Jin et al. Military Medical Research(2020) 7:4
https://doi.org/10.1186/s40779-020-0233-6

POSITION ARTICLE AND GUIDELINEOpen Access

A rapid advice guideline for the diagnosis
and treatment of 2019 novel coronavirus(2019-nCoV) infected pneumonia (standard
version)Ying-Hui Jin1, Lin Cai2, Zhen-Shun Cheng3, Hong Cheng4, Tong Deng1,5, Yi-Pin Fan6,7, Cheng Fang1, Di Huang1,
Lu-Qi Huang6,7, Qiao Huang1, Yong Han2, Bo Hu8, Fen Hu8, Bing-Hui Li1,5, Yi-Rong Li9, Ke Liang10, Li-Kai Lin2,
Li-Sha Luo1, Jing Ma8, Lin-Lu Ma1, Zhi-Yong Peng8, Yun-Bao Pan9, Zhen-Yu Pan11, Xue-Qun Ren5, Hui-Min Sun12,
Ying Wang13, Yun-Yun Wang1, Hong Weng1, Chao-Jie Wei3, Dong-Fang Wu4, Jian Xia14, Yong Xiong10,
Hai-Bo Xu15, Xiao-Mei Yao16, Yu-Feng Yuan2, Tai-Sheng Ye17, Xiao-Chun Zhang15, Ying-Wen Zhang17,
Yin-Gao Zhang2, Hua-Min Zhang6,7, Yan Zhao14, Ming-Juan Zhao1, Hao Zi1,5, Xian-Tao Zeng1,18*,
Yong-Yan Wang6,7*, Xing-Huan Wang1,2*, for the Zhongnan Hospital of Wuhan University Novel Coronavirus
Management and Research Team, Evidence-Based Medicine Chapter of China International Exchange andPromotive Association for Medical and Health Care (CPAM)

Abstract
In December 2019, a new type viral pneumonia cases occurred in Wuhan, Hubei Province; and then named “2019novel 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 healthprofessionals 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 generalrules 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 awhole process of a successful treatment case of the severe 2019-nCoV infected pneumonia and experience andlessons 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* Correspondence: zengxiantao1128@163.com; wangyyanpublic@bta.net.cn;
wangxinghuan1965@163.com
Except the first and corresponding authors, the rest of authors werealphabetized by their last name and contributed equally.
1
Center for Evidence-Based and Translational Medicine, Zhongnan Hospitalof Wuhan University, Wuhan 430071, China
6
China Academy of Chinese Medical Sciences, Beijing 100700, China
Full list of author information is available at the end of the article© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Jin et al. Military Medical Research(2020) 7:4

1 Background
In December 2019, the 2019 novel coronavirus (2019nCoV) was discovered and identified in the viral pneumonia cases that occurred in Wuhan, Hubei Province,
China; And then was named by the World HealthOrganization (WHO) on 12 January 2020. In the following month, the 2019-nCoV quickly spreading inside andoutside 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 fromfrontline 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 healthworkers and community residents.
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 andcomposed of individuals from health professionals andmethodologists. 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 andnurses, 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.

Page 2 of 23

interests were surveyed and disclosed and subsequently
assessed in consensus conference in order to minimize
potential bias in guideline development. Finally, there isno 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 theemerging infectious disease of 2019-nCoV. Due to theurgent need and tight work schedule, we conducted
no wide-range survey but a discussion meeting withfront-line clinicians who managed patients with2019-nCoV infections to finalize guideline topics andkey 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 andWHO 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 beassessed. If there is a lack of higher-level quality evidence, our panel considered observational studies andcase series. Because of the limited time, we did not perform new systematic review. We identified relevant literature up to 20 January 2020.

2.3 The target population of the guideline

2.6.2 Search resources

This guideline is aimed to serve the healthcare professionals to tackle the suspected 2019-nCoV infectedcases, confirmed 2019-nCoV infected cases, clustered2019-nCoV infected cases, and those with close contacts
or suspicious exposure to 2019-nCoV infected cases.

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 Commissionof the People’s Republic of China (http://www.nhc.gov.
cn/), and National Administration of Traditional Chinese Medicine (http://www.satcm.gov.cn/).

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 thisguideline. Relevant financial as well as nonfinancial

Jin et al. Military Medical Research(2020) 7:4

Page 3 of 23

2.6.3 Frontline data collection and summary

2.8 Forming the recommendations

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 ofthis virus. In these situations, obtaining evidence fromthe experts who fighting the disease on the frontline canbe efficient and the main source [3].
Until to 24:00 on 29 January 2020, 11,500 persons werescreened, and 276 were identified as suspected infectious
victims, and 170 were diagnosed (including 33 in criticalcondition) for 2019-nCoV infection in Zhongnan Hospitalof Wuhan University. During this process, frontline clinicians and nurses have accumulated valuable experience inthe 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 tocollect information on treatment evidence during theguideline panel’s meeting, so that it could be integrated
into the guideline panel in the summary of findings (seeAdditional files 1 and 2). Experts’ evidence can be solicitedby the description of case reports, summaries, and reportsof topics or questions of all cases they management.

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. The full revision will be published in New
Medicine (Chinese name: Yixue Xinzhi; http://www.
jnewmed.com/), Volume 30 and Issue 1 2020 [7].

3 Epidemiological characteristics
2.7 Grading the evidences and recommendations

3.1 Scope of the 2019-nCoV infection outbreak

We accorded to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) basic
approaches and rules [4, 5], and particularly consideredexperts’ evidence to assess the quality of a body of evidence to make recommendations.
The quality of evidence reflects whether the extent towhich our confidence estimating the effect is adequate
to support a particular recommendation. The level ofevidence was categorized as “high quality”, “moderatequality”, “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 isbased on the severity of the disease, patient willingness,safety, and economics [4]. See Tables 1 and 2 [4, 6].

Since December 2019, multiple cases occurring unexplainable pneumonia were successively reported in some
hospitals in Wuhan city with a history of exposure to alarge Hua’nan seafood market in Wuhan city, Hubei
province, China. It has been confirmed to be an acuterespiratory 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 oftravel to Wuhan emerged. Also, confirmed cases without
clear exposure to the Wuhan seafood market have beenfound in many foreign countries or regions [8].
At 24:00 on 26 January 2020, the National HealthCommission 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 werereported from Hong Kong, Macao and Taiwan ofChina: 8 cases in Hong Kong, 5 cases in Macao, and 4cases in Taiwan. In addition, confirmed cases had beenreported from abroad: 7 in Thailand, 4 in Australia, 4in Singapore, 3 in France, 3 in Japan, 3 in Korea, 3 inTable 1 Classification and description of recommendation
Classification ofrecommendation

Description

Strong recommendation

It is definite that the desirable effects
of an intervention outweigh its
undesirable effects or the undesirable
effects of an intervention outweigh its
desirable effects

Weak recommendation

The desirable effects probably outweighthe undesirable effects or undesirable
effects probably outweigh the desirable
effects

Jin et al. Military Medical Research(2020) 7:4

Page 4 of 23

Table 2 Rules for grading the recommendations
Strength of recommendationand quality of evidence

Benefit vs. risk and burdens

Methodological quality of supporting evidencea

Implications

Strong recommendation,
high-quality evidence

Benefits clearly outweigh risk
and burdens, or vice versa

RCTs without important
limitations or overwhelming
evidence from observational
studies

