Chronic Obstructive Pulmonary Disease (COPD) with Respiratory Failure

By: Amrita Samra & Brittany Fellows

Prevalence of COPD
3rd leading cause of death in the United States About 13.5 million people have been diagnosed with COPD in the United States It is estimated an equal number are undiagnosed (1) Kills more women than breast cancer or diabetes (1) COPD is responsible for more than 120,000 deaths per year That equals 1 death every four minutes (2)
(1) (2) http://www.healthinaging.org/aging-and-health-a-to-z/topic:copd/ http://www.legislature.mi.gov/%28S%2854i4nn45wqtv1jmc3yhsi13h%29%29/documents/20112012/Journal/House/pdf/2012-HJ-11-28-075.pdf

Incidence COPD in the United States

millions)

(In

13.1

The incidence 8.9of COPD is on the rise

7.1

10.5

Source: U.S Centers for Disease Control and Prevention

Incidences of COPD vary depending on Geographic's

Can you guess why?

Because of the prevalence of smokers

Regions which have the lowest population of smokers also have a lower incidence of COPD

What is COPD?
COPD is an umbrella term used to characterize a group of abnormal inflammatory response in the lungs and partially obstruct airflow
COPD develops over time and continually worsens, lifestyle and medication can slow the progression but the damage is not reversible
Key Signs of COPD - Chronic cough - Increased mucous - Short of breath during physical activities

Key Point Airflow obstruction

Airflow: Oxygen & Carbon Dioxide

Inspiration: Lung Expands & Diaphragm Contracts Expiration: Lung Relaxes & Diaphragm relaxes

Oxygen is inhaled through the mouth and nose

Carbon dioxide goes through the capillary membrane and into the alveolar membrane Carbon dioxide continues on through the alveoli to the bronchioles

Goes down pass the trachea into the bronchi

Travels through the bronchioles to the alveoli

Up through the trachea

Through the alveolar membrane to the capillary membrane and into the blood

And exhaled through the mouth and nose

Chronic Bronchitis
Definition: Inflammation of the bronchial mucous membrane, characterized by cough, hypersecretion of mucus, and expectoration of sputum over a long period of time and associated with increased vulnerability to bronchial infection.
Inflammation of the bronchial results in the production of mucus Mucus clogs the airway making it difficult to breath This results in chronic coughing which causes more damage to the bronchial tubes
http://medical-dictionary.thefreedictionary.com/chronic+bronchitis

Emphysema
Definition: Emphysema is a chronic respiratory disease where there is overinflation of the air sacs (alveoli) in the lungs, causing a decrease in lung function, and often, breathlessness.
The walls of the alveoli become damaged and lose there elasticity, pockets of air called bullae are formed in damaged areas The damaged areas cause narrowing of the airways, making breathing difficult

Affecting the ability to exhale first and progressively the ability to inhale
http://medical-dictionary.thefreedictionary.com/emphysema

COPD is caused by.

Inflammation and damage to lung tissue caused by: Smoking (or 2nd hand) Pollution

Genetics
Stress
1. J. of Nutritional Biochemistry, Vol23, Issue7

Symptoms
Cough
Wheezing Hemoptysis Chest pain
Anemia Altered taste Fatigue Malaise Depression

Anorexia
Early satiety Weight loss Dyspnea Tachypnea

Assessing COPD
Preparing Meals Quality of life should be looked into as it pertains to the inability to cook and prepare meals (EAL).

Assessing Body Composition Can be done with BMI as a starting point, should not be the only indicator used for a patients status (EAL).

Assessing Calorie Needs Inflammation increases REE so more calories are needed for the patient (EAL).

http://andevidencelibrary.com/topic.cfm?cat=3708

Testing for COPD

Spirometry
Mild = >80% Moderate= 50-80% Severe = 30-50% Very Severe =<30%

X-ray
ABG
http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm http://copdcanada.ca/understanding_your_numbers.htm

Medications & Surgery

Surgery to remove a damaged part of the lung can be done to help the non-damaged part function normally.

