Shanghai Expert Consensus on Covid-19 Treatment

The City of Shanghai Expert Consensus on Comprehensive Treatment
of COVID-19

Shanghai Expert Group on Clinical Treatment of New Coronavirus Disease.
Chinese Journal of Infectious Diseases, 2020, 38: Pre-published online. DOI: 10.3760 / cma.j.issn.1000-6680.2020.0016

With the deepening of the understanding of corona virus disease 2019 (COVID-19), the Shanghai COVID-19 Clinical Treatment Expert Group followed the National COVID-19 Diagnosis and Treatment Program, and fully absorbed the experience of domestic and foreign peers in the treatment, and continuously optimized and refined the treatment protocol. This expert consensus was formed from the three aspects of etiology and epidemiological characteristics, clinical characteristics and diagnosis, and treatment protocol.

Cite this article: Shanghai Expert Group on Clinical Treatment of New Coronavirus Diseases. Expert Consensus on Comprehensive Treatment of Coronavirus Diseases in Shanghai in 2019 [J / OL]. Chinese Journal of Infectious Diseases, 2020,38 (2020-03-01). DOI: 10.3760 / cma.j.issn.1000-6680.2020.0016. [Pre-published online].

Corona virus disease 2019 (COVID-19) was first reported in Wuhan, Hubei Province on December 31, 2019 [1,2]. COVID-19, as a respiratory infectious disease, has been included by the Law of the People’s Republic of China on the Prevention and Control of Infectious Diseases in the Class B infectious diseases stipulated and managed as a Class A infectious disease.
With the deepening of understanding of the disease, China has accumulated some experience in the prevention and control of COVID-19. The Shanghai COVID-19 Clinical Treatment Expert Team follows the National COVID-19 Diagnosis and Treatment Program [3], and fully absorbs domestic and foreign colleagues’ experience in the management of this disease, to improve the success rate of clinical treatment and reduce the patient’s mortality rate, to prevent the progress of the disease, and gradually reduce the proportion of severe cases and improves their clinical prognosis. Based on the continuous optimization and refinement of the treatment protocol, expert consensus has been formed on the relevant clinical diagnosis and treatment.

I. Etiology and epidemiological characteristics
2019 novel coronavirus (2019-nCoV) is a new coronavirus belonging to the genus β. On February 11, 2020, the International Committee on Taxonomy of Viruses (ICTV) named the virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [ 4]. Patients with COVID-19 and asymptomatic infection can transmit 2019-nCoV. Respiratory droplet transmission is the main route of transmission, and the virus can also be transmitted through contact. There is a risk of aerosol transmission in confined enclosed spaces. 2019-nCoV can be detected in patients’ stool, urine, and blood. Some patients can be tested positive for fecal pathogenic nucleic acid after the pathogenic nucleic acid test of respiratory specimens is negative. The whole population is generally susceptible. Children, infants, and young children also develop disease, but the condition is relatively mild.

