Transcript Case Study: Nutrition Management of Aspiration Pneumonia

Case Study: Nutrition Management
of Aspiration Pneumonia
Renee (Pik Shan) Fung
Dietetic Intern
ARAMARK Healthcare
Distance Learning Dietetic Internship
Maple Grove Hospital
Disease Description
Definitions
 Aspiration- the inhalation of oropharyngeal or gastric
contents into the larynx and lower respiratory tract
 Aspiration Pneumonitis- Chemical injury caused by
the inhalation of sterile gastric contents
 Aspiration Pneumonia- Infectious process caused by
the inhalation of oropharyngeal secretions that are
colonized by pathogenic bacteria
Aspiration
 Aspiration can cause serious illnesses and even death.
 Four common problems of aspiration:
 1. Failure to distinguish aspiration pneumonitis from
aspiration pneumonia
 2. Tendency to consider all pulmonary complications of
aspiration as infectious
 3. The failure to identify the spectrum of pathogens in
patients with infectious complications
 4. Misconception that aspiration must be witnessed for
it to be dx.
Etiology
 Half of all healthy adults aspirate.
 The human body is capable of removing foreign
objects by coughing
 Individuals who have problem with removing foreign
objects properly are at risk of developing aspiration
pneumonia/ pneumonitis
Pathophysiology
 Common cause of aspiration pneumonia is the
inhalation of Haemophilus influenza and Streptococcus
Pneumonia.
 They are colonized in the nasopharynx or
oropharynex before they are aspirated.
Pathophysiology
 Since aspiration pneumonitis is the inhalation of
sterile gastric contents, bacterial infection does not
play an important role at early stage.
 At a later stage of aspiration pneumonitis, bacterial
colonization may occur if the individual has
gastroparesis, small-bowel obstruction, receives
enteral feedings, or has higher pH gastric acids. In this
case, the individual has aspiration pneumonia.
Aspiration Pneumonia Diagnosis
 Signs/symptoms: (signs of aspiration) Persistent
cough and fever. However, many times silent
aspiration can develop. In aspiration pneumonia, the
episode of aspiration is generally not witnessed.
 Swallowing evaluation by an SLP
 CT scan- radiographic evidence of foreign material
infiltrating in patient’s lungs (some may be
undetectable)
Individuals who are at risk of
aspiration pneumonia
 Currently, there are no recognized guidelines for risk factors of aspiration
pneumonia
 Elderly
 Neurologic Dysphagia
 Unconscious individuals
 Individuals at hospitals
 Disruption of the gastroesophageal junction
 Abnormalities of the upper GI tract
 Poor oral care individuals
 Patients with stroke
 After the removal of an endotracheal tube due to residual effects or sedative
drugs, the presence of an NG tube, and swallowing dysfunction related to
alterations of upper-airway sensitivity, glottic injury, and laryngeal muscular
dysfunction
Co-morbidity
 Increased LOS
 Increased cost
 Increased morbidity and mortality
Decrease aspiration pneumonia
complication
 Early detection of patents who are at risk of or have
aspiration pneumonia
 SLP evaluation
 Barium swallow
 CT scan
 Provide appropriate care
Evidenced Based Nutrition
Recommendations for Aspiration
Pneumonia
AND Evidence Analysis Library and
the A.S.P.E.N
 30-45 degree head of bed elevation position
 Promotility agents
 AND: if >500 mL GRV
 A.S.P.E.N: If >250 mL GRV
 E.g. Metoclopramide and Erythromycin
 Associated with reduced GRV in critically ill pts
 Recommend to be used in critically ill pts who
experience feeding intolerance (high gastric residuals,
emesis)
Horiuchi A, et al (2013) – Elemental diets may reduce
the risk of aspiration pneumonia in bedridden
gastrostomy-fed patients
 Hypothesis: Elemental diets may be useful for the
prevention of aspiration pneumonia possibly through
more rapid gastric emptying than standard liquid
diets.
 This study is separated into 2 different parts.
