Notice on printing and distributing the influenza diagnosis and treatment plan (revised version in 2018)
Guo Wei Ban Yi Han [2018] No.1019
All provinces, autonomous regions, municipalities directly under the central government and the Health and Health Committee of Xinjiang Production and Construction Corps (Health and Family Planning Commission) and the Administration of Traditional Chinese Medicine:
In order to further standardize and strengthen the clinical management of influenza, reduce the occurrence of severe influenza and reduce the mortality rate, combined with the recent research results at home and abroad and the previous experience of influenza diagnosis and treatment in China, the Influenza Diagnosis and Treatment Plan (2018 Edition) was adjusted and improved, and the Influenza Diagnosis and Treatment Plan (2018 Edition Revised Edition) was formed. Is issued to you, please local health administrative departments at all levels (including the competent department of traditional Chinese medicine) attach great importance to the medical treatment of influenza.
General Office of National Health and Wellness Commission
Office of the State Administration of Traditional Chinese Medicine
November 19, 2018
Influenza diagnosis and treatment plan
(2018 revision)
Influenza (hereinafter referred to as influenza) is an acute respiratory infectious disease caused by influenza virus, which breaks out and spreads all over the world.
The onset of influenza is acute, although most of them are self-limited, but some of them can develop into severe influenza due to complications such as pneumonia, and a few severe cases progress rapidly and may die due to acute respiratory distress syndrome (ARDS) and/or multiple organ failure. Severe influenza mainly occurs in high-risk groups such as the elderly, young children, pregnant women or those with chronic basic diseases, and can also occur in the general population.
The results of previous influenza surveillance in China show that China is about to enter the influenza epidemic season. In order to further standardize and strengthen the clinical management of influenza, reduce the occurrence of severe influenza and reduce the mortality rate, this diagnosis and treatment plan is formulated on the basis of the Influenza Diagnosis and Treatment Plan (2018 Edition), combined with recent research results at home and abroad and previous experience in influenza diagnosis and treatment in China.
I. Etiology
Influenza virus belongs to orthomyxoviridae and belongs to RNA virus. According to nuclear protein and matrix protein, it can be divided into four types: A, B, C and D.
At present, people are mainly infected with H1N1 and H3N2 subtypes of influenza A virus and Victoria and Yamagata strains of influenza B virus.
Influenza virus is sensitive to common disinfectants such as ethanol, iodophor and tincture of iodine. Sensitive to ultraviolet rays and heat, it can be inactivated at 56℃ for 30 minutes.
Second, epidemiology
(1) the source of infection. Influenza patients and recessive infected people are the main sources of influenza infection. It is contagious from the end of latent period to the acute period. Viruses generally detoxify in human respiratory secretions for 3-6 days, and children and patients with impaired immune function can detoxify for more than 1 week.
(2) means of transmission. Influenza is mainly spread by droplets such as sneezing and coughing, and is directly or indirectly infected by mucous membranes such as mouth, nose and eyes. Contact with items contaminated by viruses can also be infected through the above channels.
(3) Susceptible population. People are generally susceptible. Vaccination with influenza vaccine can effectively prevent influenza virus infection of corresponding subtypes.
(4) High-risk groups of severe cases. The following people infected with influenza virus are more likely to develop into severe cases, so they should be given great attention, treated with antiviral drugs as soon as possible, and tested for influenza virus nucleic acid and other necessary examinations.