II. Clinical characteristics and diagnosis
(A) clinical characteristics
The incubation period is 1 to 14 d, mostly 3 to 7 d, with an average of 6.4 d. Main symptoms are fever, fatigue, and dry cough. Symptoms can include runny nose, sore throat, chest tightness, vomiting and diarrhea. Some patients have mild symptoms, and a small portion of patients has no symptoms or no pneumonia.
The elderly and those suffering from basic diseases such as diabetes, hypertension, coronary atherosclerotic heart disease, and extreme obesity tend to develop severe illness after infection. Some patients develop symptoms such as dyspnea within 1 week after the onset of the disease. In severe cases, they can progress to acute respiratory distress syndrome (ARDS) and multiple organ dysfunction. The time to progression to severe illness was approximately 8.5 days. It is worth noting that in the course of severe and critically ill patients, there may be moderate to low fever, even without obvious fever. Most patients have a good prognosis, and deaths are more common in the elderly and those with chronic underlying disease.
The early CT examination showed multiple small patches or ground glass shadows, and the internal texture of the CT scans was thickened in the form of grid cables, which was obvious in the outer lung zone. A few days later, the lesions increased and the scope expanded, showing extensive lungs, multiple ground glass shadows, or infiltrating lesions, some of which showed consolidation of the lungs, often with bronchial inflation signs, and pleural effusions were rare. A small number of patients progressed rapidly, with imaging changes reaching a peak on days 7 to 10 of the course. Typical “white lung” is rare. After entering the recovery period, the lesions are reduced, the scope is narrowed, the exudative lesions are absorbed, part of the fiber cable shadow appears, and some patients’ lesions can be completely absorbed.
In the early stage of the disease, the total number of white blood cells in the peripheral blood was normal or decreased, and the lymphocyte count was reduced. Some patients may have abnormal liver function, and the levels of lactate dehydrogenase, muscle enzyme, and myoglobin may increase; troponin levels may be increased. Most patients had elevated CRP and ESR levels and normal procalcitonin levels. In severe cases, D-dimer levels are elevated, other coagulation indicators are abnormal, lactic acid levels are elevated, peripheral blood lymphocytes and CD4 + T lymphocytes are progressively reduced, and electrolyte disorders and acid-base imbalances are often caused by metabolic alkalosis. Elevated levels of inflammatory cytokines (such as IL-6, IL-8, etc.) can occur during the disease progression stage [5].
(B) diagnostic criteria
1. Suspected cases:
Combined with the following epidemiological history and clinical analysis. Suspected cases were diagnosed as having any one of epidemiological history and meeting any two of the clinical manifestations, or having no clear epidemiological history but meeting three of the clinical manifestations. ① Epidemiological history: Travel history or residence history of Wuhan and surrounding areas or other communities with case reports within 14 days before the onset; history of contact with 2019-nCoV infected person(s) (positive nucleic acid test) within 14 days before the onset ; Patients with fever or respiratory symptoms from Wuhan and surrounding areas or from communities with case reports within 14 days before the onset of the disease; or cluster onset. ② Clinical manifestations: fever and / or respiratory symptoms; with the above-mentioned imaging features of the new coronavirus pneumonia; the total number of white blood cells was normal or decreased in the early stage of onset, and the lymphocyte count decreased.
2. Confirmed cases:
A confirmed case is diagnosed with one of the following pathogenic evidence. ① Real-time fluorescent reverse transcription PCR detected 2019-nCoV nucleic acid positive. ② Viral gene sequencing revealed high homology with the known 2019-nCoV. ③ Besides nasopharyngeal swabs, it is recommended to take as much sputum as possible. Lower respiratory tract secretions can be collected for viral nucleic acid testing in patients undergoing tracheal intubation.
(C) Differential diagnosis
It is important to distinguished COVID-19 diagnosis from other known viral pneumonias such as influenza virus, parainfluenza virus, adenovirus, respiratory syncytial virus, rhinovirus, human metapneumovirus, severe acute respiratory syndrome (SARS) coronavirus, etc. , and from Mycoplasma pneumoniae, Chlamydia pneumonia and bacterial pneumonia. In addition, it should be distinguished from non-infectious diseases, such as pulmonary interstitial lesions and organizing pneumonia caused by connective tissue diseases such as vasculitis and dermatomyositis [6,7].
(D) clinical classification
1. Mild type:
The clinical symptoms were mild, and no pneumonia manifested on imaging examination.

2. Moderate (common) type:
With fever, respiratory tract and other symptoms, imaging examination showed pneumonia.

Early warning of severe cases progressed from moderate (common) type patients should be strengthened. Based on current clinical studies, early warning indicators of progression into severe disease include elderly (age> 65 years) with underlying diseases, CD4 + T lymphocyte count 50%on in lung imaging for 2 to 3 consecutive days, lactic dehydrogenase (LDH)> 2 times the upper limit of normal value, blood lactic acid ≥ 3 mmol / L, and metabolic alkalosis [8].
3. Severe type:
Meet any of the following. ① Shortness of breath, respiratory rate ≥ 30 times / min; ② In resting state, arterial oxygen saturation (SaO2) ≤ 93%; ③ arterial partial pressure of oxygen, PaO2) / fraction of inspired oxygen (FiO2) ≤300 mmHg (1 mmHg = 0.133 kPa). At high altitudes (above 1 000 m), PaO2 / FiO2 should be corrected according to the following formula: PaO2 / FiO2 × [Atmospheric Pressure (mmHg) / 760].
Pulmonary imaging showing lesions progressed significantly within 24 to 48 hours, and those with more than 50% of the lesions were managed as severe.
4. Critical type:
Those who meet any of the following can be judged as critical. ①Respiratory failure occurs and requires mechanical ventilation; ②Shock occurs; ③Combination with other organ failure requiring ICU monitoring and treatment.