Strong recommendation,
can apply to most patientsin most circumstances
without reservation

Strong recommendation,
moderate quality evidence

Benefits clearly outweigh risk
and burdens, or vice versa

RCTs with important limitations(inconsistent results, methodologicalflaws, indirect or imprecise) or
exceptionally strong evidence fromobservational studies

Strong recommendation,
can apply to most patientsin most circumstances
without reservation

Strong recommendation, lowor very low quality evidence

Benefits clearly outweigh risk
and burdens, or vice versa

Observational studies or case series

Strong recommendation
but may change whenhigher quality evidence
becomes available

Weak recommendation,
high-quality evidence

Benefits closely balanced withrisks and burden

RCTs without important limitations
or overwhelming evidence fromobservational studies

Weak recommendation,
best action may differ
depending on circumstancesor patients’ or societal values

Weak recommendation,
moderate quality evidence

Benefits closely balanced withrisks and burden

RCTs with important limitations(inconsistent results, methodologicalflaws, indirect or imprecise) or
exceptionally strong evidence fromobservational studies

Weak recommendation,
best action may differ
depending on circumstancesor patients’ or societal values

Weak recommendation, lowor very low quality evidence

Uncertainty in the estimates ofbenefits, risks and burden; benefits,risk and burden may be in a closely
balanced

Observational studies or case series

Very weak recommendations;other alternatives may beequally reasonable

RCTs randomized controlled trialsaThe evidence agreed on by more than 70% frontline clinicians in consensus meeting is viewed as high-quality evidence

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 isbelieved 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 andits ability to spread between people remain unknown, an
increasing number of cases show the signs of human-tohuman transmission [8, 13].

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 foundin 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 patientsdischarging 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 thesemutations indicate adaptability to human hosts [11].

3.4 Etiology and pathogenesis

3.6 Incubation and contagious period

The 2019-nCoV isolated from the lower respiratory tractof 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

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].

Jin et al. Military Medical Research(2020) 7:4

Page 5 of 23

3.7 Prognostic factors

4.1.4 Close contacts

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, anda few patients are in critical condition. Death cases are
more frequently seen in the elderly and those withchronic underlying diseases [12].
The newest study including the first 41 confirmed
cases admitted to Wuhan between 16 December 2019and 2 January 2020 showed the median age of patientswas 49 years; and the main underlying diseases were diabetes, hypertension, and cardiovascular diseases. Of
them, 12 cases experienced acute respiratory distresssyndrome (ARDS), 13 cases were admitted to the intensive care unit (ICU), and 6 cases died [16].

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 haveclose contact with the confirmed cases, or other close contacts such as working closely with or sharing the sameclassroom 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 theconfirmed 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 whohave close contact with the patients in a same transport
vehicle, including those who had taken care of the patientson the vehicle; the person who had companied the patients (family members, colleagues, friends, etc.); otherpassengers and traffic staff considered having likely close
contact with the patients by investigation and evaluation.
(4) other circumstances considered to be closely contactedwith the person with close contact with the patients by
the professional investigation and evaluation.

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 andany epidemiological risk: (1) clinical features: fever, imaging
features of pneumonia, normal or reduced white blood cellcount, or reduced lymphocyte count in the early stages ofthe 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 caseThose with one of the following pathogenic evidence isthe 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 offever 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-tohuman transmission due to close contact or infection due toco-exposure, then it is determined as a clustered case [8, 18].

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 ofwild 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 the2019-nCoV infected patients or suspicious environmental exposure. Once they display any symptoms, especiallyfever, respiratory symptoms such as coughing, shortnessof 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 carryingout 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 andsuspected infection may consider in-home isolation andhome care (weak recommendation). Suspected infectedwith severe symptoms and those who need to stay inJin et al. Military Medical Research(2020) 7:4

Page 6 of 23

Table 3 Recommendations for those with close contacts andsuspicious exposures
No.

Recommendation items

Recommendation
strength1

Strictly take the observation periodof 14 days, and go to the hospitalfor diagnosis and treatment if
symptoms appear (fever, cough, etc.).

Strong2

If available, inform the designatedhospital in advance to send cars topick up the patients with symptoms
to the hospital.

Weak

3

Patients should wear N95 masks(priority strategy).

Strong4

Using disposable surgical mask
(alternative strategy).

Weak

5

Avoid taking public transportation
to the hospital, choose an ambulanceor private vehicle, and open vehicle
windows for ventilation on the way tothe hospital (priority strategy).

Strong6

When walking on the road or waitingin the hospital, try to stay away fromother people (at least 1 m away) andwear a mask.

Strong

7

The family members accompanying
those for inspection should immediately
follow the monitoring recommendations
to close contacts, keep the respiratory
hygiene and clean their hands properly.

Strong

8

The community or street hospital should
be informed before the suspected contacts
to the hospital. The vehicle used should becleaned and disinfected with 500 mg/L
chlorine-containing disinfectant, and thewindow should be opened for ventilation.

Strongthe patients’ medication and symptoms should be closely
recorded and their caregivers should also monitor theirbody 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; andavoiding 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 difficultyin 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].

5 Diagnosis of the 2019-nCoV cases
hospital for observation by doctor’s judgment should
follow the isolation guidelines for suspected patients (seeTables 4 and 5 for details).
It should also be noted that: (1) whether the suspectedpatients 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 worsenedin condition during home care, they need to go to thedoctor for treatment. (3) during the period of home care,

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 feveris still the typical symptom of 2019-nCoV infection.
5.2 Physical examination

Table 4 Criteria to define patients with suspected mild symptoms
No.

Definition of suspected patients with mild symptoms

1In-home isolation and care after assessment
by doctor (golden standard)

2

With a fever < 38 ℃

3

The fever can go down by itself

4

No dyspnea, no asthma

5With or without cough6

No underlying chronic diseases, e.g.: heart, lungand kidney diseases

Patients with mild symptoms may not present positive
signs. Patients in severe condition may have shortness ofbreath, 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.

Jin et al. Military Medical Research(2020) 7:4

Page 7 of 23

Table 5 Home care and isolation guidelines for suspectedpatients with mild symptoms

Table 5 Home care and isolation guidelines for suspectedpatients with mild symptoms (Continued)

No.

No.

Recommendation items

Recommendation
strength

Suspected patients with mild symptoms
1

Well-ventilated single rooms(preferred strategy).

Strong2

Maintain a bed distance of atleast 1 m from the patient(alternative strategy).

Weak

3

Clean and disinfect householdarticles using 500 mg/L chlorinecontaining disinfectant frequently
every day (wide range).

Strong4

Limit visits by relatives and friends.

Strong

5

The caregiver should be a healthyfamily member without underlying
diseases.

Weak

6

Restrict the patient’s activity

Strong

7

Open windows for ventilation inshared areas such as toilets andkitchens.

Strong8

Avoid sharing toothbrush, towel,
tableware, bed sheet and otheritems with patients. The patient’s
daily necessities are for single use
only and should be placed separatelyfrom that of their family members.

Strong9

When coughing or sneezing, it isnecessary to wear a medical mask,
or cover with a paper towel andbent elbow, and clean hands
immediately after coughing andsneezing.

Strong

10

N95 masks should be worn inthe same room with patients(preferred strategy).

