Diagnosis and Treatment Protocol for COVID-19(Trial Version 7)

Diagnosis and Treatment Protocol for COVID-19

(Trial Version 7)

　　Traditional Chinese medicine (TCM) treatment

　　The COVID-19 belongs to plague in TCM with the etiology of epidemic factor exposure. Different regions can refer to the following plans for syndrome differentiation and treatment, according to the disease, local climate characteristics and different constitutions. Prescriptions which exceed maximum dose according to pharmacopoeia should be used under the guidance of a physician.

　　(1) Medical observation period

　　1.1 Clinical manifestation: fatigue with gastrointestinal discomfort

　　Recommended Chinese patent medicine: Huoxiang Zhengqi Capsule (Pill, Liquid, Oral liquid)

　　1.2 Clinical manifestation: fatigue with fever

　　Recommended Chinese patent medicines: Jinhua Qinggan Granule, Lianhua Qingwen Capsule (Granule), Shufeng Jiedu Capsule (Granule)

　　(2) Clinical treatment period (confirmed cases)

　　1) Qingfei Paidu Decoction

　　Scope of application: in accordance with the clinical observations of doctors in various locations, it is suitable for mild, moderate and severe cases, and can be used reasonably with the consideration of the actual conditions of critically ill patients.

　　The basic formula: Ma Huang (Ephedrae Herba) 9g, Zhi Gan Cao (Glycyrrhizae Radix) 6g, Xing Ren (Armeniacae Semen) 9g, Sheng Shi Gao (Gypsum fibrosum) (decocted first) 15-30g, Gui Zhi (Cinnamomi Ramulus) 9g, Ze Xie (Alismatis Rhizoma) 9g, Zhu Ling (Polyporus) 9g, Bai Zhu (Atractylodis macrocephalae Rhizoma) 9g, Fu Ling (Poria) 15g, Chai Hu (Bupleuri Radix) 16g, Huang Qin (Scutellariae Radix) 6g, Jiang Ban Xia (Pinellinae Rhizoma Praeparatum) 9g, Sheng Jiang (Zingiberis Rhizoma recens) 9g, Zi Wan (Asteris Radix) 9g, Kuan Dong Hua (Farfarae Flos) 9g, She Gan (Belamcandae Rhizoma) 9g, Xi Xin (Asari Radix et Rhizoma) 6g, Shan Yao (Dioscoreae Rhizoma) 12g, Zhi Shi (Aurantii Fructus immaturus) 6g, Chen Pi (Citri reticulatae Pericarpium) 6g, Huo Xiang (Pogostemonis Herba) 9g.

　　Administration: traditional Chinese herbal pieces in decoction. One package per day. Take warm twice (40 minutes after meal in the morning and evening). One course of treatment is for three packages.

　　If possible, half bowl of rice soup after taking the decoction is advised. For the patients with dry tongue due to fluid depletion, one bowl of rice soup is suggested. (Note: If no fever, the dosage of gypsum should be reduced. In case with fever or high fever, the amount of gypsum can be increased. If the symptoms improve but not toally recovered, continue the second course of treatment. If the patient has a special condition or other underlying diseases, the formula can be modified according to the actual situation in the second course. If the symptoms disappear, the drug should be discontinued.

　　Reference: The General Office of the National Health Commission of the people’s Republic of China The Office of the National Administration of Traditional Chinese Medicine “Notice on Recommending the Use of Qingfei Paidu Decoction in Pneumonia Treated with Integrated Chinese and Western Medicine for the COVID-19 Infection” (National Administration of Traditional Chinese Medicine Office Medical Letter [2020] No.22)

　　2) Mild case

　　① Cold-damp constraint in the lung pattern

　　Clinical manifestation: fever, fatigue, generalized body aches, cough, expectoration, chest tightness and labored breathing, poor appetite, nausea, vomiting and sticky stool, pale enlarged tongue with tooth marks or light red tongue and coating which is white, thick, curd-like, and greasy or white and greasy, and soggy of slippery pulse.