Lung transplant (most severe)

http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm

Management & Prevention

http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm

Respiratory Quotient
Amount of CO2 produced/ amount of O2 consumed For glucose 1.0 For fat 0.7 For protein 0.8 RQ for conversion of glucose to fat >1.0

MNT for COPD

Calories:
Increased calorie needs with labored breathing/ malnutrition Overfeeding results in increased difficulty breathing for the patient, requires a balance

Protein:
1.2-1.7 g/kg/ per day

Diet recommendation to balance RQ:

15-20% Protein 30-45% Fat 40-55% CHO

Vitamin C Supplementation
Micronutrients: Vitamin C

Grade A Study: Randomized double-blind study done with COPD patients. Experiment: One control group given placebo, One experimental group given ascorbic acid for 14 days; Patients required to write daily symptoms of COPD in diaries Results: Severity of symptoms decreased as experiment went on; Vitamin C supplementation may work to decrease symptoms of COPD
http://web.ebscohost.com.mantis.csuchico.edu/ehost/detail?sid=5a1d0df0-0935-42ef-802d8f2c32193ce6%40sessionmgr113&vid=1&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=65430245

Vitamin D Supplementation
Micronutrients: Vitamin D

Grade C Study: Randomized case-control study done with COPD patients and patients w/out COPD
Experiment: COPD patients and non-COPD patients were split into two groups and Vitamin D levels were measured in both Results: COPD patients had severely lower levels of Vitamin D compared to patients w/out COPD

http://web.ebscohost.com.mantis.csuchico.edu/ehost/pdfviewer/pdfviewer?sid=6e2b4b7b-fcde-49cd-afe3a4477db40541%40sessionmgr115&vid=2&hid=122

Micronutrients
Smoker: Vitamin C Prevent Osteoporosis: Mg & Ca Mg & Phos (Monitor & supplement if low) Malnutrition & Meds: Vitamin D & K If Cor Pulmonale is present: Fluid restriction

Meet Mr. & Mrs. Hayato

Patient Information
Patient: Daishi Hayato Age: 65 Sex: Male
Ethnic background: Asian American Household Members: Wife Occupation: Retired manager of local grocery store

Chief Complaint
Patient was working in the yard and became very short of breath. Patients wife then called the doctor and was told to take him to the emergency room immediately.

Medical Diagnosis

Peripheral Vascular Disease with Intermittent Claudication

Acute Respiratory Distress

COPD

Nutrition Care Process

Assessment Monitoring & Evaluation

Diagnosis

Intervention

Step 1: Assessment
Medical History:
COPD secondary to chronic tobacco use, 2 packs per day for 50 years Limited exercise capacity due to dyspnea on exertion Intermittent claudication Total dental extraction 5 years ago Emphysema >10 years ago

Cholecystectomy 20 years ago

Step 1: Assessment
Medication Prior to Hospitalization: Combivent: 2 inhalations 4 times/day

Lasix: daily
Oxygen: L/hour via nasal cannula at night Risk Screening: Current Smoker: 2 packs per day for 50 years

Allergies:
Penicillin

Step 1: Assessment
Patient Report: General appetite is only fair Breakfast is normally his largest meal

Appetite has decreased for past several weeks

Usual Dietary Intake: AM: Egg, hot cereal or muffin, and hot tea with milk and sugar Lunch: Soup, sandwich, and hot tea with milk and sugar Dinner: Small amount of meat, rice, 2-3 kinds of vegetables, and hot tea with milk and sugar

24-Hour Recall: 2 scrambled eggs, few bites of Cream of Wheat, sips of hot tea, bite of toast

Ate nothing rest of day- sips of hot tea

Step 1: Physical Examination

General Appearance: Acutely dyspneic in acute respiratory distress Heart Rate: 118bpm (slightly elevated) Throat: trachea is shifted to the right Extremities: Cyanosis, with 1 + Edema Skin: Warm, dry to touch Chest/Lungs: harsh breath sounds over right chest w/absent sound on left side, use of accessory muscles at rest

Anthropometric Data
Weight: 122lbs 55kg Height: 54 64in. 163cm Usual Body Weight: 135lbs Ideal Body Weight: 130lbs 59kg

Body Mass Index: 21 (Normal)

Percent Ideal Body Weight: 90%(Adequate E stores)

Percent Usual Body Weight: 94% (Normal)

Calories: 66.5+(13.8x59kg)+(5x163cm) (6.8x65)= 1253.5 1253.5 X 1.3 X 1.4= 2281 kcals/day Based on Body Weight 1,475 2065 Kcals

Protein: 59kg x 1.6g/kg /protein per day= 94.4g of Protein/day

Laboratory Analysis
Acidosis Anemia Hemoglobin = 13.2(L) Anemia Hematocrit= 39(L) Anemia Transferrin 173(L) Result of low pH Anemia

Serum Protein

Albumin= 3.5 (Low end) PEM Prealbumin= 17 (Low end) PEM

ph = 7.22(L) Acidosis pCO2 = 66(H) Hypoventilation Acidosis pO2 = 57(L) Respiratory Failure HCO3(bicarbonate) = 37(H)

Hospital Course Story

Chest tube was inserted into the left thorax with drainage under suction. The oropharynx was cleared.