Strong11

Disposable surgical mask
(alternative strategy).
Use the mask in strict accordancewith the instruction manual.

Weak

12

After washing hands with runningwater, dry them with a paper towel(preferred strategy).

Strong13

Dry with a towel, and washand disinfect the towel daily(alternative strategy).

Weak

Home caregivers
1

Clean and disinfect hands after
contact with the patient, before
leaving patient’s room or thehouse, before and after eating,after using the toilet and after
entering house from outside(for visible contaminant on
hands, wash hands with runningwater then use hand disinfection).

Strong2

Avoid direct contact with patient’s
secretions or discharges, especiallyoral or respiratory discharges; avoid
direct contact with patient’s feces.

StrongRecommendation items

Recommendation
strength3

Wear disposable gloves (double layers)
when providing oral and respiratory careto patients, handling patient’s feces andurine, and cleaning the patient’s room,
etc. Wash hands before wearing gloves
and after removing the gloves.

Strong4

Wash the patient’s clothes, bed
sheets, bath towels, towels, etc.
with ordinary washing soap
and water, or use a washingmachine at 60–90 ℃ with ordinary
household washing liquid (Strong
recommendation), or routinely washthem with washing machine after
soaking in low concentration
disinfectant (Weak recommendation).

Strong/Weak5

Put the contaminated bedding into
the laundry bag. Do not shake
contaminated clothing and avoid
direct contact.

Strong

6

The waste generated by the patient
should be put into the closed garbage
bags and replaced frequently.

Strong

The imaging features of lesions show: (1) dominantdistribution (mainly subpleural, along the bronchial
vascular bundles); (2) quantity (often more than three ormore 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 groundglass 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 thefine-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

Jin et al. Military Medical Research(2020) 7:4

Page 8 of 23

Fig. 1 Typical CT imaging manifestation (case 1). A 38 years old male with fever without obvious inducement (39.3 ℃), dry cough and shortnessof breath for 3 days. Laboratory test: normal white blood cells (6.35 × 109/L), decreased lymphocytes percentage (4.1%), decreased lymphocytes
count (0.31 × 109/L), decreased eosinophil count (0 × 109/L)), increased C-reaction protein (170.91 mg/L), increased procalcitonin (0.45 ng/ml).
Imaging examination: multiple patches, grid-like lobule and thickening of interlobular septa, typical “paving stone-like” signs. a SL(Slice): 6 mm;
b high-resolution computed tomography(HRCT). HRCT. high-resolution computed tomography

opacities with fuzzy edge (Fig. 2: 9 cases, 10.8% in a
total of 83 cases).
(2) Multiple, patchy or large patches of consolidation inboth lungs, with a little grid-like or honeycombshaped interlobular septal thickening, especially inthe middle and lower lobes (Fig. 3: 26 cases, 31.3%
in a total of 83 cases). It was more common in theelderly or severe condition patients.
Atypical CT/X-ray imaging manifestation, including(1) Single, or multiple, or extensive subpleural grid-likeor honeycomb-like thickening of interlobular septum,
thickening of the bronchial wall, and tortuous andthick 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 ismostly seen in the elderly.
(2) Single or multiple solid nodules or consolidated
nodules in the center of lobule, surrounded byground-glass opacities (Fig. 5: 5 cases, 6.2% in a totalof 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 stageof patients without clinical manifestation, negativelaboratory test but positive throat swab for 2019-nCoV

Fig. 2 Typical CT / X-ray imaging manifestation (case 2). A 51 years old male with general muscle ache and fatigue for 1 week, fever for 1 day(39.1 ℃), anemia. Laboratory test: normal white blood cells (9.24 × 109/L), lymphocytes percentage (5.1%), decreased lymphocytes (0.47 × 109/ L),decreased eosinophil count (0 × 109/L), increased C-reaction protein (170.91 mg/L), increased procalcitonin (0.45 ng/ml), increased erythrocyte
sedimentation rate (48 mm/h). Imaging examination: a shows patchy shadows in the outer region of the left lower lobe, b shows large groundglass opacity in the left lower lobe, and c shows subpleural patchy ground-glass opacity in posterior part of right upper lobe and lower tongueof left upper lobe, d shows large ground-glass opacity in the basal segment of the left lower lobe

Jin et al. Military Medical Research(2020) 7:4

Page 9 of 23

Fig. 3 Typical CT / X-ray imaging manifestation (case 3). A 65 years old male with fever for 4 days (38.7 ℃). Laboratory test: normal white blood
cells (3.72 × 109/L), decreased lymphocytes (0.9 × 109/ L), decreased eosinophil count (0 × 109/L), increased C-reaction protein (53.0 mg/L),
increased procalcitonin (0.10 ng/ml), reduced liver function, hypoproteinemia, and mild anemia. Imaging examination: a and b showed large
consolidation in the right middle lobe, patchy consolidation in the posterior and basal segment of the right lower lobe, with air-bronchogram
inside, c showed patchy consolidation in the outer and basal segment of the left lower lobe, and a small amount of effusion in the right chestwithin 1–2 weeks after being exposed to a viruscontaminated 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, doubleor scattered focal ground-glass opacity, nodules
located in central lobule surrounded by patchy
ground-glass opacities, patchy consolidation and signof 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 isdilatation and congestion of alveolar septal capillary,exudation of fluid in alveolar cavity and interlobularinterstitial edema. It showed that single or multiple
scattered patchy or agglomerated ground-glass
opacities, separated by honeycomb-like or grid-likethickened of interlobular septa (Fig. 7: 45 cases, 54.2%
in a total of 83 cases).

(3) Rapid progression stage. This stage refers to theperiod about 3–7 days after clinical manifestations
started, the pathological features in this stage are
the accumulation of a large number of cell-richexudates in the alveolar cavity, vascular expansion
and exudation in the interstitium, both of whichlead 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 periodaround 7–14 days after clinical manifestations
appeared. The main pathological features in thisstage are the fibrous exudation of the alveolar cavity
and the disappearance of capillary congestion in thealveolar 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).

Fig. 4 Atypical CT / X-ray imaging manifestation (case 1). An 83 years old female with fever for 4 days (maximum temperature of 38.8 ℃), cough,chills, sore throat, dry cough for 1 week, chest tightness and shortness of breath aggravating for 1 week. Laboratory test: normal white blood cells(4.6 × 109/L), normal neutrophil percentage (65.8%), decreased lymphocytes percentage (19.9%). Imaging examination: a and b showed diffuse
interlobular septum thickening in both lungs to form a grid opacity, thickening of bronchial wall, and consolidation in the left sublobal lung. cshowed diffused grid-like opacities in both lungs, especially in the left lungJin et al. Military Medical Research(2020) 7:4

Page 10 of 23

Fig. 5 Atypical CT / X-ray imaging manifestation (case 2). A 56 years old female with fever for 3 days. Laboratory test: decreased total protein(54.0 g/L),decreased albumin (35.5 g/L),decreased globulin (18.5 g/L), normal white blood cells (4.87 × 109/L), decreased lymphocytes percentage(10.1%), decreased lymphocytes (0.49 × 109/ L), decreased eosinophil count (0 × 109/L)), decreased eosinophil count percentage (0%). Imaging
examination: a showed two consolidation nodulesat the center of the lateral segment of middle lobe of the right lung which was surrounded byground-glass opacities; b showed patchy ground-glass opacity in the anterior segment of the right upper lung with patchy consolidation lesions
in it; c showed patchy ground-glass opacities in both lungs with patchy consolidation lesions in it. d showed patchy consolidation in the groundglass opacities in the middle lobe and dorsal segment of lower lobe of right lung(5) Dissipation stage. This stage refers to the periodroughly between 2 and 3 weeks after the onset ofclinical manifestations. The range of lesions was further
reduced. CT imaging showed patchy consolidation or
strip-like opacity. As time goes on, it showed grid-likethickening of interlobular septum, thickening andstrip-like twist of bronchial wall and a few scatteredpatchy consolidations (Fig. 10: 17 cases, 20.5% in a
total of 83 cases).

