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Frontiers of Medicine

Front. Med.    2020, Vol. 14 Issue (5) : 674-680     https://doi.org/10.1007/s11684-020-0796-3
CASE REPORT
Successful management of seven cases of critical COVID-19 with early noninvasive–invasive sequential ventilation algorithm and bundle pharmacotherapy
Mian Peng1, Xueyan Liu2(), Jinxiu Li3, Di Ren4, Yongfeng Liu5, Xi Meng3, Yansi Lyu6, Ronglin Chen5, Baojun Yu7, Weixiong Zhong1
1. Department of Intensive Care Unit, The Third Affiliated Hospital of Shenzhen University, Shenzhen 518001, China
2. Department of Intensive Care Unit, Shenzhen People’s Hospital, First Affiliated Hospital of Southern University of Science and Technology, The Second Affiliated Hospital of Jinan University, Shenzhen 518020, China
3. Department of Intensive Care Unit, The Third People’s Hospital of Shenzhen, Shenzhen 518112, China
4. Department of Intensive Care Unit, The Second People’s Hospital of Shenzhen, Shenzhen 518035, China
5. Department of Intensive Care Unit, Shenzhen Longgang Central Hospital, Shenzhen 518116, China
6. Department of Dermatology, Shenzhen University General Hospital, Shenzhen 518055, China
7. Department of Intensive Care Unit, Shenzhen Baoan District People’s Hospital, Shenzhen 518101, China
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Abstract

We report the clinical and laboratory findings and successful management of seven patients with critical coronavirus disease 2019 (COVID-19) requiring mechanical ventilation (MV). The patients were diagnosed based on epidemiological history, clinical manifestations, and nucleic acid testing. Upon diagnosis with COVID-19 of critical severity, the patients were admitted to the intensive care unit, where they received early noninvasive–invasive sequential ventilation, early prone positioning, and bundle pharmacotherapy regimen, which consists of antiviral, anti-inflammation, immune-enhancing, and complication-prophylaxis medicines. The patients presented fever (n = 7, 100%), dry cough (n = 3, 42.9%), weakness (n = 2, 28.6%), chest tightness (n = 1, 14.3%), and/or muscle pain (n = 1, 14.3%). All patients had normal or lower than normal white blood cell count/lymphocyte count, and chest computed tomography scans showed bilateral patchy shadows or ground glass opacity in the lungs. Nucleic acid testing confirmed COVID-19 in all seven patients. The median MV duration and intensive care unit stay were 9.9 days (interquartile range, 6.5–14.6 days; range, 5–17 days) and 12.9 days (interquartile range, 9.7–17.6 days; range, 7–19 days), respectively. All seven patients were extubated, weaned off MV, transferred to the common ward, and discharged as of the writing of this report. Thus, we concluded that good outcomes for patients with critical COVID-19 can be achieved with early noninvasive–invasive sequential ventilation and bundle pharmacotherapy.

Keywords COVID-19      noninvasive–invasive sequential ventilation      bundle pharmacotherapy     
Corresponding Author(s): Xueyan Liu   
Just Accepted Date: 28 June 2020   Online First Date: 06 August 2020    Issue Date: 12 October 2020
 Cite this article:   
Mian Peng,Xueyan Liu,Jinxiu Li, et al. Successful management of seven cases of critical COVID-19 with early noninvasive–invasive sequential ventilation algorithm and bundle pharmacotherapy[J]. Front. Med., 2020, 14(5): 674-680.
