Ministry of Health Clinical Path Clinical Path for Respiratory Diseases I. Community-acquired Pneumonia Clinical Path (I) Applicable objects. The first diagnosis of community-acquired pneumonia (non-severe) (ICD-10: J15, 901) (b) Diagnostic basis. According to Clinical Diagnostic and Treatment Guidelines Respiratory Disease Subsection (Chinese Medical Association, People’s Health Publishing House), Guidelines for the Diagnosis and Treatment of Community-Acquired Pneumonia (Chinese Medical Association, Respiratory Disease Subsection, 2006) 1. Coughing, coughing up sputum, or aggravation of existing respiratory disease symptoms with purulent sputum, with or without chest pain. 2. Fever. 3, Signs of pulmonary solid changes and/or smell of wet woven grass 4, White blood cell count >10×109/L or <4×109/L, with or without left shift of nuclei. 5. Chest imaging shows flaky, patchy infiltrative shadows or interstitial changes. The clinical diagnosis can be confirmed by any one of the above 1-4 items plus item 5, and excluding other lung diseases. (iii) Selection of treatment program. According to Clinical Diagnostic and Treatment Guidelines Respiratory Diseases (Chinese Medical Association, People's Health Publishing House), Guidelines for the Diagnosis and Treatment of Community-Acquired Pneumonia (Respiratory Diseases Branch of the Chinese Medical Association, 2006), 1. Supportive and symptomatic treatment. 2. 2. Empirical antimicrobial therapy. (3) Adjustment of antimicrobial therapy according to pathogenetic examination and response to treatment. (D) Standard hospitalization is 7-14 days. (E) Entry pathway criteria. (1) The first diagnosis must be in accordance with ICD-10: J15, 901 Community-acquired pneumonia disease code. 2.When the patient has other disease diagnosis at the same time, but does not need special treatment during the treatment and does not affect the implementation of the clinical pathway process of the first diagnosis, it can enter the pathway. (vi) Days 1-3 after admission. 1. Necessary examination items: (1) blood routine, urine routine, stool routine; (2) liver and kidney function, blood glucose, electrolytes, blood sedimentation, C-reactive protein (CRP), infectious disease screening (hepatitis B, hepatitis C, syphilis, AIDS, etc.); (3) pathogenicity examination and drug sensitivity; (4) chest radiographs, electrocardiogram. (2) According to the patient's condition: blood culture, blood gas analysis, chest CT, D-dimer, oxygen saturation, B ultrasound, invasive examination. (vii) Treatment options and drug selection. 1.Evaluate the risk factors of specific pathogens and give antimicrobial drugs as soon as possible after admission (within 4-8 hours). 2. Drug selection: According to the Guiding Principles for the Clinical Application of Antimicrobial Drugs (Guiding Principles for the Clinical Application of Antimicrobial Drugs) (No. 285 of Weimedifa [2004]) and Guidelines for the Diagnosis and Treatment of Community-Acquired Pneumonia (Respiratory Diseases Branch of the Chinese Medical Association, 2006), antimicrobials should be used reasonably according to the patient's conditions. Clinical assessment should be carried out after 2-3 days of initial treatment, and antimicrobial drugs should be adjusted according to changes in the patient's condition. 4. Symptomatic supportive treatment: antipyretic, antitussive, sputum relief, oxygen inhalation. (H) Discharge criteria. 1.Symptoms improve, body temperature is normal for more than 72 hours. 2.Imaging suggests obvious absorption of lung lesions. (IX) Variation and cause analysis. 1.Accompanied by comorbidities affecting the therapeutic effect of the disease, requiring relevant diagnosis and treatment, resulting in prolonged hospitalization. 2.Severe condition, meeting the criteria of severe pneumonia, transferred to the appropriate pathway. 3.Ineffective or aggravated by conventional treatment, transferred to the corresponding pathway. II. Chronic obstructive pulmonary disease clinical pathway (a) Applicable objects. The first diagnosis is acute exacerbation of chronic obstructive pulmonary disease (ICD-10: J44, 001/J44, 101) (b) Diagnostic basis. According to the Clinical Diagnosis and Treatment Guidelines - Respiratory Disease Subchapter (Chinese Medical Association, People's Health Publishing House), COPD Diagnosis and Treatment Guidelines (2007 Revision) (Respiratory Disease Branch of Chinese Medical Association, Chronic Obstructive Pulmonary Disease Group), the patient should have a history of chronic obstructive pulmonary disease (COPD). 