1. Children under 5 years old (children under 2 years old are more likely to have serious complications);
2. Older people over 65 years old;
3. Those who are accompanied by the following diseases or conditions: chronic respiratory diseases, cardiovascular diseases (except hypertension), nephropathy, liver diseases, hematological diseases, nervous system and neuromuscular diseases, metabolic and endocrine system diseases, and immunosuppression (including immunosuppression caused by immunosuppressants or HIV infection);
4. Obese people [body mass index (BMI) is greater than 30, BMI= weight (kg)/ height (m) 2];
5. Pregnant and perinatal women.
Third, the pathogenesis and pathology
(1) Pathogenesis. Influenza A and B viruses initiate infection by binding HA to the surface of respiratory epithelial cells containing sialic acid receptors. Influenza virus enters cells through endocytosis, and the virus genome is transcribed and replicated in the nucleus. A large number of new progeny virus particles were replicated, which spread through respiratory mucosa and infected other cells. After influenza virus infects human body, it can induce cytokine storm, lead to systemic inflammatory reaction, ARDS, shock and multiple organ failure, and children may have acute necrotizing encephalopathy.
(2) Pathological changes. Pathological changes are mainly manifested as cluster shedding of ciliated epithelial cells in respiratory tract, metaplasia of epithelial cells, congestion of mucosal cells in lamina propria, edema with monocyte infiltration and other pathological changes. Diffuse alveolar damage can occur in severe pneumonia. Diffuse congestion, edema and necrosis of brain tissue occur when encephalopathy is complicated. Acute necrotizing encephalopathy in children is characterized by symmetrical necrotizing lesions mainly in thalamus, and there is no obvious inflammatory reaction in the local area. Inflammatory reactions such as myocardial cell swelling, interstitial hemorrhage, lymphocyte infiltration and necrosis occur when heart damage is complicated.
Four, clinical manifestations and laboratory examination
The incubation period is usually 1-7 days, mostly 2-4 days.
(1) Clinical manifestations. The main symptoms are fever, headache, myalgia and general malaise. The body temperature can reach 39-40℃, and there may be chills and chills, accompanied by systemic symptoms such as sore muscles and joints, fatigue, loss of appetite, and often sore throat, dry cough, nasal congestion, runny nose and post-sternal discomfort. Facial flushing, conjunctival congestion.
Some of them are characterized by vomiting, abdominal pain and diarrhea, which are common in children infected with influenza B.
Without complications, the course of the disease is self-limited. After 3-4 days of onset, the body temperature gradually subsides and the general symptoms get better, but it usually takes 1-2 weeks for cough and physical recovery.
(2) Complications. Pneumonia is the most common complication of influenza. Other complications include nervous system damage, heart damage, myositis, rhabdomyolysis syndrome and septic shock.
1. Pneumonia
Pneumonia complicated by influenza can be divided into primary influenza virus pneumonia, secondary bacterial pneumonia or mixed pneumonia. The illness worsened 2-4 days after the onset of influenza, or worsened after the recovery of influenza, with high fever, severe cough, purulent sputum, dyspnea, moist rales in the lungs and signs of lung consolidation. The total number of white blood cells and neutrophils in peripheral blood increased significantly, mainly streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae.
2. Nervous system injury
Including encephalitis, meningitis, acute necrotizing encephalopathy, myelitis, Guillain-Barre syndrome, etc.
3. Heart damage
Heart injury is not common, mainly myocarditis and pericarditis. It can be seen that creatine kinase is elevated and ECG is abnormal, and heart failure may occur in severe cases. In addition, the risk of hospitalization and death related to myocardial infarction and ischemic heart disease increased significantly after being infected with influenza virus.
4. Myositis and rhabdomyolysis
The main symptoms are myalgia, myasthenia, renal failure, increased serum creatine kinase and myoglobin, and acute kidney injury.
5. Septic shock
It is characterized by high fever, shock and multiple organ dysfunction.
(3) Laboratory inspection.
1. Peripheral blood routine: the total number of white blood cells is generally not high or low, and the lymphocyte count in severe cases is obviously reduced.
2. Blood biochemistry: hypokalemia occurred in some cases, and creatine kinase, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase and creatinine increased in a few cases.
