Jessica Leis
Final Case Study
November 13, 2012
COPD with Respiratory Failure
I. Understanding the Disease and Pathophysiology
1. Mr. Hayato was diagnosed with emphysema more than 10 years ago. Define emphysema
and its underlying physiology.
Emphysema is a condition characterized by thinning and destruction of the alveoli, resulting in
decreased oxygen transfer into the bloodstream and shortness of breath. It is one of two
conditions that are generally classified under chronic obstructive pulmonary disease (COPD), a
progressive disease in which airflow is limited. Emphysema develops gradually over years,
usually as a result of exposure to cigarette smoke. More males than females generally suffer from
this condition and 95 percent of the time are over the age of 45.
Most cases are caused by inflammation of the airways and lung tissue. The inflammatory process
can increase oxidative stress and contribute to the development of emphysema. In rare cases, it is
caused by a protein deficiency. The protein alpha 1-antitrypsin (ATT) is produced by the
bloodstream, where it travels to the lungs to protect them from the destructive actions of
common illnesses and exposures. Only about 5 percent of cases are caused by this deficiency.
(Nutrition Therapy & Pathophysiology, pg. 657-578)
2. Define the following terms found in the history and physical for Mr. Hayato:
a. Dyspnea: shortness of breath or difficulty breathing
b. Orthopnea: difficulty breathing while lying down
c. Pneumothorax: the collection of air in the space around the lungs. This buildup of air puts
pressure on the lung, so it cannot expand as much as it normally does when you take a breath
d. Endotracheal intubation: a medical procedure in which a tube is placed into the windpipe
(trachea), through the mouth or the nose; usually placed to open up the airway to give oxygen,
anesthesia, or medication, to remove blockages from the airway, protect the lungs, etc; most time
patients will then be placed on a breathing machine
e. Cyanosis: blue-tinged mucous membranes and skin due to inadequate oxygen supply
(www.ncbi.nlm.nih.gov)
(Nutrition Therapy & Pathophysiology, 648)
(http://www.nlm.nih.gov/medlineplus/ency/article/003449.htm)
3. Identify features of the physician’s physical examination that are consistent with his
admitting diagnosis. Describe the pathophysiology that might be responsible for each physical
finding.
In his physical examination, the doctor identified cyanosis of extremities with 1+ pitting edema.
This form of edema is classified as barely detectable impression left on the skin when a finger is
pressed into the skin. The cyanosis of his extremities and this pitting is most likely contributed to
Mr. Hayato’s poor ventilation of oxygen to his outer body parts. With less oxygen available to
bind with hemoglobin, the number of deoxygenated hemoglobin increases causing blue-tinged
mucous membranes and skin.
The physician also identified hyperresonance to percussion over the left chest anteriorly and
posteriorly. There was also harsh inspiratory breath sounds that were noted over the right chest
with absent sounds on the left. This hyperresonance is indicative of decreased breath sounds due
to the patient’s increased effort to breath as a result of decreased lung function. This could also
be contributed to the pneumothorax that was discovered by the chest radiograph in the ER that
showed tension on the left lung.
(http://www.meddean.luc.edu/lumen/meded/mech/cases/case8/copdqa.htm)
II. Understanding the Nutrition Therapy
4. What is the relationship between nutritional status and respiratory function? Define
respiratory quotient (RQ). What dietary factors affect RQ?
Weight loss and low BMI have been associated with increased mortality in patients with COPD.
Losses of lean body mass is another anthropometric measurement that is generally examined in a
nutritional assessment. Excessive weight gain may be deleterious by increasing the workload of
an already compromised respiratory system. Individuals who are morbidly obese have difficulty
breathing caused by restrictions on the chest wall due to the accumulation of fat in and around
the thoracic cage, diaphragm, and abdomen. This results in reduced lung volume accompanied
by poor oxygen and carbon dioxide exchange.
Respiratory quotient (RQ) is the ratio of the volume of carbon dioxide evolved to that of oxygen
consumed by an organism, tissue, or cell in a given time. Due to limited airflow through their
airways from either a loss of elasticity and/or inflamed, damaged, or mucous-clogged airways,
breathing for COPD patients becomes difficult and the lungs begin to lose their ability to
effectively take up oxygen and remove carbon dioxide. Patients are typically thin, if not
underweight, and often exhibit extreme weight loss due to the increased energy requirements
associated with labored breathing and a once unconscious effort that becomes conscious and
difficult.
