新冠肺炎之處置：藥物治療及重症照護

Coronavirus Disease 2019 (COVID-19): Medication Treatment and Management in Critical Illness

鄭舒帆(Shu-Farn Tey) ； 鄭高珍(Kuo-Chen Cheng)

《內科學誌》 31卷4期 (2020/08) Pp. 239-246

https://doi.org/10.6314/JIMT.202008_31(4).03

摘要

2019年末，一種新型冠狀病毒在中國武漢被發現且迅速蔓延開來，並造成新冠肺炎在2020年全世界大流行。目前尚未發現有效的藥物治療，而疫苗的研發和新型抗病毒藥物的研發也在持續進行。瑞德西韋（Remdesivir）目前適合用在嚴重新冠肺炎的住院病人。其他治療方式包括日舒（Azithromycin）合併羥基奎寧（Hydroxychloroquine）、恢復期血漿（Convalescent plasma）、法匹拉韋（Favipiravir）等，但目前臨床試驗尚未發現明確的助益而未有定論。嚴重新冠肺炎的病人往往需接受氧氣、侵襲性或非侵襲性呼吸器治療，但需注意潛在飛沫形成的狀況，是隔離防疫應注意的事項。重症呼吸衰竭病患插管的時間亦不應被延遲。在產生急性呼吸窘迫徵候群的新冠肺炎重症的處置治療上大致上與一般敗血性休克和急性呼吸窘迫症候群的病患雷同，如肺保護通氣策、提供適當的吐氣末正壓等目前常用通氣設定。若病人氧合惡化可考慮俯臥姿勢甚至是體外心肺循環系統（Extracorporeal membrane oxygenation, ECMO）。正腎上腺素則是治療休克的首選。

關鍵字

嚴重急性呼吸道症候群－冠狀病毒2（Severe acute respiratory syndrome coronavirus 2（SARS-CoV-2） ； 瑞德西韋（Redemsivir） ； 新型冠狀病毒疾病（Coronavirus Disease 2019, COVID-19）

並列摘要

At the end of 2019, a novel coronavirus was identified in cluster of pneumonia patients and spreading rapidly in Wuhan, China, resulting in a global pandemic in 2020. There is no specific medication with promising benefit until now. Vaccine development and investigation of anti-viral medication are ongoing. Remdesivir is recommended for the hospitalized patients with severe disease. The others option including combination of azithromycin and hydroxychloroquine, convalescent plasma or Favipiravir, but, the results of clinical trial showed lack of clear benefit. The patients with severe disease often need oxygenation support, invasive or non-invasive ventilation, but need consideration of aerosol-generating procedures that warrant specific isolation precautions. Intubation and invasive ventilator support should not be delayed among the patient developing respiratory failure. The management of COVID-19 related acute respiratory distressed syndrome and septic shock is similar as before. Protective ventilation strategy and positive end-expiratory pressure (PEEP) are recommended in ventilator setting. For patient who fail after protective ventilation strategy, prone ventilation is the preferred next step or even the use of extracorporeal membrane oxygenation if deterioration of hypoxia. Norepinephrine is favored during shock status.