3. Etiology related examination:
(1) Detection of virus nucleic acid: Detect influenza virus nucleic acid in respiratory tract samples (throat swab, nose swab, nasopharyngeal or tracheal extract, sputum) by RT-PCR (preferably real-time RT-PCR). The specificity and sensitivity of virus nucleic acid detection are the best, and it can distinguish virus types and subtypes.
(2) Virus antigen detection (rapid diagnostic reagent detection): colloidal gold and immunofluorescence can be used for rapid antigen detection. Because the sensitivity of rapid antigen detection is lower than that of nucleic acid detection, the interpretation of the results of rapid antigen detection should be combined with the patient’s epidemic history and clinical symptoms.
(3) Serological detection: The dynamic detection of IgG antibody level in recovery period is 4 times or more than 4 times higher than that in acute period, which has retrospective diagnostic significance.
(4) Virus isolation and culture: influenza virus was isolated from respiratory tract samples. During the influenza epidemic season, patients with negative rapid antigen diagnosis and immunofluorescence detection of influenza-like cases are advised to isolate the virus.
(4) Imaging findings. Imaging examination of patients complicated with pneumonia showed patchy, ground glass shadow and multilobal exudative lesions in the lung; Those who progress rapidly can develop into diffuse exudative lesions or consolidation in both lungs, and pleural effusion can be seen in some cases.
In children complicated with pneumonia, the patchy shadows in the lungs appear earlier, with multiple and scattered distribution, which is easy to be inflated, and the imaging manifestations change rapidly. When the disease progresses, the lesions expand and fuse, and signs such as pneumothorax and mediastinal emphysema may appear.
V. Diagnosis
The diagnosis is mainly combined with epidemiological history, clinical manifestations and pathogenic examination.
(1) Clinically diagnosed cases. The above-mentioned clinical manifestations of influenza have epidemiological evidence or positive detection of influenza rapid antigen, and other diseases causing influenza-like symptoms are excluded.
(two) to determine the diagnosis of cases. Have the above-mentioned flu clinical manifestations, and have one or more of the following pathogen test results positive:
1. Influenza virus nucleic acid test is positive.
2. The isolation and culture of influenza virus were positive.
3. The level of influenza virus-specific IgG antibody in acute phase and recovery phase increased by 4 times or more.
Six, severe and critical cases
(a) one of the following circumstances is a severe case.
1. Persistent high fever > 3 days, accompanied by severe cough, expectoration of pus, blood sputum, or chest pain;
2. Rapid breathing, dyspnea and cyanosis of the lips;
3. Mental changes: unresponsiveness, lethargy, restlessness, convulsions, etc.
4. Severe vomiting, diarrhea and dehydration;
5. pneumonia;
6. The original underlying diseases are obviously aggravated.
(two) one of the following circumstances is a critical case.
1. Respiratory failure;
2. Acute necrotizing encephalopathy;
3. Septic shock;
4. Multiple organ dysfunction;
5. There are other serious clinical conditions that need to be monitored and treated.
Seven, differential diagnosis
(1) The common cold. The general symptoms of influenza are more serious than the common cold; Tracking the epidemiological history is helpful for identification; The influenza pathogen test of the common cold is negative, or the corresponding evidence of infection pathogen can be found.
(2) Other types of upper respiratory tract infections. Include acute pharyngitis, tonsillitis, rhinitis and sinusitis. Infection and symptoms are mainly confined to the corresponding parts. The local secretion was negative for influenza etiology.
(3) Other lower respiratory tract infections. Influenza with cough symptoms or complicated with tracheobronchitis should be differentiated from acute tracheobronchitis; Pneumonia should be differentiated from other pneumonia, including bacterial pneumonia, chlamydia pneumonia, mycoplasma pneumonia, viral pneumonia, fungal pneumonia and tuberculosis. According to the clinical features, a preliminary judgment can be made, and the diagnosis can be made by pathogenic examination.
Eight, treatment
(1) Basic principles.
