Respiratory Failure: Individual Patient Case Study

1. Respiratory Failure: Individual Patient Case Study Holly Dinh, Dietetic Intern Houston San Jacinto Methodist Hospital The University of Texas Medial Branch Nutrition & Metabolism

2. Overview • Respiratory Failure: Pathophysiology • Mechanical Ventilation • Medical Management/Relevance of Nutrition • Background • Nutrition Assessment • Client History • Food & Nutrition Information • Nutrition Diagnosis • Nutrition Prescription • Nutrition Intervention • Goals • Monitoring and Evaluation • Results • Summary & Conclusion • References

3. Respiratory Failure: Pathophysiology • Respiratory failure is a condition in which not enough oxygen passes from your lungs into your blood. Your body’s organs, such as your heart and brain, need oxygen-rich blood to work well. (NHLBI, 2011) • It can also occur if your lungs can’t properly remove carbon dioxide(CO2) from your blood. Too much CO2 in your body can cause harm to your organs. (NHLBI, 2011) • Symptoms can include: • Short of breath (SOB) • Rapid breathing • Confusion • Cyanosis (NHLBI, 2011)

4. Mechanical Ventilation • Patients with acute respiratory failure frequently require intubation and mechanical ventilation to sustain life. (Burns et al., 2013) • Important to minimize time on vent, due to complications that can occur such as: • Respiratory muscle weakness • Ventilator-associated pneumonia (Burns et al., 2013) (NHLBI, 2011)

5. Medical Management/Relevance of Nutrition • Millions of people are affected by acute respiratory failure every year in the U.S., requiring mechanical ventilation. (Rice et al., 2011) • Patients requiring mechanical ventilation usually require potential nutrition support. (Rice et al., 2011) • Studies suggest enteral nutrition supports the structural and functional integrity of patients in the ICU compared to parenteral nutrition. (Rice et al., 2011)

6. Medical Management/Relevance of Nutrition • A multi-professional team approach can help make appropriate enteral tube feeding recommendations to meet the patient’s estimated needs. (Shaw et al., 2015) • Nutritional support has been shown to have a positive effect on quality of life, particularly in those who are malnourished. (Shaw et al. 2015)

7. Patient Timeline • Clinical Symptoms: • Patient came in with SOB – respiratory distress • Daughter heard “lungs crackle” days before • Patient unable to sleep well • At Emergency Department: • Was then intubated • History obtained from daughter

8. Physical Assessment • Overall appearance: cachectic • Body language: lethargic • Skin: normal color, warm and dry • Head & Neck: supple, trachea midline, thyromegaly • Cardiovascular: regular & rhythm, no murmurs • GI: soft; non-tender; PEG tubeplaced in mid upper abdomen • Respiratory: respirations non-labored; rales; rhonchi; on ventilator • Musculoskeletal: normal strength and range of motion, muscle wasting • Neurological: alert and oriented, with intact reflexes and sensations, normal strength, responds to verbal commands • Wound • Pressure ulcer, sacral spine, stage I

9. Vital Signs • Respirations (breaths/min) 22 • SpO2 (%) 100 • Non-Invasive Systolic 139 • Non-Invasive Diastolic 68 • B/P Site Left Arm • B/P Position Supine • Heart Rate (beats/min) 87 • Device Ventilator • Temp (degrees F) 98 • Temp (degrees C) 36.6 • Temperature Site Temporal

10. Nutritional Status: Initial Assessment • Anthropometric Measurements • Height, weight, BMI • Pertinent lab values, tests/ procedures • Ex. Glucose, BUN/Cr, Computed Tomography (CT) etc. • Nutrition-Focused Physical Findings • Bowel movements (BM), PO intake • Food/Nutrition-Related History • Ex. Indications of dysphagia, dehydration • Client History • Past medical history, past surgical history

11. Assessment: Client History • Past Medical History: • HTN, MI, thyroid problem, CHF, CVA, CAD • Past Surgical History • Carotid endarterectomy, PEG tube, heart catheterization, appendectomy, cholecystectomy • Family Medical History: • Mom- heart disease, Dad- lung cancer (CA), sister- CA • Allergies: • Penicillins, benadryl allergy sinus, phenobarbital, sulfonamides, iodine, aspirin, lasix

12. Patient’s PEG tube history • 2/26/15: Patient had cardiac arrest/stroke, which left her with residual deficit with swallowing • PEG tube was placed • Has been on tube feedings (TF) • A PEG tube is considered a more secure method of feeding stroke patients who require longer-term nutritional support. (Rowat, 2015) • In systematic reviews, PEG TF was associated with fewer treatment failures, less GI bleeding, and higher delivery of feeding for stroke patients . (Rowat, 2015)

13. Anthropometric Assessment Patient: • Age: 84 years old • Female • Height: 65” / 5’5” • Weight: 97.2 lbs / 44 kg • BMI: 16.2  Underweight Status • BMI goal: 18.5 kg/m^2 healthy body weight • IBW: 125 lbs +/- 10%

14. Medication Record • Home Medication: • Levothyroxine – Synthroid • Pantoprazole – Protonix • Lipitor – Atorvastatin • Bumetanide – Bumex • Carvedilol – Coreg • Hospital Medication: • Bumetanide – Bumex • Carvedilol – Coreg • Levothyroxine – Synthroid • Pantoprazole – Protonix • Spironolactone – Aldactone • Vitamin C • Clopidogrel – Plavix • Simvastatin – Zocor • Docusate sodium – Colace