5.5 Techniques for laboratory tests
5.5.1 Hematology examination

In the early stage of the disease, the total number ofleukocytes decreased or keeps normal, with decreased
lymphocyte count or increased or normal monocytes.
High attention should be paid on the situation where theabsolute 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 bloodroutine changes after 3 days.

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, SARSrCoV, 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.

5.5.2 Detection of pathogens in respiratory tract(1) Flu antigens. At present, routinely detected flu antigens
are A, B, and H7N-subtypes. Sampling of throatswabs is conducive to early rapid screening for flu
because of the fast test, but it has a relatively highfalse negative rate.
(2) Respiratory virus nucleic acid. The detection of
respiratory virus nucleic acid is commonly used toFig. 6 CT imaging of ultra-early stage. a A 33 years old female with patchy ground-glass opacities after occupational exposure. b A 67 years oldmale with a history of contact with infected patients, showing large ground-glass opacity. c A 35 years old female exhibiting large consolidated
opacity with air-bronchogram inside after occupational exposureJin et al. Military Medical Research(2020) 7:4

Page 11 of 23

Fig. 7 CT imaging of early stage. Male, 38 years old, fever without obvious inducement (39.3 ℃), dry cough and shortness of breath for 3 days.
Laboratory test: decreased white blood cells (3.01 × 109/L), decreased lymphocytes (0.81 × 109/ L), increased C-reaction protein (60.8 mg/L),
increased procalcitonin (0.16 ng/ml). Imaging examination: a (thin layer CT) and b (high-resolution CT) showed multiple patchy and lightconsolidation in both lungs and grid-like thickness of interlobular septa

detect the infection by other common respiratory
viruses, mycoplasma and chlamydia infection,such as adenovirus, parainfluenza virus, respiratorysyncytial 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 otherrespiratory 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 etiologicaldiagnosis.
(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 oftuberculosis (TB) subgroup, complement, anti-acidstaining, etc. Blood gas analysis is helpful to judge
the oxygenation of moderately-illed and severe
patients. Combining the increase of lactic acid, it isfeasible to screen the patients with high-risk ofoxygenation disorder. Some infected patients haveincreased liver enzymes, muscle enzyme, ESR andmyoglobin. The detection of CRP and PCT is ofcertain value to distinguish whether there wasbacterial infection in the lung. D-dimer of most
severe patients was significantly increased in thisepidemic, with frequent clotting disorders andmicrothrombotic formation in peripheral blood

Fig. 8 CT imaging of rapid progression stage. A 50 years old female with anorexia, fatigue, muscle soreness, nasal congestion and runny nose for
1 week, sore and itching throat for 2 days. Laboratory test: increased erythrocyte sedimentation rate (25 mm/h), normal white blood cells(4.08 × 109/L), decreased lymphocytes (0.96 × 109/ L), increased C-reaction protein (60.8 mg/L). Imaging examination: a (thin layer CT) andb (high-resolution CT) showed multiplepatchy and light consolidation in both lungs and grid-like thickness of interlobular septa

Jin et al. Military Medical Research(2020) 7:4

Page 12 of 23

Fig. 9 CT imaging of consolidation stage. A 65 years old male with fever (maximum temperature of 39 ℃). Laboratory test: hypoproteinemia(decreased total protein (62.20 g/L), decreased albumin (35.70 g/L)), abnormal liver function (increased alanine aminotransferase (79 U/L),
increased aspartate aminotransferase (72 U/L)), increased procalcitonin (0.10 ng/ml), increased C-reaction protein (53 mg/L), decreased whiteblood cells (3.72 × 109/L), decreased lymphocytes (0.9 × 109/ L), mildanemia (decreased red blood cells (4.10 × 1012/L), decreased hemoglobin(131.10 g/L), decreased hematocrit (39.0%). Imaging examination: a (thin layer CT) and b (high-resolution CT) showedmultiple patchyand large
consolidation in right middle lobe, posterior and basal segment of right lower lobe and outer and basal segment of left lower lobe, with
air-bronchogram inside

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) andmyoglobin increased. CRP, ESR, and IL-6 increased, and
PCT was normal in most patients. The increased Ddimer 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 averagevalue 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.

Fig. 10 CT imaging of dissipation stage. A 79 years old female with intermittent fever. Laboratory test after 3 days of comprehensive treatment:
decreased red blood cells (3.73 × 1012/L), hemoglobin (107 g/L), decreased hematocrit (31.8%), decreased lymphocytes percentage (13.9%),
decreased lymphocytes (0.62 × 109/ L), decreased eosinophil count percentage (0%), decreased eosinophil count (0 × 109/L), increased alanine
aminotransferase (46 U/L), deceased total protein (56.8 g/L), decreased albumin (33.5 g/L), normal C-reaction protein and procalcitonin. Imaging
examination: a patchy ground-glass opacity and grid-like thickening of interlobular septa in the tongue-like segment of left upper lobe, andpatchy consolidation in the posterior segment of right middle and lower lobe. b 9 days after admission to hospotial, CT scan showed absorptionof lesions in the middle lobe, narrowing of lesions in the lower lobe of the right lung, and absorption of lesions in the tongue-like segment ofleft upper lobe which exhibited a cord-like changeJin et al. Military Medical Research(2020) 7:4

Compared with 120 healthy check-ups, the absolutevalue 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 vs3.7) × 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 notchange 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 thediscovery of specific nucleic acid detection technology.
In addition, NGS detection can tell whether the pathogen has mutated or not.

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 sameward, 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 forvital signs (heart rate, pulse oxygen saturation,
respiratory rate, blood pressure) and given
supportive treatment to ensure sufficient energy
intake and balance for water, electrolytes, acidbase 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 withsevere respiratory infections, respiratory distress, hypoxemia or shock. The initial flow rate is 5 L/min, and thetitration flow rate is to reach the target oxygen

Page 13 of 23

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 endexpiratory pressure (PEEP) with high positive endexpiratory pressure should be used in patients withmoderate or severe acute respiratory distress syndrome,and PEEP should be titrated according to FiO2 to maintain SpO2, in order to improve alveolar atelectasis andreduce alveolar hyper-expansion and pulmonary vascular
resistance at the end of inspiration. For severe patientswith 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 withrefractory hypoxemia that is difficult to becorrected 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 beconsidered (5 million U per time for adults in sterile
injection water, twice a day) (Weak recommendation); lopinavir/ritonavir orally, 2 capsules eachtime, twice a day, can be also considered (Weakrecommendation).
Low-level evidences included retrospective cohort,historically controlled studies, case reports, and caseseries revealed that lopinavir/ritonavir alone or in combination with antivirals produced certain benefits in the