Horiuchi A, et al – Elemental diets may reduce the risk of aspiration
pneumonia in bedridden gastrostomy-fed patients
PART 1
 Participants:
 128 Bedridden PEG participants
 Age: Average 80 years old
 Gender: 60 of the participants were male.
Method:
60 subjects were assigned to elemental diet group
67 subjects were assigned to the standard liquid diet group.
Record subjects who experienced aspiration and aspiration
pneumonia
Horiuchi A, et al – Elemental diets may reduce the risk of aspiration
pneumonia in bedridden gastrostomy-fed patients
PART 1
 Result:
 The number of patients who had diet aspirated from
the trachea or who developed new aspiration
pneumonias in the elemental group was significantly
less than the standard liquid diet group.
Horiuchi A, et al – Elemental diets may reduce the risk of aspiration
pneumonia in bedridden gastrostomy-fed patients
PART 2
 Randomized, crossover trial which focused on
identifying the gastric emptying velocity differences
between the two diets via PEG
 Participants:
 19 PEG subjects
Horiuchi A, et al – Elemental diets may reduce the risk of aspiration
pneumonia in bedridden gastrostomy-fed patients
PART 2
Result:
 Elemental diets were associated with more rapid
gastric empting.
Possibly due to:
 Fatty diet takes longer time to empty and is associated
with gastroesophageal regurgitation. Standard liquid
diet has higher fat content than elemental diet.
Horiuchi A, et al – Elemental diets may reduce the risk of aspiration
pneumonia in bedridden gastrostomy-fed patients
Limitation:
 Study 1 had increased risk of bias because it was
neither randomized nor blinded
 Study 2 could not prove the hypothesis by itself
 Participants in study 1 included those who had
pervious experience of aspiration which suggested
that they can be generalized.
 Study 2 might have “carry-over” issues between
treatments.
Horiuchi A, et al – Elemental diets may reduce the risk of aspiration
pneumonia in bedridden gastrostomy-fed patients
 In summary, this study found elemental diets to be
associated with reduced episodes of aspiration and
more rapid gastric empting among bedridden PEG
patients. Nevertheless, further research is needed to
prove whether or not there is a causation effect
existing between rapid gastric empting and reduced
episodes of aspiration and aspiration pneumonia.
Jiyoung J, et al (2013) - Effect of gastric versus post-pyloric
feeding on the incidence of pneumonia in critically ill patients:
observations from traditional and Bayesian random-effects
meta-analysis.
 Examined the effect of gastric versus post-pyloric feeding on the incidence
of pneumonia in critically ill patients.
Method:
 2 reviewers reviewed and selected studies searched from MEDLINE,
EMBASE, Web of Science, and CCTRD. The reviewers then compared gastric
and post-pyloric feeding in critically ill patients.
Selection Criteria:
 Trails should report at least one of the following outcomes: incidence of
pneumonia, vomiting, or aspiration, and studies that were published in any
language. Selected studies were all published in English and were from
Canada, Australia, Italy, Spain, Taiwan, and the USA. The selected studies
included patients from general ICUs, pediatric ICU, neurological ICU, and
severe acute pancreatitis from gastroenterology.
Jiyoung J, et al - Effect of gastric versus post-pyloric feeding
on the incidence of pneumonia in critically ill patients:
observations from traditional and Bayesian random-effects
meta-analysis.
Result:
 The incidences of pneumonia were 16.3% in the post-pyloric
feeding group and 26.1% in the gastric feeding group (P =
0.001).
 There was no significant differences in the beneficial effect
of the post-pyloric feed location (duodenum (P=0.03)
versus jejunum (P= 0.07).
 there was no significant difference between post-pyloric
feeding group and gastric feeding group in the amount of
aspiration (P= 0.55) and vomiting (P = 0.56) incidence.
Jiyoung J, et al - Effect of gastric versus post-pyloric feeding
on the incidence of pneumonia in critically ill patients:
observations from traditional and Bayesian random-effects
meta-analysis.
Limitation
 Not all outcomes in the selected studies were reported.
 Many of the studies were not good qualities.