15. Weight History

16. Biochemistry Assessment: Lab Values

17. Biochemistry Assessment: Lab Values

18. Nutrition Assessment • Using current weight of 44 kg, BMI: 16.2 kg/m^2: • 1540-1760 kcal (35-40 kcal/kg) • 57-66 g protein (1.3-1.5 g protein/kg) • 1540-1760 mL fluid (~1 mL/kcal) • BMI goal: 18.5 kg/m^2 healthy body weight • IBW: 125 lbs +/- 10%

19. Nutrition Assessment: Food & Nutrition Information • PEG Tube Feedings (TF): At home • 4 (250 ml) cartons of Nutren 2.0 • 2000 kcal +80 g protein • 114% of estimated kcal needs and 121% of estimated protein needs

20. Nutrition Assessment: Food & Nutrition Information • PEG Tube Feedings (TF) Orders: Hospital Admission • 3/30/15 • Fibersource HN @40 ml/hr • 1152 kcal + 52 g protein • 65% of estimated kcal needs and 79% of estimated protein needs • 4/3/15 • Fibersource HN @55 ml/hr • 1584 kcal + 71 g protein • 100% of estimated kcal needs and 108% of estimated protein needs

21. Nutrition Diagnosis • PES Statements: • 3/30/15 • Inadequate enteral nutrition infusion (NI-2.3) related to food and nutrition related knowledge deficit concerning appropriate tube feed formula rate as evidenced by tube feed providing 65% of estimated kcal needs and 79% of estimated protein needs on initial assessment. • 4/3/15 • Inadequate enteral nutrition infusion (NI-2.3) related to compromised PEG tube as evidenced by tube feed being on hold until PEG tube is fixed.

22. Nutrition Prescription • Estimated Energy Needs • Using current weight of 44 kg, BMI: 16.2 kg/m^2: • 1540-1760 kcal (35-40 kcal/kg) • 57-66 g protein (1.3-1.5 g protein/kg) • 1540-1760 mL fluid (~1 mL/kcal) • Patient on TF 2’ history of stroke • Patient at risk for malnutrition 2’ weight loss • Haven’t been meeting needs for TF during hospital stay

23. Nutrition Intervention • 3/30/15 • Recommend to increase Fibersource HN to goal rate of 55 ml/hr to provide 1584 kcal + 71 g protein + 1070 ml free water over 24 hours • 4/3/15 • Recommend to continue current TF order of Fibersource HN @ 55 ml/hr, once PEG tube placed properly. • Suspended TF • Interventional Radiology(IR) consult

24. Goals of Nutrition Intervention • Verify TF order is being provided at goal rate to meet patient’s nutritional needs • Patient will be able to tolerate TF at goal rate without substantial amount of residuals • Adequate nutrition may help halt the development or worsening of pressure ulcers (Cox et al., 2014) • Patient will gain weight to be in normal BMI range

25. Monitoring & Evaluation Plan • Will follow up with patient to: • Monitor TF rate/tolerance • Ask RN if patient has had any residuals with TF • Monitor daily weight through electronic medical records • Monitor status of wound • Check in with Physical Therapy (PT) • Monitor patient’s labs for abnormal values

26. Results of Monitoring • 3/30/15 • Fibersource HN running at 40 ml/hr • Tolerated TF well with no complaints • 3/31/15 • Fibersource HN running at goal rate of 55 ml/hr • TF recently increased by MD • 4/1/15 • Fibersource HN running at goal rate of 55 ml/hr • Per RN, patient has been tolerating TF well w/no residuals • 4/2/15 • Fibersource HN of 55 ml/hr ordered • TF on hold 2’ angioplasty procedure • Per RN, will resume TF once procedure is done • 4/3/15 Discharge Day! • Fibersource HN of 55 ml/hr ordered • TF was withheld again 2’ improper PEG tube placement • IR consult

27. Summary & Conclusion • Patients on mechanical ventilation have higher estimated needs. • A Registered Dietitian is needed to make ample tube feeding recommendations for patients. • Enteral nutrition can help stroke patients sustain life by providing vital nutrition, hydration, and medication. • A PEG tube feed is considered a more secure method for stroke patients who require long-term nutrition support. • Adequate nutrition can help prevent and heal pressure ulcers – wounds.

28. References What Is Respiratory Failure? National Heart, Lung, and Blood Instiute Web site. http://www.nhlbi.nih.gov/health/health-topics/topics/rf Published 2011. Accessed April 4, 2015. What To Expect While on a Ventilator. National Heart, Lung, and Blood Institute Web site. http://www.nhlbi.nih.gov/health/health-topics/topics/vent/while Published 2011. Accessed April 4, 2015. Burns KE, Meade MO, Premji A, Adhikari NK, et al. Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure. The Cochrane Collaboration. 2013; 10.1002/14651858. Rice TW, Mogan S, Hays M, Bernard GR, Jensen GL, Wheeler AP, et al. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Critical Care Medicine. 2011; 39;967-974. Shaw C, Eldridge L, et al. Nutritional considerations for the palliative care patient. International Journal of Palliative Nursing. 2015; 21;7-15. Cox J, Rasmussen L, et al. Enteral Nutrition in the Prevention and Treatment of Pressure Ulcers in Adult Critical Care Patients. Critical Care Nurse. 2014; 34;15-27. Rowat A. Enteral tube feeding for dysphagic stroke patients. British Journal of Nursing. 2015; 24-138-45.