On April 15, all medical teams supporting Hubei Province were evacuated, and 315 medical teams supporting Han nationality and 35591 people have all returned. But a team of 20 experts remained in Wuhan to continue to guide the critical care. Some of the 20 Chinese experts have been fighting "epidemic" for more than three months, including Tong Chaohui, vice president of Chaoyang Hospital in Beijing, Qiu Haibo, vice president of Zhongda Hospital Affiliated to Southeast University, Du bin, director of internal medicine ICU of Peking Union Medical College Hospital, etc.
From left to right: Professor Du bin, Professor Tong Zhaohui, Professor Qiu Haibo, Professor Cao Zhaolong
China's new crown epidemic has been effectively controlled, but as of April 20, the number of overseas new crown confirmed has exceeded 2.3 million. China has participated in novel coronavirus pneumonia under the severe situation of overseas epidemic.
Born in Hubei Province and graduated from Wuhan University Medical School, Tong Zhaohui initially proposed to share the experience of anti epidemic for three months with alumni from all over the world of Wuhan University. With the support of the Beijing Alumni Association of Wuhan University and Taikang public health and Epidemic Prevention Fund, the sharing conference has become an online forum for millions of people to watch on the people's daily health client network, Netease News client and other media.
Online sharing of Beijing offline main venue
Novel coronavirus pneumonia novel coronavirus pneumonia, Tong Zhaohui, Qiu Haibo and Durbin, and four leaders of the new crown pneumonia prevention and control expert group, who have been striving for the first line in the evening of April 18th, have been online communicating with medical staff worldwide to help them with new severe pneumonia.
China's doctors from China novel coronavirus pneumonia, including doctors in the United States, Canada, Nepal, India, Singapore, Iraq, Britain, Malawi and South Africa, have asked questions from four experts in China about the problems encountered in the course of the treatment of new crown pneumonia. He is a first-line doctor in respiratory department, ICU, infection department and surgery department.
During the novel coronavirus pneumonia, experts and questions about the development of prevention and control, diagnosis and treatment, and the development trend of new crown pneumonia were discussed. In the selection of antiviral drugs, the treatment of cancer patients, the use of hormone drugs and anticoagulants, and even whether the human secretion, sweat and semen are infectious and other issues of most concern, experts have answered one by one.
17 years ago, Tong Zhaohui was ordered to fight SARS on the front line. 17 years later, he set out again. On January 19, 2020, Tong Zhaohui, as the first group of aid experts, has been in Wuhan to participate in and guide the rescue of critical patients, and has been in Han for more than three months.
Tong Zhaohui's name has appeared frequently in public media since the beginning of the epidemic. Tong Zhaohui not only treats diseases and saves people in the front line, but also shares anti epidemic experience from a professional perspective to eliminate public panic.
According to Professor Tong Zhaohui, there is no "reason why doctors and nurses can't go to the battlefield". No matter there is a shortage of protective materials or a negative pressure ward, they still have to fight without advanced weapons. He also mentioned in the sharing that he took out the photos of the masks he had worn during the SARS, and found that he was wearing gauze masks, which made him shocked. Today, in the protection of medical staff, Professor Tong believes that it should also be properly protected without excessive panic.
Professor Tong also interpreted the concept of "group immunity". He thought it was a scientific problem, and the whole society needed to pay a price. However, the national conditions of each country were different. There were 1.4 billion people in China, which would be very difficult if the proportion was 70-80%.
Professor Qiu Haibo is a famous expert in critical medicine, a member of the expert group of the Chinese Health Commission, a deputy secretary of the Party committee of the affiliated Zhongda Hospital of Southeast University, and a member of the expert group of the central steering group of China in fighting against the new crown epidemic. He has also been fighting in Wuhan for more than 80 days.
"Some people will have such doubts. If I have not been infected, will it be susceptible if I have not been immunized? Maybe the answer is "yes." But Professor Qiu Haibo thinks that there is no need to panic. At present, China's control measures for the infected are powerful. Even if there may be asymptomatic infected people today, they have not caused a lot of transmission. "I believe that life will return to normal, and the sun will still shine," Professor Qiu Haibo gave us reassurance.
Professor Du bin is the director of the internal medicine ICU of Peking Union Medical College Hospital, a famous expert in critical medicine, and a member of the expert group of the central steering group for fighting against the new crown epidemic in China. After the attack of the new crown epidemic, he also arrived at the front line of Wuhan for the first time, and has been persisting in the front line of Wuhan up to now.
Novel coronavirus pneumonia professor Cao Zhaolong is the novel coronavirus pneumonia prevention and control expert group leader of Peking University People's hospital. He is responsible for the consultation of new severe cases of severe pneumonia in Beijing People's hospital.
The new coronavirus is a common major problem for all human beings. The experience of Chinese doctors may be of reference value to the world war epidemic.
Novel coronavirus pneumonia is the core of China's top twenty national exchange activities. The NetEase has compiled the core content of the exchange.