From this increased effort, patients can increase their REE by 10 to 15 percent. If the extra
calories being expended are not being replenished in the diet, weight loss occurs. This can also
result in malnutrition, which can weaken respiratory muscles, resulting in altered ventilation,
poor muscle strength, and impaired immune function. Low dietary intake, from a number of
COPD factors, can also be a potential cause for this weight loss often seen in COPD patients.
Dyspnea, bloating, anorexia, early satiety, and fatigue can decrease oral intake.
5. Do nutrition support and nutritional status play a role in the ability to be weaned from
respiratory ventilator? Explain.
Absolutely. In COPD patients, it is important that they receive adequate nutrition, however,
overfeeding a patient using mechanical respiration is of primary concern because it can be
associated with increased CO2 production. This can further complicate ventilation. Glucose and
protein have been show to stimulate ventilatory drive, excess glucose increases CO2 production
and can make weaning from ventilation difficult. Despite the potential for increased production,
generally, if patients are given moderate total kcal amounts (about 30 percent above their normal
basal needs), there is little effect on CO2 production. Overfeeding is the main concern when it
comes to producing excess carbon dioxide and weaning an individual from a ventilator.
(Nutrition Therapy & Pathophysiology, pg. 662)
III. Nutrition Assessment
A. Evaluation of Weight/Body Composition
6. Evaluate Mr. Hayato’s admitting anthropometric data for nutritional assessment.
Weight: 122 pounds/ 55.5 kg
Height: 5’4” / 1.6 m
BMI: 55.5/ (1.6)2 = 21.7 kg/m2
IBW: 106 + 5(4) = 126 pounds
% IBW: 122 lbs/126 lbs = 97 %
UBW: 135 pounds
%UBW: 122 lbs/135 lbs = 90%
From his anthropometric data, it can be seen that Mr. Hayato is experiencing relatively severe
weight loss. Although his BMI at 21.7 kg/m2 does not categorize him as underweight, he is 97%
of his IBW and 90% of his usual body weight of 135 pounds, as indicated by his wife.
B. Calculation of Nutrient Requirements
7. Determine Mr. Hayato’s energy and protein requirements using the Harris-Benedict
equation, the Ireton-Jones equation, and the COPD predictive equations. Compare
them. As Mr. Hayato’s clinician, which would you set as your goal for meeting his
energy needs?
Harris-Benedict (for Men):
66.5 + (13.75 x wt (kg)) + (5 x ht (cm)) – (6.78 x age (yrs))
66.5 + (13.75 x 55.5) + (5 x 163) – (6.78 x 65) = 1200 kcals energy needs
Protein needs: At 20% total kilocalories = 240 kcals or 60 grams protein
Ireton-Jones:
(5 x weight (kg)) – (11 x age) + (244 if male) + (239 if trauma present) + (840 if burns
present) + 1784
(5 x 55.5) – (11 x 65) + 244 + 239 + 1784 = 1800 kcals energy needs
Protein needs: At 20% total kilocalories = 360 kcals or 90 grams protein
COPD predictive equations:
55.5 kg x 27 kcal = 1500 kcals energy needs
55.5 x 1.5 grams protein = 83 grams protein needs
As his clinician, I would recommend Mr. Hayato follow the kcal intake and protein needs
calculated using the general COPD predictive equations. The Harrist-Benedict formula tends to
underestimate measured REE by 10 to 15 percent, which means it would not be providing Mr.
Hayato with sufficient nutrition considering his condition and needs. Providing 25 to 30 kcals/kg
of body weight with approximately 20 percent of these kcals coming from protein (at 1.2 – 1.7
grams/kg body weight) would be a good starting place for Mr. Hayato. I determined that an
intermediate value of 27 kcals/kg and 1.5 grams/kg protein would be good for Mr. Hayato.
8. Determine Mr. Hayato’s fluid requirements.
1 cc/kcal = 1500 cc fluid (1.5 L)
Mr. Hayato needs to stay hydrated with non-caffeinated beverages to help thin the
mucous buildup, making it easier for him to cough up.
C. Intake Domain
9. From the information gathered within the intake domain, list possible nutrition
problems using the diagnostic term.