1. The clinically diagnosed cases and confirmed cases should be treated in isolation as soon as possible.
2 hospitalization standards (meet one or more of the following standards):
(1) women in the middle and late pregnancy and perinatal period.
(2) The basic diseases are obviously aggravated, such as chronic obstructive pulmonary disease, diabetes, chronic cardiac insufficiency, chronic renal insufficiency and liver cirrhosis.
(3) Meet the diagnostic criteria for severe or severe influenza.
(4) accompanied by organ dysfunction.
3. Non-hospitalized patients are isolated at home and keep the room ventilated. Get enough rest, drink plenty of water, and the diet should be easy to digest and nutritious. Closely observe the changes of the disease, especially children and elderly patients.
4. High-risk groups infected with influenza virus are prone to severe influenza. Early antiviral treatment can alleviate symptoms, reduce complications, shorten the course of disease and reduce mortality.
5. Avoid blind or improper use of antibacterial drugs. Use antibacterial drugs only when there are indications of bacterial infection.
6. Children should avoid aspirin or aspirin-containing drugs and other salicylic acid preparations.
(2) symptomatic treatment. People with high fever can carry out physical cooling or apply antipyretic drugs. Patients with severe cough and expectoration are given antitussive and expectorant drugs. According to the degree of hypoxia, oxygen therapy is carried out in an appropriate way.
(3) antiviral treatment.
1. Timing of anti-influenza virus treatment
Patients with severe or high-risk factors of severe influenza should be given anti-influenza virus treatment as soon as possible, without waiting for virus test results. Antiviral treatment within 48 hours of onset can reduce complications, mortality and hospitalization time. Severe patients with onset time over 48 h can still benefit from antiviral treatment.
Patients who are not severe and have no high risk factors for severe influenza may also consider antiviral treatment within 48 hours after the onset of the disease and after evaluating the risks and benefits.
2. Anti-influenza drugs
Neuraminidase inhibitor (NAI) is effective for influenza A and B..
(1) oseltamivir (capsule/granule): The adult dose is 75mg each time, twice a day. Children aged 1 year and above should be given drugs according to their weight: those weighing less than 15Kg should be given 30mg twice a day; Those who weigh 15 ~ 23 kg are given 45mg twice a day; Those weighing 23 ~ 40kg were given 60mg twice a day; Those who weigh more than 40Kg are given 75mg twice a day. The course of treatment is 5 days, and the course of treatment for severe patients can be extended appropriately. Patients with renal insufficiency should adjust the dose according to renal function.
(2) Zanamivir: suitable for adults and adolescents over 7 years old, usage: twice a day with an interval of 12 hours; 10mg each time (inhaled twice). However, inhalants are not recommended for patients with severe illness or complications.
(3) Paramivir: the dosage for adults is 300-600 mg, 6mg/kg for newborns less than 30 days, 8mg/kg for infants 31-90 days, and 10mg/kg for children aged 91-17 years, once a day for 1-5 days, and the course of treatment for severe cases can be appropriately extended. At present, the clinical application data is limited, and the adverse reactions should be closely observed.
Ion channel M2 blockers amantadine and rimantadine are only effective for influenza A virus, but the current monitoring data show that influenza A virus is resistant to them, so it is not recommended to use them.
(4) Treatment of severe cases.
Treatment principle: actively treat the primary disease, prevent and treat complications, and provide effective organ function support.
1. In case of hypoxemia or respiratory failure, corresponding treatment measures should be given in time, including oxygen therapy or mechanical ventilation.
2. Give corresponding anti-shock treatment when combined with shock.
3. When other organ functions are damaged, give corresponding support and treatment.
4. When secondary infection occurs, give corresponding anti-infection treatment.
(5) Chinese medicine treatment
1. Treatment scheme based on syndrome differentiation for mild symptoms.
(1) Wind-heat invasion.
Main symptoms: early onset, fever or no fever, red throat discomfort, mild cough with little phlegm, and no sweat.
