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

1. Case Report: Nutritional Management of Patient’s with Chronic Obstructive Pulmonary Disease By: Lauren Martin ARAMARK Dietetic Intern Bryn Mawr hospital April 6th, 2012

2. Disease Description • Evidence-Based Nutrition Recommendations • Case Presentation • Nutrition Care Process: • Assessment • Diagnosis • Interventions • Monitoring & Evaluation • Conclusions Overview

3. COPD Disease Description Etiology Epidemiology Pathology Clinical signs and symptoms Related co-morbidities

4. Etiology

5. 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

6. Pathophysiology

7. Clinical Signs & Symptoms Emphysema Chronic Bronchtitis Underweight and cachectic Hypoxia Normal hematocrit Corpulmonale develops much later SOB & wheezing Tissue destruction Chronic to mild coughing Normal weight or overweight Hypoxemia hematocrit Corpulmonale Excess mucus production SOB Inflamed bronchial tubes

8. Evidence-Based Nutrition Recommendations The academy of nutrition and dietetics evidence analysis Library Recommendations Literature review

9. AND EAL Major Recommendations

10. 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. FarmaciaHospitalaria. 2007;31(4):238-242.

11. 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. FarmaciaHospitalaria. 2007;31(4):238-242.

12. 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, 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.

13. 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.

14. 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.

15. 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.

16. Case Presentation

17. 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

18. Nutrition Care Process: ADIME

19. 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

20. 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

21. 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

22. 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

23. 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

24. Nutrition Care Process: Assessment

25. Nutrition Care Process: Assessment

26. Nutrition Care Process: Assessment • Biochemical Data, Medical Tests & Procedures • Respiratory acidosis, metabolic alkalosis

27. Nutrition Care Process: Assessment • Diagnosis-Related Group • “Other Severe Protein Calorie Malnutrition” • ARAMARK Classification Status • High – 20 points • Nutrient Needs

28. 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

29. 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)

30. Nutrition Care Process: Monitoring and Evaluation • Goals: • Increase PO Intake • Optimize enteral feedings to meet needs • Decrease TPN to prevent refeedingsyndrome • Significant weight gain • Elevated glucose • No refeeding

31. Nutrition Care Process: Monitoring and Evaluation Labs for Refeeding

32. 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

33. 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

34. 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. FarmaciaHospitalaria. 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.

35. Questions?