Jin et al. Military Medical Research(2020) 7:4

treatment of SARS and MERS, such as reducing theincidence 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 ofantibacterial drugs, especially the combination ofbroad-spectrum antibacterial drugs. Enhancement ofbacteriological surveillance should be performed andpromptly 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 thepathogenic bacteria are clarified.
6.3.3 Corticosteroid therapy

The use of corticosteroids for severe ARDS is controversial; therefore, systemic use of glucocorticoids needs tobe 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 thattimely 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 theclinical symptoms of patients with SARS, reduce the degree of disease progression, and accelerate the absorptionof lung lesions; but it cannot shorten the length of hospital
stay [35, 36]. Be cautious that hormone therapy has someincidence 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 forPage 14 of 23

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 notconducive 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 isrecommended to eat protein-rich foods (such as eggs,
fish, lean meat, dairy products) and carbohydratecontaining 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 mountof 18 g protein/time, protein powder can be addedon the basis of standard whole protein preparations.
Enteral nutrition tube should to be placed when thepatient cannot intake supplemental nutrition byoral routine.
(3) Reduce the incidence of stress ulcers and gastrointestinal
bleeding. Use H2 receptor antagonists or proton pumpinhibitors in patients with gastrointestinal bleedingrisk factors. The risk factors for gastrointestinal
bleeding include mechanical ventilation ≥48 h,
coagulation dysfunction, renal replacement therapy,
liver disease, various complications, and a higher scoreof organ failure.
(4) Reduce the secretion of lung glands and improve
the respiratory function. For patients withdyspnea, cough, wheeze, and respiratory distresssyndrome due to the increased respiratory glandsecretion, 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 highrisk 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.

Jin et al. Military Medical Research(2020) 7:4

6.4.2 Prevention(1) Community. Implement relevant national regulations
and take great effort to keep away from contaminatedmaterials, disinfect the environment, and improve thehealthcare management.
(2) Individual. It is recommended to take food in properamount and balanced nutrition, have regular daily
life and physical activities, and avoid overloaded
work.
(3) Psychology. Develop proper interests and career ina 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 andbath the feet into the medical liquid when thetemperature is suitable. Soak feet for about
20 min.
iv Prescription of Chinese herbs for prophylaxis:
Astragalus mongholicus 12 g, roasted rhizoma
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 atreatment course. If for children, cutting thedose 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 thewater 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 clinicalsymptoms 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).

Page 15 of 23(2) Clinical symptoms 2: hypodynamia and fever. And therecommended 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 ofcold-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 loosestool, yellow urine, frequent micturition and yellow
urine. The therapeutic logic is to dissipate coldand 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 perillaleaf 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, ornausea, 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 andresolve 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), amomumtsao-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 chestwith anhelation, cough with wheezes, panting on

Jin et al. Military Medical Research(2020) 7:4

exertion; or red tongue, slimy yellow fur or yellow
dry fur, slippery and rapid pulse. Therefore, thetherapeutic logic is clearing heat and detoxicating.
And the recommended prescription comprisesof almond 10 g, gypsum 30 g (predecoction),trichosanthes kirilowii 30 g, rhubarb 6 g (endaddition), 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 generatingstasis. In this stage, the clinical manifestations is
known as high fever, oppression in chest withanhelation, 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, andToxin-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 ofrehmannia 15 g above yielded decoction.
The recommended Chinese patent medicines is the
Xiyanping injection, Xuebijing injection, Qingkailinginjection, 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 rootlesspulse. 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 shortnessof breath, fatigue and hypodynamia, anorexia, nausea
and vomiting, glomus and fullness, weak stools,
ungratifying loose stool, pale tender-soft enlarged

Page 16 of 23

tongue, slimy white tongue fur. Therefore, therapeutic
logic is to supplement the spleen and lung.
The recommended prescription comprises of rhizoma
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 andamomum 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 andnourish Yin.
The recommended prescription is Zhuye Shigao
decoction with cogongrass rhizome and rhizoma
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, andpolished 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 thesymptoms 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 clinicaldeterioration, 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 andreservoir 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 capillarypermeability and alveolar epithelial cell damage.
It can be divided into mild, moderate and severeJin et al. Military Medical Research(2020) 7:4

Page 17 of 23

Table 6 The Berlin definition for acute respiratory distress syndrome
Item

Mild

Onset time

Respiratory symptoms developed/aggravated within 1 week after clinically known damage

Moderate

Hypoxemia

PaO2/FiO2 201–300 mmHg,
PEEP or CPAP ≥5 cmH2O

Causes of pulmonary edema

Respiratory failure cannot be completely explained by heart failure or fluid overload. Objective assessment(such as echocardiography) is needed to eliminate the possibility of hydrostatic pulmonary edema if otherrisk factor is absent.

Abnormality in imaging

Decreased transparence of two lungs cannot be completely explained by pleural effusion, atelectasis or nodules.

PaO2/FiO2 101–200 mmHg,
PEEP≥5 cmH2O

SeverePaO2/FiO2 ≤ 100 mmHg,
PEEP≥10 cmH2O

PEEP positive end-expiratory pressure, CPAP continuous positive airway pressure

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 thebreathing rate increases rapidly, then HFNO
should be considered. HFNO can deliver 60 L/minof 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 oreven 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 improveoxygenation. But NIV guidelines recommend theuse 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 andeven 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 supportof HFNO (the demand for FiO2 > 70% and gas flow
> 50 L/min) or NIV, ARDS still exists and evenacutely 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 anoperation that may produce a large number ofcontagious aerosols.
The strategy of protective lung ventilation should be
implemented in invasive mechanical ventilation:
lower tidal volume (4–6 ml/kg), lower plateau pressure(< 30 cmH2O), and appropriate PEEP. For patientswith 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 mechanicalventilation.
(5) Extracorporeal Life Support (ECLS). In the processof invasive mechanical ventilation when the patient isstill in the state of hypoxia, combined with increased
partial pressure of carbon dioxide (excluding
ventilation dysfunction, PaCO2 > 60 mmHg), especiallyafter 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 toright atrium through internal jugular vein after
oxygenation through membrane oxygenator) and
VA-ECMO (blood is pumped from femoral vein anddirectly 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 withmoderate-severe ARDS; Where available, ECMO inconjunction with low tidal-volume mechanicalJin et al. Military Medical Research(2020) 7:4

ventilation can be considered in the treatment ofpatients with severe refractory hypoxemia in whom
standard therapy are failing; Routine use of highfrequency oscillatory ventilation (HFOV) in patientswith 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 usedin 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 ina 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 illpatients, 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 tomaintain mean arterial pressure (MAP) ≥65 mmHg
with lactate ≥2 mmol/L, the existence of septic shockshould 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

Page 18 of 23

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 forresuscitation. 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 extravasationand 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 to21%, the air flow rate has dropped to 0, and theventilator 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 hfrom 3 L/min, and the hemodynamic condition isstable. The blood flow rate is reduced to 1.5 L/minwithin 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, sothat the body’s hemodynamics is driven by theheart. 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 tooffline 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

Jin et al. Military Medical Research(2020) 7:4

function; and no need for organ support treatment(CRRT, artificial liver, etc.). Consider transferring thepatient out of ICU procedure.

Page 19 of 23

protective equipment of various levels is necessary. Personal protective equipment should be worn strictly inaccordance with the instructions and only used for one
time (Table 8, Strong recommendation).