On prevention and control: "group immunity" is very difficult in China
Novel coronavirus pneumonia is a serious reason, because it is very infectious. According to media reports, more than 9000 medical and nursing staff in the United States are infected, and there are many infections in other countries. It should be said that protection is the first way of treatment and the most important thing. It is very important for doctors to carry out effective self-protection. Recently, the concept of group immunity has also been discussed. Is group immunity an effective means of protection? Can we be protected? Experts believe that there are 1.4 billion people in China. If the concept of group immunity requires more than 70-80% of the population, this proportion is very large. No matter in which country, it's hard to do it.
Question 1: how do experts understand the concept of "group immunity", which is very popular recently?
Tong Zhaohui:First, answer this question from the scientific level. Group immunity is a scientific problem, just like people who accept some microorganisms and antigens will produce antibodies. But there is a problem, so-called group immunity must meet the percentage of the population, so as to achieve the total immunity.
There are 1.4 billion people in China. If the concept of group immunity needs more than 70-80 percent, this proportion is very large. No matter in which country, it's hard to do it.
Second, even if there are antibodies, whether it's avian influenza, swine flu or SARS, the time of influenza like antibodies in human body is relatively short. Some people can't detect them in less than a year. Like SARS antibody, most people can't detect it in six months, some people have it in one year, and a few people will have it in two years. The low maintenance time of producing antibody is limited.
We should treat the concept of "group immunity" correctly. For example, how much it costs, even if it costs so much to produce antibodies can protect how long, this is the problem to face.
We should think about it in different environments. One is to face this scientific problem first, and the other is to pay what price. Third, the national conditions are different. The national conditions of each country are different. China is a country that stresses emotion, human feelings and filial piety. It respects the old and loves the young, so it is different.
Question 2: is novel coronavirus pneumonia necessary for a full range of protection? Is a negative pressure ward needed? What do you think of this prevention and control policy in the UK in response to the issue of "group immunity"?
Tong Zhaohui:First answer the question of "group immunity". First of all, we should recognize that the UK is a country that has done a very good job in public health. Experts in public health and epidemiology are all top in the world. The concepts they put forward should also be suitable for national conditions. We should learn from them in many aspects.
Wear N95 and gloves well. I even think it's more important to wash hands frequently than gloves. Don't pick your nose or eyes while you are working. Wash your hands and take a bath after work. There is no need for over protection, which is my consistent view.
Qiu Haibo:I agree with Dean Tong. In terms of the overall protection of the new crown ward, what we have done is very positive.
As a respiratory infectious disease mainly transmitted by droplets, N95 mask may be the most important, followed by contact transmission. That is to say, if you enter the ward of covid-19 patients and do not perform any operation, or do not do any polluting operation, N95 mask, surgical isolation suit and gloves are enough.
However, if you want to do sputum aspiration, tracheal intubation, organ incision and other high-risk operations, you need to have an eye mask and a screen, which is at least necessary. If possible, a positive pressure head cover can be used. It is necessary to improve the level of protection only in high-risk operations. As Dean Tong said, such a level of protection is sufficient for the general situation.
Question 3: China novel coronavirus pneumonia in India, can we provide some experience to China's rural areas with the experience of rural areas? I really want to learn from Chinese experience professors.
Du Bin:This is a very difficult problem. There are many similarities and differences between China and India. But China city novel coronavirus pneumonia is also a new outbreak of the rural community health care system. There are three very good phases of the diagnosis and treatment system, including the parts of Wuhan City, and almost all the rural areas in Wuhan.
Novel coronavirus pneumonia clinics are also designated hospitals for new crown pneumonia, where free patients are treated, even if there are patients, even if the patient comes from rural areas in Wuhan. China's central and local governments have made a lot of efforts to ensure the isolation of all suspected cases and pre-treatment, but this experience is difficult to replicate in other countries. I'm not sure about the situation in India. If you don't have such a medical system, my suggestion is that keeping social distance may be a more practical and practical way.
Cao Zhaolong:Hubei also faced these problems two or three months ago. In addition to Wuhan, there are also many patients in many prefecture level cities. We should try our best to send the patients to large hospitals in the city for centralized treatment, which may be a guarantee for the successful treatment of the patients. After all, respiratory infectious diseases come so suddenly that the treatment of township hospitals and the concentration of patients in the city's hospitals are certainly different for the treatment and health assurance of patients.
Question 4: if there is no N95 mask in the area of material shortage, when entering the infectious ward to contact with covid-19 patients face to face, will wearing more masks have certain protective effect?
Tong Zhaohui:In fact, wearing a mask does not care how many layers, but whether the surrounding area fits closely with the face. I think a lot of people wear N95 and then wear a surgical mask outside. In fact, the surgical mask is cocked.
Why N95? Block 95% of microorganisms. Surgical masks, called N90, block 90% of microorganisms. If there is no N95, wear a surgical mask. In fact, one layer is enough, but it only blocks 90% of microorganisms. The key is to fit the face and nose closely.
I took out the picture of the mask I wore when I was in SARS. I found that I was wearing gauze mask, and any microorganism could come in. I wanted to be shocked later. As you know, gauze masks were washed and used repeatedly.
