The patient, male, 64 years old, denied the trip to and from Wuhan and the history of contact with patients of a confirmed diagnosis of COVID–19 appeared a dry cough after getting up in the morning on February 16, 2020, and gradually developed shortness of breath and dyspnea. He came to the hospital that night and was admitted to the isolation ward. The patient previously underwent radical resection in the department of thoracic and cardiac surgery in TaiHe hospital of Shiyan city in October 2019 due to esophageal cancer. Anastomotic fistula appeared after the operation in approximately one week, and the gastric tube was placed and retained for more than 2 months. On January 6th,2020, he was re-admitted to the hospital. A review of the barium meal of the digestive tract and chest CT showed that the fistula was closed, and the gastric tube was removed, the patient was thereby discharged on January 13th, 2020. Admission examination: T 36.1 ℃, P 81bpm, R 15bpm, BP 96/54 mmHg, SpO2 98%. The patient’s consciousness was clear, the superficial lymph nodes were not swelling nor enlargement, the breath sounds of both lungs were weak, and that of the right lower lung was more significant. No wet and dry crackles were heard. Outpatient check-up chest CT on February 16th, 2020 (Figure 1b) revealed: anastomosis-pleural fistula after esophageal cancer, encapsulated pneumatosis and pleural effusion in the right pleural cavity, the nature of double lung infection to be determined (progression of pneumatosis, pleural effusion and local infection compared to2020–02–11 (Figure 1a)); chronic bronchitis and emphysema. Outpatient blood check routine showed: WBC 8.95G / L, NE% 95.2%, LY: 0.4G / L, LY%: 2.3%, RBC 3.59T / L, HGB 107g / L, PLT: 389G / L. hs-CRP: 197.59mg / L. ESR: 60mm / h. PCT: 0.32ng / ml. After admission, the blood gas analysis (without oxygen) showed: pH 7.476, PCO2 37mmHg, PO2 65 mmHg, Lac 1.29mmol/L. The treatment was given in single isolation, anti-infection (Cefotillar 2g bid), relieving asthma, expectorant, nutritional support. Blood routine on the second day of admission (February 17th,2020) showed: WBC 5.62G/L, NE% 89.7%, LY: 0.44G/L, LY%:7.8%, RBC 2.89T/L, HGB 85g/L. His lab examination of liver function revealed albumin of 28.9g/L with others normal; renal function, electrolytes, BNP, troponin, myoglobin, PCT were all normal. On 17th February, pharyngeal swabs of novel coronavirus RNA examination was positive, novel coronavirus IgG, IgM exams were all negative. The diagnosis of novel coronavirus pneumonia was confirmed, and the patient was transferred to the novel coronary Intensive Care Isolation Unit and was given Arbidol orally, α-interferon nebulized inhaled antiviral treatment as well as traditional Chinese medicine.
The jejunal nutrient tube was recommended for the patient, but the patient’s family refused. The Cefoselis was replaced with Tienam combined with moxifloxacin for anti-infection treatment on February 18th. On February 19th, the throat swab novel coronavirus RNA test was positive. On February 22th, the Sputum culture and drug sensitivity test prompted: 1. Pseudomonas aeruginosa was found and intermediate to Piperacillin, Ceftazidine, Ticarcillin/rod acid, and was sensitive to other antibiotics; 2 Staphylococcus aurei were found and expressed multiple drug resistance. The Patients developed wheezing aggravation on February 23rd, according to sputum culture results, the Moxifloxacin was replaced with Teicoplanin, and Tienam was continued to use. The blood routine examination of February 24th showed: WBC 8.69G/L, LY: 0.53G/L, LY%:6.1% and the result of February 25th progressed: WBC 16.39G/L, LY: 0.13G/L, LY%:0.8%, which showed increased leucocytes count and progressive decline of lymphocytes. On February 25th, the pharyngeal swab of the novel coronavirus RNA test was still positive. The Chest color ultrasound revealed right enveloping effusion (reduced sound transmission, not suitable for puncture drainage). Since February 25 at solstice on February 27, the patient had an acute exacerbation of intermittent wheezing and was given nasal hyperoxia therapy. Repeated examinations of BNP, troponin, PCT showed normal.