 For example, potential biases may exist in the selected
studies, clinical heterogeneity in the studies that may account
for the statistical heterogeneity that were found in this study
which could have affected the result, and not all studies
reported adequate concealment, blinding of participants, and
outcome assessment.
 The amount of eligible studies was relatively small. (757
pts; 15 studies)
Jiyoung J, et al - Effect of gastric versus post-pyloric feeding
on the incidence of pneumonia in critically ill patients:
observations from traditional and Bayesian random-effects
meta-analysis.
In summary, Jiyong J, et al suggested that critically ill
patients with post-pyloric feeding is associated with
reduced incidence of pneumonia when compared with
gastric feedings. Meanwhile, there is no significant
difference in incidence of neither aspiration nor
vomiting between the two groups. Finally, no significant
beneficial difference was found between post-pyloric
feeds to the jejunum or duodenum.
Case Presentation
Case Presentation
 58 yrs old F
 Lives at group home
 Aspiration noted by group home manager. Patient
had continuous coughing and developed a fever.
Patient was admitted to the ER the next day
Nutrition Care Process- Assessment
Client Hx
 Mental Retardation
 Epilepsy
 Schilder’s cataract
 Hypothyroidism
Family Hx
Unknown; pt was in foster care since the age of 2
DNR status
Nutrition Care Process- Assessment
 Food/ Nutrition-Related Hx
 Patient consumes a ground diet (Dysphagia 2) with
honey thickened liquids for the past 15 yrs due to
recurrent aspirations
 NKFA
 Upon admission, patient was provided with calcium + vit
D pills, D5W NS @ 125 mL/hr, Colace, Synthroid,
Protonix, Miralax, and Propofol ranging 7-10 mL/hr
Nutrition Care Process- Assessment
 Nutrition-Focused Physical Findings



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
Patient had gained 14 lbs in 2 days.
Patient has fluid retention.
Skin integrity: minor impairment
Appetite: Fine prior to aspiration episode
SLP recommended patient to be NPO besides
medications are crushed into applesauce.
 Patient unable to self-feed
Nutrition Care Process- Assessment
Anthropometric Measurements
 UBW: Unable to obtain d/t patient’s mental state
 Height: 4’10”
 IBW: 95 lbs +/- 10%
 BMI: 28.5 – overweight
 *Patient is retaining fluid, weight may not be a good
indicator for nutrition status
Nutrition Care Process- Assessment
Biochemical Data, Medical Tests, and Procedures
 A swallowing evaluation was performed by the SLP.
The SLP noted signs and symptoms of aspiration
 The patient will have an OJ tube placed for short-term
nutrition support.
 A chest x-ray was done before patient being
intubated.
Lab Results
Component
Value Norm Date
al
Rationale
ALBUMIN
g/dL
GLUCOSE
mg/dL
GLUCOSE
3.0* 3.5-5 9/25/2013
Malnutrition, acute inflammation
91
9/27/2013
GLUCOSE
116*
9/26/2013
Elevation due to stressed state
9/27/2013
Check for hydration status
9/27/2013
GI loss, malabsorption
94
70110
9/27/2013
SODIUM
139
mEq/L
POTASSIUM 3.2*
mEq/L
PHOSPHORUS 3.1
136145
3.55.5
9/25/2013
Check for re-feeding syndrome risk
MAGNESIUM
mg/dL
CHLORIDE
mEq/L
CALCIUMSER
UM mg/dL
BUNUREANR
O
CREATININE
mg/dL
2.0
1.8-3 9/25/2013
Check for re-feeding syndrome risk
106
95105
7.6* 9-11
9/27/2013
Check for fluid/ acid-base imbalances
9/27/2013
Low serum calcium; Corrected Ca: 8.4*
19*
9/27/2013
Malnutrition
9/27/2013
Check for kidney function
1.15
0.61.2
Nutrition Care Process- Assessment
 Nutrition Need
 Calories: 1300 kcal (30kcal/kg IBW)
 Protein: 65-86 gm (1.5-2 gm/kg IBW)
 Fluids: 1300 mL
Nutrition Classification:
Severely Compromised, Will follow up every 1-3 days
New TF (+4), Low Albumin (+2), Swallowing Problems (+3),
Dysphagia (+3)
Nutrition Care Process: Nutrition Diagnoses
 #1 Swallowing difficulty (NC-1.1) related to respiratory
status as evidenced by NPO status, need for
dysphagia diet, and aspiration history.