First, proper protection; second, not too much fear; third, there will not be so many negative pressure wards in general hospitals in China. For example, 20 beds in ICU, 20 negative pressure wards? Not likely. Do soldiers stop fighting without advanced weapons? Don't you go to war? Every time I go to a place, I say that it's better to open windows for ventilation in a negative pressure ward. As long as the window air flow is good and the ventilation is good, this kind of working environment is the best.
Let's think about it. Where has the negative pressure been absorbed? It's all inhaled into the ward, and the concentration will be higher after entering. Why negative pressure? Isn't it better for the windows to open and flow? Some views are also wrong, and our conditions are not available. It is also a big investment to build a negative pressure ward. For example, some infectious disease hospitals do not mean that every ICU is a negative pressure ward, only a few negative pressure wards. There are not enough ICU beds in many cases like Wuhan and European and American countries, let alone negative pressure ward. I don't think this thing is necessary or the reason why we can't go to the battlefield.
Question 5: how to protect patients when they are admitted to surgery, especially when they are undergoing surgery? How can doctors protect themselves from the virus?
Tong Zhaohui:First of all, the patients of each operation should be screened. First of all, there should be indications for surgery, or emergency surgery, which is a condition. Novel coronavirus pneumonia is often diagnosed by a nucleic acid test, and whether it is a suspected or a close tie. If it is the case above, the patients who choose the operation are not recommended to rush for the operation.
Second, if the emergency needs surgery, in fact, many patients in Wuhan have done surgery, and medical staff have also received surgery under special circumstances. For novel coronavirus pneumonia, if the operation is needed because of the emergency surgical indication, the operation room should have special procedures. Basically, novel coronavirus pneumonia is a three level protection in Tongji and Concorde in Wuhan, and some of them will wear positive pressure cover to help them perform operations.
But usually, if we can achieve three levels of protection in the isolation ward, that is, the so-called "red area", including goggles, screens and positive pressure head cover in good conditions, I think there is no problem in the operation.
Question 6: what are the possible transmission channels of excreta in patients with new crown? Can our sweat and semen be spread as a way of transmission?
Cao Zhaolong:The spread of the new crown, because it is a respiratory infectious disease, droplet spread and contact spread, is very certain. Including the problem of aerosols, it was controversial at the beginning, but the latest 7th and 6th versions of the treatment plan also regard aerosols as a way of diagnosis and treatment, especially when taking the elevator, or in the middle of a closed environment, such as the subway, meeting room, which also has a clear requirement for what people can't sit too close to now.
The new coronavirus was also detected in the urine and stool of patients. Generally speaking, the infectivity caused by the new coronavirus in urine and feces is mentioned in the 6th or 7th Edition, but it is not the main way of transmission. Therefore, for the excreta of these patients, the toilet cover should be covered first after defecation, and then the water flushing should be carried out to avoid the pollution caused by aerosol to the surrounding environment as much as possible.
In fact, it is also mentioned that it will have an impact on male fertility, which may have an impact in the near future. It is generally recommended that these patients go to reexamine half a year later to see if they can recover.
Du Bin:As far as I know, no virus has been detected in semen, only in autopsy. Virus may be detected in testicles and ovaries, and the virus has a certain impact on fertility. Now some experts have mentioned that the impact on fertility may be due to safety considerations, rather than the exact evidence that it does have an impact on fertility.
Question 7: is the current situation of isolation temporary or continuous? Or can we take off the mask after November or summer? Will our life change because of the epidemic?
Qiu Haibo:At least from the experience of Wuhan, the closure measures have been lifted and the life order is recovering.
Although there are 50000-60000 confirmed cases in Wuhan, it is a very small number compared with tens of millions of people in Wuhan. Some people will have such a question, if I have not been infected, will not be immune susceptible? Maybe the answer is "yes". However, due to our control of the infected, the asymptomatic infected and the people who may cause transmission, there are basically no new cases in Wuhan, or very few new cases, only a few asymptomatic cases can be seen.
Even in such asymptomatic cases, the infectivity is very low. From the epidemiological survey in Wuhan and Hubei, we can see that the number of virus carriers among the people returning to work is less than 1 / 1000, which is very low. If further investigation, asymptomatic virus carriers or people close to the infected people basically do not see the infection.
In fact, even today there may be asymptomatic viral or infected people who do not cause a lot of transmission. I believe that life will still return to normal, the sun will still be shining, so you don't have to worry about it. Of course, we can't rule out whether there will be a small-scale outbreak in winter, which is possible. The spread of new crown virus in Wuhan, Hubei Province and all over the world has taught us a profound lesson. I believe that if we can insist on the protective measures for respiratory diseases, especially the respiratory protective measures and the personal hygiene measures for contact transmission, I believe that it will not cause large-scale transmission, and it will happen again on a large scale, but a small scale may be unavoidable.
Case diagnosis: the positive rate of nucleic acid test is about 30% - 50%
The novel coronavirus pneumonia is currently diagnosed by 30%-50%, which is a difficult problem for the diagnosis of new crown pneumonia. Experts suggest that no matter whether the nucleic acid test is negative or positive, as long as the clinical symptoms or other clinical evidence support, the experts suggest to follow the diagnosis and treatment process of covid-19. Besides nucleic acid detection, CT is also a very powerful tool. At present, some foreign countries are not equipped with CT scanning conditions, in this case, the diagnosis of patients has a great limit, experts also give advice on comprehensive diagnosis and treatment.
