Outcome of coronavirus-associated severe acute respiratory syndrome using a standard treatment protocol

OBJECTIVE: There is so far no consensus on the optimal treatment strategy for the coronavirus-associated severe acute respiratory syndrome (SARS). We aimed to analyse the outcomes of a standard treatment strategy comprising antibiotics, a combination of ribavirin, a 3-week step-down course of corticosteroids, and the possibility of pulsed methylprednisolone rescue in the event of deterioration. METHODOLOGY: This was a prospective cohort study performed at a major public-funded hospital in Hong Kong. Eighty-eight World Health Organisation/Centers for Disease Control and Prevention probable cases of SARS (97% laboratory-confirmed) were treated with a standard protocol previously reported. Seventy-one patients treated de novo were analysed in detail with regard to time to clinical stabilization after combination treatment, requirement of additional therapy (pulsed methylprednisolone; assisted ventilation); and final outcomes (recovery, mortality). RESULTS: The mean age was 42. Twenty-one patients (24%) had comorbidities. Three of 71 treated de novo recovered with antibiotics alone. The remaining 68 received combination treatment at a mean of 5.8 days after symptom onset, of whom 30 subsequently required pulsed methylprednisolone rescue (independent predictors: older age and higher LDH) and 18 required assisted ventilation (independent predictors: older age, higher oxygen requirement and creatinine level). Their median time to clinical stabilization was 8.0 days after combination treatment (independent predictor for longer time to stabilization: median age of 41 or above). Common complications were hyperglycaemia (58%), pneumo-mediastinum/thoraces (13%), psychiatric manifestations (7%) and ventilator-associated pneumonia (2%). One patient (1%) died of SARS-related respiratory failure. All-cause mortality was 3.4%, occurring in patients aged > 65 years only. None of the discharged survivors required continuation of oxygen therapy. CONCLUSIONS: This standard treatment protocol resulted in overall satisfactory outcomes. Randomized controlled trial is suggested to confirm its efficacy.     

重症胰腺炎合并ARDS的诊断治疗

目的探讨重症胰腺炎（SAP）并发成人呼吸窘迫综合症（ARDS）的诊断和治疗。方法对我院近10年收治的72例重症胰腺炎（SAP）其中并发成人呼吸窘迫综合症38例进行回顾性临床总结,分析其血气PaO2／FiO2、Qs／Qt等与诊断和治疗的关系。结果重症胰腺炎（SAP）并发ARDS的发生率52．77％（38／72）．在及时合理治疗原发病的基础上,均给予机械通气,平均6．5天,机械通气24h后血气分析显示PaO2为（94．85±12．25）mmHg,PaO2为（34．4±7．05）mmHg,Qs／Qt值为5．25％±6．85％,全组死亡10例,放弃治疗3例,死亡率26．31％。结论重症胰腺炎（SAP）在及时处理原发病的基础上,对并发的ARDS进行早期诊断和治疗,正确使用呼吸机,防治并及时处理其它并发症,是降低病死率的有效措施。     

中山市首批重症SARS应用糖皮质激素的回顾性分析

目的探讨糖皮质激素在严重急性呼吸综合症(SARS)治疗价值及时机。方法回顾性分析中山市人民医院和中医院于2003年1-3月收治的11例重症SARS临床资料,总结治疗效果,探讨糖皮质激素治疗的最佳时机及剂量。结果9例重症SARS用糖皮质激素治疗后肺炎吸收,有效率81.8%,开始用激素治疗的时间在起病后平均6.8天。结论糖皮质激素是治疗SARS的有效手段之一,只要应用剂量和时机得当,对于有糖尿病、高血压、溃疡病等基础病的病人也是安全的。     

Severe acute respiratory syndrome (SARS) in Hong Kong

Severe acute respiratory syndrome (SARS) is a recently recognized and highly contagious pneumonic illness, caused by a novel coronavirus. While developments in diagnostic, clinical and other aspects of SARS research are well underway, there is still great difficulty for frontline clinicians as validated rapid diagnostic tests or effective treatment regimens are lacking. This article attempts to summarize some of the recent developments in this newly recognized condition from the Asia Pacific perspective.     

