to prepare this guideline.

2.5 Guideline’s structural setup and refining the topics and coverage of this guideline
This guideline is a rapid guideline to responding to the emerging infectious disease of 2019-nCoV. Due to the urgent need and tight work schedule, we conducted no wide-range survey but a discussion meeting with front-line clinicians who managed patients with 2019-nCoV infections to finalize guideline topics and key questions.

2.6 Literature searching and preparation of evidence profiles

2.6.1 General notes
Considering the lack of direct evidence for this newly identified 2019-nCoV infection, we searched and referred to the guidelines that related to the SARS (Severe Acute Respiratory Syndrome), MERS (Middle East Respiratory Syndrome), and influenza. We also referred to the guidelines which were newly-issued by the National Health Commission of People’s Republic of China and WHO for 2019-nCoV. In addition, we have an independent literature searching team to search available indirect evidence from systematic reviews and/or RCTs (randomized controlled trials), which were for the treatment and/ or chemoprophylaxis of SARS, MERS, or other influenza virus infections.

If the existing evidence addressed topics or questions covered by the guideline, then its quality should be assessed. If there is a lack of higher-level quality evidence, our panel considered observational studies and case series. Because of the limited time, we did not perform new systematic review. We identified relevant literature up to 20 January 2020.

2.6.2 Search resources
We searched the bibliographic databases: PubMed, Embase, and Cochrane library. We also searched following websites: the WHO (https://www.who.int/), CDC (Centers for Disease Control and Prevention, https://www.cdc.gov/), NICE (National Institute for Health and Clinical Excellence, https://www.nice.org.uk/), National Health Commission of the People’s Republic of China (http://www.nhc.gov.cn/), and National Administration of Traditional Chinese Medicine (http://www.satcm.gov.cn/).

2.6.3 Frontline data collection and summary

As the 2019-nCoV is a newly identified pathogen responsible for the outbreak of the pandemic disease, there is no sufficient evidence to reveal the whole nature of this virus. In these situations, obtaining evidence from the experts who fighting the disease on the frontline can be efficient and the main source [3].

Until to 24:00 on 29 January 2020, 11,500 persons were screened, and 276 were identified as suspected infectious victims, and 170 were diagnosed (including 33 in critical condition) for 2019-nCoV infection in Zhongnan Hospital of Wuhan University. During this process, frontline clinicians and nurses have accumulated valuable experience in the diagnosis, treatment and nursing for 2019-nCoV infected patients. Hence, these experiences were assessed and then used as “Expert Evidence” for our guideline development. We took interviews and group surveys to collect information on treatment evidence during the guideline panel’s meeting, so that it could be integrated into the guideline panel in the summary of findings (see Additional files 1 and 2). Experts’ evidence can be solicited by the description of case reports, summaries, and reports of topics or questions of all cases they management.

2.7 Grading the evidences and recommendations

We accorded to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) basic approaches and rules [4, 5], and particularly considered experts’ evidence to assess the quality of a body of evidence to make recommendations.

The quality of evidence reflects whether the extent to which our confidence estimating the effect is adequate to support a particular recommendation. The level of evidence was categorized as “high quality”, “moderate quality”, “low quality”, or “very low quality”; Recommendations were classified as “strong” or “weak.”

The strong recommendation does not always mean there is sufficient intervention effectiveness. Besides the effectiveness of intervention, the forming of recommendations is based on the severity of the disease, patient willingness, safety, and economics [4]. See Tables 1 and 2 [4, 6].

2.8 Forming the recommendations

Before meetings, experts’ evidence was collected systematically and available to panel members. Once the evidence has been identified and assessed, recommendations were formulated based on the evidence by a face-to-face meeting of panel members and supplemented by experts participating in the panel meeting.

Experts’ evidence was highly valued in this guideline development. During the consensus process, if the evidence was agreed on by more than 70% frontline clinicians in the consensus meeting, it is considered as highquality evidence.

In specific recomendations, we used “should” or “strongly recommend” for strong recommendations; whereas, “suggest” or “consider” was used for weak ones.

2.9 Drafting and publishing the guideline

This guideline was published in both Chinese and English versions at the same time. Due to space limitations, the current standard revision does not include evidence descriptions.

　

2指引制定方法學

該指引是根據WHO指引制定的方法和一般規則以及WHO快速建議指引[1、2]編寫的。

2.1組建指引制訂小組
該指引制定小組是多學科的，由衛生專業人員和方法學家組成。衛生專業人員包括一線臨床醫生，在呼吸內科，發燒診所，危重病，急診科，傳染病科工作的護士以及呼吸道傳染病和醫院管理委員會的專家。方法學家包括指引制定，系統評價和文獻搜索專業人員的方法學家。

2.2指引的目標用戶
本指引適用於一線醫生和護士，醫院和醫療保健部門的經理，健康社區居民，公共醫療保健人員，相關研究人員以及所有對2019-nCoV管理感興趣的人員。

2.3指引的目標人群
本指引旨在為醫療保健專業人員提供服務，以解決疑似2019-nCoV感染病例，確診的2019-nCoV感染病例，成群的2019-nCoV感染病例以及與2019-nCoV感染病例有密切聯繫或可疑接觸的病例。 2.4利益衝突調查在開始本指引時，在第一次會議上對相關人員的財務利益進行了口頭詢問。對相關的金融和非金融利益進行了調查和披露，隨後在共識會議上進行了評估，以最大程度地減少準則制定中的潛在偏見。最後，參與本指引編制的所有人員都沒有利益衝突。

2.5指引的結構設置以及完善的主題和範圍
該指引是應對2019-nCoV新興傳染病的快速指引。由於迫切需要和緊迫的工作時間表，我們沒有進行廣泛調查，而是與處理2019-nCoV感染患者的一線臨床醫生進行了討論會議，以最終確定指引主題和關鍵問題。

2.6文獻檢索和證據簡介的準備

2.6.1一般說明
考慮到這種新發現的2019-nCoV感染缺乏直接證據，我們搜索並參考了與SARS（嚴重急性呼吸綜合徵），MERS（中東呼吸綜合徵）和流感相關的指引。我們還參考了由中華人民共和國國家衛生委員會和WHO共同發布的2019-nCoV指引。此外，我們有一個獨立的文獻檢索小組，可以從系統評價和/或RCT（隨機對照試驗）中檢索可用於治療和/或化學預防SARS，MERS或其他流感病毒感染的間接證據。

如果現有證據解決了指引中涉及的主題或問題，則應評估其質量。如果缺乏更高級別的質量證據，我們的小組將考慮觀察性研究和病例係列。由於時間有限，我們沒有進行新的系統審查。我們確定了截至2020年1月20日的相關文獻。

2.6.2搜索資源
我們搜索了書目數據庫：PubMed，Embase和Cochrane庫。我們還搜索了以下網站：WHO（https://www.who.int/)、CDC（疾病控制和預防中心，https：//www.cdc.gov/），NICE（國家衛生與臨床研究所）卓越獎（https://www.nice.org.uk/），中華人民共和國國家衛生委員會（http://www.nhc.gov.cn/）和國家中醫藥管理局（http： //www.satcm.gov.cn/）。

2.6.3前線數據收集與匯總
由於2019-nCoV是新發現的導致大流行病爆發的病原體，因此沒有足夠的證據來揭示這種病毒的全部性質。在這種情況下，從第一線與疾病作鬥爭的專家那裡獲取證據可能是有效且主要的來源[3]。
截至2020年1月29日至24:00，在武漢大學中南醫院對11,500人進行了篩查，確定了276名可疑傳染病受害者，並診斷出170例（包括33例危重病）。在此過程中，一線臨床醫生和護士在2019-nCoV感染患者的診斷，治療和護理方面積累了寶貴的經驗。因此，對這些經驗進行了評估，然後用作我們制定指引的“專家證據”。我們在準則小組會議期間進行了訪談和集體調查，以收集有關治療證據的信息，以便可以將其納入調查結果摘要的準則小組中（請參閱其他文件1和2）。可以通過案例報告的描述，摘要以及他們管理的所有案例的主題或問題的報告來徵求專家的證據。

2.7對證據和建議進行分級
我們符合建議書評估，發展和評估等級（GRADE）的基本方法和規則[4，5]，並且特別考慮了專家的證據來評估提出建議的證據的質量。
證據的質量反映了我們對效果的信心程度是否足以支持特定建議。證據級別分為“高質量”，“中等質量”，“低質量”或“非常低質量”；建議被分類為“強”或“弱”。
強烈的建議並不總是意味著有足夠的干預效果。除了乾預的有效性外，建議的製定還基於疾病的嚴重程度，患者的意願，安全性和經濟性[4]。參見表1和2 [4，6]。

2.8形成建議
在會議之前，專家證據被系統地收集並提供給小組成員。一旦確定並評估了證據，小組成員面對面的會議將根據證據提出建議，並由參加小組會議的專家補充。
專家的證據在該指引的製定中受到高度重視。在共識過程中，如果證據被超過70％的一線臨床醫生在共識會議上達成共識，則被認為是高質量的證據。
在具體的建議中，我們使用“應該”或“強烈推薦”作為強力推薦；而“建議”或“考慮”則用於弱者。

2.9起草和發布指引
該指引同時以中文和英文發布。由於篇幅所限，當前的標準修訂版不包括證據說明。

　

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3 Epidemiological characteristics

3.1 Scope of the 2019-nCoV infection outbreak
Since December 2019, multiple cases occurring unexplainable pneumonia were successively reported in some hospitals in Wuhan city with a history of exposure to a large Hua’nan seafood market in Wuhan city, Hubei province, China. It has been confirmed to be an acute respiratory infection caused by a novel coronavirus. So far, the number of cases without a history of the Hua’-nan seafood market exposure is increasing. In addition, clustered cases and confirmed cases without a history of travel to Wuhan emerged. Also, confirmed cases without clear exposure to the Wuhan seafood market have been found in many foreign countries or regions [8].
At 24:00 on 26 January 2020, the National Health Commission of the People’s Republic of China has recorded a total of 2744 confirmed cases of pneumonia with 2019-nCoV infection from 30 provinces (districts and cities), including 461 severe cases and 80 deaths. A total of 51 cases have been cured and discharged. At present, 5794 suspected cases were recorded, 32,799 with close contacts to the confirmed patients have been tracked, 583 people were released from medical observation that day, and 30,453 people were still undergoing medical observation. A total of confirmed cases were reported from Hong Kong, Macao and Taiwan of China: 8 cases in Hong Kong, 5 cases in Macao, and 4 cases in Taiwan. In addition, confirmed cases had been reported from abroad: 7 in Thailand, 4 in Australia, 4 in Singapore, 3 in France, 3 in Japan, 3 in Korea, 3 in Malaysia, 3 in the United States, 2 in Vietnam, and one in Nepal [9].

3.2 Host and reservoir
Wild animal, bats [10] is the most possible host of the 2019-nCoV. It requires further confirmation whether pneumonia infected by the 2019-nCoV is transmitted directly from bats or through an intermediate host. It is believed that clarifying the source of the virus will help determine zoonotic transmission patterns [11].

3.3 Route of transmission
Up to present, the main infection source was the patients who with pneumonia infected by the 2019-nCoV. Respiratory droplet transmission is the main route of transmission, and it can also be transmitted through contact [12]. Although many details, such as the source of the virus and its ability to spread between people remain unknown, an increasing number of cases show the signs of human-tohuman transmission [8, 13].

3.4 Etiology and pathogenesis
The 2019-nCoV isolated from the lower respiratory tract of patients with unexplainable pneumonia in Wuhan, and it is a novel coronavirus belonging to the β genus. The 2019-nCoV has an envelope; its particles are round or oval, often polymorphic, with a diameter from 60 nm to 140 nm. Its genetic characteristics are significantly different from SARSr-CoV (SARS related coronaviruses) and MERSr-CoV (MERS related coronaviruses). Current research shows it has more than 85% homology with SARSr-CoV (bat-SL-CoVZC45). 2019-nCoV can be found in human respiratory epithelial cells 96 h after in vitro isolation and culture, while it takes about 6 days in VeroE6 or Huh-7 cell lines [12]. The source of the virus, the time span of the patients discharging infective virus, and the pathogenesis are still not clear [14].

3.5 Molecular epidemiology
No evidence of viral mutation has been found so far [14]. It is necessary to obtain much more clinically isolated viruses with time and geographical variety to assess the extent of the virus mutations, and also whether these mutations indicate adaptability to human hosts [11].

3.6 Incubation and contagious period
Based on currently epidemiological survey, the latency period is generally from 3 to 7 days, with a maximum of 14 days [10]. Unlike SARSr-CoV, 2019-nCoV is contagious during the latency period [15].

3.7 Prognostic factors
The population is generally susceptible to the virus. The elderly and those with underlying diseases show more serious conditions after infection, and children and infants also get infected by the 2019-nCoV. From current knowledge of the cases, most patients have a good prognosis, the symptoms of children are relatively mild, and a few patients are in critical condition. Death cases are more frequently seen in the elderly and those with chronic underlying diseases [12].
The newest study including the first 41 confirmed cases admitted to Wuhan between 16 December 2019 and 2 January 2020 showed the median age of patients was 49 years; and the main underlying diseases were diabetes, hypertension, and cardiovascular diseases. Of them, 12 cases experienced acute respiratory distress syndrome (ARDS), 13 cases were admitted to the intensive care unit (ICU), and 6 cases died [16].

