Case Report: Nutritional Management
of Patient’s with Chronic Obstructive
Pulmonary Disease
BY: LAUREN MARTIN
ARAMARK DIETETIC INTERN
BRYN MAWR HOSPITAL
A P R I L 6 TH, 2 0 1 2
 Disease Description
Overview
 Evidence-Based Nutrition
Recommendations
 Case Presentation
 Nutrition Care Process:




Assessment
Diagnosis
Interventions
Monitoring & Evaluation
 Conclusions
COPD Disease Description
ETIOLOGY
EPIDEMIOLOGY
PATHOLOGY
CLINICAL SIGNS AND SYMPTOMS
RELATED CO-MORBIDITIES
Etiology
Pollution
Smoking:
emphysema
or chronic
bronchitis
Asthma
Metabolic
disorders
COPD
Alpha-1
antitrypsin
deficiency
Epidemiology
 Forth leading cause of death
 Affects 32 million people
 6th leading cause of death worldwide
 ~ 440,000 deaths/year due to smoking
 Men are more likely to have COPD
 >40 years old
Pathophysiology
COPD
Asthma
Emphysema
(Type I)*
Enlarged
airspaces of the
terminal
bronchioles
Permanent
destruction of
the alveoli
Chronic
Bronchitis
(Type II)
Inflammation of
the bronchi
Additional lung
changes
Clinical Signs & Symptoms
Emphysema
Chronic Bronchtitis
 Underweight and cachectic
 Normal weight or overweight
 Hypoxia
 Hypoxemia
 Normal hematocrit
  hematocrit
 Cor pulmonale develops much
 Cor pulmonale
later
 SOB & wheezing
 Tissue destruction
 Chronic to mild coughing
 Excess mucus production
 SOB
 Inflamed bronchial tubes
Evidence-Based Nutrition
Recommendations
THE ACADEMY OF NUTRITION AND
DIETETICS EVIDENCE ANALYSIS
LIBRARY RECOMMENDATIONS
LITERATURE REVIEW
AND EAL Major Recommendations
Prevention
of weight
loss
COPD
Use BMI &
weight
changes
Assess
quality of
life
Article #1
 “Patients at risk of malnutrition: assessment of 11 cases
of severe malnutrition with individualized TPN”
 Methods




Retrospective observational study
Purpose: To assess the use of individualized nutritional support in
severely malnourished patients
n = 11
Inclusion Criteria:
Adult patients
 Moderate or severe malnutrition
 TPN >5 days between January 2003 – June 2006
 At risk for developing refeeding syndrome


Description
Individualized TPN + MVI + electrolytes
 Monitored for refeeding

Luque S, Berenguer N, Mateu de Antonio J, Grau S, Morales-Molina JA. Patients at risk of malnutrition: assessment of 11 cases of
severe malnutrition with individualized total parenteral nutrition. Farmacia Hospitalaria. 2007;31(4):238-242.
Article #1
 Results
 Albumin: in 4; constant in 7
 Cholesterol: in 3; constant in 6; in 2
 Lymphocytes: in 4; constant in 3; in 4
 4 died
 All labs corrected by day 7
 Conclusion
 Low levels of nutrition support
 Reestablish the anabolic metabolism
 Eliminate other mechanisms which may be leading to
starvations
Luque S, Berenguer N, Mateu de Antonio J, Grau S, Morales-Molina JA. Patients at risk of malnutrition: assessment of 11 cases of
severe malnutrition with individualized total parenteral nutrition. Farmacia Hospitalaria. 2007;31(4):238-242.
Article #2
 “Nutritional status and longer-term mortality in hospitalized
patients with COPD”
 Methods




Prospective, observational study
Purpose: assess the association between nutritional status and longterm mortality in hospitalized COPD patients
n = 261
Inclusion Criteria:
Acute hospital admission >24hrs
 Hospitalized consecutively for COPD
 Stage 1 or > for COPD


Description
Anthropometric assessment; health status obtained
 2 years post discharge assessed mortality
 Cause of death: respiratory, cardiovascular, malignancy, other

Hallin R, Gudmundsson G, Ulrik CS, et al. Nutritional status and longer-term mortality in hospitalized patients with chronic
obstructive pulmonary disease. Respiratory Medicine. 2007;101:1954–1960.
Article #2
 Results
 19% underweight; 41% normal weight; 26% overweight; 14%
obese
 Underweight group 3x more likely to die
 Lowest mortality = overweight
 Diabetes
 Conclusion
 Underweight COPD patients have a higher risk for death in the
next 2 years
Hallin R, Gudmundsson G, Ulrik CS, et al. Nutritional status and longer-term mortality in hospitalized patients with chronic
obstructive pulmonary disease. Respiratory Medicine. 2007;101:1954–1960.
Article #3
 “ Body mass and prognosis in patients hospitalized with
acute exacerbation of COPD”
 Methods