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 fortwo consecutive times (one-day sampling time interval
at least); and the patient can be released from isolation.

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 andtertiary protection, all personnel entering various zones
should be evaluated using individual inventory tables according to the exposure risk level. Chose personal

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 andillness at home. If your body temperature continues tobe higher than 38 ℃, or your breath is getting worse,
you should seek medical treatment timely.
In addition to taking protective measures, the homecaregivers 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 foroxygen. Adjust the oxygen flow as appropriate according
to the patient’s condition and doctor’s instruction, andTable 7 Restriction and isolation guidelines checklist for patients/suspected cases (Strong recommendation)
Category

Tactics

Precautions in practiceEnvironmental requirements

1.There should be clean areas, potentiallycontaminated areas, contaminated areas,
contaminated channels and clean channels

1.1 clearly arrange and mark the 3 areas
and transport materials or move fromclean area to contaminated area.
Retrograde is not allowed.
1.2 Each area should be physicallypartitioned and clearly marked

2. Isolation in single (priority strategy)
Collective isolation for the confirmed
patients, collective isolation for thesuspected cases (alternative strategy)

2.1 < 4 persons per isolation ward,
bed spacing ≥1.1 m
2.2 Equipped with separate toilet
2.3 Equipped with hand-cleaning anddisinfection apparatus
2.4 Minimize the unnecessary items(e.g. remove the curtains, etc.)

3. Ensure that the environment and articles
are clean and disinfected

3.1 Follow the Disinfection Guidelines
checklist
3.2 Exclusive use of articles in isolation areas

Requirements to the patient/suspected Patient

4. Proper medical waste management

4.1 The medical waste should be put insealed double-layer yellow medical wastebags for regulated disposal procedure.

5. Restrict the range of patient/suspectedpatient for their activities.

5.1 No escort or minimize the numberof escorts.
5.2 Clear route for patient transport (get inor out through contaminated channels)
5.3 Patients going out should wear N95 masks
or surgical masks
5.4 Follow the disinfection guidelines after
being discharged from hospital.

Requirements to the medical
staff request

6. Medical personnel enter the isolation areawith proper self-protection through designatedchannels.

6.1 Medical staff should perform the personal
protection practice under the Personal Protection
Guidelines in Table 8

Jin et al. Military Medical Research(2020) 7:4

Page 20 of 23

Table 8 Personal protection guidelines checklist (Strong recommendation)
Item

Exposure
Protective measurement
intensity of
Coverall Eye protector/
Latex Barrier Protective Shoe cover/ Comprehensivea Round N95
infection risk
hatmask
Protective panel gloves gown clothing Bootstrap
respiratory apparatus

Recommendations as per work area
Pre-examination triage

Low

✓

✓

✓

✓

General out-patient
service

Low

✓

✓

✓

✓

General ward

Medium

✓

✓

✓

✓

✓

✓

High

✓

✓

✓

✓

✓

✓

✓

Medium

✓

✓

✓

✓

✓

✓

✓

✓

High

✓

✓

✓

✓

✓

✓

✓

✓

Medium

✓

✓

✓

✓

✓

✓

✓

✓

Fever clinic

Isolation room (Area)

✓

✓

High

✓

✓

✓

✓

✓

✓

✓

✓

Medium

✓

✓

✓

✓

✓

✓

✓

✓

High

✓

✓

✓

✓

✓

✓

✓

✓

✓

High

✓

✓

✓

✓

✓

✓

✓

✓

✓

Medium

✓

✓

✓

✓

✓

✓

✓

✓

Staff in pre-examination Medium
triage

✓

✓

✓

✓

✓

✓

✓

✓

Medical staff in Outpatient Department

Medium

✓

✓

✓

✓

✓

✓

✓

✓

Medical staff in theobserving ward

High

✓

✓

✓

✓

✓

✓

✓

✓

Medium

✓

✓

✓

✓

✓

✓

✓

✓

Assisting staff

Medium

✓

✓

✓

✓

✓

✓

Administrative andsupporting staff

Low

✓

✓

✓

✓

✓

✓

Department of
infectious diseases✓

Recommendations as per personnel
Medical staff in theisolation area✓a
Low risk, general contact with patients or exposure to contaminated environment, such as escorting the patients during diagnosis, triage, palpation,
consultation, etc
Medium risk, direct contact with body fluid, mucosa or incomplete skin, such as oral examination, puncture, oral care, surgery, etc
High risk, there is a risk of spatter of secretions or contaminants onto the body and face of medical staff, such as oral diagnosis, endotracheal intubation, etc

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 ofbone marrow. Attention should be paid to identify thechange of clinical manifestations or adverse drug reactions.

(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 ofvarious organs, monitor patients’ infection indicators,
and determine the occurrence of complications such asacute respiratory distress syndrome, septic shock, stressulcers, and deep vein thrombosis.

8.2.3 Nutritional support

8.3.2 Sequential oxygen care

According to the patients’ condition, provide highprotein, high-vitamin, carbohydrate-containing diets

The critically illed patients mainly use oxygen therapy
such as HFNO, NIV and invasive mechanical ventilation.

Jin et al. Military Medical Research(2020) 7:4

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 bemonitored 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 ahigh-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 tohigh and gradually reaches the target value. The
human-machine coordination is maximized. The patient’s consciousness and respiratory function areclosely observed. Patients with artificial airway established should use a closed suction tube to reduce
virus spread. Nurses should wear goggles or a faceshield 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 sametime, be cautious to prevent pressure ulcers, falling bed,
tube slippage, and eye damage by pressure and othercomplications. Patients treated with ECMO should bemonitored for the performance of the oxygenator. If theoxygenator changes its color to darker, indicating thepossibility of coagulation, the doctor should be notified
to adjust the heparin dose as necessary. The oxygenatorshould be replaced if necessary. The coagulation function need to be monitored dynamically, including thewhole 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 skinand mucous membranes, bleeding in the nasal cavity,
oral cavity, bloody sputum, hematuria, blood in thestool, swelling of the abdomen, moving dullness, and thesize 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 andregulations for aseptic operation and isolation should bestrictly followed to prevent ventilator-related pneumonia, catheter-related sepsis, urinary catheter related urinary tract infections and other secondary infections.

Page 21 of 23

8.3.5 Nutrition support

Dynamically assess the patients’ nutritional risks andtimely nutritional support can be given if needed. For thepatients 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 andpanic by building up their optimistic confidence in overcoming the disease.

9 Limitations of this guideline
Our guideline has three major limitations: Firstly, time isso limited that we cannot fully consider all clinical issues
for this emergency disease. Secondly, many evidencescame from data search is indirect. Thirdly, because somerecommendations 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, islikely to change current recommendations.
10 Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s40779-020-0233-6.
Additional file 1. A successful treatment case of the severe 2019-nCoV
infected pneumonia patient.
Additional file 2. Experience and lessons in hospital rescue for 2019nCoV infections.