　

3流行病學特徵

3.1 2019-nCoV感染暴發的範圍
自2019年12月以來，武漢市的一些醫院相繼報告了多起發生不可解釋性肺炎的病例，歷史上曾接觸過中國湖北省武漢市的大型華南海鮮市場。已經證實是由新型冠狀病毒引起的急性呼吸道感染。迄今為止，沒有華南海產品市場歷史的病例數量正在增加。此外，還出現了沒有去武漢的歷史的聚集病例和確診病例。此外，在許多外國或地區也發現了沒有明確暴露於武漢海產品市場的確診病例[8]。
2020年1月26日24:00，中華人民共和國國家衛生委員會記錄了來自30個省（區和市）的2744例確診為2019-nCoV感染的肺炎病例，包括461例嚴重病例和80例死亡。治愈治愈51例。目前，共記錄疑似病例5794例，與確診患者有密切聯繫的32,799例，當天有583人被釋放出醫療觀察，仍有30,453人仍在接受醫療觀察。中國香港，澳門和台灣地區共報告確診病例：香港8例，澳門5例，台灣4例。此外，還報告了國外的確診病例：泰國7例，澳大利亞4例，新加坡4例，法國3例，日本3例，韓國3例，馬來西亞3例，美國3例，越南2例，一個在尼泊爾[9]。

3.2宿主和被傳染者
蝙蝠是野生動物[10]，是2019-nCoV的最有可能寄主。它需要進一步確認是否是從蝙蝠直接傳播或通過中間宿主傳播被2019-nCoV感染的肺炎。據信，澄清病毒的來源將有助於確定人畜共患病的傳播方式[11]。

3.3傳播途徑
到目前為止，主要的感染來源是2019-nCoV感染的肺炎患者。呼吸液滴的傳播是主要的傳播途徑，也可以通過接觸傳播[12]。儘管尚不清楚許多細節，例如病毒的來源及其在人之間傳播的能力，但越來越多的病例顯示出人與人之間傳播的跡象[8，13]。

3.4病因與發病機制
從武漢市無法解釋的肺炎患者的下呼吸道分離出的2019-nCoV是一種新型的冠狀病毒，屬於β屬。 2019-nCoV有一個信封;它的顆粒是圓形或橢圓形，通常是多形的，直徑為60 nm至140 nm。它的遺傳特徵與SARSr-CoV（SARS相關冠狀病毒）和MERSr-CoV（MERS相關冠狀病毒）明顯不同。目前的研究表明，它與SARSr-CoV（bat-SL-CoVZC45）具有超過85％的同源性。在體外分離和培養96小時後，可在人呼吸道上皮細胞中發現2019-nCoV，而在VeroE6或Huh-7細胞系中則需要約6天的時間[12]。病毒的來源，傳播感染性病毒的患者時間跨度以及發病機理仍不清楚[14]。

3.5分子流行病學
迄今為止，尚未發現病毒突變的證據[14]。有必要獲得更多具有時間和地域多樣性的臨床分離病毒，以評估病毒突變的程度，以及這些突變是否表明對人宿主的適應性[11]。

3.6潛伏期和感染期
根據當前的流行病學調查，潛伏期通常為3到7天，最長為14天[10]。與SARSr-CoV不同，2019-nCoV在潛伏期具有傳染性[15]。

3.7影響預後的因素
人群通常容易感染該病毒。老年人和患有基礎疾病的人在感染後表現出更嚴重的狀況，兒童和嬰兒也被2019-nCoV感染。根據目前的情況，大多數患者預後良好，兒童症狀相對較輕，少數患者處於危急狀態。死亡病例在老年人和患有慢性基礎疾病的人群中更為常見[12]。
最新研究包括2019年12月16日至2020年1月2日之間入院的前41例確診病例，顯示患者的中位年齡為49歲;最主要的潛在疾病是糖尿病，高血壓和心血管疾病。其中，有12例經歷了急性呼吸窘迫綜合徵（ARDS），有13例進入重症監護病房（ICU），有6例死亡[16]。

　

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4 Screening for diseased cases and preventive measures for population

4.1 Case definitions

4.1.1 Suspected case
Patients with any 2 of the following clinical features and any epidemiological risk: (1) clinical features: fever, imaging features of pneumonia, normal or reduced white blood cell count, or reduced lymphocyte count in the early stages of the disease onset. (2) epidemiologic risk: a history of travel to or residence in Wuhan city, China or other cities with continuous transmission of local cases in the last 14 days before symptom onset; contact with patients with fever or respiratory symptoms from Wuhan city, China or other cities with continuous transmission of local cases in the last 14 days before symptom onset; or epidemiologically connected to 2019-nCoV infections or clustered onsets [12].

4.1.2 Confirmed case
Those with one of the following pathogenic evidence is the confirmed case: (1) positive for the 2019-nCoV by the real-time PCR test for nucleic acid in respiratory or blood samples [17]. 2) viral gene sequencing shows highly homogeneity to the known 2019-nCoV in respiratory or blood samples [12].

4.1.3 Clustered cases
Suspected clustering cases are defined when one confirmed case and at the same time, one or more cases of fever or respiratory infection are found in a small area (such as a family, a construction site, a unit, etc.) within 14 days.
Under the above circumstances, 2 or more confirmed cases are found, and there is the possibility of human-to-human transmission due to close contact or infection due to co-exposure, then it is determined as a clustered case [8, 18].

4.1.4 Close contacts
Those who have one of the following contacts after the onset of confirmed cases in the absence of effective protection [18]: (1) those who live, study, work, or have close contact with the confirmed cases, or other close contacts such as working closely with or sharing the same classroom or living in the same house with the confirmed case. (2) medical and nursing staffs and their family members living with them, who treated, nursed or visited the confirmed case, or other personnel who have similar close contact with the case, such as providing direct treatment or care of the case, visiting the case or staying in a closed environment where the cases are located; other patients or caregivers in the same room with the case. (3) people who have close contact with the patients in a same transport vehicle, including those who had taken care of the patients on the vehicle; the person who had companied the patients (family members, colleagues, friends, etc.); other passengers and traffic staff considered having likely close contact with the patients by investigation and evaluation. (4) other circumstances considered to be closely contacted with the person with close contact with the patients by the professional investigation and evaluation.

4.1.5 Suspicious exposure
Persons with suspicious exposure are those who are exposed without effective protection to processing, sales, handling, distributing, or administrative management of wild animals, materials, and the environments that are positive for the 2019-nCoV test [18].

4.2 Prevention

4.2.1 Persons with close contacts and suspicious exposure
Persons with close contacts and suspicious exposure should be advised to have a 14-day health observation period, which starts from the last day of contact with the 2019-nCoV infected patients or suspicious environmental exposure. Once they display any symptoms, especially fever, respiratory symptoms such as coughing, shortness of breath, or diarrhea, they should reach out for medical attention immediately [19]. Contact surveillance should be carried out for those who had exposed to accidental contact, low-level exposure to suspected or confirmed patients, i.e. checking any potential symptoms when carrying out daily activities [20]. See Table 3 for details [21].

4.2.2 Patients with suspected 2019-nCoV infection
Patients with a suspected infection should be isolated, monitored, and diagnosed in hospital as soon as possible. Doctors should make recommendations based on the patient’s situation. Patients with mild symptoms and suspected infection may consider in-home isolation and home care (weak recommendation). Suspected infected with severe symptoms and those who need to stay in hospital for observation by doctor’s judgment should follow the isolation guidelines for suspected patients (see Tables 4 and 5 for details).
It should also be noted that: (1) whether the suspected patients should be given in-home isolation and care or not requires careful clinical evaluation and safety assessment by professionals. (2) if the suspected patients do not get improvement in the symptoms or even worsened in condition during home care, they need to go to the doctor for treatment. (3) during the period of home care, the patients’ medication and symptoms should be closely recorded and their caregivers should also monitor their body temperature daily.
Throughout the period of home care, healthcare personnel should perform regular (e.g., daily) follow-up through face-to-face visits or phone interviews (ideally, if feasible) to follow the progress of symptoms and, if necessary, specific diagnostic tests should be conducted [14, 19, 21].

4.2.3 Prevention for travellers (Strong recommendation)
International visitors should take routine precautions when entering and leaving the affected areas, including avoiding close contacts with people with acute respiratory infection, washing hands frequently, especially after contacting with the sick or their surrounding environment; following appropriate coughing etiquette; and avoiding close contact with live or dead farming animals or bats or other wild animals [22, 23]. Passengers should avoid unnecessary travel as possible.
If they had travelled to Hubei Province (especially Wuhan city) in the past 14 days and is in fever, cough or difficulty in breathing, they should: (1) see a doctor immediately; (2) call the doctor about his/her recent trips and symptoms before going to the doctor’s office or emergency room; (3) avoid contact with others; (4) not to travel around; (5) cover mouth and nose with a tissue or sleeve (not hands) when coughing or sneezing; and (6) wash hands with soap and water for at least 20 s. If soap and water are not available, use alcohol-based hand sanitizers [24].

　

4疾病篩查和人群預防

4.1病例定義

4.1.1疑似病例
具有以下任何兩項臨床特徵和任何流行病學風險的患者：（1）臨床特徵：疾病發作初期發燒，肺炎的影像學特徵，白細胞計數正常或減少或淋巴細胞計數減少。 （2）流行病學風險：在症狀發作前的最近14天內曾在中國武漢市或其他城市旅行或居住過且持續傳播本地病例的歷史；在症狀發作前的最後14天與來自中國武漢市或其他城市的發燒或呼吸道症狀患者進行接觸，並持續傳播本地病例;或在流行病學上與2019-nCoV感染或成簇發作有關[12]。

4.1.2確認病例
具有以下病原學證據之一的那些是確診病例：（1）通過實時PCR檢測呼吸道或血液樣本中的核酸，2019-nCoV呈陽性[17]。 2）病毒基因測序顯示與呼吸或血液樣本中的已知2019-nCoV具有高度同源性[12]。

4.1.3聚集性案例
當在14天之內在一個小區域（例如家庭，建築工地，單位等）發現一個或多個發燒或呼吸道感染病例時，就定義為可疑病例。
在上述情況下，發現2例或更多的確診病例，並且由於緊密接觸或因共同暴露引起感染而可能發生人際傳播，因此確定為聚集病例[8，18] 。

4.1.4密集接觸者
在沒有得到有效保護的情況下，在確診病例發生後具有以下一種接觸的人[18]：（1）與確診病例生活，學習，工作或密切接觸的人，或與與確診病例密切合作或共享同一間教室，或住在同一所房子裡。 （2）治療，護理或看過確診病例的醫護人員及其家屬，或與病例有密切聯繫的其他人員，例如提供直接治療或護理，案件或留在案件所在地的封閉環境中；與病例在同一房間的其他患者或護理人員。 （三）與同一運輸工具上的患者有密切接觸的人員，包括在運輸工具上照顧過患者的人員；陪同患者的人（家人，同事，朋友等）；其他乘客和交通人員認為通過調查和評估可能與患者密切接觸。 （4）經專業調查和評價，認為與患者有密切聯繫的其他情況。

4.1.5可疑暴露者
可疑接觸者是指在沒有有效保護野生動物，材料和對2019-nCoV測試呈陽性的環境的加工，銷售，處理，分配或行政管理中暴露的人[18]。

4.2人員預防

4.2.1親密接觸者和可疑暴露者
應建議與密切接觸和可疑接觸的人有14天的健康觀察期，從與2019-nCoV感染患者或可疑環境接觸的最後一天開始。一旦出現任何症狀，特別是發燒，呼吸道症狀（例如咳嗽，呼吸急促或腹瀉），就應立即尋求醫療救助[19]。對於那些意外接觸，低水平接觸可疑或確診患者的人，應進行接觸監視，即在進行日常活動時檢查任何潛在症狀[20]。有關詳細信息，請參見表3。

4.2.2疑似2019-nCoV感染患者
懷疑有感染的患者應盡快隔離，監測和診斷。醫生應根據患者情況提出建議。症狀較輕且懷疑感染的患者可考慮在家中隔離和家庭護理（建議不佳）。懷疑有嚴重症狀的感染者和需要住院以醫生判斷進行觀察的人，應遵循針對可疑患者的隔離指引（有關詳細信息，請參見表4和表5）。
還應注意：（1）是否對可疑患者進行家庭隔離和護理，需要專業人員進行仔細的臨床評估和安全性評估。 （2）如果懷疑患者在家庭護理期間症狀沒有改善甚至病情惡化，則需要去看醫生。 （3）在家庭護理期間，應密切記錄患者的用藥情況和症狀，看護者還應每天監測體溫。
在整個家庭護理期間，醫護人員應通過面對面訪問或電話訪談（理想情況下，如果可行）進行定期（例如每天）隨訪，以跟踪症狀的進展以及必要時的特定診斷測試應該進行[14，19，21]。

4.2.3旅行者的預防（強烈建議）
國際遊客進入和離開受影響地區時應採取常規預防措施，包括避免與急性呼吸道感染患者密切接觸，經常洗手，尤其是在與病人或其周圍環境接觸後；遵循適當的咳嗽禮節；並避免與活的或死的農場動物或蝙蝠或其他野生動物緊密接觸[22，23]。乘客應避免不必要的旅行。
如果他們過去14天曾去過湖北省（尤其是武漢市），並且發燒，咳嗽或呼吸困難，則應：（1）立即去看醫生； （2）在去醫生辦公室或急診室之前，打電話給醫生有關他/她最近的旅行和症狀的信息； （3）避免與他人接觸； （四）不要四處旅行； （5）咳嗽或打噴嚏時要用紙巾或袖子（而不是手）遮住口鼻。 （6）用肥皂和水洗手至少20 s。如果沒有肥皂和水，請使用酒精類洗手液[24]。

　

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5 Diagnosis of the 2019-nCoV cases

5.1 Clinical manifestation

The 2019-nCoV infected cases have symptoms like fever, fatigue, dry cough, dyspnea etc., with or without nasal congestion, runny nose or other upper respiratory symptoms [13, 16]. Despite the atypical symptoms were reported [25], Nan-Shan Zhong, the academician of Chinese Academy of Engineering in an exclusive interview with Xinhua News Agency on 28 January 2020, pointed out that fever is still the typical symptom of 2019-nCoV infection.

5.2 Physical examination

Patients with mild symptoms may not present positive signs. Patients in severe condition may have shortness of breath, moist rales in lungs, weakened breath sounds, dullness in percussion, and increased or decreased tactile speech tremor, etc.

5.3 Imaging examination

5.3.1 CT imaging (strong recommendation)

The imaging findings vary with the patient’s age, immunity status, disease stage at the time of scanning, underlying diseases, and drug interventions.

The imaging features of lesions show: (1) dominant distribution (mainly subpleural, along the bronchial vascular bundles); (2) quantity (often more than three or more lesions, occasional single or double lesions); (3) shape (patchy, large block, nodular, lumpy, honeycomblike or grid-like, cord-like, etc.); (4) density (mostly uneven, a paving stones-like change mixed with ground glass density and interlobular septal thickening, consolidation and thickened bronchial wall, etc.); and (5) concomitant signs vary (air-bronchogram, rare pleural effusion and mediastinal lymph nodes enlargement, etc.).

 

5.3.2 Clinical data from Zhongnan Hospital of Wuhan University

Typical CT/X-ray imaging manifestation, including

(1) Multiple, patchy, sub-segmental or segmental groundglass density shadows in both lungs. They were classified as “paving stone-like” changes by fine-grid or small honeycomb-like thickening of interlobular septa. The thinner the CT scan layers, the clearer the ground-glass opacity and thickening of interlobular septa were displayed. A slightly high-density and ground-glass change with fuzzy edge in the fine-grid or small honeycomb-like thickening of interlobular septa were presented by the high-resolution computed tomography (HRCT), (Fig. 1: 45 cases, 54.2% in a total of 83 cases). The resolution of X-ray was worse lower than that of CT in the resolution, which was basically manifested as ground-glass opacities with fuzzy edge (Fig. 2: 9 cases, 10.8% in a total of 83 cases).

(2) Multiple, patchy or large patches of consolidation in both lungs, with a little grid-like or honeycomb-shaped interlobular septal thickening, especially in the middle and lower lobes (Fig. 3: 26 cases, 31.3% in a total of 83 cases). It was more common in the elderly or severe condition patients.

