Pneumonia not only affects the lungs How to improve the rate of severe treatment?

The rescue of severe cases of new coronary pneumonia is a key part of winning the battle against the epidemic. As of February 13, 2020, more than 60,000 cases of new coronary pneumonia had been confirmed nationwide, of which 10,204 cases of severe cases were notable. While plasma-free treatment is a boon for severe cases, the road to treatment is still long – respiratory failure, cytokine storms occur more frequently than SARS.

Recently, the third military medical university led the study also found that the new coronary pneumonia can lead to kidney insufficiency, and eventually may lead to multiple organ failure and even death.

New coronary pneumonia is mostly induced by lack of oxygen

Currently, patients with severe neo-coronary pneumonia tend to experience a significant decrease in oxygenation, and CT-suggestive polypulmonary lesions (which actually appearto in patients with mild symptoms and not obvious breathing distress sometimes occur softened), which actually highlights an important problem facing patients: lack of oxygen.

On the evening of February 13th, Tong Zhaoxuan, an expert in the medical treatment team of the Central Steering Group and vice-president of Chaoyang Hospital in Beijing, also introduced that patients with new coronary pneumonia had made faster progress in respiratory failure compared to SARS in 2003, and that lack of oxygen had sometimes developed more obviously.

It is understood that the problem of lack of oxygen can not be underestimated. Li Yueping, director of the ICU of the Infection Center of the Eighth People’s Hospital in Guangzhou, said:

Lack of oxygen may induce cytokine storms.

Cytokine storms can directly lead to death – cytokine storms are phenomena that occur rapidly in large quantities of cytokines (e.g. leukocyte interleukins, chemokines, etc.) in body fluids caused by severe stimulation (e.g. infection of microorganisms, etc.) in the human body. Virus attacks can cause a full-body inflammatory response to the host, resulting in multiple tissue and organ damage, even exhaustion and even death.

In response, the National Health and Reform Commission and the State Administration of Traditional Chinese Medicine stated on February 4th that lung resuscitation is recommended for patients with severe acute respiratory distress syndrome (ARDS) in the “Pneumonia Treatment Program for New Coronary Virus Infections (Trial 5th Edition). Where adequate human resources are available, do more than 12 hours of lying-down ventilation per day. Those who do not perform well, if conditions permit, should consider ECMO as soon as possible.

The so-called ECMO, or Extracorporeal Membrane Oxygenation, Chinese known as the in vitro membrane pulmonary oxygenation, commonly known as “Yeke membrane”, “artificial lung”, is a medical first aid equipment for patients with severe cardiopulmonary failure to provide continuous in vitro breathing and circulation, to sustain the life of the patient (see Baidu Encyclopedia for details). In other words, ECMO can play a partial cardiopulmonary replacement role, maintaining the oxygenation of human organs tissue.

Pneumonia not only affects the lungs How to improve the rate of severe treatment?

Recently, Wuhan, Shanghai, Lanzhou and other places have appeared with ECMO to save the lives of critically ill patients success stories. As Ma Qi, vice president of Huashan Hospital affiliated with Fudan University, said:

In the absence of special drugs, ventilators and ECMO are significant in the treatment of new coronary pneumonia. It is known that the lung function of the new coronary pneumonia is obviously impaired, at this time there is a ventilator to support it, additional oxygen supply, can allow the patient’s lung function to obtain the best recovery. In other cases, lung damage is severe, at which point ECMO can provide very good support to patients.

However, this does not represent the large-scale scaling of ECMO. Many medical experts have mentioned its technical threshold before, the Chinese Academy of Medical Sciences outside the hospital in vitro circulation center director Ji Bingyang even pointed out that the use of ECMO process may occur related accidents and complications, including bleeding, blood clots, infections, limb ischemia, multi-organ failure, serious and even life-threatening.

In addition, ECMO equipment is expensive (it is understood that an ECMO costs more than RMB 1 million, consumables are expensive and have a high discount rate) and a limited number of products. According to China News Network reporter reported that even as a powerful sanjia hospital in Wuhan, Wuhan City People’s Hospital has only one, Wuhan City Center Hospital has 2, one of which was donated by the Han Hong Love Charity Foundation not long ago.

In addition, Li Yueping in an interview with the Southern Daily News said:

We are conducting research on early warning factors for severe and critical conditions and have identified several very clear early warning factors: lymphocyte decline, elevated lactic acid dehydrogenase, D2 polymer elevation, continuous oxygenation index decline, viral emias, etc.

It can be seen that the treatment of seriously ill patients at this stage is still very difficult.

Pay attention to the patient’s kidney function abnormality

Meanwhile, a recent study found that the new coronavirus impairs kidney function and should provide patients with special care for abnormal kidney function.

On February 12, a paper led by the research team of the Third Military Medical University, entitled “Precautions for Renal Insufficiency in Patients with New Coronary Pneumonia 2019” (Caution on Kidney Dysfunctions of 2019-nCoV Patients), was pre-printed on the website medRxi v published.

Pneumonia not only affects the lungs How to improve the rate of severe treatment?

According to the paper, because the 2019 new coronavirus and SARS virus have a common cellular mechanism – human angiotensin conversion enzyme 2 (ACE2) are both of the two viruses into the host cell of the presumed receptor, so the team investigated previous retrospective case studies on SARS and found that acute kidney damage in SARS┬áThe mortality rate is quite high (91.7% and 33 out of 36) is high in patients.

Based on this, the team conducted a study of 59 cases of kidney function in patients with neo-coronary pneumonia, including 28 severe cases and 3 deaths.

Studies have shown that ACE2 is not expressed only in respiratory organs. Previous reports of the expression of ACE2 in human tissue through the RNA-seq method indicate that ACE2 is expressed much higher in the gastrointestinal tract (small intestine, duodenum) or urinary organ (kidney) than in respiratory organs (nearly 100 times). In other words, the kidneys are the target of new coronavirus infection.

Pneumonia not only affects the lungs How to improve the rate of severe treatment?

The specific data obtained from the study are as follows:

63% (32/51) of patients developed proteinuria, indicating kidney damage;

19% (11/59) and 27% (16/59) increased plasma creatinine and urea nitrogen levels, respectively;

The CT scan showed that 100% (27/27) of the patient had abnormal kidney imaging.

It is not difficult to see that renal insufficiency is common in patients with neo-coronary pneumonia, which can eventually lead to multiple organ failure and death.

Therefore, the team strongly recommends careful monitoring of the patient’s kidney function, while taking potential interventions (such as continuity renal replacement therapy CRRT, a blood purification treatment that continuously and slowly removes water and solutes through in vitro circulating blood purification to replace kidney function) and protects kidney function as early as possible. Especially for patients with elevated plasma creatinine is necessary, can be said to be the key to prevent the death of serious patients.

Although the paper is a pre-printed, has not been peer-reviewed, but after more rigorous research, still the treatment of patients with severe coronary pneumonia still has reference significance. We expect more substantial progress in increasing the rate of treatment of critically ill patients and reducing mortality.