Question 8: novel coronavirus pneumonia is the most important detection tool. Nucleic acid detection is the most important tool. But sometimes the results of nucleic acid detection are negative. This brings a lot of trouble to doctors. How should doctors judge? How should false negative patients be managed and treated?
Cao Zhaolong:Nucleic acid testing is novel coronavirus pneumonia in 2019 and SARS in 2003. There was no nucleic acid test for SARS in that year, which was based on clinical diagnosis.
This time, nucleic acid detection was included in the necessary detection, especially in the early patients, many of which were not enough. Later, the amount of detection gradually increased, and more and more patients were diagnosed. Finally, the cases of clinical diagnosis were included in the confirmed cases after a period of time in Wuhan. However, the current positive rate of nucleic acid test is not 100%. At present, the best positive rate in China may only be about 50%, so there are many false negative problems.
Secondly, it may have something to do with the specimens we took. From the data we have now, the highest false-positive rate of the specimens we have now is the secretion of the lower respiratory tract, and the bronchoalveolar lavage may be the best, followed by the sputum flowing to the lower respiratory tract, followed by the oropharynx and nasopharynx test papers. The positive rate is related to the current test level, so in many cases, the so-called "two negative and then re Yang" may not be the problem of re Yang, but the previous test may be false negative.
In the case of false negative cases, in the epidemic area, such as Wuhan, all the clinical manifestations such as fever, respiratory symptoms, including CT manifestations in the lung suggest that he is a pneumonia caused by a new coronavirus. At this time, even if the nucleic acid test is negative, the treatment also needs to be carried out according to covid-19, which is not questionable. Even if he is negative, treatment and nucleic acid positive cases should be treated equally.
Question 9: what are the current diagnosis and treatment methods? Is there a comprehensive diagnosis of all means to determine whether this patient is an infected person with covid-19, and is there any other diagnostic method?
Tong Zhaohui:You know that our national diagnosis and treatment program has been published in the 7th Edition. What does this mean? One version is better than the other. Either Professor Du or professor Qiu, we have participated in the revision of these editions respectively. For example, when we were not familiar with the disease in the early stage, we summed up some clinical features, including fever, respiratory symptoms, and even proposed the diagnosis of nucleic acid. At present, foreign countries also rely on nucleic acid diagnosis. The situation faced by all countries is basically the same. At the beginning, the detection capacity was insufficient. Later, when everyone's technical capacity improved, the amount of detection was large.
Many countries are also saying, why has the recent number increased so much every day? In France, Italy and the United States, nucleic acid detection capacity is improving. We still rely on this technology, but there are some differences in the level of detection, technology and kit in different countries.
In clinical diagnosis of pneumonia, sometimes we can not completely rely on laboratory tests. As a clinical doctor, we may need to combine the patient's symptoms, such as the contact history of respiratory infectious diseases, the obvious epidemiological history, and of course, some of them may not; second, the respiratory symptoms such as fever and cough; third, combined with CT images. The CT images of the new crown are different from those of H1N1 or viral pneumonia in the past. Some experts have compared the two images and published some articles, but there are still great differences.
Nucleic acid test, in the daily pneumonia called "etiology test". Usually, culture, PCR technology, including second-generation sequencing is also a clinical diagnostic method. Many companies have developed serological antibody testing, but in fact, we are relatively quick and sensitive in clinical nucleic acid testing.
It is undeniable that the positive percentage of nucleic acid test is not high. Professor Cao said that 50% may be high. In fact, the average level is less than 50%, and the average level is about 30%. The good can reach 50%, the low can reach 30%. There is a category, which is the percentage of nucleic acid. When only 30% - 40% of nucleic acids are positive, some of them will be negative. When the negative rate is high, we will face some false negative problems. At this time, we may have to combine clinical symptoms, CT image features, and rely on second-generation sequencing or even antibodies. If there is Adam antibody, even if the nucleic acid is negative, we should also consider a comprehensive diagnosis. With the progress of technology and the development of kits, people's understanding of the disease and the means of diagnosis are getting higher and higher, the comprehensive consideration is getting better and better, and the diagnosis reliability of the new crown is getting higher and higher.
Question 10: how to manage patients without CT? In some countries, medical conditions are not as good as those in China. How should patients be managed under such medical conditions?
Cao Zhaolong:The main cumulative target of covid-19 is the lung. Through this communication with overseas Chinese and doctors, there are many patients with mild illness, such as fever, cough, respiratory symptoms are not serious when local doctors do not do CT. At this time, there are some problems in the lungs, but if the respiratory distress is not very serious, it may have an impact on our judgment of whether covid-19 infection or not.
As a respiratory specialist, chest imaging is our third eye. If we don't have a third eye, the use of light diagnosis of infectious diseases is relatively less. Of course, it's not very convenient now. Without these tests, there is no radiology for our diagnosis and treatment of covid-19. Especially in this period of time, we are all answering the questions of Chinese staying abroad, whether they have respiratory symptoms or not, whether they are serious. If they have respiratory symptoms, they have respiratory distress, suffocation and dyspnea. If it is possible to have a blood oxygen saturation, the oxygen saturation is lower than 93%. In this way, we suggest that they go to the hospital as soon as possible, because it has already prompted him The condition of the lesion is already quite serious.