(NI-1.4) Inadequate energy intake
(NI-2.1) Inadequate oral intake
(NI-3.1) Inadequate fluid intake
(NI-5.1) Increased nutrient needs
(NC-3.2) Unintended weight loss
D. Clinical Domain
10. Evaluate Mr. Hayato’s biochemical indices for nutritional assessment on day 1.
pH: 7.2 L, 7.30 L, 7.36, 7.22 L
Normal: 7.35-7.45
Glucose: 108 mg/dL (Date: 3/26) and 110 mg/dL (Date: 3/29)
Normal: 70 – 110 mg/dL
Arterial blood gases:
pO2: 56 L, 58 L, 60 L, 57 L
Normal: >80 mmHg
pCO2: 65 H, 59 H, 50 H, 66 H
Normal: 35 – 45 mmHg
CO2: 35, 30, 29, 36
Normal: 23-30 mmol/L
HCO3 : 38 H, 33 H, 32 H, 37 H
Normal: 24 – 28 mEq/L
Alk phos: 114
Normal: 30-120
HDL low, LDL high
Potentially indicative of malnutrition
High neutrophil count, low lymphocyte and monocyte levels
-
11. From the information gathered within the clinical domain, list possible nutrition
problems using the diagnostic term.
(NI-2.1) Inadequate oral intake
(NI-3.1) Inadequate fluid intake
(NI-5.1) Increased nutrient needs
(NC-3.2) Unintended weight loss
(NC-2.2) Altered nutrition-related laboratory values
IV. Nutrition Diagnosis
12. Select two high priority nutrition problems and complete the PES statements for each.
PES #1: Inadequate energy intake related to decreased appetite and low caloric intake as
evidenced by unintended weight loss of 13 pounds over the past several weeks.
PES #2: Increased caloric needs related to increasing required REE as evidenced by COPD with
respiratory failure.
V. Nutrition Intervention
13. Mr. Hayato was started on Isosource @ 25 cc/hr continuously over 24 hours.
A. At this current rate, how many kcalories and grams of protein should he receive per
day?
25 cc/hr x 24 hours = 600 cc/day
1.20 kcal/mL x 600 cc = 720 calories
43 g protein/L
1000 mL = 1 L
0.043 g protein/mL x 600 cc = 25.8 grams protein per day
B. Calculate his nutrition prescription utilizing this enteral formula. Include goal rate,
free water requirements, and the appropriate progression of the rate.
Goal Rate for continuous feeding at 600 cc per day = 600 cc/24 hr = 25 cc/hr
To provide 1500 cc, goal rate is: 1500 cc/24 hr = 62.5 cc/hr
To progress this enteral feeding rate, tolerance first needs to be established with the 25 cc
per hour rate; once tolerance is established, the rate should be increased by 20 cc every 4
hours (as tolerated) to the goal rate of 63 cc/hr.
Free water of Isosource: 78% of 600 cc = 468 cc free water
468 cc/4 flushes = 117 cc/flush
Flush with 117 cc fluid free water every 5-6 hours to meet fluid needs.
14. What type of formula is Isosource? What is the percentage of kilocalories from
carbohydrate, protein, and lipid? Should the patient have been started on a disease-specific
formula? Support your responses. What is the rationale for pulmonary formula?
Isosource is a complete liquid formula designed for tube feeding patients with increased calorie
and protein needs and/or limited volume tolerance. To meet 100 percent RDI (mL), a volume of
1165 mL is needed. Energy provided per mL is 1.20, protein is 43 grams/L, fat is 39 g/L, and
carbohydrates provided are 170 g/L.
% kcals protein: 18%
% kcals carbohydrate: 44%
% kcals lipid: 38%
Mr. Hayato may have benefited from a disease-specific formula because it would have
potentially prevented the need for the change from enteral to peripheral parenteral nutrition back
to enteral feedings. However, disease-specific feeds may not be nutritionally complete, they are
very expensive, and any available data must be analyzed for benefits before administration. For
pulmonary care patients, formulas must be assessed for their sodium, magnesium, phosphate, and
potassium levels, density of carbohydrates, protein, and lipid and many other factors to ensure
adequate (and not excessive) nutrition.
VI. Nutrition Monitoring and Evaluation
15. Examine the patient care summary sheet. How much enteral feeding did the patient
receive?
The patient received 400 cc of tube feed during his time in the hospital. He received 25 cc/hour
for 15 hours, but his TF was discontinued in the evening due to high residuals. During hour 05
(night), increasing the TF to 50 cc was attempted but was not successful. The same was done on
hour 10 (day) with no progress.
16. You read in the physician’s orders that the patient experienced high gastric residuals and
the enteral feeding was discontinued. What does this mean, and what is the potential cause of
this problem?
Monitoring gastric residual values is important for assessing the safety of enteral tube feeding.