(E) Clinical monitoring
The patient’s clinical manifestations, vital signs, fluid volume, gastrointestinal function and mental state are monitored daily.
All patients were dynamically monitored for terminal blood oxygen saturation. For severe and critical patients, timely blood gas analysis is performed according to the changes of the patient’s condition; blood routine, electrolytes, CRP, procalcitonin, LDH, blood coagulation function indicators, blood lactic acid, etc. are tested at least once every 2 days; liver function, kidney function , ESR, IL-6, IL-8, lymphocyte subsets, at least once every 3 days; chest imaging examination, usually every 2 days. For patients with ARDS, routine ultrasound examination of the heart and lungs at the bedside is recommended to observe extravascular lung water and cardiac parameters. For monitoring of extracorporeal membrane oxygenation (ECMO) patients, refer to the implementation section of ECMO.

III. Treatment plans
(A) antiviral treatment
Recommend experimental use of hydroxychloroquine sulfate or chloroquine phosphate, or abidol for oral administration, interferon atomization and inhalation, interferon κ is preferred. It is not recommended to use 3 or more antivirals at the same time. The antiviral treatment should be stopped immediately after viral nucleic acid becomes negative. The efficacy of all antiviral drugs remains to be evaluated in further clinical studies.
For severe and critical patients with viral nucleic acid positive, plasma from recovered patients can be used. For detailed operation and management of adverse reactions, please refer to the “Clinical Treatment Protocol for COVID-19 using Plasma from COVID-19 Patients in Recovery Period” (trial version 1) [3]. Infusion within 14 days of the disease onset may be more effective. If the viral nucleic acid is continuously detected positive at the later stage of the disease, the plasma treatment can also be used.
(B) treatment for mild and moderate types
Recommend enhanced supportive treatment to ensure sufficient heat; maintenance of water and electrolyte balance for internal environment stability; close monitoring of patient vital signs and finger oxygen saturation. Give effective oxygen therapy in time. Antibacterials and glucocorticoids are not recommended in principle. The patient’s condition needs to be closely monitored. If the disease progresses significantly and there is a risk of progressing into severe disease, it is recommended to take comprehensive measures to prevent the disease from progressing to severe. Low-dose short-course glucocorticoids can be used with caution (see the application section of glucocorticoids for specific protocols). Heparin anticoagulation and high-dose vitamin C treatment are recommended [9,10]. Low-molecular-weight heparin 1 to 2 dose per day, continued until the patient’s D-dimer level returned to normal. Once fibrinogen degradation product (FDP) ≥10 µg / mL and / or D-dimer ≥5 μg / mL, switch to unfractionated heparin. Vitamin C is administered at a dose of 50 to 100 mg / kg per day, and should be continued until significant improvement in the oxygenation index. If lung lesions progress, it is recommended to apply large doses of broad-spectrum protease inhibitors from 600 to 1 million units / day until the pulmonary imaging examination improves. In case of “cytokine storm”, intermittent short veno-venuous hemofiltration (ISVVH) is recommended [11].
(C) Organ function supportive treatment for severe and critically ill patients
1. Protection and maintenance of cyclic functions:
Implement the principle of early active controlled fluid replacement. It is recommended to evaluate the effective volume and initiate fluid therapy as soon as possible after admission. Severe patients can choose intravenous or transcolonic fluid resuscitation depending on the conditions. The preferred supplement is lactated Ringer’s solution. Regarding vasoactive drugs, noradrenaline and dopamine are recommended to maintain vascular tone and increase cardiac output. For patients with shock, norepinephrine is the first choice. It is recommended to start low-dose vasoactive drugs at the same time as fluid resuscitation to maintain circulation stability and avoid excessive fluid infusion. Cardioprotective drugs are recommended for severe and critically ill patients, and sedative drugs that inhibit the heart are avoided as much as possible. For patients with sinus bradycardia, isoprenaline can be used. For patients with sinus rhythm, heart rate 300 mmHg, the dose of broad-spectrum protease inhibitor can be reduced to 1 million units / d. Anticoagulation therapy can be used to protect endothelial cells and reduce cytokine release. Anticoagulation with unfractionated heparin (3 to 15 IU / kg per hour) when FDP ≥10 µg / mL and / or D-dimer ≥5 μg / mL . The patient’s coagulation function and platelets must be re-examined 4 h after the first use of heparin. With ISVVH, 6 to 10 hours per day.
7. Sedation and Artificial Hibernation:
Patients undergoing mechanical ventilation or receiving ECMO need to be sedated on the basis of analgesia. For patients with severe man-machine confrontation during the establishment of an artificial airway, short-term application of low-dose muscle relaxants is recommended. Hibernation therapy is recommended for severe patients with oxygenation index 8. Oxygen therapy and respiratory support:
① Oxygen therapy with nasal cannula or mask, SaO2 ≤93% under resting air, or SaO2 <90% after exercise, or oxygenation index (PaO2 / FiO2) 200-300 mmHg; with or without respiratory distress. Continuous oxygen therapy is recommended. ② Transnasal high-flow nasal cannula oxygen therapy (HFNC), receiving nasal cannula or mask oxygen therapy for 1 to 2 hours. HFNC is recommended when oxygenation fails to meet treatment requirements, and respiratory distress does not improve; or hypoxemia during treatment and / or exacerbation of respiratory distress; or an oxygenation index of 150 to 200 mmHg. ③ Noninvasive positive pressure ventilation (NPPV) is an option when receiving 1 to 2 h of HFNC oxygenation does not achieve the treatment effect, and there is no improvement in respiratory distress; or hypoxemia and / or exacerbation of respiratory distress during treatment; or When the oxygenation index is 150 ~ 200 mmHg. ④ Invasive mechanical ventilation should be considered when HFNC or NPPV treatment for 1 to 2 hours oxygenation cannot meet the treatment requirements, no improvement in respiratory distress; or hypoxemia and / or exacerbation of respiratory distress during treatment; or oxygenation index 9. ECMO implementation:
Those who meet one of the following conditions may be considered implementing ECMO. ① PaO2 / FiO2 60 mmHg for more than 6 h. ECMO mode is preferred for intravenous-venous ECMO.