Question 11: how long does it take to reexamine nucleic acid and CT in China, especially when reexamining CT, do you consider the problem of CT radiation?
Tong Zhaohui:In the novel coronavirus pneumonia process, novel coronavirus pneumonia should be treated as usual. We are also unlikely to do so much CT for patients, because these patients are in isolation ward. There may be X-ray near the bed, so it is not necessary to do CT.
In the whole treatment process, for example, if the patient is in hospital for three weeks, one X-ray per week is good. Some X-rays are common before discharge, and the nucleic acid is negative twice within three days before discharge. Of course, the nucleic acid interval between two times is 24 hours, and then one image is rechecked. There is obvious absorption, basically no obvious respiratory symptoms, or even no fever. If the patient meets the discharge standard, the patient will be treated Discharge, this is the condition of discharge.
After discharge from hospital, it is required to go to a fixed place for another two weeks, and non Hubei area may be isolated at home. In the case of home isolation, it is often 14 days to the hospital for reexamination, and CT can be done if conditions permit. If the recovery is good, and there is no respiratory symptoms, X-ray is OK. Of course, it is possible to give the patient another nucleic acid and check the antibody 14 days after discharge. I think that's enough.
Treating patients: considering the ability of doctors to manage patients comprehensively
The symptoms of novel coronavirus pneumonia are mild and severe. In most countries, the symptoms of mild pneumonia are recommended. However, if the disease is serious, how should we judge it? At the same time, the treatment of severe and critical diseases and patients with basic diseases is more challenging. Four domestic experts elaborated their own experience and views on these issues.
Question 12: what is the current treatment strategy of covid-19? Is there an age indicator? After the age index passed, we will not be able to use the ventilator. Is there such an index?
Qiu Haibo:This is actually a serious topic involving ethics, but we do face it. For doctors, patients should not be too old to be treated. In front of such a profession as doctor, all patients, no matter how old, no matter gender, no matter occupation, we should give him active treatment and standard treatment, which is the basic principle as a doctor.
However, it does exist in this process, especially for severe patients, such as antiviral therapy, immunomodulatory therapy and respiratory therapy, especially general oxygen therapy, high flow oxygen therapy, invasive ventilation, noninvasive ventilation, and even lung transplantation. If it is taken as the whole treatment process, each treatment choice needs to be based on whether the patient has treatment or not Treatment indications should also consider whether there are corresponding contraindications. In addition to indications and contraindications, patients or their families should also be consulted.
Medical problems have never been solved by doctors alone. Especially for the elderly in the nursing home, if their normal quality of life is very high, they have the ability to express themselves and what kind of treatment they want, we should respect his ideas. However, if he does not have the ability to express himself, we need to communicate the treatment measures with the patient's family members who have the right to decide what kind of treatment to give him. Maybe age and gender are some factors, but I think as a doctor, first of all, we have enough medical resources for patients today, and some effective treatment programs for patients, but we really need to consider the wishes of patients and their families.
Question 13: when is intubation in ICU? Is intubation started as soon as the patient enters the ICU or when the patient's blood oxygen content is relatively low? We prefer non-invasive oxygen therapy. At what time node do we decide to intubate? What kind of patients need intubation?
Qiu Haibo:I'm Qiu Haibo. I'm in Wuhan now. Whether or not to intubate or when to intubate for severe patients is still a controversial issue.
The early experience in Wuhan is like this. We have some early lessons. We think the SpO2 of this patient is OK. The previous indicator is that if the blood oxygen concentration is above 100 or 150, we think we can wait a little longer. Covid-19 patients have a very obvious performance, even if the patient has hypoxia, his symptoms may not be obvious, so we call it "silent hypoxemia".
Patients may have low oxygen, but their symptoms are not obvious and respiratory distress is not very serious. So, in the early days, we tend to get in late. But we will encounter a big problem. When we decide to intubate patients, some patients will stop their hearts, so this gives us a very strong hint whether our intubation is late.
Another one, even if the patient's heart doesn't stop, but after we insert it late, if we maintain 60 ml / kg tidal volume, the driving pressure is often very high at this time, which also reminds us that the patient's intubation is late. So later in the Chinese treatment plan, there are some suggestions for the treatment plan of the severe or critical patients. For the severe or critical patients, noninvasive ventilation will be used first. In this process, if the oxygenation index is less than 150 or 100-150, intubation is needed, which is an indicator.
But this index is often larger than most patients. Most patients seem to be able to maintain their oxygen saturation index after taking high oxygen. We need to pay attention to other indicators. At this time, respiratory rate may be a very important indicator. For example, we see that the respiratory rate of such patients is still above 30 or 35. In this case, the patient's inspiratory effort is obvious. It needs to be seen that if there is a tidal volume display on the non-invasive ventilator, especially the tidal volume display, if the tidal volume is greater than 10ml, or even greater than 8ml-10ml / kg body weight, that is to say, we often see that the tidal volume of patients can reach 800ml, or even 1000ml. According to the kilogram weight, it's about 10 ml or more, so the patient's inspiratory effort is very big, so we also think that the patient should be intubated.