Atypical CT/X-ray imaging manifestation, including

(1) Single, or multiple, or extensive subpleural grid-like or honeycomb-like thickening of interlobular septum, thickening of the bronchial wall, and tortuous and thick strand-like opacity. Several patchy consolidations, occasionally with a small amount pleural effusion or enlargement of mediastinal lymph nodes, can be seen (Fig. 4: 6 cases, 7.2% in a total of 83 cases). This is mostly seen in the elderly.

(2) Single or multiple solid nodules or consolidated nodules in the center of lobule, surrounded by ground-glass opacities (Fig. 5: 5 cases, 6.2% in a total of 83 cases).

Stage based on CT image

The CT imaging demonstrates 5 stages according to the time of onset and the response of body to the virus, including:

(1) Ultra-early stage. This stage usually refers to the stage of patients without clinical manifestation, negative laboratory test but positive throat swab for 2019-nCoV within 1–2 weeks after being exposed to a virus-contaminated environment (history of contact with a patient or patient-related family members, unit, or medical staff in a cluster environment). The main imaging manifestations are single, double or scattered focal ground-glass opacity, nodules located in central lobule surrounded by patchy ground-glass opacities, patchy consolidation and sign of intra-bronchial air-bronchogram, which was dominant in the middle and lower pleura (Fig. 6: 7 cases, 8.4% in a total of 83 cases).

(2) Early stage.This stage refers to the period of 1–3 days after clinical manifestations (fever, cough, dry cough, etc.). The pathological process during this stage is dilatation and congestion of alveolar septal capillary, exudation of fluid in alveolar cavity and interlobular interstitial edema. It showed that single or multiple scattered patchy or agglomerated ground-glass opacities, separated by honeycomb-like or grid-like thickened of interlobular septa (Fig. 7: 45 cases, 54.2% in a total of 83 cases).

(3) Rapid progression stage. This stage refers to the period about 3–7 days after clinical manifestations started, the pathological features in this stage are the accumulation of a large number of cell-rich exudates in the alveolar cavity, vascular expansion and exudation in the interstitium, both of which lead to further aggravation of alveolar and Interstitial edema. The fibrous exudation connects each alveolus through the inter-alveolar space to form a fusion state. The CT manifested a fused and large-scale light consolidation with air-bronchogram inside (Fig. 8: 17 cases, 20.5% in a total of 83 cases).

(4) Consolidation stage. This stage refers to the period around 7–14 days after clinical manifestations appeared. The main pathological features in this stage are the fibrous exudation of the alveolar cavity and the disappearance of capillary congestion in the alveolar wall. CT imaging showed the multiple patchy consolidations in slighter density and smaller range than that of the previous stage. (Fig. 9: 26 cases, 31.2% in a total of 83 cases).

(5) Dissipation stage. This stage refers to the period roughly between 2 and 3 weeks after the onset of clinical manifestations. The range of lesions was further reduced. CT imaging showed patchy consolidation or strip-like opacity. As time goes on, it showed grid-like thickening of interlobular septum, thickening and strip-like twist of bronchial wall and a few scattered patchy consolidations (Fig. 10: 17 cases, 20.5% in a total of 83 cases).

5.4 Differential diagnosis

It mainly should be distinguished from other known viral virus of pneumonia, such as influenza viruses, parainfluenza virus, adenovirus, respiratory syncytial virus, rhinovirus, human metapneumovirus, SARSr-CoV, etc.; and also from mycoplasma pneumonia, chlamydia pneumonia, and bacterial pneumonia. In addition, it should be distinguished from non-infectious diseases, such as vasculitis, dermatomyositis, and organizing pneumonia.

5.5 Techniques for laboratory tests

5.5.1 Hematology examination

In the early stage of the disease, the total number of leukocytes decreased or keeps normal, with decreased lymphocyte count or increased or normal monocytes. High attention should be paid on the situation where the absolute value of lymphocyte is less than 0.8 × 109/L, or the numbers of CD4 and CD8 T cells are significantly decreased, which generally recommend rechecking the blood routine changes after 3 days.

5.5.2 Detection of pathogens in respiratory tract

(1) Flu antigens. At present, routinely detected flu antigens are A, B, and H7N-subtypes. Sampling of throat swabs is conducive to early rapid screening for flu because of the fast test, but it has a relatively high false negative rate.

(2) Respiratory virus nucleic acid. The detection of respiratory virus nucleic acid is commonly used to detect the infection by other common respiratory viruses, mycoplasma and chlamydia infection, such as adenovirus, parainfluenza virus, respiratory syncytial virus, mycoplasma, chlamydia, influenza A and influenza B virus, etc.

(3) 2019-nCoV nucleic acid detection. Accurate RNA detection of 2019-nCoV is with diagnostic value (Strong recommendation). The RNA of 2019-nCoV positive in the throat swab sampling or other respiratory tract sampling by fluorescence quantitative PCR method, especially that from multiple samples and detection kits, excluding sample quality, sample collection time, contaminatory and technical problems, is of great support for etiological diagnosis.

(4) Other laboratory testing. There are other laboratory tests for the status of 2019-nCoV infection, including blood gas analysis, liver and kidney function, myocardial enzyme, myoglobin, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Procalcitonin (PCT), lactate, D-dimer, coagulation image, urine routine test, inflammatory factors (interleukin(IL)-6, IL-10, TNF - α), 11 items of tuberculosis (TB) subgroup, complement, anti-acid staining, etc. Blood gas analysis is helpful to judge the oxygenation of moderately-illed and severe patients. Combining the increase of lactic acid, it is feasible to screen the patients with high-risk of oxygenation disorder. Some infected patients have increased liver enzymes, muscle enzyme, ESR and myoglobin. The detection of CRP and PCT is of certain value to distinguish whether there was bacterial infection in the lung. D-dimer of most severe patients was significantly increased in this epidemic, with frequent clotting disorders and microthrombotic formation in peripheral blood vessels. Detection of other inflammatory factors may help to preliminarily evaluate the immune status of patients.

5.5.3 Clinical data from Zhongnan Hospital of Wuhan University

In the early stage of this disease, the total number of leukocytes in peripheral blood was normal or decreased, and the lymphocyte count decreased. In some patients, liver enzyme (transaminase), creatine kinase (CK) and myoglobin increased. CRP, ESR, and IL-6 increased, and PCT was normal in most patients. The increased D-dimer occurred in severe cases.

The data from the first 38 patients with 2019-nCoV infection who hospitalized in Zhongnan Hospital of Wuhan University were collected. Analysis revealed that the average value of white blood cells (WBC) was 5.45 (2.30– 13.82) × 109/L, PLT was 164.5 (47–317) × 109/L, lymphocyte was 0.87 (0.24–2.27) × 109/L, and monocyte was 0.38 (0.12–0.62) × 109/L. The average value of ALT (alanine aminotransferase) was 37.6 (6–128) U/L and AST (aspartate aminotransferase) was 53.3 (18–169) U/L. The average value of CK was 315 (33–3051) U/L, ESR was 29.3 (8–67) mm/h, CRP was 61.8 (3–170.91) mg/L, IL-6 was 57 (3.1–134.4) pg/ml, and D-dimer was 400 (46–3330) ng/ml.

Compared with 120 healthy check-ups, the absolute value of lymphocyte (0.87 vs 2.13) × 109/L, lymphocyte percentage (19.5% vs 33.7%), eosinophil percentage (0.13% vs 2.16%), and absolute value (0.0061 vs 0.1417) × 109/L in 2019-nCoV patients were significantly reduced (P < 0.05). The absolute number (4.2 vs 3.7) × 109/L and the percentage (72.0% vs 57.0%) increased in 2019-nCoV patients (P < 0.05). The percentage of monocytes increased slightly (8.1% vs 6.8%), while the absolute number of monocytes did not change significantly (0.38 vs 0.44) × 109/L.

5.6 Other early diagnosis methods

The next generation sequencing (NGS) and electron microscope technology play a role in the early diagnosis, but their diagnostic values have been weakened by the discovery of specific nucleic acid detection technology. In addition, NGS detection can tell whether the pathogen has mutated or not.

　

5 2019-nCoV病例的診斷

5.1臨床表現
2019-nCoV感染的病例有發燒，乏力，乾咳，呼吸困難等症狀，有無鼻塞，流鼻涕或其他上呼吸道症狀[13，16]。儘管報導了非典型症狀[25]，但中國工程院院士鐘南山在2020年1月28日接受新華社獨家專訪時指出，發燒仍然是2019-nCoV感染的典型症狀。

5.2身體檢查
症狀較輕的患者可能不會出現陽性體徵。病情嚴重的患者可能會出現呼吸急促，肺部濕ra音，呼吸音減弱，敲擊鈍音以及觸覺語言震顫增加或減少等。

5.3影像學檢查

5.3.1 CT像像（強烈推薦）
影像學發現隨患者的年齡，免疫狀況，掃描時的疾病階段，基礎疾病和藥物干預而異。
病變的影像學表現顯示：（1）佔優勢的分佈（主要是胸膜下，沿支氣管血管束）； （2）數量（通常三個或更多病變，偶有單或雙病變）； （3）形狀（斑點狀，大塊狀，結節狀，塊狀，蜂窩狀或網格狀，帘線狀等）； （4）密度（多為不平整，鋪路石樣變化，並伴有毛玻璃密度和小葉間隔增厚，合併和支氣管壁增厚等）； （5）伴隨體徵變化（支氣管造影，罕見的胸腔積液和縱隔淋巴結腫大等）。

5.3.2武漢大學中南醫院臨床資料

　
典型的CT / X射線影像表現，包括
（1）兩個肺中有多個，斑塊狀，亞節段性或節段性的毛玻璃密度影。通過細小網格或小蜂窩狀的小葉間隔增厚，將它們歸類為“鋪路石樣”變化。 CT掃描層越薄，顯示出毛玻璃的不透明性和小葉間隔的增厚越明顯。高分辨率計算機斷層掃描（HRCT）顯示小葉間隔的細網格或小蜂窩狀增厚中的高密度和毛玻璃的邊緣略微模糊（圖1：45例，54.2％總共83例）。 X射線的分辨率比CT的分辨率差，這主要表現為毛玻璃片混濁，邊緣模糊（圖2：9例，佔83例的10.8％）。

（2）在兩個肺中有多個，片狀或大塊的鞏固斑塊，有一點網格狀或蜂窩狀的小葉間間隔增厚，特別是在中葉和下葉（圖3：26例，佔總數的31.3％） 83例）。在老年人或重症患者中更常見。

　

非典型CT / X射線影像表現，包括
（1）小葉間隔的單個或多個或廣泛的胸膜下網格狀或蜂窩狀增厚，支氣管壁增厚，以及曲折且濃厚的股狀不透明。可見數個斑塊狀的鞏固，偶有少量的胸腔積液或縱隔淋巴結腫大（圖4：6例，佔83例的7.2％）。這主要發生在老年人中。

（2）小葉中央有單個或多個實性結節或合併結節，周圍有毛玻璃樣混濁（圖5：5例，佔83例的6.2％）。

　

基於CT影像的階段

CT影像根據發病時間和身體對病毒的反應顯示出5個階段，包括：
（1）超早期階段。此階段通常指沒有臨床表現，實驗室測試陰性但暴露於病毒污染環境後1-2週內2019-nCoV陽性咽拭子的患者階段（與患者或患者相關家庭的接觸史）集群環境中的成員，單位或醫務人員）。主要影像學表現為單發，雙發或散在的局灶性玻璃樣混濁，結節位於中央小葉，周圍有斑片狀的玻璃混濁，斑片狀鞏固和支氣管內氣管造影的徵象，在胸膜中下部佔優勢。 （圖6：7例，佔83例的8.4％）。

（2）早期階段。該階段是指臨床表現（發燒，咳嗽，乾咳等）後的1-3天。在此階段的病理過程是肺泡中隔毛細血管擴張和充血，肺泡腔內液體滲出和小葉間質水腫。結果顯示，單個或多個散佈的斑片狀或團塊狀的混濁玻璃混濁，被蜂窩狀或網格狀的小葉間隔增厚隔開（圖7：45例，佔83例的54.2％）。

（3）快速發展階段。此階段是指臨床表現開始後約3–7天，此階段的病理特徵是肺泡腔中大量細胞富集性滲出物積聚，間質內血管擴張和滲出，兩者導致肺泡進一步加重和間質水腫。纖維滲出物通過牙槽間空間連接每個牙槽以形成融合狀態。 CT表現為融合的大範圍光融合，內部有支氣管造影（圖8：17例，佔83例的20.5％）。

（4）鞏固階段。此階段是指臨床表現出現後約7-14天。在此階段的主要病理特徵是肺泡腔內的纖維滲出和肺泡壁內毛細血管充血的消失。 CT成像顯示多個斑塊狀固結，密度較前一階段小，範圍較小。 （圖9：26例，佔83例的31.2％）。

（5）耗散階段。此階段是指臨床表現發作後大約2至3週的時間。病變範圍進一步縮小。 CT成像顯示斑片狀鞏固或條狀不透明。隨著時間的流逝，其顯示小葉間隔的網格狀增厚，支氣管壁增厚和條狀扭曲以及少量散在的斑塊狀鞏固（圖10：17例，佔83例的20.5％）。

　

5.4鑑別診斷
主要應區別於其他已知的肺炎病毒，例如流感病毒，副流感病毒，腺病毒，呼吸道合胞病毒，鼻病毒，人間質肺病毒，SARSr-CoV等；以及支原體肺炎，衣原體肺炎和細菌性肺炎。此外，應區別於非傳染性疾病，例如血管炎，皮肌炎和組織性肺炎。

5.5實驗室測試技術

5.5.1血液學檢查
在疾病的早期階段，白細胞總數減少或保持正常，淋巴細胞計數減少或單核細胞增加或正常。應高度注意淋巴細胞絕對值小於0.8×109 / L，或CD4和CD8 T細胞數量明顯減少的情況，通常建議在3天后重新檢查血液常規變化。

5.5.2呼吸道病原體的檢測
（1）流感抗原。目前，常規檢測到的流感抗原是A，B和H7N亞型。由於檢測速度快，對咽拭子的採樣有助於早期快速篩查流感，但其假陰性率較高。

（2）呼吸道病毒核酸。呼吸道病毒核酸的檢測通常用於檢測其他常見呼吸道病毒，支原體和衣原體感染，例如腺病毒，副流感病毒，呼吸道合胞病毒，支原體，衣原體，甲型流感和乙型流感病毒等。

（3）2019-nCoV核酸檢測。準確檢測2019-nCoV的RNA具有診斷價值（強烈建議）。通過熒光定量PCR方法在咽拭子採樣或其他呼吸道採樣中獲得的2019-nCoV陽性RNA，尤其是來自多個樣品和檢測試劑盒的RNA，不包括樣品質量，樣品採集時間，污染和技術問題，為檢測提供了有力支持病因診斷。