Nutrition Care Process: Nutrition
Intervention
#1 Enteral Nutrition (ND-2.1).
Recommend initiate enteral nutrition via OJ tube or NJ tube, once
placement verified start Isosource 1.5 at rate of 15 mL/hr x 8 hrs; if
tolerating advance by 10 mL every 8 hrs to current goal rate of 30 mL/hr
x 24 hrs/day. No current free water flushes until IVF addressed. (Table 5)
#2 Collaboration and Referral of Nutrition Care: Collaboration
with other providers (RC-1.4).
No residual checks with Jejunal feeding
Nutrition Care Process: Nutrition
Intervention
Short-term Goal/ Expected Outcome :
 Maximize nutrient intake: Patient receives more than 75%
of recommended nutritional needs via PO or nutrition
support.
 Patient maintains admission weight.
Long-term Goal/ Expected Outcome:
 Patient will be able to meet more than 75% of
recommended nutritional needs via PO intake or long-term
tube placement in place for feeding.
 Patient reduces aspiration incidence.
Nutrition Care Process: Monitoring and
Evaluation
Monitor and Evaluation (Nutrition Intervention Performed):
 #1Enteral nutrition intake (FH). Formula/ solution (1.3.1).
 Patient was receiving enteral support via OJ tube with Isosource 1.5 formula at 30
mL/hr x 24 hours. Patient tolerated tube feeding at goal rate. The patient is receiving
100% of recommended kcal and protein needs via nutrition support.
 #2 Micronutrient Intake (1.6) Mineral/ element intake (2)
 Calcium (1). Patient’s corrected calcium is WNL. Phosphorus (6). Patient is on
phosphorus replacement protocol.
 #3 Biochemical data, medical tests and procedures (BD). Glucose/
endocrine profile (1.5).
 Glucose, fasting(1). Glucose continues to be high. High glucose possibly due to stress
since Hgb A1c is WNL. Electrolyte and renal profile (1.2). Continued to monitor
patient’s renal lab.
 #4 Anthropometric Measurements (AD). Weight change (1.1.4).
 Patient gained 9 lb since admission.
Nutrition Care Process: Monitoring and
Evaluation
 Short-term goal:
 (Achieved) Short-term goal: Maximize nutrient intake: Patient
receives more than 75% of recommended nutritional needs via
PO or nutrition support.
 (Not Achieved) Patient maintain current weight.
 Long-term goal:

(Not Achieved) Patient will be able to meet more than 75% of
recommended nutritional needs via PO intake or long-term tube
placement in place for feeding.
 (Not Achieved) Patient reduces aspiration incidence.
Nutrition Care Process: Monitoring and
Evaluation
 The patient was admitted to the hospital from 9.27 to 10.14. The
patient was followed up everyday by a dietitian. Meanwhile, the
patient had developed acute respiratory failure and was at
critical condition. Her tube feeding formula was switched from
Isosource 1.5 to Impact Peptide 1.5 which is an elemental formula
for patients who are in stressed condition. The patient then
became more stable, and had a PEG placement for long-term
nutrition support. The patient was discharged with nocturnal
feeds Isosource 1.5 65 mL/hr x 12 hours/day. The reason why she
was discharged with Isosource 1.5 instead of Impact Peptide 1.5
was because her insurance company would not cover Impact
Peptide 1.5 since it is an elemental formula and is more
expensive.
Patient’s Progress after Discharge
The patient was re-admitted to the hospital 4 days after
being discharged. The patient was re-admitted for aspiration
because she was having PO intake. The patient is on DNR
status. The RD recommended modifying the PEG tube to a
PEG-J tube, however, IR stated that PEG needed to be in
place for 3-4 weeks prior to adjust tube. During her second
admission, the tube feeding was either running at a low rate
or on hold for a few times due to reoccurring emesis. Finally,
the patient was able to tolerate tube feeding with bolus
feeds. The patient was discharged on 10/26/2013 with the
same recommendation of tube feeding regimen as previous
time.