If there is no tidal volume monitoring on the ventilator, it may be necessary to look at the patient's chest breathing and abdominal breathing. That is to say, when receiving noninvasive and high flow, although the oxygen saturation respiratory rate may be a little faster, if you look at the patient's chest and abdomen without tidal volume, if the abdominal breathing aid machine is very hard, it tells us that the patient is very hard to breathe. If so, such patients should be intubated. In most cases, when the patient looks at the driving pressure after inserting the tube and after calming the muscle, he will often see that the driving pressure is very high, suggesting that the timing of intubation for such patients needs to be strictly considered.
Of course, I know that some professors will say recently that the mortality of such patients after intubation is still very high, but our experience is that early intubation may avoid the high mortality caused by delayed intubation.
Question 14: Patients with basic diseases may have low blood oxygen, about 94%. Can such patients isolate themselves at home without going to the hospital for treatment? In most cases, we will admit such patients into the hospital, but can we isolate these patients at home when the hospital resources are relatively scarce?
Du Bin:On the one hand, it depends on what kind of disease he is, whether it is a basic disease related to the lung or not.
From the perspective of basic diseases, to what extent, whether it is so serious or not, and from the perspective of blood oxygen saturation, what kind of continuous state it is. Patients with underlying diseases, such as blood oxygen, are 94%. We need to see if there are other complications.
It depends on his respiratory rate, whether there are symptoms or signs of respiratory distress. If the patient is relatively young and may have basic diseases unrelated to heart or lung, the saturation of blood oxygen is about 94%, and breathing is not particularly difficult, he can be isolated at home. We need to see how his whole symptoms are after he is at home. Once the condition worsens, there must be such a mechanism that he can be sent from home to a designated hospital immediately. This mechanism is necessary.
Qiu Haibo: I agree with Professor Du. If the patient is at home, we should attach great importance to it. Breathing is a very big problem for non critical patients when they are developing to severe.
Because even if the development of severe saturation becomes very bad, but the patient's symptoms are not obvious, which creates a very big difficulty. In China, the elderly often have heart rate and saturation monitoring, just like the blood glucose monitor. If there is no saturation or heart rate monitoring, the easiest way is to get out of bed. When the patient is at home, if he has a basic disease, let him get out of bed and move. If the saturation is very serious, he should go to the hospital at this time. If the saturation is not obvious when it comes down, and the patient's symptoms are not obvious, the problem is not too big. Perhaps home-based self-management may help to prevent serious illness, because symptoms are not obvious and delay the time to go to the hospital.!
Tong Zhaohui:Let me add a little. I agree with what the two professors said just now. China is different from other countries. Young people estimate that when there is no disease, they may go to the hospital if there is hypoxia or tachycardia. If the elderly, the elderly or even the bedridden patients have difficulty in breathing, or the activities will hold their breath, including the acceleration of heart rate. Once they have a response, they do not have obvious feelings. Therefore, once the elderly people with basic diseases have a response, the disease may get worse later. I think the observation and treatment in the family should be divided into ages, depending on the basic diseases of the elderly, how old, which should be paid attention to.
Cao Zhaolong: if the basic patients are infected with the new crown, it really brings some problems to our treatment. Some patients simply suffer from new crown, even if some patients to the severe, after the general oxygen therapy, after their own acute recovery. For the patients with COPD, diabetes and coronary heart disease, there are many complications in the course of the new crown, especially in the process of acute aggravation, which is why the death of patients over 65 and 70 years old in Wuhan is related to the basic diseases. The more basic diseases are combined, the greater the possible influence on the patients and the more difficult the treatment.
In the treatment of new coronavirus, the treatment of diabetes should be taken into account. Some patients need to use hormone, and the blood sugar level will be very high after using hormone. Some patients also have chronic diseases and chronic obstructive pulmonary disease, so comprehensive treatment should be involved. In the later period of Wuhan, many patients who can't get out of the hospital have combined basic diseases. For example, they can't get out of the hospital if they want to dialysis. These patients recover slowly because of heart problems.
Now we still need to consider the ability of doctors to manage patients comprehensively, which is not a big problem for doctors in general hospitals to deal with these patients. However, due to the detailed specialization, the medical teams sent by each hospital may not be the same. We have brought in new experts and endocrine experts in the past, and our team can solve problems. Some of us carry out MDT in the rear and manage these patients together. Sometimes we even ask Tongji professional doctors. If this patient has pacemaker, if we don't have experts in this field, we will also ask Tongji experts to help us deal with these problems together. All in all, we have managed covid-19 patients with multiple diseases through MDT.
Question 15: we all know that the mortality rate of cancer patients in covid-19 is relatively high, especially in patients undergoing chemotherapy or surgery. Now the cancer center begins to check whether there are symptomatic infections or symptomatic ones. How to decide whether patients should receive chemotherapy or surgery. Some patients have already got covid-19, which may be much better in three or four weeks. But when is the safest time for them to start chemotherapy or operation?