2. Continuous deterioration beyond the daily condition and the need to change the routine use of medication. (3) Patients with short-term worsening of cough, sputum, shortness of breath and/or wheezing, increased sputum volume, or changes in sputum character, which may be accompanied by fever and other manifestations of markedly worsening inflammation. (iii) Choice of treatment program. According to the Clinical Diagnosis and Treatment Guidelines - Respiratory Disease Subchapter (Chinese Medical Association, People's Health Publishing House), COPD Diagnosis and Treatment Guidelines (2007 Revision) (Chinese Medical Association, Respiratory Disease Section, Chronic Obstructive Pulmonary Disease Group), 1, choose the treatment plan according to the severity of the disease. 2, if necessary, tracheal intubation should be carried out. (2) Endotracheal intubation and mechanical ventilation if necessary. (D) The standard hospitalization period is 10-21 days. (E) Entry pathway criteria. The first diagnosis must be in accordance with ICD-10: J44, 001/J44, 101 Chronic Obstructive Pulmonary Disease Acute Exacerbation Disease Codes. 2.When the patient has other disease diagnosis at the same time, but does not need special treatment during hospitalization and does not affect the implementation of the clinical pathway process of the first diagnosis, it can enter the pathway. (F) Days 1-3 after hospitalization. 1.Necessary examination items: (1) blood routine, urine routine, stool routine; (2) liver and kidney function, electrolytes, blood gas analysis, coagulation function, D-dimer, blood sedimentation, C-reactive protein (CRP), infectious disease screening (hepatitis B, hepatitis C, syphilis, AIDS, etc.); (3) sputum pathogenicity examination; (4) chest medial and lateral view film, electrocardiogram, B ultrasound, lung function (When condition permits). (2) According to the patient's condition: chest CT, echocardiography, lower extremity venous ultrasound. (vii) Principles of treatment. 1.Smoking cessation. 2.General treatment: oxygen inhalation, rest and so on. 3, Symptomatic treatment: stopping cough, resolving phlegm, calming asthma and so on. 4.Antibacterial drugs. 5.Treatment of various complications. (H) Discharge criteria. 1.Symptoms are relieved obviously. 2, clinical stability for more than 24 hours. (IX) Variation and cause analysis. 1.The existence of complications, the need for relevant diagnosis and treatment, prolonged hospitalization. 2.Serious condition, need for respiratory supporter, categorized into other pathways. III. Clinical pathway of bronchiectasis (I) Applicable objects. The first diagnosis is bronchiectasis (ICD-10:J47) (II) Diagnostic basis. According to the Clinical Diagnosis and Treatment Guidelines - Respiratory Disease Subchapter (Chinese Medical Association, People's Health Publishing House) 1, history: repeated cough, coughing up purulent sputum, hemoptysis. 2, imaging tests show that bronchiectasis is a serious disease, but the diagnosis is based on the following criteria. (2) Imaging examination shows abnormal changes of bronchial dilatation. (C) Selection of treatment program. According to Clinical Diagnosis and Treatment Guidelines - Respiratory Disease Subchapter (edited by Chinese Medical Association, People's Health Publishing House) 1, keep the airway open, and actively discharge the sputum. 2.Actively control the infection. 3.Hemostatic treatment should be given when hemoptysis occurs. (4) Symptomatic treatment. (D) The standard hospitalization period is 7-14 days. (E) Entry pathway criteria. (1) The first diagnosis must be in accordance with ICD-10:J47 Bronchiectasis Disease Code. 2, when the patient also has other disease diagnosis, but does not require special treatment during hospitalization and does not affect the implementation of the clinical pathway process of the first diagnosis, can enter the pathway. (vi) Days 1-3 after hospitalization. 