(D) Some Specific issues and managements
1. Application of glucocorticoids:
Use glucocorticoids with caution. Glucocorticoids can be added with imaging shows significant progress in pneumonia; SaO2 ≤ 93% or shortness of breath (respiratory frequency ≥ 30 breaths / min) or oxygenation index ≤ 300 mmHg in the state of no oxygen inhalation, especially when the disease progresses significantly faster and there is a risk for intubation. It is recommended to promptly withdraw glucocorticoid when intubation or ECMO support can maintain effective blood oxygen concentrations. For non-severe patients, it is recommended to use methylprednisolone at 20 to 40 mg / d, and for severe patients at 40 to 80 mg / d, and the course of treatment is generally 3 to 6 days. Can be increased or decreased according to body weight [12].
2. Use of immunomodulatory drugs:
Injecting thymosin subcutaneously twice a week has certain effects on improving patients’ immune function, preventing the disease from becoming worse, and shortening the time of detoxification. Due to the lack of specific antibodies, high-dose intravenous immunoglobulin therapy is currently not supported. However, some patients have low levels of lymphocytes and at the risk of co-infection with other viruses, and in these cases human immunoglobulin can be infused intravenously at 10 g / d for 3 to 5 days.
3. Accurate diagnosis and treatment of bacterial and fungal infections:
Clinical microbiological monitoring should be done to all severe and critical cases. The sputum and urine samples are collected daily for culture. Blood culture should be promptly done in patients with high fever. All patients with suspected sepsis who have indwelling vascular catheters should be sent for peripheral venous blood culture and catheter blood culture at the same time. For patients with suspected sepsis, it may be considered collecting peripheral blood for molecular diagnostic tests for etiology, including PCR-based molecular biology testing and next-generation sequencing.
Elevated procalcitonin levels indicate for the diagnosis of sepsis / septic shock. When COVID-19 progresses, there is an increase in CRP levels, which is not specific for the diagnosis of sepsis caused by bacterial and fungal infection.
Critically ill patients with open airways are often prone to bacterial and fungal infections at a later stage. If sepsis occurs, empirical anti-infective treatment should be given as soon as possible. For patients with septic shock, empirical antibacterial drugs can be used in combination before obtaining an etiological diagnosis, while covering the most common Enterobacteriaceae, Staphylococcus and Enterococcus infections. Patients with infection after hospitalization can choose β-lactamase inhibitor complex. If the treatment effect is not good, or the patient has severe septic shock, it can be replaced with carbapenem drugs. In considering enterococci and staphylococcal infections, glycopeptide drugs (vancomycin) can be added for empirical treatment. Daptomycin can be used for bloodstream infections, and linezolid can be used for lung infections. Attention should be paid to catheter-related infections in critically ill patients, and treatment should be empirically covered with methicillin-resistant staphylococci. Glycopeptide drugs (vancomycin) can be used for empirical treatment. Candida infection is also more common in critically ill patients. Candida should be covered empirically when necessary. Echinocin drugs can be added. With the length of hospitalization of critically ill patients, drug-resistant infections can gradually increased. At this time, the use of antibacterial drugs must be adjusted according to drug sensitivity tests.
4. Nosocomial infection prevention and control:
① According to the Basic System for Infection Prevention and Control of Medical Institutions (Trial) [13] of the China National Health and Health Commission 2019, hospitals should actively implement evidence-based infection prevention and control clustering intervention strategies to effectively prevent ventilator-associated pneumonia and intravascular catheter-related blood flow Infections, urinary tract-associated urinary tract infections, multi-resistant bacteria and fungal infections such as carbapenem-resistant gram-negative bacilli. ② Strictly follow the National Health and Health Commission’s “Technical Guidelines for the Prevention and Control of New Coronavirus Infection in Medical Institutions (First Edition)”, “Guidelines for the Use of Common Medical Protective Products in the Prevention and Control of Pneumonia of New Coronavirus Infection (Trial)” and “New Coronary Pneumonia During the epidemic, the requirements of Technical Guidelines for Protecting Medical Staff (Trial) [14,15,16], hospitals should strengthen process of management, and the correct selection and usage of personal protective equipment such as masks, gowns, protective clothing, eye masks, protective masks, gloves, etc, and implement disinfection and quarantine measure to minimize the risk of nosocomial infections and to eliminate infections in medical staff.
5. Treatment of infants and young children:
Children with mild symptoms are treated with symptomatic oral medicines. For moderate disease type, treatments with Traditional Chinese Medicine (TCM) with syndrome differentiation can be considered in addition to symptomatic oral treatments. If combined with bacterial infection, antibacterial drugs can be added. Severely ill children are mainly under symptomatic and supportive treatments. By experience, Ribavirin injection is given for antiviral therapy empirically at 15 mg / kg (2 times / day). Ribavirin treatment should be limited to no more than 5 days.
(E) Integrated traditional Chinese and western medicine
The combination of traditional Chinese and western medicine for the treatment of new coronavirus pneumonia can improve the synergistic effect. For adult patients, the condition can be improved through TCM syndrome differentiation. For mild disease, those with a syndrome of wind-heat type are given the TCM Yinqiaosan plus and minus treatment; those with gastrointestinal symptoms and those with damp-wetting and yang-type syndrome are given the plus and minus Xuanpuxialing and Sanren decoction. For moderate disease, those with syndromes of hot and evil stagnation of lungs can be treated with Ma Xing Shi Gan Decoction; those with syndromes of dampness and stagnation of lungs can be treated with Da Yuan Yin, Gan Lu Fang Dan, etc. These treatments can control to some degree the progression of the disease, reducing the incidence of progression from moderate to severe type. For anorexia, nausea, bloating, fatigue, anxiety and insomnia, the Xiao Chai Hu Tang plus and minus treatment can significantly improve symptoms. For severe patients, if the fever persists, or with high fever, bloating, and dry stools or constipation, and those who are heat-tolerant and the lungs are closed, Dachengqi Decoction enema can be given to release symptoms, or Baihu Decoction, Shengjiang San and Xuanbai Chengqi Decoction plus and minus can be used to reduce the progression from severe to critical illness.
In children with mild symptoms, the syndrome differentiation belongs to the epidemic offence, Yinqiaosan or Xiangsusan plus and minus treatment can be used. Children with moderate symptoms, those with damp heat and closed lungs, are given Ma Xing Shi Gan Decoction and Sanren Decoction; those with moderate scorching dampness and heat such as bloating and vomiting with abdominal distension can be BuHuanJinzhengqi San plus and minus. For severe children patients with epidemic toxicity closing the lung (currently rare in the country), please refer to adult Xuanbai Chengqi Decoction and Manna Disinfection Danjiao; if the poisonous hot accumulates, the gas can’t pass, and food and medicines are not tolerated, the Rhubarb Decoction is given to enema for emergency.
(F) discharge standards
Those who meet all the following conditions can be considered for discharge: ①The body temperature returns to normal> 3 d; ②Respiratory symptoms have improved significantly; ③Imaging of the lungs shows a significant improvement of acute exudative lesions; ④Two consecutive negative airway nucleic acid tests (sampling time at least 1 d apart); ⑤ After the nucleic acid test of the respiratory specimen is negative, the fecal pathogenic nucleic acid test is also negative; ⑥ The total disease course exceeds 2 weeks.
(G) Self-management of discharged patients
1. For discharged patients, close follow-up is still required. Follow-up is recommended at 2 weeks and at 4 weeks after discharge to the designated follow-up clinic.