Qiu Haibo:If the nucleic acid test is positive, it is very dangerous to receive chemotherapy, radiotherapy or anti-tumor treatment at this time.
The effect of covid-19 on immune function is relatively large, especially in symptomatic patients, we can see that lymphocytes are significantly reduced. The volume of spleen is obviously reduced, and the cancer cells in spleen are very few. Such changes tell us that patients are often in a state of extremely low immunity. If the patient's nucleic acid test is positive, once the patient becomes infected, it may have a great impact on the immune function. For such cancer patients, when they receive chemotherapy or radiotherapy and their immune function comes down again, the virus may be easier to replicate and become an infected person from an asymptomatic infected person or virus carrier. The consequences may be more serious. My personal opinion is that we should be very careful with this kind of patients and treat them carefully.
Cao Zhaolong:During the period of the prevalence of covid-19, all the wards with blood diseases were admitted. All patients should be screened by PCR during the outbreak. Although there is a false negative problem, we need to do some screening for patients in the incubation period. Generally speaking, the covid-19 can't be operated on or treated with chemotherapy for cancer patients.
We also treated such patients in Tongji, Wuhan. These patients were originally treated in the ordinary ward. As a result, during this period, when they had fever, they came to the infectious diseases ward. The treatment of these patients is very different from that without covid-19. Once these patients are unfortunately infected with covid-19, their recovery will be greatly reduced. For such a group of patients, how to protect them from infection in the early stage? Once they are infected, there are many treatments for them, such as radiotherapy, chemotherapy and immunosuppression. As long as it is inhibited, the nucleic acid of this patient could have turned negative and could not turn negative. It may be in the incubation period. If there is no symptom, it may lead to the outbreak of the virus of the patient and the aggravation of the symptoms. The effect on the basic patients was the greatest.
The patients with novel coronavirus pneumonia have improved, and the Department of Hematology doctors and oncologist should achieve a balance. An assessment is needed. Can the lung problems tolerate chemotherapy and immune therapy? There is no problem with the general course of pneumonia, but according to the course of covid-19, it should be relieved in the clinic at about 4 weeks, because the most serious is 2-3 weeks, and it is basically in the recovery period at the fourth week. If it's safe to say, six weeks is more reassuring. But it's painful to wait six weeks for the treatment of renal cancer, immune therapy, or chemotherapy for lung cancer to make the primary disease worse. If a patient gets a new crown for 4 weeks, I think we can consider the treatment of the primary disease.
Post epidemic problems: treatment for other diseases is limited during the epidemic period
Question 16: the patients with heart disease or diabetes should go to the hospital for regular treatment, but now the hospital has gone to treat the patients with new crown. What should the patients do if their condition gets worse?
Du Bin:This is also the complexity of the patient himself, such as diabetes or heart disease or coronary heart disease.
There are very serious patients, most of them are old people. There are many basic diseases, such as heart disease, coronary heart disease, diabetes. We did meet many such patients in Wuhan. As we have seen in the academic journals before, diabetes does account for a large part of the mortality rate of new crown patients. We do have some patients with myocardial infarction. As far as I know, some doctors in France have identified 1 cases. The incidence rate of heart thrombosis is higher in patients with COVID-19, and some patients will suffer from thrombocytopenia and lymphocytopenia. Most of them are due to myocardial infarction. It's true that many patients develop severe myocardial infarction.
I don't know the cause and effect. The relationship between myocardial infarction and cardiac performance and covid-19 itself.
Question 17: novel coronavirus pneumonia patients with heart and cerebrovascular diseases, who have had diabetes, have not received enough treatment during the new crown pneumonia, and the patient has suddenly increased. Is there any statistics in this regard?
Cao Zhaolong:It must be. Novel coronavirus pneumonia is basically a novel coronavirus pneumonia hospital in Wuhan in December and January. In this case, many patients with chronic renal failure dialysis, coronary heart disease and diabetes may have to prescribe drugs, seek treatment and visit the hospital once a month, but because these hospitals are all treated with new crown pneumonia, the general treatment is affected. This situation will certainly have some impact on the follow-up of chronic patients.
During this period of time, internet medical service, including many hospitals, has developed online consultation and even online easy follow-up. In Beijing, patients with coronary heart disease, diabetes mellitus and COPD can consult online. Many respiratory experts and cardiologists go to the Internet for open consultation. Patients with chronic diseases can go to the Internet for consultation with professional doctors to prepare drugs.
Even so, I believe that the treatment of some patients with chronic diseases will be affected. For example, if the cancer patients need chemotherapy, the patients will be affected more or less. In this regard, as soon as the number of confirmed cases in Wuhan has decreased, we will focus on patients, shrink the battlefield, and use more hospitals to treat ordinary patients.
When I was in Wuhan, there were volunteers to help chronic patients buy medicine. These patients should be in a relatively constant state, so the delay of buying medicine by volunteers didn't seem to have such a big impact on the disease.