High GRV’s occur when the patient experiences delayed gastric emptying caused by intolerance
to the TF. Excessive accumulation of feeding formula and gastric secretions causes distention
and greatly increases the potential for regurgitation and vomiting with pulmonary aspiration of
gastric contents into the lungs.
The determination of high (or low) GRV’s is still up for debate but currently, according to the
American Society for Parenteral and Enteral Nutrition guidelines for nutrition support in patients
who are critically ill, EN should not be stopped for a GRV of less than 500 mL unless there are
other signs of feeding intolerance.
(http://www.in.gov/fssa/files/aspiration_prevention_8.pdf)
17. Dr. McFarland elected to begin peripheral parenteral nutrition using a formula called
ProcalAmine. She began the PPN @ 100 cc/hr and discontinued Mr. Hayato’s regular IV of
D5 ½ NS at TKO. What is ProcalAmine and how much nutrition does this provide?
TKO – maintenance rate to keep vein open
Mr. Hayato was initially on 5% dextrose and ½ normal saline, a hypertonic standard IV solution.
In a hypertonic solution, the osmolality is greater than 340 mOsm/kg. Hypertonic solutions exert
more osmotic pressure than the extracellular fluid so when these solutions are infused, fluid gets
pulled into the vascular system. Patients on this need to be monitored for fluid overload. He was
then switched to PPN with ProcalAmine at 100 cc/hr.
ProcAlamine is a 3% amino acid and 3% glycerin formula that is used to help maintain and
improve the balance of body protein in patients who require nutritional supplement for a short
period of time. It provides utilizable essential and nonessential amino acids, a nonprotein energy
source, and a balanced pattern of maintenance electrolytes. The amino acids provide substrates
for protein synthesis as well as sparing body protein and muscle mass. Glycerin, the utilizable
energy substrate, serves to preserve body protein as well.
1000 mL = 29 grams protein, 130 nonprotein calories
100 cc/hr x 24 hr = 2400 cc/day
2400/1000 = 2.4 x 29 grams protein = 69.6 grams total protein
2.4 x 130 kcals = 312 kcals
18.Was this adequate to meet the patient’s nutritional needs? Explain.
No, this was not adequate to meet Mr. Hayato’s needs. ProcalAmine provides nonprotein
calories, amino acids, maintenance electrolytes, and water. While his protein needs in the form of
broken down amino acids are being met, Mr. Hayato was not being provided with any lipid and
was not receiving an adequate amount of calories.
19. Do you feel it was a good idea to begin peripheral parenteral nutrition (PPN)? What are
the pros and cons? What are the limitations of using this form of nutrition support? Were
other nutrition support options available for the health care team?
I do not feel the PPN by itself was necessarily the best route to take. It initially caused a decrease
in Mr. Hayato’s respiratory status and once it was discontinued, improvement was made and
stability was established. I feel that the doctor should have considered administering PPN in
conjunction with smaller enteral feedings. This would have helped lower gastric residuals,
increase absorption, and continued the use of the gut to help prevent any muscle atrophy that
might occur from not being used. I agree that it was the best route to take as a means of
protecting Mr. Hayato and his ability to breathe because it eliminated the chance of aspiration or
regurgitation from non-tolerated enteral feeds, but I think it would have been best to pair the
peripheral parenteral line with the enteral feeds for the best overall nutrition care.
PPN does have its advantages. It is a way of providing nutritional support when GI intolerance
prevents oral or enteral feeding. However, it can cause irritation around the site of insertion and
is a very expensive method of tube feeding. Also, PN formulas are very complex mixtures that
could potentially cause harm to the patient if the correct one is not used.
The health care team could have possibly tried bolus, intermittent or cyclic enteral feedings,
instead of a continuous drip line, to see if there was any improved tolerance by the GI. Pairing
the enteral feeds with PPN may have been a route to try as well, to test Mr. Hayato’s tolerance to
smaller enteral feeds while ensuring that he still getting the remaining amount of nutrition he
needs to promote healing through a peripheral vein.
(http://www.nutritioncare.org/assets/0/48/100/168/172/9EA75C7D-B801-44CB-89BCF5B0290BE699.pdf)
20. On day 4, the enteral feeding was restarted at 25 cc/hr and then increased to 50 cc/hr after
12 hours. You document that the ProcalAmine @ 100 cc/hr was also continued. What would
have been the total energy intake for Mr. Hayato?