　　Recommended formula: Sheng Ma Huang (Ephedrae Herba) 6g, Sheng Shi Gao (Gypsum fibrosum) 15g, Xing Ren (Armeniacae Semen) 9g, Qiang Huo (Notopterygii Rhizoma seu Radix) 15g, Ting Li Zi (Lepidii/Descurainiae Semen) 15g, Guan Zhong (Cyrtomii Rhizoma) 9g, Di Long (Pheretima) 15g, Xu Chang Qing (Cynanchi paniculati Radix) 15g, Huo Xiang (Pogostemonis Herba) 15g, Pei Lan (Eupatorii Herba) 9g, Cang Zhu (Atractylodis Rhizoma) 15g, Yun Ling (Poria) 45g, Sheng Bai Zhu (Atractylodis macrocephalae Rhizoma) 30g, Jiao San Xian (Jiao Shan Zha (Crataegi Fructus), Jiao Shen Qu (Massa medicate fermentata), and Jiao Mai Ya (Hordei Fructus germinatus)) 9g each, Hou Po (Magnoliae officinalis Cortex) 15g, Jiao Bing Lang (Arecae Semen) 9g, Wei Cao Guo (Tsaoko Fructus) 9g, Sheng Jiang (Zingiberis Rhizoma recens) 15g.

　　Administration: one package daily, 600ml after decocting, divide into three times, equally in the morning, afternoon and evening, take before meal.

　　② Damp-heat accumulation in the lung pattern

　　Clinical manifestation: low-grade fever or absence of fever, slight aversion to cold, fatigue, heavy sensation in the head and body, muscle soreness, dry cough with little sputum, sore throat, thirst without desire to drink, or accompanied with chest tightness and epigastric fullness, absence of sweating or disturbed hidrosis, or vomiting with anorexia, loose stool or sticky stool. The tongue is light red and coating is white, thick and greasy or thin and yellow. The pulse is slippery and rapid or soggy.

　　Recommended formula: Bing Lang (Arecae Semen) 10g, Cao Guo (Tsaoko Fructus) 10g, Hou Po (Magnoliae officinalis Cortex) 10g, Zhi Mu (Anemarrhenae Rhizoma) 10g, Huang Qin (Scutellariae Radix) 10g, Chai Hu (Bupleuri Radix) 10g, Chi Shao (Paeoniae Radix rubra) 10g, Lian Qiao (Forsythiae Fructus) 15g, Qing Hao (Artemisiae annuae Herba) (added later) 10g, Cang Zhu (Atractylodis Rhizoma) 10g, Da Qjng Ye (Isatidis Folium) 10g, Sheng Gan Cao (Glycyrrhizae Radix) 5g.

　　Administration: one pack daily, 400ml after decocting, divide into twice, and half in the morning and half in the evening.

　　3) Moderate case

　　① Damp-toxin constraint in the lung pattern

　　Clinical manifestation: fever, cough with little sputum or yellow sputum, chest tightness and shortness of breath, abdominal distension, and constipation with difficult defecation. The tongue body is dark-red, and tongue shape is enlarged. The cotaing is yellow greasy or yellow dry. The pulse is slippery and rapid or wiry and slippery.

　　Recommended formula: Sheng Ma Huang (Ephedrae Herba) 6g, Ku Xing Ren (Armeniacae Semen) 15g, Sheng Shi Gao (Gypsum fibrosum) 30g, Sheng Yi Yi Ren (Coicis Semen) 30g, Mao Cang Zhu (Atractylodis Rhizoma) 10g, Guang Huo Xiang (Pogostemonis Herba) 15g, Qing Hao Cao (Artemisiae annuae Herba) 12g, Hu Zhang (Polygoni cuspidati Rhizoma) 20g, Ma Bian Cao (Verbenae Herba) 30g, Gan Lu Gen (Phragmitis Rhizoma) 30g, Ting Li Zi (Lepidii/Descurainiae Semen) 15g, Hua Ju Hong (Citri grandis Exocarpium rubrum) 15g, Sheng Gan Cao (Glycyrrhizae Radix) 10g.

　　Administration: one package daily, 400ml after decocting, and equally divide into twice, in the morning and evening.

　　② Cold-damp obstructing the lung pattern

　　Clinical manifestation: low-grade fever, unsurfaced fever or no fever, dry cough with little sputum, lassitude and fatigue, chest tightness, stomach discomfort, or nausea, and loose stool. The tongue is pale or light red and coating is white or white greasy. The pulse is soggy.