Evidence-based recommendation
implemented on this case
 30-45 degrees head of bed position
 Enteral nutrition support to decrease risk of
aspiration
 Jejunal feeds rather than gastric feeds
 Elemental formula was used
Conclusion
 The current recommendation for Aspiration Pneumonia
care is to feed patients who are receiving tube feeding in a
30-45 degree elevation of head of bed position. Promotility
agents are also encouraged to use. There are controversial
in whether or not jejunal feeding is more beneficial over
gastric feeding; More research need to be done to confirm
this finding. Further more, research suggest that elemental
formula may be a better choice than standard formula,
however, elemental formulas are more expensive and
many insurance do not cover it.
References
1.
2.
3.
4.
5.
6.
7.
Horiuchi A, Nakayama Y, Sakai R, Suzuki M, Kajiyama M, Tanaka N. Elemental diets may reduce the
risk of aspiration pneumonia in bedridden gastrostomy-fed patients. Am J Gastroenterol. 2013; 108:
804-810.
Jiyong J, Tiancha H, Huiqin W, Jingfen J. Effect of gastric versus post-pyloric feeding on the
incidence of pneumonia in critically ill patients: observations from traditional and Bayesian randomeffects meta-analysis. Clin Nutr. 2013; 32: 8-15.
Echevarria IM, Schwoebel A. Development of an intervention model for the prevention of aspiration
pneumonia in high-risk patients on a medical-surgical unit. Medsurg Nurs.2012; 21 (5): 303-308.
Marik P. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001; 344(9): 665-671.
Komiya K, Ishii H, Umeji K, et al. Impact of aspiration pneumonia in patients with communityacquired pneumonia and healthcare-associated pneumonia: A multicenter retrospective cohort
study. Respirology.2013; 18 :514-521.
Garcia J, CCC, Chambers E. Managing dysphagia through diet modifications. Am J Nurs. 2010; 110(11):
26-33
Recommendations Summary CIU: Optimizing Enteral Nutrition Delivery. Academy of Nutrition and
Dietetics Evidence Analysis Library Web site.
http://andevidencelibrary.com/template.cfm?key=3256.Accessed December 14, 2013
Reference
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Bankhead R, Boullata J, Brantlet S, et al. Enteral nutrition practice recommendations. J Parenter Enteral
Nutr. 2009; 33(2): 123-167.
Ho KM, Dobb GJ, Webb SA. A comparison of early gastric and post-pyloric feeding in critically ill patients:
a meta-analysis. Intens Care Med. 2006; 32: 630-649
Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003; 7: R46-R51.
Heyland DK, Drover JW, Dhaliwal R, Greenwood K. Optimizing the benefits and minimizing the risks of
enteral nutrition in the critically ill: role of small bowel feeding. Jpen-Parenter Enter. 2002; 25: S51-S55
American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd ed.
Chicago, Il: American Dietetic Association; 2009.
Pronsky ZM, Crowe SR. Food Medication Interactions. 17th ed. Birchrunville, PA: Food-Medication
Interactions; 2012.
Nutrition Care Manual Web site. https://www.nutritioncaremanual.org/to
pic.cfm?ncm_category_id=1&lv1=5538&lv2=255469&ncm_toc_id=255469&ncm_heading=Nutrition%20Car
e. Accessed Dec 15, 2013.
ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet.
Patient Food Services: Policies and Procedures, Volume IV; 2007.
White JV, Guenter P, Jensen G, et al. Consensus statement: academy of nutrition and dietetics and
American society for parenteral and enteral nutrition: characteristics recommended for the identification
and documentation of adult malnutrition (undernutrition). J Parenter Enteral Nutr. 2012; 36: 278-279
American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd ed.
Chicago, Il: American Dietetic Association; 2009.