Cao Zhaolong:The wards of the patients who have been treated with infectious diseases should be changed back to the wards of the ordinary patients and disinfected properly. Now many hospitals in Wuhan need to disinfect the patients after transferring the new crown. Both huoshenshan and leishenshan have fire officers and soldiers in the army to help disinfect, and there are disinfectants containing chlorine for spraying and ventilation. Some hospitals can also choose peroxycaproic acid and hydrogen peroxide, but they use more disinfectants containing 500 mg / L chlorine. After spraying, they can ventilate, which can kill the virus.
Medicine: there is no specific medicine at present
For severe doctors and severe patients, the supportive treatment is only an auxiliary treatment. Most patients, even the light patients, may not use the ventilator, or even the high flow of oxygen. Many patients still stay on the drug problem. For the current development of drugs, in fact, we are confused, because we have not got a specific evidence to prove that a certain drug must be effective.
Question 19: the use of glucocorticoids is a controversial issue, not only in China, but also in the United States. According to your experience in Wuhan, have you found one, such as the clinical standard related to anticoagulation or the clinical standard of glucocorticoid use. If you have clinical standards, what kind of patient groups are used and what dose is more effective for patients?
Du Bin:This problem is very difficult. Glucocorticoid has always been a difficult problem, the efficacy of patients has not been clear. So far, there is no accurate experimental data to confirm the effectiveness of glucocorticoids. Of course, some doctors strongly recommend anti-inflammatory drugs, or as the patient's blood clotting function declines, some doctors recommend these drugs. Many doctors recommend increasing the amount of glucocorticoid once the patient has a condition, but others always oppose the use of this treatment. I belong to the second category. However, the long-term high dose of glucocorticoids is not helpful. So far, I am not very clear about the efficacy and safety of this drug. In the late 3-5 days, we compared and determined the glucocorticoids, for example, 1-2kg body weight matched with 1g glucocorticoids. It can be used for 5 days when the patient's inflammatory reaction is serious or the respiratory performance of the patient is seriously reduced. But I'm not sure that the glucocorticoid will work very fast.
When it comes to anticoagulant drugs, we actually have a wide range of uses, but they are all used for different treatment purposes. For example, some of them will be used when the patient is in bed for several days. In fact, it is difficult to have a relatively certain data to show the real effect of anticoagulant drugs. We do have some indirect evidence, such as some other therapies.
Question 20: can you share the latest development of drug treatment? The novel coronavirus pneumonia is only based on in vitro studies. Can it be used as a drug for treating patients with new crown pneumonia?
Tong Zhaohui:First of all, drugs are divided into viral pneumonia. We should first seek antiviral drugs in the early stage of viral pneumonia. Many drugs have been paid attention to in China and other countries, but we are looking forward to a specific drug to inhibit the replication of the virus or to inhibit the progress of serious reactions, but so far no specific antiviral drugs have been found, including ridcivir, Rogan chloroquine or fabiravir.
Maybe you see Rhett seway, translated into Chinese as "the hope of the people". The original product of fabiravir is Japanese, but in fact, it is also said to be effective. In any case, these studies may be in the process of doing. Including the results of ridcivir in China, the research has been stopped now, and the results of strict clinical multicenter research have not been obtained. Chloroquine is a chicken feather, and it is difficult to see its effectiveness. This is the understanding of antiviral drugs. We can't deny some drugs, but we need to get sufficient evidence.
For the treatment of viral pneumonia, there is no evidence that hormones are effective from SARS avian influenza A Ebola. Even most drugs can increase the mortality rate and reduce the virus clearance in most viral pneumonia, and no obvious effect is seen. The only study was Spanish evidence of hormone efficacy in CP. In ARDS, no matter what the cause of ARDS is, because viral pneumonia is also ARDS, so many years of rapid research in ARDS has not proved that it is effective. But there is novel coronavirus pneumonia. We should pay attention to the opportunity. For example, when the patient is coming up with lymphocytes in the later stage, there may be some new crown pneumonia or fibrosis in the lung. At this time, the infection of the lung is controlled. When the lymphocyte base is recovered, the use of small dose of hormone may be beneficial to the improvement of the lung, which is the understanding of hormones.
In terms of anticoagulation, many patients may have done CRT, and it is certain that these serious diseases are fighting the epidemic. In addition, there are many studies in patients with ARDS to prove that there are some extensive micro thrombosis, so some people may also give a small amount of preventive dose in ARDS. As for novel coronavirus pneumonia, VTE found that 20% of these articles found 30% of thrombosis. No matter what the new crown pneumonia is, the proportion of thrombosis is relatively high. At the same time, it is also a severe pneumonia ARDS. Third, viral pneumonia will also attack the coagulation and fibrinolysis system. At the same time, there are more thrombus found in ultrasound or clinical than in daily life, so it is usually recommended to prevent and treat drugs. However, once there is evidence of the formation of VTE and PTE, anticoagulant therapy may be necessary.
Many drugs are in vitro experiments, in vitro experiments are more effective. The novel coronavirus pneumonia is also effective in vitro, including azithromycin. Including the chloroquine we said, in fact, the experimental indicators in vitro are also very good. They also found that Chinese patent medicines in our country can inhibit the new coronavirus in vitro.