　　Recommended formula: Cang Zhu (Atractylodis Rhizoma) 15g, Chen Pi (Citri reticulatae Pericarpium) 10g, Hou Po (Magnoliae officinalis Cortex) 10g, Huo Xiang (Pogostemonis Herba) 10g, Cao Guo (Tsaoko Fructus) 6g, ShengMa Huang (Ephedrae Herba) 6g, Qiang Huo (Notopterygii Rhizoma seu Radix) 10g, Sheng Jiang (Zingiberis Rhizoma recens) 10g, Bing Lang (Arecae Semen) 10g.

　　Administration: one package daily, 400ml after decocting, and equally divide into twice, in the morning and evening.

　　4) Severe case

　　① Epidemic toxin blocking the lung pattern

　　Clinical manifestation: fever with red face, cough with little yellow and sticky sputum, or blood-stained sputum, chest tightness and short of breath, lassitude, dryness, bitterness and stickiness in the mouth, nausea and loss of appetite, difficult defecation, and scanty dark urine. The tongue is red with yellow greasy coating. The pulse is slippery and rapid.

　　Recommended formula: Huashi Baidu Formula

　　The basic formula: Sheng Ma Huang (Ephedrae Herba) 6g, Xing Ren (Armeniacae Semen) 9g, Sheng Shi Gao (Gypsum fibrosum) 15g, Gan Cao (Glycyrrhizae Radix) 3g, Huo Xiang (Pogostemonis Herba) (added later) 10g, Hou Po (Magnoliae officinalis Cortex) 10g, Cang Zhu (Atractylodis Rhizoma) 15g, Cao Guo (Tsaoko Fructus) 10g, Fa Ban Xia (Pinellinae Rhizoma Praeparatum) 9g, Fu Ling (Poria) 15g, Sheng Da Huang (Rhei Radix et Rhizoma) (added later) 5g, Sheng Huang Qi (Astragali Radix) 10g, Ting Li Zi (Lepidii/Descurainiae Semen) 10g, Chi Shao (Paeoniae Radix rubra) 10g.

　　Administration: 1-2 packages daily, decoction, 100-200ml each time, 2-4 times per day, oral administration or nasal feeding.

　　② Blazing of both qi and ying pattern

　　Clinical manifestation: high fever with polydipsia, tachypnoea and shortness of breath, delirium and unconsciousness, blurred vision or accompanied with macules and papules, or hematemesis, epistaxis or convulsion of the four limbs. The tongue is crimson with little or no coating. The pulse is deep, thready and rapid, or floating, large and rapid pulse.

　　Recommended formula: Sheng Shi Gao (Gypsum fibrosum) (decocted first) 30-60g, Zhi Mu (Anemarrhenae Rhizoma) 30g, Sheng Di (Rehmanniae Radix) 30-60g, Shui Niu Jiao (Bubali Cornu) (decocted first) 30g, Chi Shao (Paeoniae Radix rubra) 30g, Xuan Shen (Scrophulariae Radix) 30g, Lian Qiao (Forsythiae Fructus) 15g, Dan Pi (Moutan Cortex) 15g, Huang Lian (Coptidis Rhizoma) 6g, Zhu Ye (Phyllostachys nigrae Folium) 12g, Ting Li Zi (Lepidii/Descurainiae Semen) 15g, Sheng Gan Cao (Glycyrrhizae Radix) 6g.

　　Administration: one pack daily, decoction, Shi Gao and Shui Niu Jiao should be decocted first, 100-200 ml each time, 2-4 times per day, oral administration or nasal feeding.

　　Recommended Chinese patent medicines: Xiyanping injection, Xuebijing injection, Reduning injection, Tanreqing injection, and Xingnaojing injection. Drugs with similar effects can be selected according to individual conditions, or can be used in combination according to clinical symptoms. Traditional Chinese medicine injection can be used together with TCM decoction.

　　5) Critical case

　　① Internal blockage and external desertion pattern

　　Clinical manifestation: Dyspnea, panting on exertion or mechanical ventilation required, accompanied with unconsciousness and dysphoria, sweating, cold extremities. The tongue is dark and purple with thick greasy or dry coating. The pulse is floating and large without root.

　　Recommended formula: Take Su He Xiang Wan or Angong Niuhuang Wan with the following decoction composed of Ren Shen (Ginseng Radix) 15g, Hei Shun Pian (Aconiti Radix lateralis praeparata) (decocted first) 10g, Shan Zhu Yu (Corni Fructus) 15g.