The patient was placed on ventilator with high flow oxygen, 15 breaths/min with an FiO2 of 100%.
Day 2: Enteral feedings initiated, however due to high residuals the patient was started on ProcalAmine. Day 4: Enteral feedings restarted Day 5: ProcalAmine discontinued Day 8: Enteral feedings discontinued and patient was weaned from ventilator Day 11: Discharged home Day 12: Patient meets with his new RDs

Step 2: Diagnosis

Inadequate energy intake (NI-1.4) related to shortness of breath and early satiety as evidenced by unintended weight loss, 24-hour recall, and patient report.

Step 3: Intervention
Nutrition Education: Recommended modifications (E-1.4) - Increase fat and protein, decrease carbohydrate - Small frequent meals

Nutrition Education: Nutrition relationship to health/ disease (E-1.4)

- Education on smoking, exercise, & nutrition
Coordination of Nutrition Care: Referral to community agencies (RC-1.4) -COPD support group/ Smoking support group

Nutrition Counseling: Social support (C-2.4) - Educate & Counsel patients wife on important modifications

Implementing Intervention
Recommended Modifications
We educated the patient on the importance of small frequent meals throughout the day to increase oral intake. Also educating the patient on the importance of high fat & protein and low carbohydrate to help manage oxygen levels.

Nutrition Relationship to Disease

Educated the patient on the relationship between smoking and the progression of COPD. Educated the patient on the benefits of exercise on dyspnea

Referral to Community Agencies

Refer patient to community support groups for COPD & smoking.

Social Support
Educated the wife about the importance of nutrition and calorie dense food choice Answering any questions or concerns she had

Patients Goals
After educating the patient and his wife on the importance of nutrition and lifestyle modifications the patient set personal goals to achieve such modifications. Goal 1: The patient and his wife agreed that every two hours she would offer a calorie dense meal, using the handout of high calorie recipes. Goal 2: The patient also decided to attend COPD & smoking support groups every other week for one month. Barriers:

The patients primary barrier was giving up smoking and does not wish to modify behavior at this time, but will supplement vitamin C as long as he continues to smoke. The patient was also concerned with tolerance of additional feedings, and agreed to trying oxygen support during meals if needed.

Action goals
Small frequent meals High fat & protein Low carbohydrate

COPD/Smoking support group

If trouble tolerating increased meals add oxygen during meal If continues smoking supplement vitamin C

Short Term Goals: Outcome goals

Increase fat & protein Increase overall kcals consumed orally Stabilize RQ value

Decrease dyspnea at meal time

Long Term Outcome Goals

Prevent malnutrition
Prevent PEM

Minimize progression of COPD

Education Materials

Simple recipes for increasing fat & protein

Tips for decreasing dyspnea

Scope ofIs Practice Tree This In Our Scope Requested Act or Service Of Practice?
1. Is it permitted? No or Not Sure Yes

2. Is it covered by any national or organizational explicit guidance?

No

Yes 3. Would it be reasonable for a dietetics practitioner to do? No 5. Can I demonstrate the knowledge, skill, and competence? Yes No

Yes

4. Do I personally have the education needed?

Yes

No
STOP Until additiona l educatio n acquired
Proceed if authorization documented

STOP Performance of activity or service may place dietetics practitioner and client at risk!

STOP Until current knowledge, skill, and competence demonstrated

STOP The accountability is not assumed! Notify appropriate person(s)

No

6. Do I accept responsibility and accountability for my Yes actions?

Monitoring & Evaluating

Anthropometric: Dry weight: biweekly Laboratory Analysis: Albumin & Prealbumin: biweekly pH, pCO2, pO2, HCO3-: biweekly Vitamin & Mineral Status: C, D, K, Mg, Ca++, Phos: Once a month Evaluate patients understanding and adherence through biweekly appointments. Using motivational interviewing to understand our patients ability and confidence to maintain changes. Assess barriers and patient concerns

Follow up Recommendations

Follow up biweekly with outpatient RD Support groups available weekly for COPD Support & Smoking sensation support

Approximately every four minutes someone dies from COPD

Approximately seven people died of COPD during this presentation

References
http://pats.atsjournals.org/content/8/4/363.full http://www.sciencedirect.com/science/article/pii/S095528631100132X
http://andevidencelibrary.com/topic.cfm?cat=3708

http://web.ebscohost.com.mantis.csuchico.edu/ehost/pdfviewer/pdfviewer?sid=6e2b4b7b-fcde-49cd-afe3a4477db40541%40sessionmgr115&vid=2&hid=122
http://web.ebscohost.com.mantis.csuchico.edu/ehost/detail?sid=5a1d0df0-0935-42ef-802d8f2c32193ce6%40sessionmgr113&vid=1&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=65430245 http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm http://copdcanada.ca/understanding_your_numbers.htm http://medical-dictionary.thefreedictionary.com/emphysema