Retrospective study
Purpose: to assess the association between BMI and long-term
mortality in COPD patients after acute hospital care
n = 968
Inclusion Criteria:
Hospitalization for acute COPD exacerbation
 February 2002 – June 2007


Description
Patients were assessed for primary COPD diagnosis
 Followed up 3.26 years for mortality

Lainscak M, Haehling SV, Doehner W, et al. Body mass index and prognosis in patients hospitalized with acute exacerbation
of chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle. 2011;2:81-86.
Article #3
 Results
 22% BMI <21kg/m2
 44% of patients died – lowest mortality in overweight group
  BMI 1kg/m2 was associated with 5% less chance of death
 GOLD stages decreased over BMI quartiles
 Conclusion
 A higher BMI predictive of better long-term survival
 Low BMI <21kg/m2 frequent in hospitalized COPD patients
Lainscak M, Haehling SV, Doehner W, et al. Body mass index and prognosis in patients hospitalized with acute exacerbation
of chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle. 2011;2:81-86.
Case Presentation
Case Presentation
 84 year old, Caucasian women
 Diagnosis: SOB & COPD exacerbation
 Respiratory failure, intubation, sedation, extubation, death
 Additional medical diagnosis:
 Ischemic colitis
 Clostridium difficile colitis
 CHF
 Volume status
 GI bleed
 Malnutrition
 Severe aortic stenosis
 Severe mitral regurgitation
 Rate-controlled atrial fibrillation
Nutrition Care Process: ADIME
Evaluation
Assessment
Nutrition
Diagnosis
Monitor
Intervention
Nutrition Care Process: Assessment
 Client History
 Ex-smoker
 No drug or alcohol abuse
 Lives at home with husband
 Recent swelling in extremities
 Poor historian
 Family history noncontributory
Evaluation
Assessment
Nutrition
Diagnosis
Monitor
Intervention
Nutrition Care Process: Assessment
 Food/Nutrition-Related History
 No allergies, use of herbal supplements
 Refused Boost
 Minimal activity due to SOB
 Outpatient Medications:
Digoxin
 Coumadin
 Spiriva
 Lasix
 Potassium
Evaluation
Assessment

Nutrition
Diagnosis
Monitor
Intervention
Nutrition Care Process: Assessment
 In-patient Medications
 Methylprednisolone
 Budesonide
 Heparin
 Vancomycin HCL
 Abuterol
 Acetylcysteine
 Florastor
 SSI
 Digoxin
 Lopressor







Potassium Chloride
Ducolax
Senokot
Maalox
Colace
Diprivan
Sodium Chloride
Nutrition Care Process: Assessment
 Anthropometric Measurements
 5”; 72 lbs; BMI 14.06kg/m2
 72% IBW of 100lbs
 16# unintentional weight loss in past 8 months
 Nutrition-Focused Physical Findings
 Generalized poor appetite
 Lungs with bilateral wheezing with rhonchi
 Extremities with mild edema
 Cachectic
Evaluation
Assessment
Nutrition
Diagnosis
Monitor
Intervention
Nutrition Care Process: Assessment
 Biochemical Data, Medical Tests and Procedures
 Abnormal Labs on Admission:
Sodium: 129mEq/L  - edema, diuretics, starvation, hyperglcemia
 Creatinine: 0.8mg/dL- inadequate PO intake
 Glucose: 158mg/dL - Steroid use
 Total Bilirubin: 2.9mg/dL – prolonged fasting
Evaluation
Assessment
 AST: 42U/L - Liver function
 BNP: 485pg/Ml – Heart failure