Tongue pulse: red tongue, thin or greasy fur, floating pulse.
Treatment: dispelling wind and relieving exterior syndrome, clearing away heat and toxic materials.
Basic prescription: Yinqiao powder combined with Sangju drink.
Honeysuckle 15g forsythia 15g mulberry leaf 10g chrysanthemum 10g
Platycodon grandiflorum 10g burdock 15g bamboo leaves 6g reed rhizome 30g
Mint (bottom) 3g raw licorice 3g
Decocting method: decoct with water, 400 ml for each dose, 200 ml for each oral administration, twice a day; If necessary, you can take 2 doses a day, once every 6 hours, 200 ml each time.
Addition and subtraction: thick and greasy fur with 10g of Pogostemon and 10 g of Eupatorium odoratum;
10g almond and 10g roasted loquat leaves are added to cough;
6g of Coptidis Rhizoma and 3 g of Radix Aucklandiae are added for diarrhea;
9g of Brocade and 15g of Scrophularia are added for sore throat.
If you vomit, you can first take 6g of Rhizoma Coptidis and 10g of Folium Perillae with water.
Commonly used Chinese patent medicines: dispersing wind and relieving exterior syndrome, clearing away heat and toxic materials, such as Jinhua Qinggan Granule, Lianhua Qingwen Capsule (granule), Qingkailing Granule (capsule, soft capsule, tablet), dispersing wind and toxic materials, Yinqiao Jiedu Granule, Sangju Colds, etc.
Children can choose children’s anti-flu granules and children’s chiqiao Qingre granules.
(2) Heat toxin attacks the lungs.
Main symptoms: high fever, cough, sticky and uncomfortable phlegm, thirst, sore throat and red eyes.
Tongue pulse: red tongue, yellow or greasy fur, and slippery pulse.
Treatment: clearing away heat and toxic materials, dispersing lung and relieving cough.
Basic prescription: Maxing Shigan Decoction.
Roasted ephedra 5g almond 10g gypsum Fibrosum (fried first) 30g.
Anemarrhena rhizome 10g Fritillaria thunbergii 10g Platycodon grandiflorum 10g Scutellaria baicalensis 15g
Bupleurum chinense 15g raw licorice 10g
Decocting method: decoct with water, 400 ml for each dose, 200 ml for each oral administration, twice a day; If necessary, you can take 2 doses a day, once every 6 hours, 200 ml each time.
Addition and subtraction: 6 g of raw rhubarb (lower back) for constipation;
10g of Rhizoma Atractylodis and 10g of Cortex Magnolia Officinalis are added for thick and greasy fur;
15g of Artemisia annua and 10g of Cortex Moutan are added for continuous high fever.
Commonly used Chinese patent medicines: clearing away heat and toxic materials, dispersing lung and relieving cough, such as Lianhua Qingwen capsule (granule), Yinhuang preparation, Lianhua Qingre preparation, etc.
Children can choose Xiaoer Feire Kechuan Granule (oral liquid), Xiaoer Kechuanling Granule (oral liquid) and antelope horn powder.
2. Severe syndrome differentiation treatment scheme.
(1) Toxic heat blocks the lung.
Main symptoms: persistent high fever, severe cough, little or no phlegm, shortness of breath, head and body pain; Or accompanied by palpitations, irritability.
Tongue pulse: red tongue, thin yellow or greasy fur, and numerous pulse strings.
Treatment: detoxification and heat clearing, purging lung and activating collaterals.
Basic prescription: Xuanbai Chengqi Decoction.
Roasted Ephedra 6g Gypsum Fibrosum (fried first) 40g Almond 9gAnemarrhena 10g
Houttuynia cordata 15g Lepidium 10g Scutellaria baicalensis 10g Fritillaria thunbergii 10g
Raw rhubarb 6g Artemisia annua 15g Radix Paeoniae Rubra 10g Radix Glycyrrhizae 3g
Decocting method: decoct with water, 400 ml for each dose, 200 ml for each oral administration, twice a day; If necessary, you can take 2 doses a day, once every 6 hours, 200 ml each time. Can also be nasal feeding or colon drip.
