Introduction

pneumonia

Severe pneumonia is one of the common acute critical illnesses, which means not only the common respiratory diseases of pneumonia but also the manifestations of respiratory failure and other systems involved. The novel coronavirus-infected pneumonia epidemic that broke out during the Spring Festival in China, 2020, up to now, 80,175 cases have been diagnosed nationwide, killing 2,915 people.

Symptoms of severe pneumonia

Common clinical features of pneumonia include fever, cough, expectoration, and chest pain. If pneumonia is complicated by multiple organ failure, such as respiratory failure, heart failure, coagulopathy, renal failure, shock, etc., it means that the condition is often very critical. Therefore, treatment and monitoring in the ICU are required for weeks or longer.

Diagnosis of severe pneumonia

Severity assessment of pneumonia at present:

  • Guidelines of the Chinese Thoracic Society (CTS)
  • The expert consensus of Chinese Medical Doctor Association
  • PSI (Pneumonia Severity Index) and CURB-65 (clinical prediction rule)

If symptoms meet any of the major criteria or 3 more of the minor criteria then to diagnose:

Major Criteria Minor Criteria
Endotracheal intubation requires mechanical ventilation Respiratory rate ≥ 30 breaths per minute
Vasoactive drugs are still required after septic shock with active humoral resuscitation PaO2/FiO2≤250mmHg
  Multilobar lung infiltrates
  Consciousness disorders and / or disorientation
  Serum uric acid nitrogen≥20mmg/dL
  Leukopenia: WBC (white blood cells)<4*109/L 
  Thrombocytopenia:  platelets<100*109/L
  Drop in body temperature(central temperature<36℃
  Low blood pressure requires fluid resuscitation

ICU Admission Standards

The following symptoms are listed as the manifestations of severe pneumonia in the guidelines for CAP (community-acquired pneumonia) diagnosis and treatment published by the CTS:

  • Consciousness disorders
  • Respiratory rate≥ 30 breaths per minute
  • PaO2 <60mmHg, oxygenation index (PaO2 / FiO2) <300mmHg, requiring mechanical ventilation
  • Blood pressure<90 / 60mmHg
  • The chest radiograph shows bilateral or multiple lung lobe involvement, or the lesion enlarges ≥50% within 48 hours of admission.
  • Oliguria: urine output <20ml/h, or <80ml/4h; or acute renal failure requiring dialysis treatment; sporadic onset of HAP (admission> 5d, mechanical ventilation> 4d); and those with high risk factors. Failure to fully meet the criteria for severe pneumonia is also considered severe.

Treatment of severe pneumonia

  • Drug treatment: antibacterial drugs (ladder-like therapy), glucocorticoids (SCAP patients with or without septic shock), gamma globulin (adjunct) and albumin, nutritional support
  • Non-drug therapy: monitoring, oxygen therapy, assistant respiration, drainage

The scientific community’s understanding of the novel coronavirus is still very limited so far, which has largely suppressed the research of targeted specific drugs. According to the WHO’s introduction on February 20, two clinical trials focused on treating new novel coronavirus pneumonia and related research are underway, with preliminary results expected in 3 weeks. One of the therapies uses the anti-HIV drugs lopinavir and ritonavir, and the other uses the antiviral drug rendesvir.

In addition, the malaria treatment drug chloroquine phosphate has been included in the sixth edition of the ‘Novel Coronavirus Pneumonia Diagnosis and Treatment Program’ issued by the National Health Commission, which is expected to further summarize the efficacy based on more applications. The antiviral drug piravir is also worthy of attention. Animal experiments and clinical trials are being successively advanced.

As an attempt and innovation, some hospitals in Wuhan have also adopted a combination of Chinese and Western methods, which has played a very important role and achieved good results in alleviating the symptoms of patients protected from developing to severe cases.

Nursing care for patients with severe pneumonia

Fever care

Patients with severe pneumonia are often accompanied by fever, so cooling care is particularly critical for them.

Keep the indoor air fresh and avoid convection wind. The temperature should be kept at 18-28 ℃ and the relative humidity should be 60% -65%.

If necessary, give physical cooling, or wipe with 50% warm water ethanol.

Medication care

Patients with severe pneumonia often use anti-infective treatment clinically. During the treatment, there are many types of medications. Reasonable arrangements should be made for the medication order with drug incompatibility and combination. 

For intravenous drip administration, the rate needs to be strictly controlled. 

Nursing staff also need to strictly monitor vital signs such as pulse, heart rate, blood pressure during medication.

Respiratory care

Severe pneumonia often leads to congestion and edema of lung tissue, increased secretions in the respiratory tract, and patients often experience symptoms of dyspnea. In such cases, patients should be given ultrasound atomization inhalation to relieve spasm and phlegm, and to maintain breathing clear. For patients who have developed respiratory failure, mechanical ventilation should be given.

Action should be gentle during mechanical sputum suction to ensure the aseptic operation and avoid infection. (no more than 15s each time)

Blood gas analysis, respiratory function assessment, and active oxygen therapy should be routinely performed upon admission, and blood oxygen saturation should be maintained at 94% to 98% based on a nasal catheter or mask. For patients at risk of CO2 retention, it can be maintained at around 90%.

Oxygen inhalation care

Check blood oxygen partial pressure regularly to maintain normal level. Generally, the nasal catheterization is applied to strictly grasp the concentration and flow of oxygen. If the symptoms of hypoxia have not improved significantly, try mask oxygen inhalation until the symptoms disappear.

Precautions for patients with novel coronavirus-infected pneumonia

Novel coronavirus pneumonia should be treated in the ICU department with more monitoring beds than usual basis. 

The nursing care of critically ill patients is divided into 4 levels from mild to severe with different monitoring. It is required that the monitoring data of each patient’s physical signs, such as monitoring records, real-time medication, nursing, observation, and scoring, should be recorded at the hourly frequency, and the patient’s input and output will be counted every 4 hours (calculate the amount of input drug and discharge with a calculator). The real-time status of the patient’s condition needs to be accurately observed by the doctor, but writing a large number of records is brain-intensive and calculations take up one-third of the nurse’s time. All medical personnel are under intensive physical or psychological stress in the current severe shortage of health care resources.

  • The ICU intensive care system should be adopted to automatically collect information and electronic records of equipment such as monitors to reduce the error rate in work, ensure the real time of the data, improve daily work efficiency and release the work pressure of medical staff.
  • For similar mobile cabin hospitals, adopting integrated central monitoring software is suggested for centralized admission and monitoring of dozens of patients, which simultaneously displays real-time physical monitoring information of all beds in a specific area.
  • Mark different care levels with different colours so that specific hospital bed information can be viewed at any time to observe changes in clinical performance.
Color-coded patient status indication
  • Keep the room quiet, and the monitoring equipment should be adjusted to night mode at night to ensure good sleep quality for patients.
  • The monitoring data can be stored and uploaded to the local area network for centralized reporting to the epidemic command centre, which is convenient for real-time understanding of the anti-epidemic situation in front and reasonable allocation of aid materials.

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