Transcript case study 97

• Chronic Obstructive Pulmonary Disease
o Progresive obstruction of airways
• Emphysema
o Desruction of alveoli walls
o Abnormal and permanent elargement of alveoli
• Chronic Bronchitis
o chronic and productive cough
o Inflammation of bronchi
• Decreased recoil of alveoli
walls
• Irreversible
• Causes difficulty exhaling
o Leads to hypercapnia
• Mild hypoxemia and normal
Hematocryt
• Can lead to Cor Pulmonale
o Right sided heart failure
due to enlargement of
vesicles brought on by
stress associated with
chronic lung disease
• Typical Patient: older, thin, smokers
• Inflammation of bronchi due to changes in
lung tissues
• Hypoxemia and elevated Hematocryt
• Development of Cor Pulmonale occurs
early
• Typical Patient: Normal to overweight
• Tobacco smoke
• Environmental pollution
• Genetics
Medications for Treatment
• Bronchodialators
o Decrease shortness of breath by opening
and relaxing airways
• Coticosteroids
o Can be inhaled or in pill form
o Decrease inflamation of bronchi
• Patients have increased resting energy expenditure
•125%-156% above BEE
•Protein 1.2-1.7 g/kg
•In hospital pt usually requires support feeding
•Recommend vitamin consumption: C, A , E and Beta
Carotene
Catabolic/Anabolic Balance and Muscle Wasting in
Patients With COPD.
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Evaluated the relationship between levels of catabolic
factors(interleukin, cortisol), anabolic factors (bioavailable
testosterone, dehydroepiandrosterone sulfate, and insulin-like
growth factor), and mid-thigh muscle cross-sectional area in
patients with COPD to classify levels of muscle wasting
45 men diagnosed with COPD and 16 healthy, sedentary men
participated
22% of participants with COPD exhibited elevated levels of
testosterone (campared to 0% of control)
COPD patients had lower DHEAS levels than healthy
participants
Ratios of catabolic factors to anabolic factors were greater in
COPD patients
o Shifting toward a catabolic state and possible muscle
wasting
Debigaré, Richard; Marquis, Karine; Côté, Claude H.;
Tremblay, Roland R.; Michaud, Annie; LeBlanc, Pierre; Maltais,
François. Catabolic/Anabolic Balance and Muscle Wasting in
Patients with COPD. CHEST, Jul2003, Vol. 124 Issue 1, p83
Dietary support to underweight patients with
end-stage pulmonary disease assessed for lung
transplantation
• Randomized Control Study
•Test 71 paitents
•49 Under weight
•29 Normal weight
• Study found that underweight group given a calorie dense
meal with supplement lead to an average of 1.2 kg weight gain
in 13 days
Both generic and disease specific health-related
quality of life are deteriorated in patients with
underweight COPD.
• Cohort Study
• Patients were COPD stable and getting once a month check- ups
• Study Found that underweight participants had a lower quality of life
rating due to shortness of breath, inability to exercise and bodily pain
Investigation into the nutritional status, dietary
intake and smoking habits of patients with
chronic obstructive pulmonary disease.
• Cross Sectional Study
• Split 103 participants into 2 groups: Nourished and Malnourished
• Malnourished group
•Lower lung function
•More Dietary problems
•Lower nutritional intake compared to counter parts
Age: 65
Sex: Male
Chief Complaint:
Shortness of breath due to emphysema
Medical History:
Emphysema 10 years
COPD due to Tobacco Use
Admitting Medical Diagnosis:
Chest Radiograph shows tension
pneumothorax in left lung
Daishi Hayato
Family status: Married, four grown Children
•Wife prepares meals
•She reports appetite decline in past several weeks
Ethnicity: Asian American
Education: Bachelor’s Degree
Occupation: Retired Grocery Store Manager
Religious Affiliation: Methodist
Smokes 2 ppd for past 50 years
•Continues to smoke
Anthropometrics Ht: 64”
BMI: 20.9 normal
Wt: 122 lbs
IBW: 130 lbs
UBW: 135
%IBW: 94% normal
% UBW: 90% mildly depleted energy stores
Vitals
Allergies
Respiration Rate:
Blood Pressure:
Temperature:
Heart Rate:
LDL/ HDL :
Penicillin
36 breaths per min
110/ 80
97.6 °F
118 bpm
142/32
•COPD secondary to tobacco use
•Emphysema diagnosed more than 10 yrs ago
• Cholecystectomy 20 yrs ago
• Total dental extraction 5 yrs ago
• Intermittent claudication
•Reports swelling in lower extremities
• History of dyspnea
•Two pillow orthopnea
• Family History
•Father suffered from lung cancer
Combivent Inhaler - 2 inhalations 4x a day
• Bronchiodilator
• Potential risk if allergic to: peanuts, soy and soy lecithin
• Caution if taken with diuretics
Lasix – 40 mg daily
• Diuretic
• Decrease strain on blood vessels and heart
• May reduce potassium levels in blood
• Increase sensitivity to sun
Oxygen – 2 L/hr via nasal cannula only at night
Kcal needs:
(66.5 + (13.8 x 55.45kg) + (5 x 137.16 cm) – (6 x 65)) x 1.2 x 1.6 = 2165 kcals
Usual Intake
• Breakfast
•Egg
•Hot Cereal
•Bread or Muffin
•Hot Tea w/ milk and sugar
•Lunch
•Soup
•Sandwich
•Hot Tea w/ milk and sugar
•Dinner
•Small amount of Meat
•Rice
•2-3 types of Vegetables
•Hot Tea w/ milk and sugar
* No known food allergies
24 Hour Recall
•Breakfast
•2 scrambled Eggs
•Few bites cream of wheat
•Bite of toast
•Sips of hot tea
throughout the day
•Ate Nothing Else
• Estimated Calorie
Intake: 400-500 calories
* No Daily Vitamin Intake
According to the American Lung Association a person with COPD
requires 10 times as many calories to breathe than a healthy person.