1. Necessary examination items: (1) blood routine, urine routine, stool routine; (2) liver and kidney function, electrolytes, blood sedimentation, C-reactive protein (CRP), blood glucose, coagulation function, infectious disease screening (hepatitis B, hepatitis C, syphilis, AIDS, etc.); (3) sputum pathogenicity examination; (4) chest radiographs, electrocardiogram. (2) According to the patient's condition: blood gas analysis, pulmonary function, chest CT, echocardiography. (G) Treatment program and drug selection. The first choice is broad-spectrum antibacterial drugs covering gram-negative bacilli, and those with a history of Pseudomonas aeruginosa infection or risk factors need to choose antibacterial drugs that can cover Pseudomonas aeruginosa, and can be combined with aminoglycoside antibacterial drugs if necessary. Expectorant drugs and auxiliary treatment for expectoration: postural drainage, bronchodilator, bronchoscopic aspiration if necessary. (3) Treatment of hemoptysis: rest, and use antiemetic drugs according to the condition. (H) Discharge criteria. 1.Symptoms relieved. 2.Stabilized condition. 3.No comorbidities and/or complications requiring hospitalization. (IX) Variation and cause analysis. 1, Ineffective treatment or progression of the disease, requiring review of pathogenetic tests and adjustment of antimicrobial drugs, resulting in prolonged hospitalization. 2.Accompanied by comorbidities and complications affecting the therapeutic efficacy of the disease, requiring relevant diagnosis and treatment. 3.Accompanied by a large number of hemoptysis, according to the clinical pathway of hemoptysis treatment. 4.If there are surgical indications for surgical treatment, the patient will be transferred to the surgical treatment path. IV. Bronchial asthma clinical path (a) the applicable object. The first diagnosis of bronchial asthma (non-critical) (ICD-10: J45) (b) Diagnostic basis. According to the Guidelines for the Prevention and Treatment of Bronchial Asthma (Revised by the Asthma Group of the Respiratory Diseases Branch of the Chinese Medical Association, 2008), recurrent episodes of wheezing, shortness of breath, chest tightness, or coughing are mostly related to exposure to allergens, cold air, physical and chemical stimuli, viral upper respiratory tract infections, and exercise. 2.Dispersed or diffuse rales, mainly in the expiratory phase, can be heard in both lungs during an attack. 3. The above signs and symptoms may be relieved by treatment or on their own. 4. Except for wheezing, shortness of breath, chest tightness and cough caused by other diseases. 5. For atypical clinical manifestations, at least one of the following tests should be positive: (1) positive bronchial provocation test or exercise provocation test; (2) positive bronchodilator FEV1 increase ≥ 12%, and the absolute value of FEV1 increase ≥ 200 ml; (3) Peak expiratory flow rate (PEF) variation rate ≥ 20% within a day (or 2 weeks). The diagnosis can be made if 1, 2, 3, 4, or 4 or 5 of these criteria are met. (iii) Selection of treatment program. According to the Guidelines for the Prevention and Treatment of Bronchial Asthma (Revised by the Asthma Group of the Respiratory Diseases Branch of the Chinese Medical Association, 2008), 1, according to the severity of the disease and the response to treatment, choose the program. 2, if necessary, tracheal intubation. (2) Perform endotracheal intubation and mechanical ventilation if necessary. (d) The standard hospitalization period is 7-14 days. (v) Entry pathway criteria. The first diagnosis must be in accordance with ICD-10:J45 Bronchial Asthma Disease Code. 2, when the patient also has other disease diagnosis, but does not require special treatment during hospitalization and does not affect the first diagnosis of the clinical pathway process implementation, you can enter the pathway. (F) Days 1-3 after hospitalization. 1. Necessary examination items: (1) blood routine, urine routine, stool routine; (2) liver and kidney function, electrolytes, blood glucose, blood sedimentation, C-reactive protein (CRP), blood gas analysis, D-dimer, infectious disease screening (hepatitis B, hepatitis C, syphilis, AIDS, etc.); (3) chest radiographs, electrocardiograms, and lung function (when the condition permits). (2) Selected according to the patient's condition: serum allergen determination, chest CT, echocardiography, blood theophylline concentration, sputum pathogenicity examination, etc. (G) Treatment program and drug selection. 