On February 28, the patient’s respiratory rate was around 35 times/min, pulse was around 130 times/min, and blood gas analysis reported: pH: 7.361, pCO2: 66.3 mmHg, hence the patient was given non-invasive ventilator ventilation, at the same time, the blood gas analysis was performed intermittently which revealed the pCO2 had not decreased significantly. The patient became unconscious after given noninvasive ventilator ventilation for about 4 hours. Therefore tracheal intubation, as well as mechanical ventilation (V/AC mode, Vt 380ml, PEEP 6cmH2O, FiO2 95%), was performed. At the beginning of the mechanical ventilation treatment, the ventilator alarmed of airway hypertension (up to 47 cmH2O) repeatedly and the blood gas report was reviewed again: pH: 7.240, pCO2: 110.3 mmHg. Consequently, the emergency bedside bronchoscopy under tertiary protection was performed and showed yellowish-white purulent secretions within the trachea, left and right bronchi. Mobilized chest X-rays examination revealed that the right side of the enveloping purulent lumen disappeared, and the double lung infection was aggravated (Figure 2a). After the bronchoscopic saline lavage to clear airway secretions, the blood gas analysis reported (Vt 350ml, PEEP 6cmH2O, FiO2 80%): PaCO2 86.6mmHg, which indicated the PaCO2 was slightly improved but still in high level.
From March 1st to March 11th, bedside bronchoscopy NAC inhalation solution lavage to clean the airway was performed at intervals of 1 day or 2 days: after each negative pressure suction of airway secretion was cleared under bronchoscopy, 10–15 g of NAC solution was infused into each bronchus alternately in the left and right bronchial tubes, retained for 2–3 minutes, and the airway secretion was cleared again by negative pressure suction. During the disease, the blood gas analysis was dynamically reviewed, and the patient’s PaCO2 gradually decreased to the normal range. On March 3, XueBiJing was administrated with a 100ml bid combined with ornidazole 0.5g qd. On March 4, the chest X-ray examination showed that the lung infection had progressed. On March 5th, methylprednisolone 40mg qd was given, and at the same time, the family of the patient finally agreed to place the jejunal nutrition tube and began enteral combined with parenteral joint nutritional support.
The sputum and bronchoscopic lavage fluid of the novel crown virus RNA tests were negative on February 28, March 1, and March 5. Both sputum culture and bronchoscope lavage fluid culture on March 5 indicated the detection of Pseudomonas aeruginosa. Re-examination of T lymphocyte subsets on March 7 reported: total T cells (CD3 +) 171 / ul, helper T cells (CD4 +)% 26.47%, CD4 + / CD8 + 0.75, which indicated reduced universally, cytotoxic T cells (CD8 +)% 35.44 %, appeared with increasing; re-examination of the chest X-ray on March 7 showed that the lung infection was significantly improved (Figure 2b). The patient’s blood gas analysis was reviewed on March 8 (SIMV + PSV, PS 12cm2O, f 18 times/min, PEEP 6cmH2O, FiO2 50%) and reported: PaCO2 53.9mmHg, which was significantly decreased, the descending antibiotic ladder was changed to Sulperazone combined with levofloxacin. Re-examination of blood gas analysis reported pCO2 of 46.3 mmHg on March 12th, the patient’s hypercapnia was significantly improved, and methylprednisolone was reduced to 20 mg qd. On March 17 (31st day of admission, 18 days after endotracheal intubation), the patient began to disengage from the ventilator intermittently. The endotracheal intubation catheter was given an artificial nose intermittently, and the spontaneous breathing test was performed intermittently. Re-examination of chest CT on March 18 (Figure 1c) revealed that the anastomotic pleural fistula after esophageal cancer surgery, the pleural effusion of the right chest cavity decreased compared with previous examinations; the infectious lesions of both lungs were partially absorbed, consequently the methylprednisolone application was terminated. On March 22, the patient again performed bedside bronchoscopy to clear the airway secretions and successfully removed the tracheal intubation, given nasal high-flow oxygen therapy and continued to anti-infection, airway management, nutritional support, immunity enhancement, and respiratory function exercises treatment. On March 28, the chest radiograph was reviewed: the interstitial inflammatory lesions of both lungs were significantly improved (Figure 2c). The patient’s inflammation index decreased from Hs-CRP: 197.59mg / L at admission to 22.41mg / L and IL–6 decreased from the initial 94.00pg / ml to 8.17pg / ml. On April 1st, the patient was cured and discharged with a jejunal nutrition tube. In the entire diagnosis and treatment process, patients received a total of 1700ml of plasma, including 600ml of plasma of convalescent patients with novel coronavirus pneumonia, 10U of red blood cells, 300g of albumin, and 50g of static C, and 16mg of thymalfasin during the recovery period.