Nutrition
Diagnosis
Monitor
Intervention
Nutrition Care Process: Assessment
Nutrition Care Process: Assessment
Nutrition Care Process: Assessment
 Biochemical Data, Medical Tests & Procedures
 Respiratory acidosis, metabolic alkalosis
Nutrition Care Process: Assessment
 Diagnosis-Related Group
 “Other Severe Protein Calorie Malnutrition”
 ARAMARK Classification Status
 High – 20 points
 Nutrient Needs
Nutrition Care Process: Nutrition Diagnosis
 PES Statement:
 Underweight related to generalized poor appetite as evidence
by BMI 14.06
 Unintended weight loss related to increased needs from COPD
as evidence by COPD, 16% weight loss in the past 8 months
 Increased nutrient needs related to COPD exacerbation as
evidence by underweight with BMI 14, estimated intake less
than estimated energy requirements
Assessment
Evaluation
Nutrition
Diagnosis
Monitor
Intervention
Nutrition Care Process: Interventions
 Enteral Nutrition
 Recommended: Fibersource HN 35mL/hr x 24 hours with 1
scoop Promod once a day with 80mL free water flush q 6

Provided: 1,033kcals, 50.5g protein, 1,000mL free water
 Parenteral Nutrition
 Recommended: Minimum volume, 50g Protein, 550 dextrose
calories, 240 lipid calories
 Given: Minimum volume, 110g Protein (3.3g/kg), 800 dextrose
calories, 500 lipid calories (52kcals/kg)
Evaluation
Monitor
Assessment
Nutrition Diagnosis
Intervention
Nutrition Care Process: Monitoring and Evaluation
 Goals:
 Increase PO Intake
 Optimize enteral feedings to meet needs
 Decrease TPN to prevent refeeding syndrome
Significant weight gain
 Elevated glucose
 No refeeding

Evaluation
Assessment
Nutrition
Diagnosis
Monitor
Intervention
Nutrition Care Process: Monitoring and Evaluation
 Labs for Refeeding
Nutrition Care Process: Monitoring and Evaluation
 Expiration March 4th, 2012
 Discharge Diagnosis











Hypoxemic respiratory failure
Ischemic colitis
Clostridium difficile
Moraxella pneumonia
Rate-controlled atrial fibrillation
Profound malnutrition
GI bleed
Pulmonary HTN
Severe mitral regurgitation
Severe aortic stenosis
Anemia
 Malnutrition vs Age vs Other complications
Conclusions
 High risk patient
 Nutritional Problems:
 Profound malnutrition/cachexia
 Respiratory acidosis/ metabolic alkalosis
 Respiratory failure
 GI bleeds/anemia
 Nutrition Interventions
 Enteral/Parenteral nutrition support
 Monitoring and Evaluation
 Individualized TPN
 Correcting of malnutrition/cachexia
References

1. Escott-Stump S. Nutrition and Diagnosis-Related Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 300-301.

2.Mueller, DH. Medical Nutrition Therapy for Pulmonary Disease. In: Mahan KL, Escott-Stump S eds. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis,
MO: Saunders Elsevier; 2008: 899-918.

3. Chronic Obstructive Pulmonary Disease (COPD) Major Recommendations. Evidence Analysis Library: Academy of Nutrition and Dietetics.
http://www.adaevidencelDibrary.com. Accessed March 20, 2012.

4. Luque S, Berenguer N, Mateu de Antonio J, Grau S, Morales-Molina JA. Patients at risk of malnutrition: assessment of 11 cases of severe malnutrition with
individualized total parenteral nutrition. Farmacia Hospitalaria. 2007;31(4):238-242.

5. Hallin R, Gudmundsson G, Ulrik CS, et al. Nutritional status and longer-term mortality in hospitalized patients with chronic obstructive pulmonary disease.
Respiratory Medicine. 2007;101:1954–1960.

6. Lainscak M, Haehling SV, Doehner W, et al. Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive
pulmonary disease. J Cachexia Sarcopenia Muscle. 2011;2:81-86.

7. Pronsky ZM, Crowe JP Sr. Food Medication Interactions. 16th ed. Birchrunville, PA: FOOD-MEDICATION INTERACTIONS; 2010.

8. Litchford MD. Assessment: Laboratory Data. In: Mahan KL, Escott-Stump S eds. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders
Elsevier; 2008: 411 - 431.

9. ADA Nutrition Care Manual ®. www.nutritioncaremanual.org. Update October 2, 2010. Accessed March 6, 2012.

10. Nutrition Assessment: Patient Food Services Policies & Procedures ARAMARK Policy and Procedure. Updated March 10, 2010. Accessed March 13, 2012.

11. American Dietetic Association. Pocket Guide for International Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition
Care Process. Chicago, IL; 2011.

12 Kleinschmidt P, Brenner BE. Chronic Obstructive Pulmonary Disease and Emphysema in Emergency Medicine. Medscape Reference.
http://emedicine.medscape.com/article/807143-overview#a0199. Updated January 4, 2011. Accessed March 30, 2012.
Questions?