8例严重急性呼吸综合征死亡病例特点分析

目的总结8例严重急性呼吸综合征（severe acute respiratory syndrome,SARS）死亡病例临床特点,探讨应对突发传染病的教训与经验。方法总结病例的临床表现、影像资料、实验室资料及治疗措施,分析这些因素对预后的影响。结果SARS传染性强,潜伏期短,老年、妊娠及合并基础病患者预后不良。在早期尚未找到有效抗病毒药的情况下,早休息及合理对症治疗很重要。长期过量应用糖皮质激素易致血糖升高、二重感染等致死并发症。结论对新发传染病做到严密隔离、早休息、早期合理治疗,保护好高危人群至关重要。     

Severe acute respiratory syndrome in children

Severe acute respiratory syndrome (SARS) is a newly described and highly contagious respiratory infection. Many adult patients will develop progressive hypoxia, and a large proportion will develop respiratory distress syndrome (RDS), possibly related to massive and uncontrolled activation of the immune system. The mortality has been reported to be quite high, especially in the elderly with comorbid conditions. The causative agent has been identified as a novel coronavirus, and children appear to acquire the infection by close-contact household exposure to an infected adult. However, the severity is much milder and the clinical progression much less aggressive in young children. The exact pathophysiology of SARS is still unclear, and the medical treatment of SARS remains controversial. The main treatment regime used in Hong Kong is a combination of ribavirin and steroid. To date, there have been no reported case fatalities in children with this disease. The success of reducing the burden of this infection in children will depend on proper isolation of infected adults early in the course of illness. Strict public health policy and quarantine measures are the key in controlling the infection in the community.     

Temporal changes in cytokine/chemokine profiles and pulmonary involvement in severe acute respiratory syndrome

OBJECTIVE AND BACKGROUND: Pathological changes in severe acute respiratory syndrome (SARS) suggest that SARS sequelae are associated with dysregulation of cytokine and chemokine production. To improve understanding of the immuno-pathological processes involved in lung injury associated with SARS, the temporal changes in cytokine/chemokine profiles in the sera of SARS patients were compared with those of patients with community-acquired pneumonia (CAP), according to the degree of lung involvement. METHODS: Serum levels of 11 cytokines and chemokines, in 14 patients with SARS and 24 patients with CAP, were serially checked using a bead-based multiassay system. Sera from 12 healthy subjects were used as normal controls. RESULTS: The serum levels of interferon-gamma-inducible protein-10 (IP-10), IL-2 and IL-6 were significantly elevated during SARS infection. In patients with CAP, but not in those with SARS, the levels of interferon-gamma, IL-10, IL-8 and monokine induced by interferon-gamma (MIG) were significantly elevated compared with the levels in healthy controls. Among the chemokines/cytokines, IL-6 levels correlated most strongly with radiographic scores (r=0.62). The elevation of IP-10 and IL-2 antedated the development of chest involvement and reached peak levels earlier than the radiographic scores. In contrast, the dynamic changes in IL-6, C-reactive protein and neutrophils occurred synchronously with the changes in radiographic scores. The mean ratio of IL-6 to IL-10 in SARS patients (4.84; range 0.41-21) was significantly higher than that in CAP patients (2.95; range 0.02-10.57) (P=0.04). CONCLUSIONS: The early induction of IP-10 and IL-2, as well as the subsequent over-production of IL-6 and lack of IL-10 production, probably contribute to the main immuno-pathological processes involved in lung injury in SARS. These changes in cytokine/chemokine profile are remarkably different from those observed in CAP patients.     

SARS患者的低钙血症

25例严重急性呼吸综合征 (SARS)患者入院时血清钙水平 (2 .13± 0 .0 8)mmol/L低于正常。SARS患者低钙血症发病率为 60 .0 %。重症SARS患者低钙血症发生率 (88.9% )明显高于普通SARS患者(4 3 .8% ,P <0 .0 5 )。     

Pandemic planning in China: Applying lessons from severe acute respiratory syndrome

There were three events of severe acute respiratory syndrome (SARS) in China from 2003 to 2004. Starting from 2002, we are also aware of the increasing alert of an avian flu pandemic. Epidemics of SARS and avian flu have posed huge threats to social stability, economic prosperity and human health in this country. What we have experienced during SARS outbreaks has great implications for the protectiion of people against a resurgence of SARS and potential attacks of high-pathogenic avian flu viruses. To that end, China has been preparing to contain future pandemics by applying lessons learnt from SARS.     