50 cc/hr x 24 hours = 1200 cc/day
1.20 kcal/mL x 1200 cc = 1440 calories per day
312 calories from ProcalAmine
1440 + 312 = 1712 calories total energy intake
21. Examine the values documented for arterial blood gases (ABGs)
A. On the day Mr. Hayato was intubated, his ABGs were as follows: pH 7.2, pCO2 65,
CO2 35, pO2 56, and HCO3- 38. What can you determine from each of these values?
ABGs are used to determine how well your lungs can transfer oxygen from the air into
your blood and how well carbon dioxide can be removed from the body. An ABG is done
by taking a blood sample from one of your arteries; the blood is analyzed by a machine
that records the amount of carbon dioxide (waste gas) and oxygen in your blood. One of
the uses of this test is to determine whether or not you need any extra oxygen. It is also
useful in making an initial diagnosis, as well as in determining the effectiveness of
treatment, especially in episodes of acute exacerbation.
Mr. Hayato’s pH level is low, placing him in a state of acidosis. Normal pH is usually
between 7.35 and 7.45. His pCO2, or partial pressure carbon dioxide level, is extremely
high indicating that he is not removing the carbon dioxide from his body very efficiently.
Common pCO2 levels are around 35 mmHg. His pO2 is low at 56; usually this level is
anywhere between 75 and 100 mmHg. His bicarbonate level is high at 38, with a normal
range being between 22 and 26 meq/L.
This lab data indicates that Mr. Hayato is not exchanging enough carbon dioxide in his
lungs and his levels of dissolved oxygen are low.
(http://www.livestrong.com/article/199207-arterial-blood-gases-in-copd/)
B. On day 3, while Mr. Hayato was on the ventilator, his ABGs were as follows: pH
7.36, pCO2 50, CO2 29, pO2 60, and HCO3- 32. What can you determine from each of
these values?
With the ventilator, Mr. Hayato’s pH improved to normal values, his pCO2 and CO2
levels decreased (an improvement), his pO2 level increased and improved and his
bicarbonate level decreased. Overall, mechanical ventilation had a positive effect on Mr.
Hayato’s respiratory status.
C. On day 5, after restarting enteral feeding and continuing on ProcalAmine, his
ABGs were as follows: pH 7.22, pCO2 66, CO2 36, pO2 57, and HCO3- 37. In addition,
indirect calorimetry indicated a RQ of 0.95 and measured energy intake to be 1,350
kcal. How does the patient’s measured energy intake compare to your previous
calculations? What does the RQ indicate?
Normal RQ, or respiratory quotient, values typically range between 0.65 and 1.25,
meaning that Mr. Hayato’s current RQ of 0.95 is good. Using the COPD predictive
equation caloric needs for the patient at 27 kcals per kilogram for 55.5 kg body weight,
Mr. Hayato’s average energy needs are 1,500 kcals per day. At 1,350 kcals measured
energy intake, his needs are close to being met. Using the Harris-Benedict equation, his
current intake is exceeding his needs of 1,200 calories per day, however, since this
equation typically underestimates needs it is not as accurate.
22. As Mr. Hayato is prepared for discharge, what nutritional goals might you set with him
and his wife to improve his overall nutritional status?
I would advise Mr. Hayato and his wife to ensure that Mr. Hayato does his best to
prevent further weight loss. I would advise that he consume a diet rich in antioxidants,
meaning plenty of fruit, vegetable, and fish intake. He should decrease or eliminate his
consumption of red meats, refined grains, desserts, and french fries or greasy foods. He
should increase his consumption of vitamins A, C, E and beta-carotene to help him cope
with oxidative damage that is undergone during exacerbation, which depletes these
vitamin stores. I would also instruct Mr. Hayato to consume foods containing
phosphorus, so as to ensure adequate phosphate levels within his system to aide in ATP
synthesis which is crucial for pulmonary function.
I would educate the couple on foods high in calcium and vitamin D as well, to help
prevent the risk of osteoporosis. I would create a diet plan example to help them
implement small, frequent meals that are high in calories and protein as well as nutrient
dense. I would advise Mr. Hayato to rest before meals to avoid fatigue and to alleviate
feelings of fullness and bloating. I would also encourage Mr. Hayato to do what exercise
he is capable of; this may be strength or resistance training, which has been shown to
improve skeletal muscle function. Last but not least, I would reiterate to Mr. Hayato that
the elimination of smoking from his list of habits is crucial to enhancing and improving
his lung function and overall quality of life.
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