BY: LAUREN MARTINARAMARK DIETETIC INTERN

BRYN MAWR HOSPITALAPRIL 6 T H , 2012

Case Report: Nutritional Management of Patient’s with Chronic Obstructive

Pulmonary Disease

Overview

Disease DescriptionEvidence-Based Nutrition

RecommendationsCase PresentationNutrition Care Process:

Assessment Diagnosis Interventions Monitoring & Evaluation

Conclusions

ETIOLOGYEPIDEMIOLOGY

PATHOLOGYCLINICAL SIGNS AND SYMPTOMS

RELATED CO-MORBIDITIES

COPD Disease Description

Etiology

COPD

Asthma

Smoking: emphysem

a or chronic

bronchitis

Pollution

Metabolic disorders

Alpha-1 antitrypsin deficiency

Epidemiology

Forth leading cause of deathAffects 32 million people6th leading cause of death worldwide~ 440,000 deaths/year due to smokingMen 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

Emphysema Chronic Bronchtitis

Underweight and cachectic Hypoxia Normal hematocrit Cor pulmonale develops

much later SOB & wheezing Tissue destruction Chronic to mild coughing

Normal weight or overweight

Hypoxemia hematocrit Cor pulmonale Excess mucus production SOB Inflamed bronchial tubes

Clinical Signs & Symptoms

THE ACADEMY OF NUTRITION AND DIETETICS EVIDENCE ANALYSIS LIBRARY RECOMMENDATIONS

LITERATURE REVIEW

Evidence-Based Nutrition Recommendations

AND EAL Major Recommendations

COPD

Prevention of

weight loss

Assess quality of

life

Use BMI & weight changes

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

long-term 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, otherHallin 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 quartilesConclusion

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 exacerbationRespiratory failure, intubation, sedation, extubation,

deathAdditional 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

Assessment

Nutrition Diagnosis

Intervention

Monitor

Evaluation

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

Assessment

Nutrition Diagnosis

Intervention

Monitor

Evaluation

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

Assessment

Nutrition Diagnosis

Intervention

Monitor

Evaluation

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

Assessment

Nutrition Diagnosis

Intervention

Monitor

Evaluation

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 AST: 42U/L - Liver function BNP: 485pg/Ml – Heart failure

Assessment

Nutrition Diagnosis

Intervention

Monitor

Evaluation

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

Nutrition Diagnosis

Intervention

Monitor

Evaluation

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)Assessment

Nutrition Diagnosis

Intervention

Monitor

Evaluation

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

Assessment

Nutrition Diagnosis

Intervention

Monitor

Evaluation

Labs for Refeeding

Nutrition Care Process: Monitoring and Evaluation

Nutrition Care Process: Monitoring and Evaluation

Expiration March 4th, 2012Discharge 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 patientNutritional 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?