Addition and subtraction: continuous high fever plus antelope horn powder 0.6g (separately) and Angong Niuhuang Pill 1;
Abdominal distension and constipation are added with 9g of Fructus Aurantii Immaturus and 6g of Sodium Sulfate (separately);
Ten grams of American ginseng and six grams of Schisandra chinensis are added to patients with dyspnea and sweating fatigue.
(2) Toxic heat invaginates, and the toxic heat invades.
Main symptoms: vague and indifferent knowledge, dark lips and claws, shallow breathing, pink blood, burning chest and abdomen, cold limbs, sweating and less urine.
Tongue pulse: red or dull tongue, heavy and thready pulse.
Treatment: Yiqi Gutuo, Qingre Jiedu.
Basic prescription: Shenfu decoction.
Sun-dried ginseng 15g processed aconite root (fried first) 10g coptis root 6g
Honeysuckle 20g raw rhubarb 6g Artemisia annua 15g
Cornus officinalis 15g Fructus Aurantii Immaturus 10g
Decocting method: decoct with water, 400 ml for each dose, 200 ml for each oral administration, twice a day; If necessary, you can take 2 doses a day, once every 6 hours, 200 ml each time. Can also be nasal feeding or colon drip.
3. Treatment scheme based on syndrome differentiation in recovery period.
Deficiency of both qi and yin, failure to restore healthy qi.
Main symptoms: fatigue, shortness of breath, cough, scanty phlegm and anorexia.
Tongue pulse: dark or reddish tongue, thin and greasy fur, thin pulse string.
Treatment: benefiting qi and nourishing yin.
Basic prescription: Shashen Maimendong Decoction.
Adenophora adenophora 15g Ophiopogon japonicus 15g Schisandra 10g Fritillaria thunbergii 10g
Almond 10g Artemisia annua 10g roasted loquat leaf 10g
Jiao Sanxian 10g each.
Decocting method: decoct with water, 400 ml for each dose, 200 ml for each oral administration, twice a day; If necessary, you can take 2 doses a day, once every 6 hours, 200 ml each time. Can also be nasal feeding or colon drip.
Note:
1. When pregnant women get sick, the treatment should refer to the adult plan, avoid using contraindications for pregnancy, treat the disease and prevent miscarriage simultaneously, and pay attention to the dosage, so as to stop the middle disease.
2. Children can refer to the adult treatment plan and adjust the dosage according to pediatric regulations. Chinese patent medicines without indications for children should not be used.
IX. Prevention
(1) Vaccination. Vaccination against influenza is the most effective means to prevent influenza, which can significantly reduce the risk of influenza and serious complications. It is recommended that people aged 60 and above, children aged 6 months to 5 years, pregnant women, family members and caregivers of children under 6 months, patients with chronic diseases and medical staff be vaccinated with influenza vaccine every year.
(2) drug prevention. Drug prevention can not replace vaccination, but can only be used as an emergency temporary preventive measure for high-risk groups of severe influenza who have not been vaccinated or have not gained immunity after vaccination. Oseltamivir, zanamivir, etc. can be used.
(3) General preventive measures. Maintaining good personal hygiene habits is an important means to prevent respiratory infectious diseases such as influenza. The main measures include: enhancing physical fitness and immunity; Wash your hands frequently; Keep the environment clean and ventilated; Minimize activities in crowded places and avoid contact with patients with respiratory infections; Maintain good respiratory hygiene habits, cover your mouth and nose with your upper arm or paper towel or towel when coughing or sneezing, wash your hands after coughing or sneezing, and try to avoid touching your eyes, nose or mouth; If you have symptoms of respiratory infection, you should rest at home and seek medical treatment as soon as possible.