1.General treatment: oxygen therapy, maintaining water, electrolyte, acid-base balance, etc. 2, bronchodilator: preferred fast-acting β2 agonist inhalation preparation, can also use anticholinergic drugs (inhalation preparation), theophylline drugs. 3, anti-inflammatory drugs: glucocorticoids, anti-leukotriene drugs. 4.Anti-allergic drugs: selected according to the condition. 5.Adjust the drugs and treatment program according to the severity of the disease and treatment response. (H) Discharge criteria. 1.Symptom relief. 2. Stabilization of the condition. 3.No comorbidities and/or complications requiring hospitalization. (IX) Variation and cause analysis. 1.Complications occurring during treatment, requiring special diagnosis and treatment, resulting in prolonged hospitalization. 2.Severe asthma attack requiring endotracheal intubation and mechanical ventilation for maintenance was withdrawn from this pathway. 3.The effect of conventional treatment is poor, requiring special diagnosis and treatment, leading to prolonged hospitalization. V. Spontaneous pneumothorax clinical path (a) Applicable objects. The first diagnosis is spontaneous pneumothorax (ICD-10: J93,0-J93,1) (b) Diagnostic basis. According to the Clinical Diagnosis and Treatment Guidelines - Respiratory Disease Subchapter (Chinese Medical Association, People's Health Publishing House) 1, Symptoms: chest pain, dyspnea, irritating cough. Physical signs: weakened breath sounds on the affected side, drumming or excessive clearing sounds on percussion, displacement of the trachea to the healthy side. 3.Imaging examination: X-ray chest examination shows pneumothorax line and lung tissue compression. (iii) The basis for choosing treatment program. According to Clinical Diagnosis and Treatment Guidelines - Respiratory Disease Subchapter (Chinese Medical Association, People's Health Publishing House), Clinical Technical Practice Guidelines - Respiratory Disease Subchapter (Chinese Medical Association, People's Military Medical Press) 1, general treatment: oxygenation, symptomatic. 2, Thoracentesis or closed drainage. 3.Treatment of etiology. (D) The standard hospitalization day is 6-10 days. (E) Entry pathway criteria. The first diagnosis must be in accordance with ICD-10: J93, 0-J93, 1 spontaneous pneumothorax disease code. 2.When the patient has other disease diagnosis at the same time, but does not need special treatment during hospitalization and does not affect the implementation of the clinical pathway process of the first diagnosis, it can enter the pathway. (vi) Days 1-3 after hospitalization. 1.Necessary examination items: (1) blood routine, urine routine, stool routine; (2) liver and kidney function, electrolytes, coagulation function; (3) chest front and side view film, electrocardiogram. (2) According to the patient's condition: chest ultrasound, chest CT, cardiac enzymology, blood gas analysis, D-dimer and so on. (G) Treatment program. 1, Oxygen therapy and symptomatic treatment. 2.Thoracocentesis and aspiration or closed drainage: selected according to the condition and the degree of lung tissue compression. 3.Surgical treatment. (H) Discharge criteria. 1.Clinical symptoms are relieved. 2.Chest radiograph suggests basic lung reexpansion. (IX) Variation and cause analysis. 1, due to the presence of underlying diseases or other reasons, resulting in recurrent difficult to cure pneumothorax and prolonged treatment time. 2.For patients with ineffective internal medicine treatment or recurrent episodes, they need to be transferred to surgery for relevant treatment and exit this pathway. 3.Complications occurring during treatment need to be handled accordingly. VI. Clinical path of pulmonary thromboembolism (a) Applicable objects. The first diagnosis is pulmonary thromboembolism (ICD-10: I26, 001/I26, 901) (b) Diagnostic basis. According to Clinical Diagnostic and Treatment Guidelines - Respiratory Disease Branch (Chinese Medical Association, People's Health Publishing House), Diagnostic and Treatment Guidelines for Pulmonary Thromboembolism (Draft) (Respiratory Disease Branch of the Chinese Medical Association, 2001) 1. Clinical manifestations may include dyspnea, chest pain and hemoptysis, etc. 2. Risk factors for pulmonary thromboembolism, such as deep vein thrombosis, may be present. 