　　If there is mechanical ventilation with abdominal distension, constipation or difficult defecation, 5-10g of Sheng Da Huang (Rhei Radix et Rhizoma) can be considered. If patient-ventilator asynchrony occurs, 5-10g of Sheng Da Huang and 5-10g of Mang Xiao (Natrii Sulfas) can be used together with sedation and muscle relaxant.

　　Recommended Chinese patent medicines: Xuebijing injection, Reduning injection, Tanreqing injection, Xingnaojing injection, Shenfu injection, Shengmai injection, and Shenmai injection. Drugs with similar effects can be selected according to individual conditions, or can be used in combination according to clinical symptoms. Traditional Chinese medicine injection can be used together with TCM decoction.

　　Note: Recommended usage of TCM injections for severe and critical cases

　　The use of TCM injections follows the principle of starting from a small dosage and modifying based on pattern identification in the instructions. The recommended usage is as follows:

　　Viral infection or combined with mild bacterial infection: 0.9% sodium chloride injection 250ml with Xiyanping injection 100mg (bid), or 0.9% sodium chloride injection 250ml with Reduning injection 20ml, or 0.9% sodium chloride injection 250ml with Tanreqing injection 40ml (bid).

　　High fever with disturbance of consciousness: 0.9% sodium chloride injection 250ml with Xingnaojing injection 20ml (bid).

　　Systemic inflammatory response syndrome (SIRS) or / and multiple organ failure (MOF): 0.9% sodium chloride injection 250ml with Xuebijing injection 100ml (bid).

　　Immunosuppression: glucose injection 250ml with Shenmai injection 100ml or Shengmai injection 20-60ml (bid).

　　6) Convalescence

　　① Lung-spleen qi deficiency pattern

　　Clinical manifestation: shortness of breath, lassitude and fatigue, poor appetite with nausea and vomiting, abdominal fullness, a sense of incomplete evacuation, and sticky loose stool. The tongue is pale and enlarged with white greasy coating.

　　Recommended formula: Fa Ban Xia (Pinellinae Rhizoma Praeparatum) 9g, Chen Pi (Citri reticulatae Pericarpium) 10g, Dang Shen (Codonopsis Radix) 15g, Zhi Huang Qi (Astragali Radix) 30g, Chao Bai Zhu (Atractylodis macrocephalae Rhizoma) 10g, Fu Ling (Poria) 15g, Huo Xiang (Pogostemonis Herba) 10g, Sha Ren (AmomiFructus) (added later) 6g, Gan Cao (Glycyrrhizae Radix) 6g.

　　Administration: one package daily, 400ml after decocting, and equally divide into twice in the morning and evening.

　　② Deficiency of both qi and yin pattern

　　Clinical manifestation: fatigue, shortness of breath, dry mouth, thirst, heart palpitation, profuse sweating, poor appetite, low-grade fever or no fever, dry cough with little sputum. The tongue is dry tongue with scanty fluid. The pulse is thready or weak and forceless.

　　Recommended formula: Nan Sha Shen (Adenophorae Radix) 10g, Bei Sha Shen (Glehniae Radix) 10g, Mai Dong (Ophiopogonis Radix) 15g, Xi Yang Shen (Panacis quinquefolii Radix) 6g, Wu Wei Zi (Schisandrae Fructus) 6g, Sheng Shi Gao (Gypsum fibrosum) 15g, Dan Zhu Ye (Lophatheri Herba) 10g, Sang Ye (Mori Folium) 10g, Lu Gen (Phragmitis Rhizoma) 15g, Dan Shen (Salviae miltiorrhizae Radix) 15g, Sheng Gan Cao (Glycyrrhizae Radix) 6g.

　　Administration: one package daily, 400ml after decocting, and equally divide into twice in the morning and evening.

