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《关于2019新型冠状病毒肺炎感染重症患者呼吸治疗期间预防医院感染传播的专家共识》

[Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia].

出版信息

Zhonghua Jie He He Hu Xi Za Zhi. 2020 Apr 12;43(4):288-296. doi: 10.3760/cma.j.cn112147-20200304-00239.

Abstract

Definite evidence has shown that the novel coronavirus (COVID-19) could be transmitted from person to person, so far more than 1 700 bedside clinicians have been infected. A lot of respiratory treatments for critically ill patients are deemed as high-risk factors for nosocomial transmission, such as intubation, manual ventilation by resuscitator, noninvasive ventilation, high-flow nasal cannula, bronchoscopy examination, suction and patient transportation, etc, due to its high possibility to cause or worsen the spread of the virus. As such, we developed this consensus recommendations on all those high-risk treatments, based on the current evidence as well as the resource limitation in some areas, with the aim to reduce the nosocomial transmission and optimize the treatment for the COVID-19 pneumonia patients. Those recommendations include: (1)Standard prevention and protection, and patient isolation; (2)Patient wearing mask during HFNC treatment; (3)Using dual limb ventilator with filters placed at the ventilator outlets, or using heat-moisture exchanger (HME) instead of heated humidification in single limb ventilator with HME placed between exhalation port and mask; avoid using mask with exhalation port on the mask; (4)Placing filter between resuscitator and mask or artificial airway; (5)For spontaneous breathing patients, placing mask for patients during bronchoscopy examination; for patients receiving noninvasive ventilation, using the special mask with bronchoscopy port to perform bronchoscopy; (6)Using sedation and paralytics during intubation, cuff pressure should be maintained between 25-30 cmH(2)O(1 cmH(2)O=0.098 kPa); (7)In-line suction catheter is recommended and it can be used for one week; (8)Dual-limb heated wire circuits are recommended and only changed with visible soiled; (9)For patients who need breathing support during transportation, placing an HME between ventilator and patient; (10)PSV is recommended for implementing spontaneous breathing trial (SBT), avoid using T-piece to do SBT. When tracheotomy patients are weaned from ventilator, HME should be used, avoid using T-piece or tracheostomy mask. (11)Avoid unnecessary bronchial hygiene therapy; (12) For patients who need aerosol therapy, dry powder inhaler metered dose inhaler with spacer is recommended for spontaneous breathing patients; while vibrating mesh nebulizer is recommended for ventilated patients and additional filter is recommended to be placed at the expiratory port of ventilation during nebulization.

摘要

确切证据表明,新型冠状病毒(COVID-19)可人际传播,截至目前,已有1700多名床边临床医生被感染。对于重症患者的许多呼吸治疗被视为医院内传播的高危因素,如插管、使用复苏器进行手动通气、无创通气、高流量鼻导管吸氧、支气管镜检查、吸痰及患者转运等,因为这些操作很可能导致病毒传播或使其加剧。因此,我们基于当前证据以及部分地区的资源限制,针对所有这些高危治疗制定了本共识性建议,旨在减少医院内传播并优化COVID-19肺炎患者的治疗。这些建议包括:(1)标准预防与防护以及患者隔离;(2)高流量鼻导管吸氧治疗期间患者佩戴口罩;(3)使用在呼吸机出口处放置过滤器的双肢通气机,或在单肢通气机中使用热湿交换器(HME)代替加热湿化,HME置于呼气端口与面罩之间;避免使用带有呼气阀的面罩;(4)在复苏器与面罩或人工气道之间放置过滤器;(5)对于自主呼吸患者,在支气管镜检查期间为患者佩戴面罩;对于接受无创通气的患者,使用带有支气管镜端口的专用面罩进行支气管镜检查;(6)插管期间使用镇静剂和肌松剂,套囊压力应维持在25 - 30 cmH₂O(1 cmH₂O = 0.098 kPa);(7)推荐使用内置式吸痰导管,且可使用一周;(8)推荐使用双肢加热导线回路,仅在明显污染时更换;(9)对于转运期间需要呼吸支持的患者,在通气机与患者之间放置一个HME;(10)推荐使用压力支持通气(PSV)实施自主呼吸试验(SBT),避免使用T形管进行SBT。气管切开患者撤机时,应使用HME,避免使用T形管或气管切开面罩。(11)避免不必要的气道清洁治疗;(12)对于需要雾化治疗的患者,自主呼吸患者推荐使用带储雾罐的干粉吸入器定量气雾剂;而通气患者推荐使用振动筛孔雾化器,雾化期间推荐在通气呼气端口额外放置过滤器。

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