3. The diagnosis can be confirmed by one or more of the following tests: (1) CT pulmonary arteriography (CTPA): shows a low-density filling defect in the pulmonary artery, partially or completely surrounded by impermeable blood flow, or a complete filling defect; (2) Magnetic resonance pulmonary arteriography (MRPA): reveals a low-density filling defect in the pulmonary artery, partially or completely surrounded by impermeable blood flow, or a complete filling defect. or presenting a complete filling defect; (3) Nuclide pulmonary ventilation-perfusion scanning: presenting a pulmonary perfusion defect distributed in lung segments and mismatched with the ventilation visualization, i.e., a localized perfusion defect in at least one or more lobar segments that is well ventilated or has no abnormality on X-ray chest radiographs; (4) Selective pulmonary arteriography: detecting direct signs of PE such as an intravascular contrast filling defect in the pulmonary vasculature with or without orbital signs of blood flow obstruction; (5) Echocardiography: to detect thrombus in the proximal pulmonary artery. (4) The following diseases need to be excluded: e.g., primary pulmonary artery sarcoma, amniotic fluid embolism, fat embolism, air embolism, and infectious thrombosis. (C) Selection of treatment program. According to Clinical Diagnostic and Treatment Guidelines - Respiratory Disease Subchapter (Chinese Medical Association, People's Health Publishing House), Guidelines for the Diagnosis and Treatment of Pulmonary Thromboembolism (Draft) (Respiratory Disease Subchapter of the Chinese Medical Association, 2001) 1, general treatment, hemodynamic and respiratory support. 2.Anti-coagulation and thrombolytic therapy. Other therapeutic measures: surgical thrombus removal, thrombus fragmentation and aspiration via intravenous catheter, placement of vena cava filters, and so on. (D) Standard hospitalization days: (high risk) 10-14 days, (medium and low risk) 7-10 days. (v) Entry pathway criteria. The first diagnosis must be in accordance with ICD-10: I26, 001/I26, 901 Pulmonary thromboembolism disease code. 2.When the patient has other disease diagnosis at the same time, but does not need special treatment during hospitalization and does not affect the implementation of the clinical pathway process of the first diagnosis, it can enter the pathway. (3) When there is a situation that significantly affects the routine treatment of pulmonary thromboembolism, the patient will not be entered into the clinical pathway for pulmonary thromboembolism. (F) Days 1-3 after admission to the hospital. 1.Necessary examination items: (1) blood routine, urine routine, stool routine; (2) liver and kidney function, electrolytes, blood gas analysis, blood type, coagulation function, D-dimer, infectious disease screening (hepatitis B, hepatitis C, syphilis, AIDS, etc.); (3) troponin T or I; (4) chest radiographs, electrocardiograms, echocardiograms, and ultrasound of the veins of both lower limbs. (2) One of the following relevant examinations can confirm the diagnosis: CT pulmonary arteriography, nuclear lung ventilation perfusion scanning, magnetic resonance pulmonary arteriography, selective pulmonary arteriography. According to the patient's condition, BNP, immune indicators (including cardiolipin antibodies), protein S, protein C, antithrombin III, etc. can be selected when available. (G) Selection of drugs. Thrombolytic therapy: urokinase, streptokinase, recombinant tissue-type fibrinogen activator. 2.Anti-coagulation therapy: heparin, low molecular heparin, warfarin, etc. (H) Discharge criteria. 1.Vital signs are stable. 2.Regulation of the international standardized ratio is up to standard (2,0-3,0). 3.No complications requiring continued hospitalization. (IX) Variation and cause analysis. 1.Complications occurred during treatment. 2, Accompanied by other diseases that require relevant diagnostic treatment.