Abbreviations
2019-nCoV: 2019 novel coronavirus; ALT: Alanine aminotransferase;
ARDS: Acute respiratory distress syndrome; AST: Aspartate aminotransferase;
CCEBTCM: China Center for Evidence Based Traditional Chinese Medicine;
CDC: Centers for Disease Control and Prevention; CK: Creatine kinase;
CPAM: China International Exchange and Promotive Association for Medicaland Health Care; CPAP: Continuous positive airway pressure; CRP: C-reactive
protein; CRRT: Continuous renal replacement therapies; DIC: Disseminatedintravascular coagulation; ECLS: Extracorporeal life support;
ECMO: Extracorporeal membrane oxygenation; ESR: Erythrocyte
sedimentation rate; GRADE: Grading of Recommendations Assessment,
Development and Evaluation; HFNO: High flow nasal oxygen therapy;
HFOV: High-frequency oscillatory ventilation; HRCT: High-resolution
computed tomography; ICU: Intensive Care Unit; IL: Interleukin; MAP: Meanarterial pressure; MERS: Middle East respiratory syndrome; NGS: Next
generation sequencing; NICE: National Institute for Health and ClinicalExcellence; NIV: Non-invasive ventilation; PCT: Procalcitonin; PEEP: Positiveend-expiratory pressure; PLT: Platelet; RCTs: Randomized controlled trials;
SARS: Severe acute respiratory syndrome; SBT: Spontaneous breathing test;

Jin et al. Military Medical Research(2020) 7:4

TB: tuberculosis; TNF: Tumor Necrosis Factor; WBC: White blood cells;
WHO: World Health Organization
Acknowledgements
The authors thank all the staff of the Novel Coronavirus Management andResearch Team in Zhongnan Hospital of Wuhan University, all the authors fortheir hard work for the included evidences in this guideline, and the staff ofthe Military Medical Research editorial office for their hard work. We also
thank Hao Chen’s help, the college of Acupuncture and Chinese Tuina,
Nanjing University of Chinese Medicine.
Authors’ contributions
WXH, WYY, HLQ, ZXT, ZY and LLK composed the Consultant/Advisor’s panel.
CL, CZS, CH, FYP, HB, HF, LYR, LK, MJ, PYB, PZY, PZY, SHM, WCJ, WDF, XJ, XY,
XHB, YYF, YTS, ZXC, ZYW, ZYG, and ZHM composed the Consensus experts’panel. DT, FC, HD, HQ, LBH, LLS, MLL, WYY, WH, ZMJ and ZH composed the
Evidences synthesis panel. JYH, YXM (Canada) and RXQ were themethodologists. WY and HY were the secretaries. JYH, ZXT and the membersof the evidences synthesis panel drafted the manuscript. All authors readand approved the final manuscript.
Funding
This work was supported (in part) by the Entrusted Project of National
Center for Medical Service Administration, National Health and Family
Planning Commission China (No. [2019]099), the First Level Funding of theSecond Medical Leading Talent Project in Hubei Province, and the Special
Project for Emergency of the Ministry of Science and Technology(2020YFC0841300).
Availability of data and materials
The data and materials used during the current review are all available inthis review.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Written informed consent for publication of the clinical details and clinicalimages was obtained from all patients. A copy of the consent form isavailable for review by the Editor of this journal.
Competing interests
The funder had no role in study design, data collection and analysis, decision
to publish, or preparation of the manuscript. The authors declare that there
are no conflicts of interest in this study.
Author details
1
Center for Evidence-Based and Translational Medicine, Zhongnan Hospitalof Wuhan University, Wuhan 430071, China. 2Institute of HospitalManagement, Wuhan University, Wuhan 430071, China. 3Department ofRespiratory Medicine, Zhongnan Hospital of Wuhan University, Wuhan
430071, China. 4Department of Pharmacy, Zhongnan Hospital of Wuhan
University, Wuhan 430071, China. 5Institute of Evidence-Based Medicine andKnowledge Translation, Henan University, Kaifeng 475000, China. 6China
Academy of Chinese Medical Sciences, Beijing 100700, China. 7China Center
for Evidence Based Traditional Chinese Medicine (CCEBTCM), Beijing 100700,
China. 8Department of Critical Care Medicine, Zhongnan Hospital of Wuhan
University, Wuhan 430071, China. 9Department of Clinical Laboratory,
Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
10
Department of Infectious Diseases, Zhongnan Hospital of Wuhan
University, Wuhan 430071, China. 11Division of Medical Affairs, Zhongnan
Hospital of Wuhan University, Wuhan 430071, China. 12Division of Nursing
Affairs, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
13
Office of Nosocomial Infection Control, Zhongnan Hospital of Wuhan
University, Wuhan 430071, China. 14Emergency Center, Zhongnan Hospital of
Wuhan University, Wuhan 430071, China. 15Department of Radiology,
Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
16
Department of Health Research Methods, Evidence, and Impact, McMaster
University, Hamilton, ON L8S 4L8, Canada. 17Department of Traditional
Chinese Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071,
China. 18Global Health Institute, Wuhan University, Wuhan 430072, China.

Page 22 of 23

Received: 29 January 2020 Accepted: 30 January 2020

References
1. World Health Organization. WHO handbook for guideline development. 2nded; 2019. http://apps.who.int/medicinedocs/documents/s22083en/s22083en.
pdf. Accessed 22 Jan 2020
2. Norris SL. WHO and rapid advice guidelines: history and future directions.
2013. https://g-i-n.net/conference/past-conferences/10th-conference/
monday/10-00-am-to-1-00-pm/norris-62.pdf/view. Accessed 22 Jan 2020.
3. Schünemann HJ, Zhang Y, Oxman AD, Expert Evidence in Guidelines Group.
Distinguishing opinion from evidence in guidelines. BMJ. 2019;366:l4606.
4. GRADE handbook, GRADE working group. 2013. https://gdt.gradepro.org/
app/handbook/handbook.html. Accessed 22 Jan 2020.
5. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al.
GRADE: an emerging consensus on rating quality of evidence and strengthof recommendations. BMJ. 2008;336(7650):924–6.
6. Legault K, Schunemann H, Hillis C, et al. McMaster RARE-Bestpractices clinicalpractice guideline on diagnosis and management of the catastrophic
antiphospholipid syndrome. J Thromb Haemost. 2018;16:1656–64.
7. Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, et al. A rapid advice
guideline for the diagnosis and treatment of 2019 novel coronavirus (2019nCoV) infected pneumonia (Full version). Yixue Xinzhi. 2020;30(1):35–64.
https://doi.org/10.12173/j.issn.1004-5511.2020.01.09 [Article in China].
8. Chan JFW, Yuan S, Kok KH, To KKT, Chu HC, Yang J, et al. A familial clusterof pneumonia associated with the 2019 novel coronavirus indicating
person-to-person transmission: a study of a family cluster. Lancet. 2020.
https://doi.org/10.1016/S0140-6736(20)30154-9.
9. Health Emergency Office of National Health Commission of the PRC.
Update on the epidemic of novel coronavirus (2019-nCoV) infectedpneumonia as at 24:00 on 26 January. http://www.nhc.gov.cn/xcs/yqfkdt/2
02001/3882fdcdbfdc4b4fa4e3a829b62d518e.shtml. Accessed 26 Jan 2020.
10. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia
outbreak associated with a new coronavirus of probable bat origin. Nature.
2020. https://doi.org/10.1038/s41586-020-2012-7.
11. Perlman S. Another decade, another coronavirus. N Engl J Med. 2020.
https://doi.org/10.1056/NEJMe2001126.
12. General Office of National Health Committee. Office of State Administrationof Traditional Chinese Medicine. Notice on the issuance of a programme forthe diagnosis and treatment of novel coronavirus (2019-nCoV) infectedpneumonia (Trial Version 4). 2020. http://bgs.satcm.gov.cn/
zhengcewenjian/2020-01-28/12576.html. Accessed 29 Jan 2020.
13. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus
from patients with pneumonia in China, 2019. N Engl J Med. 2020. https://doi.org/10.1056/NEJMoa2001017.
14. General Office of National Health Committee. Office of State Administrationof Traditional Chinese Medicine. Notice on the issuance of a program forthe diagnosis and treatment of novel coronavirus (2019-nCoV) infectedpneumonia (Trial Version 3). 2020. http://www.nhc.gov.cn/xcs/zhengcwj/202
001/f492c9153ea9437bb587ce2ffcbee1fa.shtml. Accessed 24 Jan 2020.
15. Information Office of the State Council. Information office to hold press
conference on joint preventing and controlling the epidemic of novel
coronavirus (2019-nCoV) infected pneumonia. 2020. http://www.scio.gov.cn/
xwfbh/xwbfbh/wqfbh/42311/42478/index.htm. Accessed 26 Jan 2020.
16. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features ofpatients infected with 2019 novel coronavirus in Wuhan, China. Lancet.
2020. https://doi.org/10.1016/S0140-6736(20)30183-5.
17. Li L, Ren MJ, Zhang YY, Li WQ, Zhao HY, Liang LC, et al. Lung CT image of aconfirmed case of the 2019 novel coronavirus (2019-nCoV) infectedpneumonia (With differential diagnosis of the SARS). Yixue Xinzhi. 2020;30(1):4–6 [Article in China].
18. Disease Control and Prevention Bureau of National Health and HealthCommission. Program for prevention and control of novel coronavirus(2019-nCoV) infected pneumonia (Trial Version 2). 2020. http://www.nhc.
gov.cn/xcs/zhengcwj/202001/c67cfe29ecf1470e8c7fc47d3b751e88.shtml.
Accessed 23 Jan 2020.
19. World Health Organization. Home care for patients with suspected novel
coronavirus (nCoV) infection presenting with mild symptoms and managementof contacts. 2020. https://www.who.int/publications-detail/home-care-forpatients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mildsymptoms-and-management-of-contacts. Accessed 24 Jan 2020.