 URL:  
http://journal.hep.com.cn/fmd/EN/10.1007/s11684-020-0796-3
http://journal.hep.com.cn/fmd/EN/Y2020/V14/I5/674
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Articles by authors
Mian Peng
Xueyan Liu
Jinxiu Li
Di Ren
Yongfeng Liu
Xi Meng
Yansi Lyu
Ronglin Chen
Baojun Yu
Weixiong Zhong
Characteristic Patient
1 2 3 4 5 6 7
Age (year) 65 57 64 46 56 71 36
Gender F F F M M M F
Body mass index 22 23 21 25 25 25 28
Underlying disease Diab, 15 years No No No Hypt, 30 years Hypt, 6 months No
Wuhan contact Yes Yes Yes Yes No, but subway worker Yes Yes
Symptoms
Fever + + + + + + +
Dry cough + + +
Weakness + +
Chest tightness +
Muscle pain +
Tab.1  Patients’ demographic and clinical characteristics
Parameter Patient
1 2 3 4 5 6 7
WCC (×109/L) 5.89 9.14 5.39 6.64 6.51 5.64 3.81
Neutrophil count (×109/L) 5.35 7.34 4.25 4.38 5.36 3.98 2.37
Lymphocyte count (×109/L) 0.42 1.42 0.90 0.83 0.93 0.79 1.08
Hemoglobin (g/L) 118 143 125 159 124 142 92
Platelet (×109/L) 118 175 176 171 153 191 282
PaO2/FiO2 ratio before intubation (mmHg) 136 165 118 150 116 110 141
Lactate (mmol/L) 2.7 2.3 2.1 2.6 2.6 1.9 1.4
Creatinine (µmol/L) 54.1 38.3 54 86 94.6 78.9 42
Urea (mmol/L) 4.48 3.71 6.35 4.36 8.48 5.78 4.13
Albumin (g/L) 34.6 37.9 39 46.6 35.5 40.8 41.3
Alanine aminotransferase (U/L) 15.7 19.7 33.3 12 34.8 26.8 15
Total bilirubin (µmol/L) 8.4 12.1 10.8 11.9 12.2 33.6 7.7
CT lung changes + + + + + + +
Respiratory nucleic acid result + + + + + + +
Tab.2  Patients’ laboratory and CT manifestation findings
Fig.1  Pretreatment chest CT scans for patients 1–7. Patient numbers are indicated in the upper left of each image.
Parameter Patient
1 2 3 4 5 6 7
MV start date (in 2020) Jan 24 Jan 27 Jan 31 Feb 1 Feb 3 Feb 4 Feb 6
MV end date (in 2020) Feb 1 Feb 12 Feb 7 Feb 6 Feb 10 Feb 13 Feb 23
MV duration (day) 8 16 7 5 7 9 17
ICU admission date (in 2020) Jan 24 Jan 26 Jan 28 Feb 1 Feb 3 Feb 4 Feb 6
ICU transfer out date (in 2020) Feb 6 Feb 13 Feb 9 Feb 8 Feb 12 Feb 16 Feb 25
ICU stay (day) 13 18 12 7 9 12 19
Notable case characteristics Sulp for ↑sputum, cultures negative VAP; sepsis; NE; sputum; culture Pm, ESBL+ E. coli; AB: Taz, Mer, Cef Sulp for ↑sputum, cultures negative Sulp for ↑sputum, cultures negative VAP; sputum culture MDR Pm; AB: Mer, Taz, Ami
Tab.3  Patients’ MV care spans, ICU admission spans, and notable case characteristics
Fig.2  Post-treatment chest CT scans for patients 1–7. Patient numbers are indicated in the upper left of each image.
Fig.3  COVID-19 diagnoses algorithm.
Fig.4  Sequential noninvasive–invasive ventilation process. Vt, tidal volume; PEEP, positive end-expiratory pressure; RR, respiratory rate; IBW, ideal bodyweight.
1 PS Masters, L Kuo, R Ye, KR Hurst, CA Koetzner, B Hsue. Genetic and molecular biological analysis of protein-protein interactions in coronavirus assembly. Adv Exp Med Biol 2006; 581: 163–173
https://doi.org/10.1007/978-0-387-33012-9_29 pmid: 17037525
2 C Drosten, S Günther, W Preiser, S van der Werf, HR Brodt, S Becker, H Rabenau, M Panning, L Kolesnikova, RA Fouchier, A Berger, AM Burguière, J Cinatl, M Eickmann, N Escriou, K Grywna, S Kramme, JC Manuguerra, S Müller, V Rickerts, M Stürmer, S Vieth, HD Klenk, AD Osterhaus, H Schmitz, HW Doerr. Identification of a novel coronavirus in patients with severe acute respiratory syndrome. N Engl J Med 2003; 348(20): 1967–1976
https://doi.org/10.1056/NEJMoa030747 pmid: 12690091
3 AM Zaki, S van Boheemen, TM Bestebroer, AD Osterhaus, RA Fouchier. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012; 367(19): 1814–1820