　　Translated by Beijing University of Chinese Medicine

新型冠状病毒肺炎诊疗方案（试行第七版）中医方案部分

　　本病属于中医“疫”病范畴，病因为感受“疫戾”之气，各地可根据病情、当地气候特点以及不同体质等情况，参照下列方案进行辨证论治。涉及到超药典剂量，应当在医师指导下使用。

　　1.医学观察期

　　临床表现1：乏力伴胃肠不适

　　推荐中成药：藿香正气胶囊(丸、水、口服液)

　　临床表现2：乏力伴发热

　　推荐中成药：金花清感颗粒、连花清瘟胶囊(颗粒)、疏风解毒胶囊(颗粒)

　　2.临床治疗期(确诊病例)

　　2.1清肺排毒汤

　　适用范围：结合多地医生临床观察，适用于轻型、普通型、重型患者，在危重型患者救治中可结合患者实际情况合理使用。

　　基础方剂：麻黄9g、炙甘草6g、杏仁9g、生石膏15～30g(先煎)、桂枝9g、泽泻9g、猪苓9g、白术9g、茯苓15g、柴胡16g、黄芩6g、姜半夏9g、生姜9g、紫菀9g、冬花9g、射干9g、细辛6g、山药12g、枳实6g、陈皮6g、藿香9g。

　　服法：传统中药饮片，水煎服。每天一付，早晚各一次(饭后四十分钟)，温服，三付一个疗程。

　　如有条件，每次服完药可加服大米汤半碗，舌干津液亏虚者可多服至一碗。(注：如患者不发热则生石膏的用量要小，发热或壮热可加大生石膏用量)。若症状好转而未痊愈则服用第二个疗程，若患者有特殊情况或其他基础病，第二疗程可以根据实际情况修改处方，症状消失则停药。

　　处方来源：国家卫生健康委办公厅 国家中医药管理局办公室《关于推荐在中西医结合救治新型冠状病毒感染的肺炎中使用“清肺排毒汤”的通知》(国中医药办医政函〔2020〕22号)。

　　2.2轻型

　　(1)寒湿郁肺证

　　临床表现：发热，乏力，周身酸痛，咳嗽，咯痰，胸紧憋气，纳呆，恶心，呕吐，大便粘腻不爽。舌质淡胖齿痕或淡红，苔白厚腐腻或白腻，脉濡或滑。

　　推荐处方：生麻黄6g、生石膏15g、杏仁9g、羌活15g、葶苈子15g、贯众9g、地龙15g、徐长卿15g、藿香15g、佩兰9g、苍术15g、云苓45g、生白术30g、焦三仙各9g、厚朴15g、焦槟榔9g、煨草果9g、生姜15g。

　　服法：每日1剂，水煎600ml，分3次服用，早中晚各1次，饭前服用。

　　(2)湿热蕴肺证

　　临床表现：低热或不发热，微恶寒，乏力，头身困重，肌肉酸痛，干咳痰少，咽痛，口干不欲多饮，或伴有胸闷脘痞，无汗或汗出不畅，或见呕恶纳呆，便溏或大便粘滞不爽。舌淡红，苔白厚腻或薄黄，脉滑数或濡。

　　推荐处方：槟榔10g、草果10g、厚朴10g、知母10g、黄芩10g、柴胡10g、赤芍10g、连翘15g、青蒿10g(后下)、苍术10g、大青叶10g、生甘草5g。

　　服法：每日1剂，水煎400ml，分2次服用，早晚各1次。

　　2.3 普通型

　　(1)湿毒郁肺证

　　临床表现：发热，咳嗽痰少，或有黄痰，憋闷气促，腹胀，便秘不畅。舌质暗红，舌体胖，苔黄腻或黄燥，脉滑数或弦滑。

　　推荐处方：生麻黄6g、苦杏仁15g、生石膏30g、生薏苡仁30g、茅苍术10g、广藿香15g、青蒿草12g、虎杖20g、马鞭草30g、干芦根30g、葶苈子15g、化橘红15g、生甘草10g。

　　服法：每日1剂，水煎400ml，分2次服用，早晚各1次。

　　(2)寒湿阻肺证

　　临床表现：低热，身热不扬，或未热，干咳，少痰，倦怠乏力，胸闷，脘痞，或呕恶，便溏。舌质淡或淡红，苔白或白腻，脉濡。

　　推荐处方：苍术15g、陈皮10g、厚朴10g、藿香10g、草果6g、生麻黄6g、羌活10g、生姜10g、槟榔10g。

　　服法：每日1剂，水煎400ml，分2次服用，早晚各1次。

　　2.4 重型

　　(1)疫毒闭肺证

　　临床表现：发热面红，咳嗽，痰黄粘少，或痰中带血，喘憋气促，疲乏倦怠，口干苦粘，恶心不食，大便不畅，小便短赤。舌红，苔黄腻，脉滑数。

　　推荐处方：化湿败毒方

　　基础方剂：生麻黄6g、杏仁9g、生石膏15g、甘草3g、藿香10g(后下)、厚朴10g、苍术15g、草果10g、法半夏9g、茯苓15g、生大黄5g(后下)、生黄芪10g、葶苈子10g、赤芍10g。