Jin et al. Military Medical Research(2020) 7:4

20. Kim JY, Song JY, Yoon YK, Choi SH, Song YG, Kim SR, et al. Middle East
respiratory syndrome infection control and prevention guideline forhealthcare facilities. Infect Chemother. 2015;47(4):278–302.
21. Wang Y, Lin LK. An advice guideline recommended by central south
hospital for the suspected patients of novel coronavirus (2019-nCoV)
infected pneumonia and their close contactsas at home quarantine.
2020. https://mp.weixin.qq.com/s/xFO10WAFB9OUnM7VN92R2w.
Accessed 25 Jan 2020.
22. World Health Organization. Infection prevention and control during healthcare when novel coronavirus (nCoV) infection is suspected. 2020. https://www.who.int/publications-detail/infection-prevention-and-control-duringhealth-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125.
Accessed 26 Jan 2020.
23. World Health Organization. WHO advice for international travel and trade in
relation to the outbreak of pneumonia caused by a new coronavirus in
China. 2020. https://www.who.int/ith/2020-0901_outbreak_of_Pneumonia_
caused_by_a_new_coronavirus_in_C/en/. Accessed 23 Jan 2020.
24. Centers for Disease Control and Prevention. CDC: travelers’ health - novel
coronavirus in China. 2020. https://wwwnc.cdc.gov/travel/notices/watch/novel-coronavirus-china. Accessed 23 Jan 2020.
25. Wang W, Hu H, Song L, Gong X, Qu Y, Lu Z. Image of pulmonary anddiagnosis of atypicalnovel coronavirus (2019-nCoV) infected pneumonia:
case series of 14 patients. Yixue Xinzhi. 2020;30(1):7–9 [Article in China].
26. Chan KS, Lai ST, Chu CM, Tsui E, Tam CY, Wong MM, et al. Treatment ofsevere acute respiratory syndrome with lopinavir/ritonavir: a multicentre
retrospective matched cohort study. Hong Kong Med J. 2003;9(6):399–406.
27. Chu CM, Cheng VC, Hung IF, Wong MM, Chan KH, Chan KS, et al. Role oflopinavir/ritonavir in the treatment of SARS: initial virological and clinicalfindings. Thorax. 2004;59(3):252–6.
28. Lai ST. Treatment of severe acute respiratory syndrome. Eur J Clin Microbiol
Infect Dis. 2005;24(9):583–91.
29. Brigitte M, Arti B, Stephan A, Judith A, Bruno R, Christoph W, et al. MERSCOV disease associated ARDS -a case report. Crit Care Med. 2015;43(12):308.
30. Jiang H, Deng H, Wang Y, Liu Z, Sun WM. The possibility of using Lopinave/
Litonawe (LPV/r) as treatment for novel coronavirus 2019-nCov pneumonia:
a quick systematic review based on earlier coronavirus clinical studies.
Zhonghua Jizhen Yixue Zazhi. 2020;29(2):182–6 [Article in China].
31. Falzarano D, de Wit E, Rasmussen AL, Feldmann F, Okumura A, Scott DP,
et al. Treatment with interferon-α2b and ribavirin improves outcome in
MERS-CoV-infected rhesus macaques. Nat Med. 2013;19(10):1313–7.
32. Chan JF, Yao Y, Yeung ML, Deng W, Bao L, Jia L, et al. Treatment withlopinavir/ritonavir or interferon-β1b improves outcome of MERS-CoV
infection in a nonhuman primate model of common marmoset. J Infect Dis.
2015;212(12):1904–13.
33. Omrani AS, Saad MM, Baig K, Bahloul A, Abdul-Matin M, Alaidaroos AY, et al.
Ribavirin and interferon alfa-2a for severe Middle East respiratory syndrome
coronavirus infection: a retrospective cohort study. Lancet Infect Dis. 2014;14(11):1090–5.
34. Khan PA, Nousheen BB, Maryam N, Sultana K. Middle east respiratory
syndrome (MERS): a systematic review. Int J Pharm Sci Res. 2018;9(7):2616–25.
35. Zhao ZW, Zhang FC, Xu M, Huang K, Zhong WN, Cai WP, et al. Clinicalanalysis of 190 cases of outbreak with atypical pneumonia in Guangzhou in
spring, 2003. Zhonghua Yixue Zazhi. 2003;83(9):713–8.
36. Meng QH, Dong PL, Guo YB, Zhang K, Liang LC, Hou W, et al. Use of
glucocorticoid in treatment of severe acute respiratory syndrome cases.
Zhonghua Yufang Yixue Zazhi. 2003;37(4):233–5 [Article in China].
37. Xiao JZ, Ma L, Gao J, Yang ZJ, Xing XY, Zhao HC, et al. Glucocorticoidinduced diabetes in severe acute respiratory syndrome: the impact of highdosage and duration of methylprednisolone therapy. Zhonghua Neike
Zazhi. 2004;43(3):179–82 [Article in China].
38. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT,
Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: theBerlin Definition. JAMA. 2012;307(23):2526–33.

Page 23 of 23