（4）其他實驗室檢測。還有其他針對2019-nCoV感染狀況的實驗室測試，包括血氣分析，肝腎功能，心肌酶，肌紅蛋白，紅細胞沉降率（ESR），C反應蛋白（CRP），降鈣素（PCT），乳酸，D-二聚體，凝血圖像，尿液常規檢查，炎性因子（白介素（IL）-6，IL-10，TNF-α），11個結核病（TB）亞組，補體，抗酸染色等。血液氣體分析有助於判斷中度和重度患者的氧合作用。結合乳酸的增加，對高危氧合疾病患者進行篩查是可行的。一些感染的患者肝酶，肌肉酶，ESR和肌紅蛋白增加。 CRP和PCT的檢測對於區分肺中是否存在細菌感染具有一定的價值。在這種流行病中，大多數嚴重患者的D-二聚體顯著增加，伴有頻繁的凝血障礙和外周血管微血栓形成。其他炎症因子的檢測可能有助於初步評估患者的免疫狀況。

5.5.3武漢大學中南醫院臨床資料
在這種疾病的早期，外周血白細胞總數正常或減少，淋巴細胞計數減少。在某些患者中，肝酶（轉氨酶），肌酸激酶（CK）和肌紅蛋白增加。大多數患者的CRP，ESR和IL-6升高，而PCT正常。 D-二聚體增加發生在嚴重病例中。
收集武漢大學中南醫院住院的前38例2019-nCoV感染患者的數據。分析顯示，白細胞（WBC）的平均值為5.45（2.30–13.82）×109 / L，PLT為164.5（47–317）×109 / L，淋巴細胞為0.87（0.24–2.27）×109 / L ，單核細胞為0.38（0.12-0.62）×109 / L。 ALT（丙氨酸轉氨酶）的平均值為37.6（6-128）U / L，AST（天冬氨酸轉氨酶）的平均值為53.3（18-169）U / L。 CK的平均值為315（33–3051）U / L，ESR為29.3（8–67）mm / h，CRP為61.8（3–170.91）mg / L，IL-6為57（3.1–134.4） pg / ml，D-二聚體為400（46–3330）ng / ml。
與120次健康檢查相比，淋巴細胞的絕對值（0.87對2.13）×109 / L，淋巴細胞百分比（19.5％對33.7％），嗜酸性粒細胞百分比（0.13％對2.16％）和絕對值（0.0061對0.1417） ）×2019-nCoV患者的109 / L顯著降低（P <0.05）。 2019-nCoV患者的絕對數（4.2 vs 3.7）×109 / L和百分比（72.0％vs 57.0％）增加（P <0.05）。單核細胞的百分比略有增加（8.1％比6.8％），而單核細胞的絕對數量沒有明顯變化（0.38比0.44）×109 / L。

5.6其他早期診斷方法
下一代測序（NGS）和電子顯微鏡技術在早期診斷中發揮了作用，但由於發現了特定的核酸檢測技術，其診斷價值已被削弱。此外，NGS檢測可以判斷病原體是否已突變。

　

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6 Treatment and control

6.1 Principles
Suspected and confirmed cases need to be treated in designated hospitals with effective isolation and protection conditions. Suspected cases need to be treated separately in single room, confirmed cases are admitted to a same ward, and critical cases should be admitted to ICU as soon as possible.

6.2 Treatment plans
(1) The patient should rest in bed, being monitored for vital signs (heart rate, pulse oxygen saturation, respiratory rate, blood pressure) and given supportive treatment to ensure sufficient energy intake and balance for water, electrolytes, acid-base levels and other internal environment factors (Strong recommendation).

(2) The patient should be monitored for blood routine, CRP, PCT, organ function (liver enzyme, bilirubin, myocardial enzyme, creatinine, urea nitrogen, Urine volume, etc.), coagulation function, arterial blood gas analysis and chest imaging (Strong recommendation).

(3) The patient should be given effective oxygen therapy, including nasal catheter, mask oxygen, high flow nasal oxygen therapy (HFNO), non-invasive ventilation (NIV) or invasive mechanical ventilation (Strong recommendation).

First, oxygen therapy is the choice for patients with severe respiratory infections, respiratory distress, hypoxemia or shock. The initial flow rate is 5 L/min, and the titration flow rate is to reach the target oxygen saturation (adults: SpO2 ≥ 90% in non-pregnant patients, SpO2 ≥ 92–95% in pregnant patients; children: SpO2 ≥ 94% in children with obstructive dyspnea, apnea, severe respiratory distress, central cyanosis, shock, coma or convulsions, and ≥ 90% in other children).

Second, respiratory support should be given to patients with hypoxic respiratory failure and acute respiratory distress syndrome. HFNO or NIV can be selected when nasal cannula or mask oxygen therapy was ineffective or the patient had hypoxic respiratory failure. However, when patients had hypercapnia (acute exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary edema), hemodynamic instability, multiple organ failure, and abnormal mental status HFNO oxygen is not the routinely adopted measure. If respiratory failure cannot be improved or worsens continuously within a short time (1 h) after using HFNO or NIV, intubation should be performed immediately. Low tidal volume (4-8 ml/kg) and low suction pressure (platform pressure < 30cmH2O) are used for invasive mechanical ventilation. It is suggested that positive end-expiratory pressure (PEEP) with high positive end-expiratory pressure should be used in patients with moderate or severe acute respiratory distress syndrome, and PEEP should be titrated according to FiO2 to maintain SpO2, in order to improve alveolar atelectasis and reduce alveolar hyper-expansion and pulmonary vascular resistance at the end of inspiration. For severe patients with ARDS, it is recommended to ventilate in prone position for more than 12 h/d.

(4) Extracorporeal Membrane Oxygenation (ECMO) should be considered for the patients with refractory hypoxemia that is difficult to be corrected by protective lung ventilation. (Strong recommendation).

6.3 Drug treatment

6.3.1 Antiviral treatment
(1) At present, there is no evidence from RCT to support specific drug treatment against the new coronavirus in suspected or confirmed cases.

(2) The α-interferon atomization inhalation can be considered (5 million U per time for adults in sterile injection water, twice a day) (Weak recommendation); lopinavir/ritonavir orally, 2 capsules each time, twice a day, can be also considered (Weak recommendation).

Low-level evidences included retrospective cohort, historically controlled studies, case reports, and case series revealed that lopinavir/ritonavir alone or in combination with antivirals produced certain benefits in the treatment of SARS and MERS, such as reducing the incidence or mortality of ARDS [26–29]. A recently systematic review showed that lopinavir/ritonavir’s anti-coronavirus effect was mainly seen in its early application, for reducing patient mortality and reduced glucocorticoid consumption. However, if the early treatment window is missed, there will be no significant effect in their late application [30]. Real-world study stills need to further explore the clinical effects of its early use in 2019-nCoV infected pneumonia.

The effectiveness of the combined use of antivirals is still controversial [31–34].

6.3.2 Antibiotic therapy
(1) Principles. Avoid blind or inappropriate use of antibacterial drugs, especially the combination of broad-spectrum antibacterial drugs. Enhancement of bacteriological surveillance should be performed and promptly given appropriate antibacterial drugs when it occurs secondary bacterial infection.

(2) According to the clinical manifestations of patients, if the accompanying bacterial infection cannot be ruled out, mild patients can take antibacterial drugs against community-acquired pneumonia, such as amoxicillin, azithromycin, or fluoroquinolones; empirical antibacterial treatment in severe patients should cover all possible pathogens, deescalating therapy until the pathogenic bacteria are clarified.

6.3.3 Corticosteroid therapy
The use of corticosteroids for severe ARDS is controversial; therefore, systemic use of glucocorticoids needs to be cautious. Methylprednisolone can be used as appropriate for patients with rapid disease progression or severe illness. According to the severity of the disease, 40 to 80 mg of methylprednisolone per day can be considered, and  the total daily dose should not exceed 2 mg/kg (Weak recommendation).
SARS management related researches showed that timely use of non-invasive continuous positive airway pressure and corticosteroids is an effective strategy for increased lung shadows and increased dyspnea. Appropriate use of glucocorticoids is able to significantly improve the clinical symptoms of patients with SARS, reduce the degree of disease progression, and accelerate the absorption of lung lesions; but it cannot shorten the length of hospital stay [35, 36]. Be cautious that hormone therapy has some incidence of adverse reactions [37].

6.3.4 Other medications
(1) Symptomatic treatment of fever.When the temperature is higher than 38.5℃, ibuprofen can be used for antipyretic (oral, 0.2 g per time, it can be used every 4–6 h in continuous fever, but no more than 4 times in 24 h), and the temperature below 38℃ is acceptable. Much lower body temperature is not conducive to antiviral treatment.

(2) Nutrition support treatment. Inpatients are screened for nutrition risk based on the NRS2002 score when they are admitted to the hospital. The recommended plan for patients with different nutrition risk scores are as follows:
First, if the total score is < 3 points, it is recommended to eat protein-rich foods (such as eggs, fish, lean meat, dairy products) and carbohydrate containing diets. The supposed ideal energy intake is 25–30 kcal / (kg∙d) and the protein mass are 1.5 g / (kg∙d).
Second, if the total score is ≥3 points, the patient should be given nutritional support as early as possible. It is recommended to increase protein intake by oral nutrition supplement, 2–3 times/day (≥ 18 g protein/time). In order to reach the mount of 18 g protein/time, protein powder can be added on the basis of standard whole protein preparations. Enteral nutrition tube should to be placed when the patient cannot intake supplemental nutrition by oral routine.

(3) Reduce the incidence of stress ulcers and gastrointestinal bleeding. Use H2 receptor antagonists or proton pump inhibitors in patients with gastrointestinal bleeding risk factors. The risk factors for gastrointestinal bleeding include mechanical ventilation ≥48 h, coagulation dysfunction, renal replacement therapy, liver disease, various complications, and a higher score of organ failure.

(4) Reduce the secretion of lung glands and improve the respiratory function. For patients with dyspnea, cough, wheeze, and respiratory distress syndrome due to the increased respiratory gland secretion, it is recommended to use selective (M1, M3) receptor anticholinergic drugs to reduce the secretion, relax the smooth muscle in airway, relieve airway spasm and improve the pulmonary ventilation.

(5) Reduce the incidence of venous embolism. Evaluate the risk of venous embolism in patients and use low-molecular-weight heparin or heparin in high risk patients without contraindications.

6.4 Traditional Chinese medicine treatment

6.4.1 Guiding principles
Treat the patient based on syndrome differentiation individually. Prevention before illness is better than treatment after getting diseased.

6.4.2 Prevention
(1) Community. Implement relevant national regulations and take great effort to keep away from contaminated materials, disinfect the environment, and improve the healthcare management.

(2) Individual. It is recommended to take food in proper amount and balanced nutrition, have regular daily life and physical activities, and avoid overloaded work.

(3) Psychology. Develop proper interests and career in a mutual promoting manner.

(4) Drug. Including:
i Fumigation with moxa in the room, 1-5 g/m2 for 30 min per day.

ii Wearing perfumed Chinese herb bags (clove, fineleaf schizonepeta herb, Perilla frutescens, atractylodes lancea, cinnamon, biond magnolia flower, asarum sieboldii, and Elettaria cardamomum, 2 g for each, crushed into powder and put it into bags for external use, change a new one every 10 days).

iii Prescription of Chinese herbs for feet bath (vulgaris 10 g, carthamus 10 g, and dried ginger 6 g) Soaking the herbs in boiling water and bath the feet into the medical liquid when the temperature is suitable. Soak feet for about 20 min.

iv Prescription of Chinese herbs for prophylaxis: Astragalus mongholicus 12 g, roasted rhizome atractylodis macrocephalae 10 g, saposhnikovia divaricata 10 g, Cyrtomium fortunei 10 g, honeysuckle 10 g, dried tangerine or orange peel 6 g, eupatorium 10 g, and licorice 10 g. Taking the medicine above yielded decoction once a day for adults, and for 5 days as a treatment course. If for children, cutting the dose to half.

v Medical tea: perilla leaf 6 g, agastache leaf 6 g, dried tangerine or orange peel 9 g, stewed amomum tsao-ko 6 g, and 3 slices of ginger. Soak the herbs in hot water and drink the water just like enjoying the tea.

vi Chinese patent medicine: Huoxiang Zhengqi capsule or Huoxiang Zhengqi Shui (in half dose).

6.4.3 Treatment [12]
In medical observation period There are two clinical symptoms in this period, including:
(1) Clinical symptoms 1: hypodynamia accompanied by gastrointestinal upset. And the recommended Chinese patent medicine is the Huoxiang Zhengqi capsules (ball, liquid, or oral liquid).

(2) Clinical symptoms 2: hypodynamia and fever. And the recommended Chinese patent medicines is the Jinhua Qinggan granules, Lianhua Qingwen capsules (granules), Shufeng Jiedu capsules (granules), or Fangfeng Tongsheng pills (granules).

Clinical treatment period This period involving 7 stages, including:
(1) Early-stage, characterized as exterior syndrome of cold-dampness. In this stage, the clinical manifestations presents as follow: aversion to cold without sweating, headache and generalized heaviness, limb pain, glomus and fullness in the chest and diaphragm, thirst with no desire to drink, ungratifying loose stool, yellow urine, frequent micturition and yellow urine. The therapeutic logic is to dissipate cold and eliminate dampness. And the recommended prescription is the Huoxiang Zhengqi powder (Yin dampness injuring superficies case from the National Famous Traditional Chinese Medical Doctor Medical Cases); which comprises of perilla leaf 10 g, atractylodes lancea 15 g, radix angelicae dahuricae 10 g, dried tangerine or orange peel 10 g, notopterygium root 10 g, agastache rugosus 10 g (end addition), mangnolia officinalis 10 g, saposhnikovia divaricata 10 g, poria peel 15 g, and Tetrapanax papyriferus 10 g above yielded decoction. In addition, the recommended Chinese patent medicine is Huoxiang Zhengqi capsules or Huoxiang Zhengqi Shui.

(2) Early-stage, characterized as cold-dampness obstructing lung. In this stage, the clinical manifestations presents as follow: aversion to cold with or without fever, dry cough, dry throat, fatigue and hypodynamia, oppression in chest, epigastric fullness, or nausea, loose stool. The tongue is pale or reddish, the tongue fur is slimy white, and soggy pulse. Hence, the therapeutic logic is to dissipate cold and resolve obstruction. And the recommended prescriptions comprises of atractylodes lancea 15 g, dried tangerine or orange peel 10 g, mangnolia officinalis 10 g, agastache rugosus 10 g (end addition), amomum tsao-ko 6 g, ephedra herb 6 g, notopterygium root 10 g, ginger 10 g, areca-nut 10 g (end addition), periostracum cicada 10 g, bombyx batryticatus 10 g, and rhizoma curcumae longae 10 g above yielded decoction.