　　服法：每日1～2剂，水煎服，每次100ml～200ml，一日2～4次，口服或鼻饲。

　　(2)气营两燔证

　　临床表现：大热烦渴，喘憋气促，谵语神昏，视物错瞀，或发斑疹，或吐血、衄血，或四肢抽搐。舌绛少苔或无苔，脉沉细数，或浮大而数。

　　推荐处方：生石膏30～60g(先煎)、知母30g、生地30～60g、水牛角30g(先煎)、赤芍30g、玄参30g、连翘15g、丹皮15g、黄连6g、竹叶12g、葶苈子15g、生甘草6g。

　　服法：每日1剂，水煎服，先煎石膏、水牛角后下诸药，每次100ml～200ml，每日2～4次，口服或鼻饲。

　　推荐中成药：喜炎平注射液、血必净注射液、热毒宁注射液、痰热清注射液、醒脑静注射液。功效相近的药物根据个体情况可选择一种，也可根据临床症状联合使用两种。中药注射剂可与中药汤剂联合使用。

　　2.5 危重型

　　内闭外脱证

　　临床表现：呼吸困难、动辄气喘或需要机械通气，伴神昏，烦躁，汗出肢冷，舌质紫暗，苔厚腻或燥，脉浮大无根。

　　推荐处方：人参15g、黑顺片10g(先煎)、山茱萸15g，送服苏合香丸或安宫牛黄丸。

　　出现机械通气伴腹胀便秘或大便不畅者，可用生大黄5～10g。出现人机不同步情况，在镇静和肌松剂使用的情况下，可用生大黄5～10g和芒硝5～10g。

　　推荐中成药：血必净注射液、热毒宁注射液、痰热清注射液、醒脑静注射液、参附注射液、生脉注射液、参麦注射液。功效相近的药物根据个体情况可选择一种，也可根据临床症状联合使用两种。中药注射剂可与中药汤剂联合使用。

　　注：重型和危重型中药注射剂推荐用法

　　中药注射剂的使用遵照药品说明书从小剂量开始、逐步辨证调整的原则，推荐用法如下：

　　病毒感染或合并轻度细菌感染：0.9%氯化钠注射液250ml加喜炎平注射液100mg bid，或0.9% 氯化钠注射液 250 ml加热毒宁注射液20 ml，或0.9%氯化钠注射液250ml加痰热清注射液40ml bid。

　　高热伴意识障碍：0.9%氯化钠注射液250ml加醒脑静注射液20ml bid。

　　全身炎症反应综合征或/和多脏器功能衰竭：0.9%氯化钠注射液250ml加血必净注射液100ml bid。

　　免疫抑制：葡萄糖注射液250ml加参麦注射液100ml 或生脉注射液20～60ml bid。

　　2.6 恢复期

　　(1)肺脾气虚证

　　临床表现：气短，倦怠乏力，纳差呕恶，痞满，大便无力，便溏不爽。舌淡胖，苔白腻。

　　推荐处方：法半夏9g、陈皮10g、党参15g、炙黄芪30g、炒白术10g、茯苓15g、藿香10g、砂仁6g(后下)、甘草6g。

　　服法：每日1剂，水煎400ml，分2次服用，早晚各1次。

　　(2)气阴两虚证

　　临床表现：乏力，气短，口干，口渴，心悸，汗多，纳差，低热或不热，干咳少痰。舌干少津，脉细或虚无力。

　　推荐处方：南北沙参各10g、麦冬15g、西洋参6g，五味子6g、生石膏15g、淡竹叶10g、桑叶10g、芦根15g、丹参15g、 生甘草6g。

　　服法：每日1剂，水煎400ml，分2次服用，早晚各1次。

2020-03-20 14:26:54

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