2. When a patient is discharged from the hospital, his place of residence and address in the city should be specified.
3. Patients should rest at home for 2 weeks after leaving the hospital, avoid activities in public places, and must wear masks when going out.
4. According to the patient’s address (including hotel), the relevant district health committee is responsible for coordinating the corresponding medical institution for health management. Professionals will visit for the patient’s temperature twice a day for 2 weeks, ask their health status, and deliver related health education.
5. If fever and / or respiratory symptoms recur, the corresponding medical institution shall report to the District Health and Health Commission and the District Centers for Disease Control and Prevention in time, and assist in sending the patient(s) to the designated medical institutions in the area for treatment.
6. After receiving the report, the District Health and Health Committee and the District Centers for Disease Control and Prevention should report to the superior department in a timely manner.
Writing experts (sorted in alphabetical order by last name): Wu Yuan (Department of Critical Medicine, Renji Hospital, Shanghai Jiaotong University School of Medicine), Hu Bijie (Department of Infectious Diseases, Zhongshan Hospital, Fudan University), Li Feng (Department of Respiratory Medicine, Shanghai Public Health Clinical Center), Xin Li (Department of Cardiovascular Surgery / ECMO Treatment Center, Zhongshan Hospital Affiliated to Fudan University), Li Yingchuan (Department of Anesthesiology, Sixth People’s Hospital Affiliated to Shanghai Jiaotong University), Lu Hongzhou (Department of Infection and Immunology, Shanghai Public Health Clinical Center), Mao Enqiang (Shanghai Jiaotong University Medicine Department of Emergency Medicine, Ruijin Hospital Affiliated to the Hospital), Qu Hongping (Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine), Shi Kehua (Department of Respiratory Medicine, Shanghai University of Traditional Chinese Medicine Hospital of Shanghai University of Traditional Chinese Medicine), Wang Lan (Department of Pulmonary Circulation, Shanghai Pulmonary Hospital Affiliated to Tongji University ), Wang Qibing (Department of Laboratory Medicine, Zhongshan Hospital Affiliated to Fudan University), Wang Sheng (Department of Emergency Medicine, Tenth People’s Hospital Affiliated to Tongji University), Yu Kanglong (Department of Emergency and Critical Care, First People’s Hospital Affiliated to Shanghai Jiaotong University), Zeng Mei ( Department of Infectious Diseases, Children’s Hospital of Fudan University), Zhang Wei ( Department of Respiratory Diseases, Shuguang Hospital Affiliated to Shanghai University of Chinese Medicine, Zhang Wenhong (Department of Infectious Diseases, Huashan Hospital Affiliated to Fudan University), Zhu Duming (Department of Critical Medicine, Zhongshan Hospital Affiliated to Fudan University), Zhu Lei (Department of Respiratory Medicine, Zhongshan Hospital Affiliated to Fudan University)

Consulting experts (in alphabetical order by last name): Li Qiang (Department of Respiratory Medicine, Oriental Hospital Affiliated to Tongji University), Li Xiangyang (Department of Respiratory Medicine, East China Hospital Affiliated to Fudan University), Qu Jieming (Department of Respiratory Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine), Song Yuanlin (Affiliated to Fudan University Department of Respiratory Medicine, Zhongshan Hospital), Tian Rui (Department of Critical Care, First People’s Hospital Affiliated to Shanghai Jiaotong University), Wang Xingpeng (Shanghai Shenkang Hospital Development Center), Wu Yingen (Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine), Xu Jinfu (Affiliated to Tongji University Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Xu Jie (Department of Infectious Diseases, Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine), Zhang Huiyong (Department of Pulmonology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine), Zhu Tongyu (Urology, Shanghai Public Health Clinical Center) Zhuchen Chen (Department of Emergency, Huashan Hospital, Fudan University)

Conflict of interest: All authors declare no conflict of interest

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The original documents in Chinese:

Translated by Dr. Qi Chen

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