(3) Middle-stage, characterized as epidemic toxin blocking the lung. In this stage, its clinical manifestations includes persistent fever or alternating cold and heat, cough with less phlegm, or yellow phlegm, abdominal distension and constipation; oppression in chest with anhelation, cough with wheezes, panting on exertion; or red tongue, slimy yellow fur or yellow dry fur, slippery and rapid pulse. Therefore, the therapeutic logic is clearing heat and detoxicating. And the recommended prescription comprises of almond 10 g, gypsum 30 g (predecoction), trichosanthes kirilowii 30 g, rhubarb 6 g (end addition), ephedra with honey fried 6 g, semen lepidii 10 g, peach kernel 10 g, amomum tsao-ko 6 g, arecanut 10 g, and atractylodes lancea 10 g above yielded decoction.
In addition, the recommended Chinese patent medicine is Xiyanping injection or Xuebijing injection.

(4) Severe stage, characterized as heat toxin generating stasis. In this stage, the clinical manifestations is known as high fever, oppression in chest with anhelation, purple-black facial complexion, lips dark and swollen, obnubilation, crimson tongue, yellow dry fur, surging and fine rapid stringlike pulse. Thus, its therapeutic logic is detoxicating and dispersing blood stasis.
The recommended prescription is three Yellows and Gypsum decoction, Shang Jiang Powder, and Toxin-Resolving Blood-quickening decoction. Its composition comprises of ephedra with honey fried 10 g, almond 10 g, gypsum 20-30 g, periostracum cicada 10 g, bombyx batryticatus 10 g, rhizoma curcumae longae 10 g, rhubarb stir-fried with wine 10 g, scutellaria baicalensis 10 g, coptis chinensis 5 g, phillyrin 15 g, angelica sinensis 10 g, peach kernel 10 g, radix paeoniae rubra 15 g, and rhizome of rehmannia 15 g above yielded decoction.
The recommended Chinese patent medicines is the Xiyanping injection, Xuebijing injection, Qingkailing injection, or Angong Niuhuang pills.

(5) Severe-stage, characterized as inner blocking causing collapse. In this stage, the clinical manifestations include dyspnea, panting on exertion or need assisted ventilation, accompanied by coma, and agitation, cold limbs with cold sweating, dark purple tongue, thick or dry thick tongue fur, floating and rootless pulse. The thrapeutic logic is rescuing from collapse by restoring Yang. Hence, the recommended prescription comprises of ginseng 15 g, aconitine 10 g (predecoction), and Cornus officinalis 15 g above yielded decoction, and both taken with fluid Suhexiang pills or Angong Niuhuang pills.
The recommended Chinese patent medicines is Xuebijing injection, Shenfu injection, or Shengmai injection.

(6) Recovery-stage, presents as lung and spleen Qi deficiency. Its clinical manifestations include shortness of breath, fatigue and hypodynamia, anorexia, nausea and vomiting, glomus and fullness, weak stools, ungratifying loose stool, pale tender-soft enlarged tongue, slimy white tongue fur. Therefore, therapeutic logic is to supplement the spleen and lung.
The recommended prescription comprises of rhizome pinellinae praeparata 9 g, dried tangerine or orange peel 10 g, Codonopsis pilosula 15 g, radix astragali preparata 30 g, poria cocos 15 g, agastache rugosus 10 g, and fructus amomi 6 g (end addition) above yielded decoction. In addition, the recommended Chinese patent medicines is pill of costus and amomum with six noble ingredients.

(7) Recovery-stage, characterized as deficiency of Qi and Yin. The clinical manifestations of this stage is generalized heat with sweating, chest heat vexation, Qi counterflow with retching and vomiting, shortness of breath and lassitude of essence-spirit, red tongue and thin tongue fur, vacuous pulse. Hence, the therapeutic logics is boost Qi and nourish Yin.
The recommended prescription is Zhuye Shigao decoction with cogongrass rhizome and rhizome phragmitis; and the composition of this prescription includes bamboo leaf 15 g, gypsum 15 g (predecoction), Codonopsis pilosula 15 g, radix ophiopogonis 10 g, pinellia ternate 9 g, cogongrass rhizome 15-30 g, rhizoma phragmitis 20 g, licorice 10 g, and polished round-grained rice 30 g above yielded decoction.
The recommended Chinese patent medicine: Shengmaiyin.

6.5 Treatment of severe patients

6.5.1 Hypoxemic respiratory failure and ARDS treatments Treatment principle: treat the patients to improve the symptoms and underlying diseases, actively prevent potential complications and secondary infection; provide timely measures to support organ function.

(1) Hypoxic respiratory failure and severe ARDS. Give oxygen therapy immediately to patients with ARDS, and closely monitor them for signs of clinical deterioration, such as rapidly progressive respiratory failure. Consider severe hypoxemic respiratory failure when standard oxygen therapy fails. When patients have increased frequency of breathing (> 30 times/min) and hypoxemia (SpO2 < 90% or PaO2 < 60 mmHg) even with oxygen delivered via a face mask and reservoir bag (gas flow of 10~15 L/min, FiO2 0.60–0.95), it may be considered as hypoxic respiratory failure.
ARDS is a status of severe acute hypoxic respiratory failure caused by increased pulmonary capillary permeability and alveolar epithelial cell damage. It can be divided into mild, moderate and severe conditions according to the Berlin definition [38] (Table 6).

(2) HFNO. Under the support of standard oxygen therapy, to maintain SpO2 above 93% stills hard, and the breathing rate increases rapidly, then HFNO should be considered. HFNO can deliver 60 L/min of gas flow and FiO2 up to 1.0. Generally, gas flow is initially set as 30–40 L/min and oxygen concentration 50%–60%, which is well tolerated and coordinated. Then settings can be adjusted according to the oxygenation status of patients. Compared with standard oxygen therapy, HFNO is able to reduce the chance of tracheal intubation. Patients with hypercapnia (like exacerbation of obstructive lung disease, cardiogenic pulmonary edema), hemodynamic instability, multi-organ failure, or abnormal mental status should not be given HFNO. HFNO may be safe in patients with mild-moderate and non-worsening hypercapnia. However, if the respiratory distress still exists or even worsens dramatically under HFNO (FiO2 > 70%, gas flow > 50 L/min for 1 hour), the respiratory supporting strategy should be changed.

(3) NIV. NIV provides a certain positive pressure ventilation effect through the positive pressure formed by the closed mask. HFNO combined with intermittent short-term NIV (1–2 h) support may be useful to reduce respiratory power consumption and improve oxygenation. But NIV guidelines recommend the use of respiratory support therapy in hypoxemic respiratory failure or pandemic viral illness. Limited data showed a high failure rate of NIV in MERS patients. Invasive mechanical ventilation should be considered in case the ARDS still exists and even acutely deteriorates in NIV process (about 1 h). Patients with hemodynamic instability, multiple organ failure, or abnormal mental status should not receive NIV.

(4) Invasive mechanical ventilation. Under the support of HFNO (the demand for FiO2 > 70% and gas flow > 50 L/min) or NIV, ARDS still exists and even acutely deteriorates, invasive mechanical ventilation should be implemented as soon as possible. Endotracheal intubation should be carried out by trained and experienced provider using airborne precautions, since endotracheal intubation is an operation that may produce a large number of contagious aerosols.
The strategy of protective lung ventilation should be implemented in invasive mechanical ventilation: lower tidal volume (4–6ml/kg), lower plateau pressure (< 30 cmH2O), and appropriate PEEP. For patients with moderate-severe ARDS (PaO2/FiO2 < 150), it is recommended to use higher PEEP, apply prone ventilation for more than 12 h per day and adopt deep sedation and analgesia muscle relaxation strategy within the first 48 h of mechanical ventilation. For patients with severe acute hypoxic respiratory failure, we should pay attention to and prevent ventilator-associated lung injury after mechanical ventilation.

(5) Extracorporeal Life Support (ECLS). In the process of invasive mechanical ventilation when the patient is still in the state of hypoxia, combined with increased partial pressure of carbon dioxide (excluding ventilation dysfunction, PaCO2 > 60mmHg), especially after muscle relaxation and prone ventilation, it is necessary to consider to implement ECLS. However, it is suggested that ECLS treatment should only be carried out under the condition that the professional center is with access to expertise. Currently the ECLS in ICU includes VV-ECMO (blood is pumped from femoral vein, and returns to right atrium through internal jugular vein after oxygenation through membrane oxygenator) and VA-ECMO (blood is pumped from femoral vein and directly enters aortic system through femoral artery after oxygenation through membrane oxygenator). For patients with severe refractory hypoxemia, neuromuscular blockade can improve oxygen supply, especially if there is still evidence of ventilator-patient dyssynchrony after the use of sedatives. However, neuromuscular blockade through continuous infusion should not be routinely used in patients with moderate-severe ARDS; Where available, ECMO in conjunction with low tidal-volume mechanical ventilation can be considered in the treatment of patients with severe refractory hypoxemia in whom standard therapy are failing; Routine use of highfrequency oscillatory ventilation (HFOV) in patients with moderate-severe ARDS is not beneficial, but may be harmful. However, HFOV may still be regarded as a rescue therapy for patients with severe ARDS and refractory hypoxemia. ECMO can be used in some severe ARDS patients (lung injury score > 3 or pH < 7.2 due to uncompensated hypercapnia), but it is not recommended for all ARDS patients. It can be considered to use extracorporeal carbon dioxide removal for ARDS patients, if there is more supportive research evidence in the future.

Conservative fluid management can be adopted for ARDS patients without tissue hypoperfusion. Use vasoactive drugs to improve microcirculation. Empirical antibiotics targeting the suspected potential infection should be used as soon as possible, blind or improper combination of broad-spectrum antibiotics should be avoided. Unless for special reasons, the routine use of corticosteroids should be avoided. Glucocorticoids can be used in a short time (3–5 days) according to the degree of dyspnea and the progress of chest imaging if appropriate and the recommended dose is not more than the equivalent to 1-2 mg/kg methylprednisone per day. Provide intensive standard supportive care to the critically ill patients, including prevention of deep vein thrombosis and stress-induced gastrointestinal bleeding, blood glucose control and so on. Enteral nutrition can be provided. Supplemental nutrition with omega-3 fatty acids and antioxidants is not recommended. Inhaled or intravenous beta-adrenergic agonists are not recommended to promote alveolar fluid clearance and resolution of pulmonary edema.

6.5.2 Treatment of septic shock

(1) Recognize the septic shock. When infection is suspected or confirmed, and on the basis of full fluid resuscitation, vasoconstrictor drugs are still needed to maintain mean arterial pressure (MAP) ≥65 mmHg with lactate ≥2 mmol/L, the existence of septic shock should be considered. If lactate cannot be monitored for some reasons, the following three manifestations (changes in mental state, oliguria, poor peripheral perfusion and prolonged capillary filling time) should be considered as signs of a combination of infection and hypoperfusion.

(2) In resuscitation from septic shock in adults, at least 30 ml/kg of isotonic crystalloid was considered for adults in the first 3 h. In resuscitation from septic shock in children, give 20 ml/kg as a rapid bolus and up to 40–60 ml/kg in first aid.

(3) Isosmotic crystal solution is recommended for resuscitation. Do not use hypotonic crystalloids, starches, or gelatins for resuscitation in the first hour. Albumin may be considered as a resuscitation fluid, but this recommendation was based on low- quality evidence under certain conditions.

(4) Administer vasoconstrictor is suggested when shock persists after fluid resuscitation, noradrenaline as the first choice. The initial blood pressure target is MAP ≥65 mmHg in adults and age-appropriate targets in children.

(5) If it is not possible to place a central venous catheter, vasopressors can be infused through the peripheral vein through large vein and signs of extravasation and local tissue necrosis should be closely monitored.

(6) If extravasation occurs, stop infusion. Vasopressors can also be administered via intraosseous needles.

6.6 Condition evaluation and treatment effect evaluation

6.6.1 Criteria to withdraw ECLS
(1) Remove VV-ECMO. The oxygen concentration of the ECMO air-oxygen mixer has dropped to 21%, the air flow rate has dropped to 0, and the ventilator is not strong enough. Lasting for 2–3 h, the respiratory rate is within 25 breaths/min, SpO2 > 92%, PaCO2 is normal, and withdrawal from VV-ECMO may be considered.

(2) Remove VA-ECMO. The blood flow rate is reduced to the rate of (0.2 to 0.5 L / min) every 5 to 6 h from 3 L/min, and the hemodynamic condition is stable. The blood flow rate is reduced to 1.5 L/min within 24 h. If there is a bridging tube, the arteriovenous end can be connected with a bridging tube to form an ECMO circuit for self-circulation, so that the body’s hemodynamics is driven by the heart. If hemodynamics is stable for at least 6 h, consider removing the machine.

6.6.2 Criteria for removing invasive breathing
When the patient is well aware, cough reflexes are obvious when sucking the sputum, the hemodynamics is stable, and the ventilator parameters are close to offline parameters, the spontaneous breathing test (SBT) is performed. After the SBT is passed, invasive breathing can be considered to remove the endotracheal tube.

6.6.3 Standards of transfer out of ICU
Patients do not need advanced respiratory support (HFNO, NIV, MV, ECLS, etc.); stable hemodynamics and tissue perfusion; no significant impairment of organ function; and no need for organ support treatment (CRRT, artificial liver, etc.). Consider transferring the patient out of ICU procedure.

6.7 Discharge standards
The body temperature returned to normal for more than 3 days; respiratory symptoms improved significantly; inflammation of the lungs showed obvious signs of absorption; and respiratory nucleic acid was negative for two consecutive times (one-day sampling time interval at least); and the patient can be released from isolation.

