Chemoprophylaxis, diagnosis, treatments, and discharge management of COVID-19: An evidence-based clinical practice guideline(updated version)

The novel severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)is the cause of a rapidly spreading illness,coronavirus disease 2019(COVID-19),affecting more than seventeen million people around the world.Diagnosis and treatment guidelines for clinicians caring for patients are needed.In the early stage,we have issued"A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus(2019-nCoV)infected pneumonia(standard version)";now there are many direct evidences emerged and may change some of previous recommendations and it is ripe for develop an evidence-based guideline.We formed a working group of clinical experts and methodologists.The steering group members proposed 29 questions that are relevant to the management of COVID-19 covering the following areas:chemoprophylaxis,diagnosis,treatments,and discharge management.We searched the literature for direct evidence on the management of COVID-19,and assessed its certainty generated recommendations using the Grading of Recommendations,Assessment,Development and Evaluation(GRADE)approach.Recommendations were either strong or weak,or in the form of ungraded consensus-based statement.Finally,we issued 34 statements.Among them,6 were strong recommendations for,14 were weak recommendations for,3 were weak recommendations against and 11 were ungraded consensus-based statement.They covered topics of chemoprophylaxis(including agents and Traditional Chinese Medicine(TCM)agents),diagnosis(including clinical manifestations,reverse transcription-polymerase chain reaction(RT-PCR),respiratory tract specimens,IgM and IgG antibody tests,chest computed tomography,chest X-ray,and CT features of asymptomatic infections),treatments(including lopinavirritonavir,umifenovir,favipiravir,interferon,remdesivir,combination of antiviral drugs,hydroxychloroquine/chloroquine,interleukin-6 inhibitors,interleukin-1 inhibitors,glucocorticoid,qingfei paidu decoction,lianhua qingwen granules/capsules,convalescent plasma,lung transplantation,invasive or noninvasive ventilation,and extracorporeal membrane oxygenation(ECMO)),and discharge management(including discharge criteria and management plan in patients whose RT-PCR retesting shows SARS-CoV-2 positive after discharge).We also created two figures of these recommendations for the implementation purpose.We hope these recommendations can help support healthcare workers caring for COVID-19 patients.

新型冠状病毒肺炎药物预防、诊断、治疗与出院管理临床指南计划书

本计划书为《新型冠状病毒(2019-nCoV)感染的肺炎诊疗快速建议指南(标准版)》更新版的研究方案。计划书涵盖指南制定方法学、指南的目标用户、指南的目标人群、利益冲突调查与声明、临床问题和结局指标的遴选与确定、证据的检索、合成与评价、证据与推荐意见分级标准、推荐意见的形成、指南的更新,并附录指南临床问题清单、文献检索策略及利益冲突调查表。

Acute exacerbation of chronic obstructive pulmonary disease treated by extracorporeal carbon dioxide removal

To the Editor: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients often required mechanical ventilation support. But ventilator-related side effects are still inevitable, leading to treatment failure. The extracorporeal carbon dioxide removal (ECCO2R) technique drains blood to artificial membrane lungs, performing oxygenation and removing carbon dioxide without mechanical ventilation. ECCO2R has been widely used outside China, but there is no official report of its use in China. Recently, we treated two AECOPD patients using ECCO2R.

Non-invasive respiratory support for patients with novel coronavirus pneumonia:clinical efficacy and reduction in risk of infection transmission

Introduction Pneumonia caused by a novel coronavirus known as 2019 novel coronavirus disease(COVID-19)[1]appeared in Wuhan,China in December 2019,and approximately 15%to 30%of patients developed acute respiratory distress syndrome within a short period of time.[2,3]To reduce respiratory symptoms and improve prognosis,respiratory support is the most important means of life support,[1]and non-invasive respiratory support systems,[2]including various conventional oxygen therapies,non-invasive positive pressure ventilation(NPPV),and high-flow nasal cannula(HFNC),are most commonly used.However,their efficacy and safety remain unclear,and whether they increase the risk of aerosol dispersion and disease transmission is particularly controversial.[4,5]Given that there are many similarities between COVID-19 pneumonia and severe acute respiratory syndrome(SARS)and Middle East respiratory syndrome(MERS),[6]this study primarily discusses clinical indications and provides details regarding the prevention of nosocomial infections during NPPV and HFNC treatment of COVID-19 pneumonia based on previous clinical data on the use of these two therapies for SARS and MERS and our experience with the treatment of COVID-19 pneumonia.

Programmed death ligand 1 is overexpressed by neutrophils in the blood of immunocompromised human immunodeficiency virus-negative patients with Pneumocystis jirovecii pneumonia

Despite recent advances in antibiotic use, in creasing numbers of human immunodeficiency virus (HIV)- negative patients with Pneumocystis jirovecii pneumonia (PCP) are being admitted to intensive care units (ICUs), and show a mortality rate of over 50%.[1] A high neutrophil count in bronchoalveolar lavage (BAL) fluid is a predictor of poor prognosis in HIV-negative patients with PCP.

Expert consensus on clinical standardized application of high-flow nasal cannula oxygen therapy in adults

High-flow nasal cannula oxygen therapy(HFNC)is a novel respiratory support technology and has been extensively applied in clinics in recent years.This therapeutic equipment mainly includes an air-oxygen blender,an active humidifier,a high-flow nasal cannula,and a connecting inspiratory circuit.It provides patients a humidified high-flow gas(8-80 L/min)with relatively stable oxygen concentration(21-100%),temperature(31-37℃)and performs oxygen therapy via a nasal cannula,which is very comfortable.

Extracorporeal membrane oxygenation support in 2019 novel coronavirus disease:indications,timing,and implementation

The 2019 novel coronavirus disease(COVID-19)has spread rapidly across Hubei province and to all regions in China owing to its person-to-person transmission and strong invasiveness targeting the lower respiratory tract.[1]By the end of February 15,2020,more than 68,000 cases of COVID-19 pneumonia had been confirmed in China,including over 1600 fatalities.[2]Most infected patients who developed COVID-19 pneumonia suffered from only mild symptoms and then completely recovered.However,in some patients,the phenotype may rapidly progress to acute respiratory distress syndrome(ARDS)and multiorgan failure.The initial clinical data,collected in Wuhan Jinyintan Hospital,showed that ARDS was reported in 12(29%)among 41 confirmed patients.[3]Among the 41 patients,13 patients received medical care in the intensive care unit(ICU),4 patients were provided invasive mechanical ventilations,whereas for two patients,extracorporeal membrane oxygenation(ECMO)treatment was applied.Finally,six of the 41 patients died.The clinical data of 99 confirmed patients from the same hospital demonstrated that 17 in 99 patients developed ARDS;among them,three received ECMO treatment,and 11 died.[4]Another study reported that 22 in 138 cases(16%)developed into ARDS and were admitted into the ICU,of which four received ECMO.[5]

Severe Lymphopenia and Related T-cell Immunity in an Avian Influenza A (H7N9)-Infected Patient

To the Editor:Following H7N9infection,the host lymphocyte immunity plays an antiviral role.[l] Furthermore,low frequencies of T-cells correlate with disease severity.[2]Herein,we present a H7N9-infected patient with life-threatening lymphopenia (only 0.06× 10^9/L in the peripheral blood),which we have barely ever seen before.We also measured the proportidns of T-cell subpopulations in the blood and bronchoalveolar lavage fluid (BALF).