https://doi.org/10.1056/NEJMoa1211721 pmid: 23075143
4 N Zhu, D Zhang, W Wang, X Li, B Yang, J Song, X Zhao, B Huang, W Shi, R Lu, P Niu, F Zhan, X Ma, D Wang, W Xu, G Wu, GF Gao, W Tan; China Novel Coronavirus Investigating and Research Team. A novel coronavirus from patients with pneumonia in china, 2019. N Engl J Med 2020; 382(8): 727–733
https://doi.org/10.1056/NEJMoa2001017 pmid: 31978945
5 P Zhou, XL Yang, XG Wang, B Hu, L Zhang, W Zhang, HR Si, Y Zhu, B Li, CL Huang, HD Chen, J Chen, Y Luo, H Guo, RD Jiang, MQ Liu, Y Chen, XR Shen, X Wang, XS Zheng, K Zhao, QJ Chen, F Deng, LL Liu, B Yan, FX Zhan, YY Wang, GF Xiao, ZL Shi. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020; 579(7798): 270–273
https://doi.org/10.1038/s41586-020-2012-7 pmid: 32015507
6 F He, Y Deng, W Li. Coronavirus disease 2019 (COVID-19): what we know? J Med Virol 2020; 92(7): 719–725
https://doi.org/10.1002/jmv.25766
7 L Lin, TS Li. Interpretation of Guidelines for the Diagnosis and Treatment of Novel Coronavirus (2019-nCoV) Infection by the National Health Commission (Trial Version 5). Natl Med J China (Zhonghua Yi Xue Za Zhi) 2020; 100(11): 805–807 (in Chinese)
8 YR Guo, QD Cao, ZS Hong, YY Tan, SD Chen, HJ Jin, KS Tan, DY Wang, Y Yan. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak—an update on the status. Mil Med Res 2020; 7(1): 11
https://doi.org/10.1186/s40779-020-00240-0 pmid: 32169119
9 L Zhou, HG Liu. Early detection and disease assessment of patients with novel coronavirus pneumonia. Chin J Tuberc Respir Dis (Zhonghua Jie He He Hu Xi Za Zhi) 2020; 43(3): 167–170 (in Chinese) 
10 S Jiang, L Du, Z Shi. An emerging coronavirus causing pneumonia outbreak in Wuhan, China: calling for developing therapeutic and prophylactic strategies. Emerg Microbes Infect 2020; 9(1): 275–277
https://doi.org/10.1080/22221751.2020.1723441 pmid: 32005086
11 JF Chan, S Yuan, KH Kok, KK To, H Chu, J Yang, F Xing, J Liu, CC Yip, RW Poon, HW Tsoi, SK Lo, KH Chan, VK Poon, WM Chan, JD Ip, JP Cai, VC Cheng, H Chen, CK Hui, KY Yuen. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020; 395(10223): 514–523
https://doi.org/10.1016/S0140-6736(20)30154-9 pmid: 31986261
12 II Bogoch, A Watts, A Thomas-Bachli, C Huber, MUG Kraemer, K Khan. Potential for global spread of a novel coronavirus from China. J Travel Med 2020; 27(2): taaa011
https://doi.org/10.1093/jtm/taaa011 pmid: 31985790
13 Expert Panel of Critical Care Medicine for COVID-19 Pneumonia in Shenzhen. The Shenzhen 2020 guidelines for the diagnosis and treatment of severe/critical COVID-19. Chin Crit Care Med (Zhonghua Wei Zhong Bing Ji Jiu Yi Xue) 2020; 32(2): 1–4 (in Chinese)
14 Y Shi, X Yu, H Zhao, H Wang, R Zhao, J Sheng. Host susceptibility to severe COVID-19 and establishment of a host risk score: findings of 487 cases outside Wuhan. Crit Care 2020; 24(1): 108
https://doi.org/10.1186/s13054-020-2833-7 pmid: 32188484
15 X Yuan, JS Mu, GX Mo, XS Hu, P Yan, LX Xie. Respiratory support for severe 2019-nCoV pneumonia suffering from acute respiratory failure: time and strategy. Chin J Tuberc Respir Dis (Zhonghua Jie He He Hu Xi Za Zhi) 2020; 43(3): 177–180 (in Chinese)
pmid: 32164082
16 K Liu, YY Fang, Y Deng, W Liu, MF Wang, JP Ma, W Xiao, YN Wang, MH Zhong, CH Li, GC Li, HG Liu. Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. Chin Med J (Engl) 2020; 133(9): 1025–1031 
https://doi.org/10.1097/CM9.0000000000000744 pmid: 32044814
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