　

6治療與控制

6.1原則
需要在有效隔離和保護條件下的指定醫院對可疑和確診病例進行治療。疑似病例需要在單人間分開處理，確診病例應在同一病房接受治療，重症​​病例應盡快入ICU。

6.2治療計劃
（1）患者應臥床休息，接受生命體徵監測（心率，脈搏血氧飽和度，呼吸頻率，血壓）並給予支持治療，以確保攝入足夠的能量並平衡水，電解質，酸鹼水平和其他內部環境因素（強烈建議）。

（2）應監測患者的血常規，CRP，PCT，器官功能（肝酶，膽紅素，心肌酶，肌酐，尿素氮，尿液量等），凝血功能，動脈血氣分析和胸部影像學檢查（強烈推薦）。

（3）應給予患者有效的氧氣療法，包括鼻導管，面罩氧氣，高流量鼻氧療法（HFNO），無創通氣（NIV）或有創機械通氣（強烈推薦）。

首先，對於患有嚴重呼吸道感染，呼吸窘迫，低氧血症或休克的患者，氧氣療法是首選。初始流速為5 L / min，滴定流速要達到目標氧飽和度（成人：非懷孕患者SpO2≥90％，懷孕患者SpO2≥92–95％；兒童：SpO2≥94阻塞性呼吸困難，呼吸暫停，嚴重呼吸窘迫，中樞性紫cyan，休克，昏迷或抽搐的兒童的百分比，其他兒童≥90％）。

其次，對低氧性呼吸衰竭和急性呼吸窘迫綜合徵的患者應給予呼吸支持。當鼻插管或面罩氧氣治療無效或患者出現低氧性呼吸衰竭時，可以選擇HFNO或NIV。但是，當患者患有高碳酸血症（慢性阻塞性肺疾病的急性加重，心源性肺水腫），血液動力學不穩定，多器官功能衰竭和精神狀態異常時，HFNO氧不是常規措施。如果使用HFNO或NIV後短時間內（1 h）呼吸衰竭無法改善或持續惡化，則應立即進行插管。低潮氣量（4-8 ml / kg）和低吸氣壓力（平台壓力<30cmH2O）用於有創機械通氣。建議中度或重度急性呼吸窘迫綜合徵患者應使用呼氣末正壓（PEEP）和呼氣末正壓高，並應根據FiO2滴定PEEP以維持SpO2，以改善肺泡肺不張並在吸氣結束時降低肺泡過度擴張和肺血管阻力。對於重度ARDS患者，建議俯臥位通氣超過12 h / d。

（4）對於難於通過保護性肺通氣難以糾正的難治性低氧血症患者，應考慮體外膜氧合（ECMO）。 （強烈建議）。

6.3藥物治療

6.3.1抗病毒治療
（1）目前，RCT尚無證據支持可疑或確診病例中針對新冠狀病毒的特殊藥物治療。

（2）可以考慮使用α-干擾素霧化吸入（成人每次在無菌注射水中每天兩次，每次5百萬U）（弱推薦）；也可以考慮口服洛匹那韋/利托那韋，每次2粒，每日兩次，建議（弱推薦）。

低水平證據包括回顧性隊列研究，歷史對照研究，病例報告，以及病例係列研究表明，單獨使用lopinavir / ritonavir或與抗病毒藥聯合使用可對SARS和MERS產生某些益處，例如降低ARDS的發生率或死亡率[ 26–29]。最近的一項系統評價顯示，洛匹那韋/利托那韋的抗冠狀病毒作用主要體現在其早期應用中，以降低患者的死亡率並減少糖皮質激素的消耗。但是，如果錯過了早期治療窗口，則在後期應用中不會有明顯的效果[30]。現實世界的研究仍然需要進一步探索其在2019年被nCoV感染的肺炎中早期使用的臨床效果。

聯合使用抗病毒藥的有效性仍存在爭議[31-34]。

6.3.2抗生素治療
（1）原則。避免盲目或不適當地使用抗菌藥物，特別是廣譜抗菌藥物的組合。當繼發細菌感染時，應加強細菌學監測，並及時給予適當的抗菌藥物。

（2）根據患者的臨床表現，如果不能排除伴隨的細菌感染，輕度患者可以服用針對社區獲得性肺炎的抗菌藥物，如阿莫西林，阿奇黴素或氟喹諾酮類；重症患者的經驗性抗菌治療應涵蓋所有可能的病原體，逐步降低治療水平，直到明確病原菌為止。

6.3.3皮質類固醇療法
對於嚴重的ARDS使用皮質類固醇有爭議。因此，全身使用糖皮質激素需要謹慎。甲基潑尼松龍可用於疾病快速發展或嚴重疾病的患者。根據疾病的嚴重程度，可以考慮每天服用40至80 mg的甲基強的松龍，並且每日總劑量不應超過2 mg / kg（弱推薦）。
SARS管理的相關研究表明，及時使用無創持續氣道正壓通氣和皮質類固醇激素是增加肺陰影和呼吸困難的有效策略。正確使用糖皮質激素能夠顯著改善SARS患者的臨床症狀，降低疾病進展程度，並加速肺部病變的吸收；但它不能縮短住院時間[35，36]。注意激素治療會產生一些不良反應[37]。

6.3.4其他藥物
（1）對症發燒。溫度高於38.5℃時，布洛芬可用於退燒（口服，每次0.2 g，連續發燒每4-6 h可使用，但不超過4次）在24小時內），並且溫度低於38℃是可以接受的。較低的體溫不利於抗病毒治療。

（2）營養支持治療。根據入院時的NRS2002分數對住院患者進行營養風險篩查。針對具有不同營養風險評分的患者的建議計劃如下：
首先，如果總分小於3分，建議吃蛋白質含量高的食物（例如雞蛋，魚，瘦肉，乳製品）和含碳水化合物的飲食。假定的理想能量攝入量為25–30 kcal /（kg∙d），蛋白質質量為1.5 g /（kg∙d）。
其次，如果總分≥3分，應儘早給予患者營養支持。建議通過口服營養補充劑增加蛋白質攝入量，每天2–3次（≥18 g蛋白質/次）。為了達到18 g蛋白質/時間的量，可以在標準全蛋白質製劑的基礎上添加蛋白質粉末。當患者無法通過口服常規飲食補充營養時，應放置腸內營養管。

（3）減少應激性潰瘍和胃腸道出血的發生。 在有胃腸道出血危險因素的患者中使用H2受體拮抗劑或質子泵抑製劑。 胃腸道出血的危險因素包括≥48小時的機械通氣，凝血功能障礙，腎臟替代療法，肝病，各種並發症以及器官衰竭評分更高。

（4）減少肺腺分泌，改善呼吸功能。 對於由於呼吸腺分泌增加而導致的呼吸困難，咳嗽，喘息和呼吸窘迫綜合徵的患者，建議使用選擇性（M1，M3）受體抗膽鹼能藥來減少分泌，放鬆氣道平滑肌，緩解氣道痙攣 並改善肺通氣。

（5）減少靜脈栓塞的發生。 評估患者靜脈栓塞的風險，並在無禁忌症的高風險患者中使用低分子量肝素或肝素。

6.4中醫治療

6.4.1指導原則
根據證候的不同分別對待患者。生病前的預防勝於生病後的治療。

6.4.2預防
（1）社區。貫徹執行國家有關規定，全力以赴遠離污染物質，消毒環境，改善醫療保健管理。

（2）個人。建議攝取適量的食物和均衡的營養，有規律的日常生活和體育鍛煉，並避免過多的工作。

（3）心理學。以相互促進的方式發展正確的興趣和職業。

（4）毒品。包含：
i每天在房間內以1-5 g / m2的艾灸熏蒸30分鐘。

ii戴上加香的中藥袋（丁香，荊芥，紫蘇，白朮，肉桂，a木蘭，細辛，細葉小荳蔻），各2克，研末，研末，裝入袋中，換成零錢。每10天更新一次）。

iii。足浴中藥的處方（尋常10克，紅花10克，姜幹6克）將草藥浸入沸水中，並在溫度合適時將腳浸入藥液中。將腳浸泡約20分鐘。

iv預防中藥的處方：黃芪12克，烤白朮10克，香蒲10克，貫葉連翹10克，金銀花10克，陳皮或桔皮6克，紫莖澤蘭10克，甘草10克。成年人每天服用上述藥物一次會產生水煎，並作為治療過程持續5天。如果是兒童，則將劑量減半。

v藥用茶：紫蘇葉6克，紫蘇葉6克，陳皮或桔皮9克，燉制砂仁砂子6克和生薑3片。將草藥浸泡在熱水中，然後像喝茶一樣喝水。

vi中成藥：火香正氣膠囊或火香正氣水（半劑）。

6.4.3治療[12]
在醫學觀察期中，該時期有兩種臨床症狀，包括：
（1）臨床症狀1：動力不足伴有腸胃不適。推薦的中成藥是火香正氣膠囊（丸劑，液體劑或口服液）。

（2）臨床症狀2：低動力和發熱。推薦的中成藥是金花清肝顆粒，聯清清溫膠囊（顆粒），舒風解毒膠囊（顆粒）或方風同生丸（顆粒）。

臨床治療期此階段涉及7個階段，包括：
（1）早期，特徵為外感濕潤綜合徵。在此階段，臨床表現如下：厭倦無汗，頭痛和全身沉重感冒，四肢疼痛，胸部和diaphragm肌的充血和飽滿，口渴而不想喝酒，未排尿的糞便鬆散，尿液發黃，尿頻和黃色的尿液。治療的邏輯是消散感冒並消除潮濕。推薦的處方為火香正氣散（全國著名中醫名醫陰虛濕邪）。其中包括紫蘇葉10 g，白朮15 g，當歸大黃10 g，陳皮或桔皮10 g，opter活根10 g，a香10 g（末添加），厚朴10 g，七葉紫蘇葉10 g ，po皮15克，Tetrapanax papyriferus以上10克，煎服。另外，推薦的中成藥是活香正氣膠囊或活香正氣水。

（2）早期，特徵是冷濕阻塞肺。在此階段，臨床表現如下：厭惡感冒或不發燒，乾咳，咽乾，疲勞和動力不足，胸部受壓，上腹飽脹或噁心，大便稀疏。舌頭蒼白或微紅，舌苔白色，有潮濕的脈搏。因此，治療邏輯是消散感冒並消除阻塞。推薦的處方包括白朮15克，桔皮或橘皮10克，厚朴10克，a香10克（末添加），砂仁砂仁6克，麻黃藥草6克，not活根10克，薑汁10克，檳榔10克（末添加），蟬骨蟬10克，貝氏灰黴10克，薑黃10克以上的煎劑。

（3）中期，特徵為流行性毒素阻塞肺部。在此階段，其臨床表現包括持續發燒或冷熱交替，咳嗽，少痰或發黃痰，腹脹和便秘。胸部壓迫伴呼吸停止，咳嗽伴喘息，勞累時喘氣；或舌質紅，粘稠的黃色皮毛或乾燥的黃色皮毛，滑而急促。因此，治療邏輯是清熱解毒。推薦的處方包括杏仁10克，石膏30克（煎劑），木瓜粉30克，大黃6克（末添加），麻黃蜂蜜炒6克，精子10克，桃仁10克，砂仁得到6克ko，10克檳榔和10克以上白朮。
另外，推薦的中成藥為喜炎平注射液或血必淨注射液。

（4）重度階段，特徵是熱毒產生淤滯。在此階段，臨床表現為高燒，胸部壓迫伴有抽搐，面色紫黑，嘴唇黑黑腫脹，閉塞，深紅色的舌頭，黃乾的毛皮，湧動的細小快速弦狀脈搏。因此，其治療邏輯是使血液淤積解毒和分散。
推薦的處方是三種黃和石膏湯，上姜散和解毒止血湯。它的成分包括麻黃，蜂蜜10 g，杏仁10 g，石膏20-30 g，蟬骨蟬10 g，牛bomb 10 g，薑黃10 g，大黃酒10 g，黃s 10 g分別以黃連，黃連5克，粉煤灰15克，當歸10克，桃仁10克，e藥丹參15克，熟地黃15克以上煎服。
推薦的中成藥為喜炎平注射液，血必淨注射液，清開靈注射液或安宮牛黃丸。

（5）嚴重階段，特徵是內部阻塞導致崩潰。在此階段，臨床表現包括呼吸困難，勞累氣喘或需要輔助通氣，並伴有昏迷和躁動，四肢發冷，出汗，舌苔暗紫，舌苔厚或乾，無根脈動。治療邏輯正在通過恢復楊從崩潰中解救出來。因此，推薦的處方包括人參15克，烏頭鹼10克（煎劑）和山茱off 15克（高於產量）的煎劑，並與蘇合香丸或安宮牛黃丸一起服用。
推薦的中成藥為血必淨注射液，神甫注射液或生脈注射液。

（6）恢復期，表現為肺脾氣虛。其臨床表現包括呼吸急促，乏力和動力不足，厭食，噁心和嘔吐，暈眩和飽脹，大便無力，大便失禁，大便淡淡，舌頭柔軟柔軟，腫脹，舌苔發白。因此，治療邏輯是補充脾和肺。
推薦的處方包括：山茱pin 9克，陳皮或桔皮10克，黨參15克，黃芪30克，po可可15克，a香10克，阿米果6克（末添加）產生煎劑。此外，推薦的中成藥是含有六種高貴成分的肋骨和砂仁藥丸。

（7）恢復期，以氣陰兩虛為特徵。該階段的臨床表現是全身熱出汗，胸熱煩惱，氣逆流，嘔吐，氣短和精疲力弱，舌紅苔薄舌，空泡。因此，治療邏輯是補氣養陰。
推薦處方為朱葉適高湯加馬鞭草根莖和根皮炎。該處方的組成包括竹葉15 g，石膏15 g（煎服），黨參15 g，麥冬10 g，半夏半夏9 g，香茅根莖15-30 g，根莖皮膜炎20 g，甘草10 g，然後將米粒加粗至30克以上，製成水煎湯。
推薦中成藥：生脈飲。

6.5重症患者的治療

6.5.1低氧性呼吸衰竭和ARDS的治療原則：治療患者以改善症狀和潛在疾病，積極預防潛在的並發症和繼發感染；及時提供支持器官功能的措施。

（1）缺氧性呼吸衰竭和嚴重的ARDS。立即對ARDS患者進行氧氣治療，並密切監視他們的臨床症狀，例如快速進行性呼吸衰竭。當標準的氧氣治療失敗時，考慮嚴重的低氧性呼吸衰竭。當患者呼吸頻率增加（> 30次/ min）和低氧血症（SpO2 <90％或PaO2 <60 mmHg）時，即使通過面罩和儲液袋輸送氧氣（氣流為10〜15 L / min，FiO2） 0.60–0.95），則可認為是低氧性呼吸衰竭。
ARDS是由於肺毛細血管通透性增加和肺泡上皮細胞損傷引起的嚴重急性低氧性呼吸衰竭。根據柏林的定義，它可以分為輕度，中度和重度[38]（表6）。

（2）HFNO。在標準氧氣療法的支持下，要使SpO2保持在93％以上仍能保持靜止，並且呼吸速率迅速增加，則應考慮使用HFNO。 HFNO可以提供60 L / min的氣流和高達1.0的FiO2。通常，氣體流量最初設置為30–40 L / min，氧氣濃度為50％–60％，可以很好地承受和協調。然後可以根據患者的氧合狀態調整設置。與標準氧氣療法相比，HFNO能夠減少氣管插管的機會。高碳酸血症（如阻塞性肺疾病加重，心源性肺水腫），血流動力學不穩定，多器官功能衰竭或精神狀態異常的患者不應給予HFNO。對於輕度中度和無惡化的高碳酸血症患者，HFNO可能是安全的。但是，如果在HFNO下仍然存在呼吸窘迫甚至嚴重惡化（FiO2> 70％，氣流> 50 L / min持續1小時），則應改變呼吸支持策略。