Follow up of aerobic capacity in children affected by severe acute respiratory syndrome

Background and objective: The aim of this study was to investigate the aerobic capacity of children 3 years after they were diagnosed with severe acute respiratory syndrome (SARS). Methods: Twenty‐seven patients who completed both pulmonary function and maximal aerobic capacity tests at 6 and 15 months after the acute illness were invited to return for reassessment. Results: Twenty‐one patients (median age 18.2 years, interquartile range (IQR) 16.5–19.7) completed all investigations at 36 months. Pulmonary function was normal in all patients. Maximal aerobic capacity, peak oxygen pulse (peak VO₂) and ventilatory anaerobic threshold showed significant improvements compared with values measured at 6 months in both boys and girls. In girls, ventilatory efficiency (ventilatory equivalents for oxygen and carbon dioxide) and perfusion of the lungs (end‐tidal partial carbon dioxide pressure) had not increased further compared with the values measured at 15 months. Although peak VO₂ improved further at 36 months in patients with or without persistent radiological abnormalities, the values were 68% (IQR 50–84) and 74% (IQR 60–99), respectively, of those for normal control subjects. Conclusions: There were improvements in aerobic capacity at 36 months in children affected by SARS; however, the measured values remained suboptimal.     

严重急性呼吸综合征所致呼吸衰竭及无创通气治疗

目的　回顾性总结严重急性呼吸综合征 (SARS)并发呼吸衰竭患者的血气特点 ,探讨应用无创正压通气 (NPPV)治疗的策略。方法　 2 0 0 3年 4月 2 2日～ 5月 1日 ,12 0例临床符合SARS诊断标准的患者入住北京地坛医院 (SARS专科医院 )的 4个病区 ,30例患者 (占 2 5 % )在病程中出现呼吸衰竭 ,达到急性肺损伤 (ALI)和 (或 )急性呼吸窘迫综合征 (ARDS)的诊断标准。 2 8例应用双水平气道正压通气 (BiPAP)。主要观察指标 :(1)住院期间的血气分析、脉搏容积血氧饱和度 (SpO2 )及呼吸频率 ,特别是上机前、上机后 1h及撤机后的结果 ;(2 )放射学检查或临床提示住院后新出现的气胸、纵隔气肿、心包积气及皮下气肿 ;(3)应用无创通气的天数 ;(4 )需气管插管行有创通气的患者数 ;(5 )患者的病死率 ;(6 )一线医务人员因护理治疗无创通气SARS患者而感染SARS的情况。结果统计 30例患者在整个病程中的动脉血二氧化碳分压 (PaCO2 )变化情况 ,16例 (5 3% )患者出现CO2 潴留 ,PaCO2为 4 5～ 5 6mmHg ,平均 (4 8± 4 )mmHg。NPPV治疗后动脉血氧分压 (PaO2 )、SpO2 、氧合指数及呼吸频率均显著改善 (P均 <0 0 1) ,但pH及PaCO2 的变化并不明显。 18例患者成功撤机 ,应用NPPV的时间为5～ 30d ,平均 (10± 6 )d。除 1例不能耐受BiPAP     

严重急性呼吸综合征患者心理与躯体症状的分析

目的　研究严重急性呼吸综合征 (SARS)患者在病情不同阶段的心理症状及与躯体症状变化的关系。方法　使用症状自评量表 (SCL 90 )对 2 9例SARS患者进行了 3次测试 ,同时记录其胸部CT、T淋巴细胞及亚群、血氧饱和度 (SaO2 )等临床指标的变化。结果　心理症状较重组SARS患者 (Ⅰ组 ) 12例 ,心理症状较轻组SARS患者 (Ⅱ组 ) 17例 ,两组在三个不同阶段的心理症状无变化(P >0 0 5 ) ,躯体指标在恢复期及严重时差异存在显著性 (P <0 0 1)。结论　一部分SARS患者可以出现较为严重的精神心理症状 ,主要表现为躯体化症状、强迫症状、抑郁及焦虑情绪 ,且自始至终存在 ,其变化与躯体病情的变化是分离的 ;大部分SARS患者始终未出现严重的心理问题。他们是否出现心理症状与个性特征有关。     

严重急性呼吸综合征对心脏影响的初步分析

目的 分析严重急性呼吸综合征(SARS)对心脏的影响。方法 选择发病1周内收住人院的15例SARS患者，收集其在住院期间的胸部平片、心电图、血常规及生化检查，经皮测动脉血氧饱和度和心率等临床资料。根据胸片分单侧肺部受累4例和双侧肺部受累11例两组进行临床分析比较。结果 (1)单侧肺部病变组患者中，发热持续时间超过1周1例，无低氧血症和低白蛋白血症出现，胸片无心影扩大；而双侧肺部病变组患者中，发热持续时间超过1周7例，其中5例患者出现低氧血症，7例患者出现低白蛋白血症，6例出现一过性心影扩大，其中3例表现为右房室大为主，3例以全心增大为主，同时伴有明显肺动脉段突出2例，其心影变化与肺部病变程度成正比。2例出现肌酸肌酶一过性增高。(2)两组多数患者发病后心率有逐渐增快的趋势，发病3周后的心电图检查显示，心率超过100次／min3例，均为窦性心率，仅有1例T波低平，未发现早搏。结论 SARS对心脏有一定损害，其机制除与肺部病变程度有关外，可能还与心肌的直接损伤有关。     