(Trendel)
Pros:
•Allows for adequate
calorie intake
• Provides for sufficient
high protein needs
•Gives patient fluids
•Maintains integrity of
the gut!
•Eliminates meal time
stress (Katsura et al
2005)
Cons:
•Discomfort for patient
Inadequate oral food and beverage intake (NI-2.1) related to difficulty
swallowing (NI-1.1) due to dyspnea as evidenced by unintentional weight
loss of 13 lbs, patient food recall and limited appetite.
ND-1: Modify distribution, type, or amount of food and nutrients within
meals or specified time
1. Diet
• Small frequent calorically dense meals high in protein
• 15-20% Protein
• 30-45% Fat
• 40-55% Carbohydrates
• Avoid foods that lower LES pressure (Barrett)
• Avoid gas producing foods that cause stomach to push on diaphragm
• Avoid sodas
• Avoid alcohol
• Eat slowly, chew well, rest before meal time
• Use Oxygen during and after meal time (Wouters)
• Add a dietary supplement at meal time (Forli et al 2001)
• Especially Vitamin C
• Breakfast:
•Eggs
• Oatmeal with Peanut Butter
•Whole Wheat toast with Peanut Butter
•Orange Juice
•Hot Tea (caffeine Free) with multivitamin
•Mid Morning Snack
•Ensure
•Lunch
•Usual Sandwich
•Yogurt
•Hot Tea
•Mid Afternoon Snack
•Rice and Beans
•Water
•Dinner
•Meat (in small pieces)
•Veggies
•Mashed potatoes
•Hot Tea
1. Supplemental Feeding
• High Protein, High Calorie supplemental
2. Nutrition Education
• Suggest trying to limit smoking ?
• Educate what are gas producing foods
• Foods that lower LES pressure
• Smart eating behavior
• Encourage family support and involvement
Short Term
• Prevent additional weight loss
• Regain 5 lbs within 1 month
•Increase food intake to minimum caloric needs of 2165 kcals per day
Long Term
• Return UBW within 6 months
• Increase physical activity to 15 minutes a day
Monitor and Evaluation of Goals:
• Patient to return in 2 weeks with wife to check anthropometrics, food intake
and diet tolerance
• Once significant progress change to monthly check up
Katsura H, Yamada K, Kida K. Both generic and disease specific health-related
quality of life are deteriorated in patients with underweight COPD. Respiratory
Medicine 2005;99:624-30.
Forli L, Pedersen JI, Bjortuft O, Vatn M, Boe J. Dietary support to underweight
patients with end-stage pulmonary disease assessed for lung
transplantation. Respiration 2001;68(1):51-7.
Regional COPD Working Group. COPD prevalence in 12 Asia–Pacific countries
and regions: Projections based on the COPD prevalence estimation model.
Respirology. June 2003, Vol. 8, Issue 2, Pgs. 192-198
Cai B, Zhu Y, Ma Y, Xu Z, Zao Y, Wang J, Lin Y, Comer GM. Effect of
supplementing a high-fat, low-carbohydrate enteral formula in COPD
patients. Nutrition 2003;19(3):229-232.
Wouters, Emil, Creutzberg, Eva, Schols, Annemie. Systemic Effects in COPD.
CHEST May 2002. Vol 121, Issue 5 Supplement. Pgs. 127S-130S
More References
Debigaré, Richard; Marquis, Karine; Côté, Claude H.; Tremblay, Roland R.;
Michaud, Annie; LeBlanc, Pierre; Maltais, François. Catabolic/Anabolic
Balance and Muscle Wasting in Patients with COPD. CHEST, Jul2003, Vol.
124 Issue 1, p83
Cochrane WJ, Afolabi OA. Investigation into the nutritional status,
dietary intake and smoking habits of patients with chronic obstructive
pulmonary disease. J Hum Nutr Diet 2004;17(1):3-11