（3）NIV。 NIV通過閉合面罩形成的正壓提供一定的正壓通氣效果。 HFNO結合間歇性短期NIV（1-2小時）支持可能有助於減少呼吸動力消耗並改善氧合。但是NIV指引建議在低氧血症性呼吸衰竭或大流行性病毒性疾病中使用呼吸支持療法。有限的數據顯示，MERS患者的NIV失敗率很高。如果ARDS仍然存在，甚至在NIV過程中急劇惡化（約1小時），則應考慮採用有創機械通氣。血液動力學不穩定，多器官功能衰竭或精神狀態異常的患者不應接受NIV。

（4）有創機械通氣。在HFNO（對FiO2的需求> 70％，氣流> 50 L / min的需求）或NIV的支持下，ARDS仍然存在，甚至嚴重惡化，應盡快實施有創機械通氣。氣管插管應由經過培訓且經驗豐富的提供者使用空中預防措施進行，因為氣管插管是一種可能產生大量傳染性氣溶膠的手術。
保護性肺通氣的策略應在有創機械通氣中實施：降低潮氣量（4–6ml / kg），降低高原壓力（<30 cmH2O）和適當的PEEP。對於中度重度ARDS（PaO2 / FiO2 <150）的患者，建議使用較高的PEEP，每天進行俯臥通氣超過12小時，並在機械通氣的前48小時內採用深度鎮靜和鎮痛肌肉放鬆策略。對於嚴重急性低氧性呼吸衰竭的患者，應注意並防止機械通氣後呼吸機相關的肺損傷。

（5）體外生命支持（ECLS）。在患者仍處於缺氧狀態下的有創機械通氣過程中，加之二氧化碳分壓增加（不包括通氣功能障礙，PaCO2> 60mmHg），特別是在肌肉鬆弛和俯臥通氣後，有必要考慮實施ECLS。但是，建議僅在專業中心具有專業知識的條件下進行ECLS治療。目前，ICU中的ECLS包括VV-ECMO（血液從股靜脈中抽出，並通過膜充氧器充氧後通過頸內靜脈返回右心房）和VA-ECMO（血液從股靜脈中抽出，並通過股骨直接進入主動脈系統）通過膜充氧器充氧後的大動脈）。對於嚴重的難治性低氧血症患者，神經肌肉阻滯可以改善氧氣供應，特別是如果仍然有證據表明使用鎮靜劑後呼吸機-患者不同步。然而，對於中度重度ARDS患者，不應常規地通過連續輸注進行神經肌肉阻滯。如果可能，ECMO結合低潮氣量機械通氣可用於治療標準治療失敗的重度難治性低氧血症患者。中度重度ARDS患者常規使用高頻振盪通氣（HFOV）無益，但可能有害。但是，HFOV仍可被視為重度ARDS和難治性低氧血症患者的搶救療法。 ECMO可用於某些重度ARDS患者（由於無代償性高碳酸血症導致肺損傷評分> 3或pH <7.2），但不建議所有ARDS患者使用。如果將來有更多的支持研究證據，可以考慮對ARDS患者使用體外二氧化碳去除。

對於無組織灌注不足的ARDS患者，可以採用保守性液體管理。使用血管活性藥物改善微循環。應盡快使用針對可疑潛在感染的經驗性抗生素，應避免盲目或不適當地使用廣譜抗生素。除非出於特殊原因，否則應避免常規使用皮質類固醇。根據呼吸困難的程度和胸部影像學進展，可在短時間內（3-5天）使用糖皮質激素，建議劑量不超過每天1-2 mg / kg甲基強的松酮。為重症患者提供深入的標準支持服務，包括預防深靜脈血栓形成和應激引起的胃腸道出血，控制血糖等。可以提供腸內營養。不建議使用omega-3脂肪酸和抗氧化劑補充營養。不建議吸入或靜脈注射β-腎上腺素能激動劑來促進肺泡液清除和肺水腫消退。

6.5.2敗血性休克的治療

（1）認識到敗血性休克。當懷疑或確診感染時，並在進行充分的液體復甦的基礎上，仍需要使用血管收縮藥來維持平均動脈壓（MAP）≥65mmHg，乳酸≥2mmol / L，應考慮存在膿毒性休克。如果由於某些原因無法監測乳酸，則應將以下三種表現（精神狀態改變，少尿，外周灌注不良和毛細管充盈時間延長）視為感染和灌注不足的結合體徵。

（2）在成人敗血症性休克復蘇中，在最初的3小時內考慮至少30 ml / kg等滲晶體。在兒童敗血性休克復蘇中，快速推注時應給予20 ml / kg，急救時應給予40-60 ml / kg。

（3）建議使用等滲晶體溶液進行複蘇。頭一小時請勿使用低滲晶體，澱粉或明膠進行複蘇。白蛋白可以被認為是一種複蘇液，但是該建議是基於某些條件下的低質量證據。

（4）液體復甦後休克持續時建議使用血管收縮藥，首選去甲腎上腺素。成人的初始血壓目標為MAP≥65 mmHg，兒童的初始血壓目標為適合年齡的目標。

（5）如果無法放置中央靜脈導管，可以通過大靜脈通過外周靜脈注入升壓藥，並應密切監測外滲和局部組織壞死的跡象。

（6）如果發生滲出，停止輸液。血管加壓藥也可以通過骨內針給藥。

6.6病情評價及治療效果評價

6.6.1移除ECLS的標準
（1）卸下VV-ECMO。 ECMO空氣氧氣混合器的氧氣濃度已降至21％，空氣流速已降至0，並且呼吸機強度不足。持續2-3小時，呼吸頻率在25次/分鐘以內，SpO2> 92％，PaCO2正常，可以考慮退出VV-ECMO。

（2）卸下VA-ECMO。血流速度從3 L / min降低到每5至6 h（0.2至0.5 L / min）的速度，血液動力學狀況穩定。血液流速在24小時內降至1.5 L / min。如果有橋接管，則動靜脈末端可與橋接管連接以形成自我循環的ECMO迴路，從而使人體的血液動力學受心臟驅動。如果血液動力學穩定至少6小時，請考慮卸下機器。

6.6.2移除有創呼吸的標準
當患者意識清楚時，吸痰時咳嗽反射明顯，血液動力學穩定，並且呼吸機參數接近離線參數，則進行自發呼吸測試（SBT）。 SBT通過後，可以考慮進行有創呼吸以移除氣管插管。

6.6.3ICU轉出的標準
患者不需要高級呼吸支持（HFNO，NIV，MV，ECLS等）；穩定的血液動力學和組織灌注；器官功能無明顯損害；無需器官支持治療（CRRT，人造肝等）。考慮將患者轉出ICU程序。

6.7出院標準
體溫恢復正常超過3天；呼吸系統症狀明顯改善；肺部炎症表現出明顯的吸收跡象；呼吸核酸連續兩次陰性（至少一天採樣時間間隔）；病人可以脫離隔離。

　

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7 Prevent and control nosocomial infection
7.1 Restriction and isolation guidelines for patient/ suspected patients
See Table 7. (Strong recommendation).

7.2 Personal protection guidelines
According to the principles of standard prevention and tertiary protection, all personnel entering various zones should be evaluated using individual inventory tables according to the exposure risk level. Chose personal protective equipment of various levels is necessary. Personal protective equipment should be worn strictly in accordance with the instructions and only used for one time (Table 8, Strong recommendation).

　

7預防和控制醫院感染
7.1患者/疑似患者的限制和隔離指引
請參閱表7。（強烈建議）。

7.2個人保護準則
根據標準預防和三級保護的原則，進入各個區域的所有人員均應根據暴露風險水平使用單獨的庫存表進行評估。選擇各種等級的個人防護裝備是必要的。嚴格按照說明穿戴個人防護設備，並且只能使用一次（表8，強烈建議）。

　

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8 Disease nursing

8.1 Nursing of isolated patients at home
The patient’s home isolation scheme is shown in Table 5.
Patients should monitor their body temperature and illness at home. If your body temperature continues to be higher than 38℃, or your breath is getting worse, you should seek medical treatment timely.
In addition to taking protective measures, the home caregivers also should monitor their body temperature closely.

8.2 Nursing the patients

8.2.1 Nursing of oxygen therapy
Mild patients generally use a nasal catheter and a mask for oxygen. Adjust the oxygen flow as appropriate according to the patient’s condition and doctor’s instruction, and closely monitor the patient’s breathing and blood oxygen saturation. If oxygen therapy fails to reach the expected effect, the nurse should analyze the cause comprehensively and be vigilant to notify the doctor.

8.2.2 Nursing of medication
Mild patients generally use antiviral drugs, antibacterial drugs (when bacterial infection exists), and symptomatic treatment. The doctor’s advice should be followed accurately and timely. The adverse reactions of oseltamivir mainly include nausea, vomiting, diarrhea, abdominal pain and bronchitis, cough, etc. The adverse reactions of interferon are mainly flu-like symptoms such as fever, fatigue, myalgia, and headache, followed by mild suppression of bone marrow. Attention should be paid to identify the change of clinical manifestations or adverse drug reactions.

8.2.3 Nutritional support
According to the patients’ condition, provide highprotein, high-vitamin, carbohydrate-containing diets (e.g. eggs, fish, lean meat, milk, etc.) for enough nutrition to improve physical condition.

8.2.4 Psychological nursing
Take good care of the patient and respond to the patient’s question timely. Positively encourage patients to reduce their anxiety and fear.

8.3 Nursing of critically illed patients

8.3.1 Condition monitoring
Dynamically monitor patients’ vital signs, waterelectrolytes balance, acid-base balance, and functions of various organs, monitor patients’ infection indicators, and determine the occurrence of complications such as acute respiratory distress syndrome, septic shock, stress ulcers, and deep vein thrombosis.

8.3.2 Sequential oxygen care
The critically illed patients mainly use oxygen therapy such as HFNO, NIV and invasive mechanical ventilation. When using various oxygen treatments in a sequential manner, the airway and breathing circuit need to be kept open, and the effect of oxygen treatment needs to be monitored dynamically. At the same time, skincare products need to be used reasonably to avoid damage to the nose, face and lips by pressure. When using a high-flow nasal catheter to inhale oxygen, the oxygen flow and temperature and humidity should be adjusted appropriately. When using non-invasive mechanical ventilation, patient should receive relevant health education. Patients are instructed to inhale through the nose. The pressure is set from low to high and gradually reaches the target value. The human-machine coordination is maximized. The patient’s consciousness and respiratory function are closely observed. Patients with artificial airway established should use a closed suction tube to reduce virus spread. Nurses should wear goggles or a face shield to avoid occupational exposure.

8.3.3 Special treatment nursing
If the patient develops moderate to severe ARDS, invasive mechanical ventilation combined with a prone position need to be adopted. Standard operating procedure for prone position needs to be followed. At the same time, be cautious to prevent pressure ulcers, falling bed, tube slippage, and eye damage by pressure and other complications. Patients treated with ECMO should be monitored for the performance of the oxygenator. If the oxygenator changes its color to darker, indicating the possibility of coagulation, the doctor should be notified to adjust the heparin dose as necessary. The oxygenator should be replaced if necessary. The coagulation function need to be monitored dynamically, including the whole set of coagulation and DIC (disseminated intravascular coagulation), and the time of activating partial thromboplastin, etc., the patient should be closely observed for signs of bleeding, such as bruising on the skin and mucous membranes, bleeding in the nasal cavity, oral cavity, bloody sputum, hematuria, blood in the stool, swelling of the abdomen, moving dullness, and the size of bilateral pupils. Make sure that the ECMO pipelines are tightly connected and firmly fixed to prevent air embolism and pipeline slippage.

8.3.4 Infection prevention
Perform oral care and skin care, assist the patient to use toilet, and take eyes on the indwelling tubes. Rules and regulations for aseptic operation and isolation should be strictly followed to prevent ventilator-related pneumonia, catheter-related sepsis, urinary catheter related urinary tract infections and other secondary infections.

8.3.5 Nutrition support
Dynamically assess the patients’ nutritional risks and timely nutritional support can be given if needed. For the patients who can eat, the diet rich in protein and carbohydrates is recommended. Those patients who cannot eat but are compatible with enteral nutrition should be given enteral nutrition as soon as possible. For the patients incompatible with enteral nutrition, parenteral nutrition should be given timely to meet energy requirement.

8.3.6 Psychological nursing
Psychological and humanistic care should be performed in high priority especially for the awake patients. Psychological techniques like mindfulness - based stress reduction can be adopted to relieve the patients’ anxiety and panic by building up their optimistic confidence in overcoming the disease.

　
8疾病護理

8.1隔離患者的居家護理
表5顯示了患者的家庭隔離方案。
患者應在家中監測體溫和疾病。如果您的體溫繼續高於38攝氏度，或者您的呼吸變得越來越差，則應及時就醫。
除採取保護措施外，家庭護理人員還應密切監視其體溫。

8.2護理病人

8.2.1氧氣療法的護理
輕度患者通常使用鼻導管和氧氣面罩。根據患者的狀況和醫生的指示適當調整氧氣流量，並密切監視患者的呼吸和血氧飽和度。如果氧療未能達到預期效果，則護士應全面分析病因並保持警惕並通知醫生。

8.2.2藥物護理
輕度患者通常使用抗病毒藥物，抗菌藥物（存在細菌感染時）和對症治療。準確，及時地遵循醫生的建議。奧司他韋的不良反應主要包括噁心，嘔吐，腹瀉，腹痛和支氣管炎，咳嗽等。干擾素的不良反應主要是流感樣症狀，如發燒，疲勞，肌痛和頭痛，其次是骨骼的輕度抑制。骨髓。應注意識別臨床表現或藥物不良反應的變化。

8.2.3營養支持
根據患者的狀況，提供高蛋白，高維生素，碳水化合物的飲食（例如雞蛋，魚，瘦肉，牛奶等），以提供足夠的營養以改善身體狀況。

8.2.4心理護理
照顧好患者並及時回答患者的問題。積極鼓勵患者減少焦慮和恐懼。

8.3重症患者的護理

8.3.1狀態監控
動態監測患者的生命體徵，水電解質平衡，酸鹼平衡和各個器官的功能，監測患者的感染指標，並確定並發症的發生，例如急性呼吸窘迫綜合徵，敗血性休克，應激性潰瘍和深靜脈血栓形成。

8.3.2順序氧氣照護
重症患者主要使用氧氣療法，如HFNO，NIV和有創機械通氣。當按順序使用各種氧氣治療時，氣道和呼吸迴路需要保持打開狀態，並且需要動態監控氧氣處理的效果。同時，需要合理使用護膚產品，以免壓力對鼻子，臉和嘴唇造成傷害。使用高流量鼻導管吸入氧氣時，應適當調節氧氣流量以及溫度和濕度。使用無創機械通氣時，患者應接受相關的健康教育。指導患者通過鼻子吸入。壓力從低到高設置並逐漸達到目標值。人機協調最大化。密切觀察患者的意識和呼吸功能。建立了人工氣道的患者應使用封閉的吸管以減少病毒傳播。護士應戴上護目鏡或面罩，以免職業暴露。