糖皮质激素治疗重症急性呼吸综合征初探

目的　探讨糖皮质激素对重症急性呼吸综合征 (SARS)病情的影响。方法　定期观察我院自 2 0 0 3年 3月 2 6日至 5月初收治的SARS病人 30例 ,病程均为 3周以上。统计激素治疗的时间和剂量 ,观察治疗前后CD+ 4 、CD+ 8、CD+ 3 T淋巴细胞计数 ,以及电解质、血象、血清白蛋白变化。结果　激素治疗前 2 7例患者CD+ 4 、CD+ 8、CD+ 3 T淋巴细胞计数分别为 (个 / μl ) 4 0 1± 2 0 3、340± 187、75 6± 383。30例中 2 9例使用甲泼尼龙治疗 ,2 4例剂量为 80～ 16 0mg/d ,最大剂量为 10 0 0mg/d(入我院前 )。应用激素后血白细胞升高 (P <0 .0 1) ;血K+ 、Na+ 、Cl-无明显变化 (P >0 .0 5 ) ;血糖升高 (P =0 .0 1) ;血清白蛋白明显下降 (P <0 .0 1) ;较大剂量的激素可明显抑制CD+ 4 、CD+ 8、CD+ 3 T淋巴细胞的水平 ;3例重症病例在大剂量激素应用下出现二重感染。结论　SARS病人在病程早期免疫功能已受到抑制 ,大剂量应用糖皮质激素可明显加重这一抑制 ,并使机体处于高代谢状态 (血糖升高、血清白蛋白下降 ) ,进一步导致病情加重 ,病人在后期易出现严重继发感染 ,因此应严格掌握激素适应证 ,不宜大剂量使用。     

严重急性呼吸综合征患者康复期肺功能研究现状

严重急性呼吸综合征（SARS）作为一种全身器官损伤性疾病,其肺部病理变化主要存在于肺泡和肺间质,康复期患者肺功能损害以弥散障碍为主,其损害程度及康复期长短与住院期间病情相关,而弥散障碍指标随康复期的延长均呈现恢复过程。就目前的随访结果而言,不论从有限的病理资料、影像学检查还是肺功能恢复情况,均提示SARS-冠状病毒对患者的肺部损害可能不同于经典急性呼吸窘迫综合征过程。     

广州地区严重急性呼吸道综合征的临床特点

目的　探讨当前流行的严重急性呼吸道综合征 (SARS)的若干临床特点。方法　回顾性统计分析广州南方医院收治的 85例SARS患者的临床资料。结果　 85例SARS患者的年龄在 4～ 87岁 ,平均 ( 38.2± 16 .7)岁 ,男 41例 ,女 44例。该病的潜伏期为 2～ 16d ,平均为 ( 7.4± 3 .8)d ;主要临床表现有发热 ( 97.6 %)、咳嗽 ( 81.2 %)、乏力 ( 74.1%)、头痛 ( 6 3 .5 %)、肌肉酸痛 ( 41.2 %) ;热程多为 4～ 12d( 81.9%) ,平均热程为 ( 7.8± 3.5 )d ;外周血白细胞计数正常或降低 ( 82 .4%) ,淋巴细胞计数减少 ( 2 7.1%) ;血液生化示丙氨酸转氨酶升高 ( 44 .7%) ,天门冬氨酸转氨酶升高 ( 5 7.6 %) ,乳酸脱氢酶升高 ( 49.4%) ,肌酸磷酸激酶升高 ( 2 0 %) ;肺部X线摄片主要表现为片状或斑片状炎症渗出( 85 .9%) ,少数表现为间质性炎症改变 ( 14.1%) ;炎症多位于双侧下肺 /中下肺 ( 5 1.8%) ,其次为单侧下肺 /中下肺 ( 36 .5 %) ;发病至肺炎症渗出完全吸收的平均时间为 ( 2 0 .3± 8.4)d ,热退后至肺炎症渗出完全吸收的平均时间为 ( 13 .1± 6 .9)d ;经验性治疗为 :病毒唑、对症支持治疗及应用广谱抗生素。结论　SARS具有传染性 ,发热、咳嗽、胸片示肺部炎症表现及外周血白细胞正常或降低是该综合征的临床特点。     