8.3.3特殊護理
如果患者發展為中度至重度ARDS，則需要採用有創機械通氣和俯臥位。需要遵循俯臥位的標準操作程序。同時，要小心避免因壓力和其他並發症而引起的壓瘡，跌倒床，管打滑和眼睛損傷。使用ECMO治療的患者應監測充氧器的性能。如果充氧器的顏色變深，表明有凝結的可能性，應通知醫生，必要時調整肝素劑量。如有必要，應更換充氧器。需要動態監測凝血功能，包括整個凝血過程和DIC（彌散性血管內凝血）以及激活部分凝血活酶的時間等，應密切觀察患者的出血徵象，例如瘀傷。皮膚和粘膜，鼻腔出血，口腔出血，痰中帶血，血尿，便血，腹部腫脹，運動遲鈍以及雙側瞳孔大小。確保ECMO管道緊密連接並牢固固定，以防止空氣栓塞和管道打滑。

8.3.4預防感染
進行口腔護理和皮膚護理，協助患者上廁所，並註視著留置管。應嚴格遵守無菌操作和隔離的規章制度，以防止呼吸機相關的肺炎，導管相關的敗血症，導尿管相關的尿路感染和其他繼發感染。

8.3.5營養支持
動態評估患者的營養風險，並在需要時給予及時的營養支持。對於可以進食的患者，建議飲食中富含蛋白質和碳水化合物。那些不能進食但與腸內營養相容的患者應盡快給予腸內營養。對於腸內營養不良的患者，應及時給予腸胃外營養以滿足能量需求。

8.3.6心理護理
應高度重視心理和人文關懷，尤其是對於清醒的患者。可以採用基於正念的減壓等心理技術，通過建立患者克服疾病的樂觀信心來減輕患者的焦慮和恐慌。

　

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9 Limitations of this guideline
Our guideline has three major limitations: Firstly, time is so limited that we cannot fully consider all clinical issues for this emergency disease. Secondly, many evidences came from data search is indirect. Thirdly, because some recommendations are based on the evidence from existing guidelines and experts’ experience, there are situations where strong recommendations were produced on the base of low-quality evidence or very low-quality evidence, so high-quality evidence, when they appear, is likely to change current recommendations.

　

9本指引的局限性
我們的指引具有三個主要局限性：首先，時間如此有限，以至於我們無法完全考慮該急診疾病的所有臨床問題。其次，許多證據來自數據搜索是間接的。第三，由於一些建議是基於現有準則和專家經驗的證據，因此在某些情況下，當出現低質量證據或非常低質量證據（即高質量證據）時，會提出強有力的建議，很可能會更改當前的建議。

　

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10 Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.1186/s40779-020-0233-6.

　
10補充信息
補充信息隨附於https://doi.org/10.1186/s40779-020-0233-6。

　

相關連結 Related links：

【醫學新知】 新型冠狀病毒感染的肺炎 診療方案　試行第六版　中國衛健委　Guideline of COVID-19 Pneumonia Diagnosis and Treatment　Pilot Version 6th　China NHC

【醫學新知】 中東呼吸症候群(MERS)臨床指引　美國疾病管制署　2015.06　Clinical Guideline of Middle East Respiratory Syndrome (MERS)　US CDC　June, 2015

【醫學新知】 疑似嚴重急性呼吸道症候群(重症非典型肺炎)的識別和評估臨床指引 美國疾病管制署第二版 Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired Illness. US CDC Version 2

　

翻譯者　Translator：

吳志賢，美國哈佛大學麻州眼耳醫院進修醫師，中國醫藥大學附設醫院前主任，國際眩暈醫學大會特邀講師，2014年高分通過台灣耳鼻喉頭頸外科專科醫師考試，臨床醫學研究所博士生。 Chih-hsien Tony Wu is a fellow of Massachusetts Eye and Ear Infirmary of Harvard Medical School, an invited speaker at Vertigo Academy International and the former director of China Medical University Hospital. He passed the examination of Otorhinolaryngology Head and neck surgery specialist in Taiwan with high scores in 2014. He is a student of PhD class in clinical medicine research of graduate school now.

●眩暈科特別門診 ●耳鼻喉頭頸外科門診

　

醫院, hospital, 醫學中心, medical center, 院長, dean, 主任, director, 教授, professor, 博士, PhD, 醫師, doctor, 權威, expert, 推薦, recommended, 效果, effect, 一次見效, effective, 健保, 保險, insurance, 診斷證明書, certificate, 自費, 費用, charge, 價格, price, 萬, 千, 百, 元, dollar, 檢查, examination, 門診, clinic, 急診, emergence, 住院, admission, 手術, surgery, 藥, medication, 飲食, diet, 生活, life, 運動, exercise, 上班, go to work, 注意, careful, 術後, post-operation, 恢復期, convalescence, 正常現象, normal, 不正常abnormal, 瘀青, bruise, 消腫, swelling, 發炎, inflammation, 感染, infection, 副作用, side effect, 後遺症, 按摩, massage, 疤痕, scar, 動暈症, Motion sickness, 良性陣發性姿勢性暈眩, BPPV, benign paroxysmal positional vertigo, 美尼爾病, Meniere's disease, 拉莫葉滋症, Lermoyez syndrome, 遲發性內淋巴水腫, Delayed endolymphatic hydrops, 小兒良性陣發性暈眩症, BPVC, benign paroxysmal vertigo of childhood, 內耳迷路震盪, Labyrinthine concussion, 外淋巴瘻管, Perilymphatic fistula, 上半規管裂損症, SSCD, semicircular canal dehiscence syndrome, 前庭神經炎, Vestibular neuronitis, 侖謝亨特症, Ramsay Hunt syndrome, 梅毒性內耳迷路炎, Syphilic labyrinthitis, 脊椎腦底動脈循環不全, VBI, vertebrobasilar insufficiency, 內耳迷路中風, Labyrinthine infarction, 聽神經瘤, 小腦橋腦角瘤, Acoustic neuroma, CP (cerebellopontine) angle tumor, 自體免疫內耳疾病, AIED, autoimmune inner ear disease, 寇甘症, Cogan's syndrome, 偏頭痛, Migraine, 暈眩型癲癇, Epileptic vertigo, 新陳代謝型暈眩, Metabolic vertigo, 藥致耳毒性, Drug-induced ototoxicity 多發性硬化症, Multiple sclerosis, 神經退化性疾患, Neurodegenerative disorder, 陣發性不協調第二型, Episodic ataxia type 2, 阿諾德-奇阿里畸形, Arnold-Chiari malformation, 暈眩, vertigo, 美尼爾病, Meniere’s disease, 耳鳴, tinnitus, 喉咽逆流, laryngopharyngeal reflux, 鼻骨折, nasal bone fracture, 鼻扭曲症, twisted nose, 各種耳鼻喉頭頸疾病, various diseases of otorhinolaryngology head and neck surgery, 耳前瘻管, pre-auricular fistula, 耳廓外傷, auricular trauma, 耳廓血腫, othematoma, 耳痛, otalgia, 耳癢, auricular itching, 耳流膿, purulent ear discharge, 耳垢, cerumen, 閉塞性角化症, keratosis obturans, 外耳炎, otitis externa, 耳鰴菌症, otomycosis, 異物, FB in ear, 耳帶狀疱疹, herpes zoster oticus, Ramsay Hunt症, 顏面神經麻痺, facial palsy, Bell麻痺, 顳顎關節症, TM joint disorder, 中耳炎, otitis media, 耳膜破洞, perforation of tympanic membrane, 耳膜硬化症, tympanosclerosis, 乳突炎, mastoiditis, Bezold膿腫, abscess, 珍珠瘤, cholesteatoma, 膽脂瘤, 聽小骨疾病, ossicular chain disorder, 耳硬化症, otosclerosis, 耳膜內陷, retracted tympanic membrane, 耳壓不平衡, tympanic pressure imbalance, 耳咽管開放症, e-tube patulus, 突發性耳聾, sudden sensorineural hearing loss, 重聽, 聽力障礙, 聽力損失, 聲創傷, acoustic trauma, 助聽器, hearing aid, 聽力語言訓練, 電子耳, cochlear implant, 頭暈, dizziness, 動暈症, motion sickness, 姿勢性暈眩, benign paroxysmal positional vertigo, 耳石脫落症, Lermoyez症, 前庭神經炎, vestibular neuronitis, 內耳迷路炎, labyrinthitis, 內耳迷路梅毒, syphilis of labyrinth, 多發性硬化症, multiple sclerosis, 偏頭痛, migraine, 失眠, insomnia, 脊椎顱底動脈循環不良症, vertebrobasilar insufficiency, 神經纖維瘤, neurofibromatosis, 聽神經瘤, acoustic neuroma, 小腦橋腦角腫瘤, cerebellopontine angle tumor, 鼻痛, nasal pain, 鼻癤, nasal vestibular furuncle, 蜂窩性組織炎, cellulitis, 流鼻涕, purulent rhinorrhea, 流鼻血, epistaxis, 異物, FB in nose, 鼻癢, nasal itching, 打噴嚏, sneezing, 過敏性鼻炎, allergic rhinitis, 慢性肥厚性鼻炎, chronic hypertrophic rhinitis, 鼻甲肥大, hypertrophy of nasal turbinate, 血管動力性鼻炎, vasomotor rhinitis, 藥物性鼻炎, rhinitis medicamentosa, 萎縮性鼻炎, atrophic rhinitis, 鼻中膈彎曲deviated nasal septum, 鼻中膈穿孔, perforation of nasal septum, 鼻因性頭痛, rhinogenic headache, 空鼻症, empty nose syndrome, 鼻竇炎, rhinosinusitis, 鰴菌性鼻竇炎, fungal, 鼻息肉, nasal polyp, Aspirin三徵, triad, 上頷竇後鼻孔息肉, choncal troanal polyp, 囊狀纖維化, cystic fibrosis, Kartagener症, Samter三徵, triad, 黏液囊腫, mucocele, 鼻唇囊腫nasolabial cyst, 嗅覺障礙, olfactory disorder, 倒生性乳頭瘤, inverted papilloa, 鼻腫瘤, nasal tumor, Wegener肉芽腫, granuloma, 鼻涕倒流, postnasal drip, 鼻淚管阻塞, obstruction of nasolacrimal duct, Tornwaldt囊腫, cyst, 鼻咽脊索瘤, chordoma, 口腔潰瘍, oral ulcer, 口腔白斑, oral leukoprekia, 紅斑, red spot, 黏膜下纖維化, submucosal fibrosis, 口腔食道念珠菌症, oral thrush, Bowen病, 舌頭炎, glossitis, 牙齦炎, gingivitis, 毛狀白斑, hairy leukoplakia, Kaposi肉瘤, sarcoma, 蛤蟆腫, ranula, Eagle症, 扁桃腺炎, tonsillitis, 扁桃腺結石, tonsolith, 口臭, halitosis, 扁桃腺旁膿瘍, peritonsillar abscess, Vincent咽峽炎, angina, 疱疹性咽峽炎, herpangina, 手足口病, HMF disease, 異物, FB, 魚刺, fish bone, 喉嚨癢, itching throat, 顎裂, cleft palate, 咽炎, pharyngitis, 喉炎, laryngitis, 結核性喉炎, tuberculus, 會厭炎, epiglottitis, 喉乳頭狀瘤, laryngeal papilloma, 聲音沙啞, hoarseness, 聲帶炎, vocal corditis, Reinke聲帶水腫, edema, 聲帶溝, sulcus vocalis, 聲帶結節, nodule, 聲帶息肉, polyp, 聲帶囊腫, cyst, 聲帶麻痺, paralysis, 老年性聲帶萎縮, presbylaryngis, 語言障礙, speech, language, 口吃, stutter, 聲門下峽窄, subglottic stenosis, 咳血, hemoptysis, 吞嚥困難, dysphagia, 清喉嚨, throat cleaning, 喉嚨卡卡, throat globus sensation, 喉嚨腫, throat swelling, 火燒心, heart burn, 吐酸, acid regurgitation, 喘鳴, stridor, 打呼, snoring, 打鼾, 睡眠呼吸中止症, sleep apnea, 起床頭暈頭痛, headache, 白天疲憊, malaise, 嗜睡, drowsiness, 記憶力差, poor memory, 脾氣暴躁, short temper, 慢性咳嗽, chronic cough, 深頸部感染, deep neck infection, Ludwig咽峽炎, 頸部腫瘤, neck mass, 甲狀舌管囊腫, thyroglossal duct cyst, 甲狀腺腫瘤, thyroid tumor, 甲狀腺炎, thyroditis, 胸腺瘤, thymoma, 鰓裂囊腫, branchial cleft cyst, 唾液腺結石, sialolithiasis, 唾液腺腫瘤, salivary gland tumor, 混合瘤, mixed, Warthin瘤, Frey症, 腮腺炎, mump, 乾燥症, sjorgren, 頸部淋巴腺腫大, enlargement of neck lymph node, Kikuchi病, Kimura病, 淋巴癌, lymphoma, EB病毒, EB virus, 鼻咽癌, nasopharyngeal carcinoma, 口腔癌, oral cancer, 口咽腫瘤, oropharyngeal, 下咽腫瘤, hypopharyngeal, 喉癌, laryngeal, 食道癌, esophageal, 小兒耳鼻喉, pediatric, 中耳積水, middle ear effusion, 腺樣體肥大, adenoid hypertrophy, 扁桃腺肥大, tonsillar hypertrophy, 發育不良, 生長遲緩, growth retardation, 哮吼, croup, 感冒, common cold, 上呼吸道感染, upper respiratory infection, 腸胃炎, acute gastroenteritis, 喉嚨痛, sore throat, 鼻塞, nasal obstruction, 流鼻水, clear rhinorrhea, 咳嗽, cough, 痰, sputum, 發燒, fever, 頭痛, headache, 肚子痛, abdominal pain, 拉肚子, diarrhea, 流感, influenza, , 全身無力, debility, 全身痠痛, general soreness, 鼻咽血管纖維瘤, angiofibroma, 喉頭軟化症, laryngomalacia, Langerhans細胞組織球增生症, cell histiocytosis, 囊狀水瘤, cystic hygroma, 隆鼻, augmentation rhinoplasty, 鼻整形, 眉心, glabella, 鼻山根, nasion, 鼻樑, dorsum, 鼻頭, nasal tip, 鼻柱, columella, 鼻翼, alar, 鼻基底, subnasale, 鼻唇溝, nasolabial groove, 矮鼻, low dorsum, 塌鼻, 短鼻, short nose, 朝天鼻, nostril show, 寬鼻, wide

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