广州市传染性非典型肺炎260例临床分析

目的　了解传染性非典型肺炎 (AP)的流行病学、临床表现、实验室检查、X线表现等特点及治疗和预后。方法　对我院于 2 0 0 3年 2～ 4月上旬收治的 2 6 0例传染性非典型肺炎的流行病学及临床资料进行回顾性分析。结果　患者年龄从 2岁到 89岁 ,平均 ( 41± 18)岁 ,男 12 3例 ,女 137例。 6 7.3 %的患者有AP患者密切接触史或明确传染他人的证据 ,呈家庭及医务人员聚集现象。传播途径以近距离飞沫和密切接触为主。潜伏期为 1～ 14d ,平均 4.5d。以发热为首发症状 ( 10 0 %) ,伴有干咳 ( 72 .7%) ,气促 ( 31.2 %)、急性呼吸窘迫综合征 (ARDS ,占 13 .8%) ,腹泻 ( 2 4.2 %) ,重症患者 36例 ( 13.8%)。外周血白细胞正常或降低占 85 %,血清丙氨酸转氨酶 (ALT)升高 6 6 .9%,乳酸脱氢酶 (LDH)升高 46 .5 %。外周血CD3+、CD4+、CD8+明显降低。全部患者都有肺部病变 ,累及双肺占 73 .8%,肺部体征与X线胸片表现不一致。治疗以综合治疗为主 ,经验性使用抗生素、抗病毒药物 ,糖皮质激素对改善中毒症状、阻止病情进展有一定疗效。需要人工通气 36例 (均出现ARDS) ,其中有创机械通气 11例。死亡 11例 ,病死率 4.2 %。结论　非典型肺炎传染性强 ,有一定的病死率 ,虽无特效抗病原药物 ,但经综合治疗可取得较好疗效。     

北京首批重症急性呼吸综合征患者临床特征及预后分析

目的　探讨重症急性呼吸综合征 (SARS)临床特征 ,分析其预后影响因素。方法　以北京地区首批 34例SARS患者为研究对象 ,观察其临床特征及辅助检查 ,并对 1例死亡患者尸检。结果　患者年龄平均 (33 4± 13 4 )岁 ;潜伏期 2～ 14d ,中位数 4d。发热 (10 0 % )、心悸 (91 7% )、肌痛(79 2 % )、头痛 (70 8% )、腹泻 (73 9% )、咳嗽 (5 8 3% )为主要临床表现。初诊时白细胞计数平均 (4 6± 1 4 )× 10 9/L ,淋巴细胞平均 0 2 7± 0 11,淋巴细胞绝对计数 (1 2 3± 0 4 6 )× 10 9/L ,6 8 4 %病例低于正常。ALT、乳酸脱氢酶、血沉水平升高者分别占 76 2 %、2 8 6 %、4 7 8% ,血清铁、血清白蛋白水平降低者分别为 6 3 2 %、38 1%。 32例有胸部X线检查异常 ,2例CT扫描发现异常。尸检 :肺脏和淋巴组织受累明显。多因素分析显示 ,不良预后独立影响因素是高龄。结论　发热、淋巴细胞和血清铁降低及胸部影像学检查可早期诊断SARS ;年龄为该病预后的独立预测因素。     

The long‐term impact of severe acute respiratory syndrome on pulmonary function,exercise capacity and health status

Background and objective: Severe acute respiratory syndrome (SARS) emerged in 2003 and its long‐term sequelae remain largely unclear. This study examined the long‐term outcome of pulmonary function, exercise capacity, health and work status among SARS survivors. Methods: A prospective cohort study of SARS patients at the Prince of Wales Hospital, Hong Kong was conducted, with serial assessments of lung function, 6MWD and 36 item Short Form General Health Survey at 3, 6, 12, 18 and 24 months after disease onset. The work status was also recorded. Results: Serial assessments were completed by 55 of the 123 (39.9%) subjects, of whom 27 were health‐care workers (HCW). The mean age of the group was 44.4 (SD 13.2) years and 19 (34.5%) were males. At 24 months, 10 (18.2%), 9 (16.4%), 6 (10.9%) and 29 (52.7%) subjects had FEV₁, FVC, TLC and DL_CO < 80% of predicted values, respectively. The mean (SD) 6MWD increased significantly from 439.0 (89.1) m at 3 months to 460.1 (102.8) m at 6 months (P 0.016) and became steady after 6 months. However, 6MWD and 36 item Short Form General Health Survey scores were lower than the normal population throughout the study. Moreover, 29.6% of HCW and 7.1% of non‐HCW had not returned to work 2 years after illness onset. Conclusions: This 2‐year study of a selected population of SARS survivors, showed significant impairment of DL_CO, exercise capacity and health status persisted, with a more marked adverse impact among HCW.