You are on page 1of 6

27-1

Kasey Hutchinson
Title: Case 27 COPD with Respiratory Failure
Questions:
1. Mr. Hayato was diagnosed with emphysema more than 10 years ago.
Define emphysema and explain its underlying pathophysiology.
Emphysema is the gradual damage of alveoli in the lungs which
leads to the rupturing of alveoli in the lungs and the airspace in
the lungs decreases. Pathology associated with emphysema
includes decrease in elastic recoil and airway narrowing. Both of
these mechanisms decrease airflow and amount of oxygen being
delivered to lungs.
2. In the emergency room, a chest tube was inserted into the left thorax with
drainage under suction. Subsequently the oropharynx was cleared. A
resuscitation bag and mask were used to ventilate the patient with highflow oxygen. Endotracheal intubation was then performed, using a
laryngoscope so the trachea could be directly visualized. The patient was
then ventilated with the help of a volume-cycled ventilator. Ventilation is
15 breaths/min with an FiO2 of 100%, a positive end-expiratory pressure of
6, and a tidal volume of 700 mL. Daily chest radiographs and ABGs were
used each AM to adjust the ventilator settings. Define the following terms
found in the history and physical for Mr. Hayato:
a. Dyspnea: shortness of breath
b. Orthopnea: shortness of breath while lying down
c. Pneumothorax: collapsed lung; air leaks out and collects in the
space between lungs and chest
d. Endotracheal intubation: this is the placement of a tube into
the trachea to increase airflow and open the airway
e. Cyanosis: this refers to the a situation in which the skin and
mucous membranes turn blue due to lack of oxygen
3. Identify features of the physicians physical examination consistent with
his admitting diagnosis. Describe the pathophysiology that might be
responsible for each physical finding.
Pulse Rate: 118, this is high which is consistent with COPD
because his heart is working harder to deliver gases to and from
tissues of the body
Resp Rate: 36; this level is high as well because his lungs are
having to work harder and faster to make up for lost villi

2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

27-2

Cyanosis and pitting edema of extremeties: this is also consistent


with COPD. His extremities are turning blue due to lack of
oxygenation.
High CO2, low O2: This is common in people with COPD. The lungs
cannot get rid of CO2 fast enough and cannot inhale enough O2.
Hyperresonane and harsh inspiration: this is due to the microvilli
damage and again the need for his lungs to work extra hard.
Low pH: his body has become acidic because of his inability to get
rid of CO2 fast enough.
4. What is the relationship between nutritional status and respiratory
function? Define respiratory quotient (RQ). What dietary factors affect RQ?
Respiratory function and nutrition status are related because when
your respiratory function declines it increases energy needs but
also decreases appetite and causes dyspnea while eating so
patients often become malnourished. Patient is at an increased risk
of respiratory infection because lung immune mechanisms are
decrease. Often patients become protein and iron deficient and
often does not consume enough calcium, magnesium, phosphorus or
potassium.
Respiratory quotient is the ratio of carbon dioxide produced to
amount of oxygen used. A quotient between .7 and 1 is normal.
Carbs have a quotient of 1, fat has a quotient of .7 and most mixed meals
have a quotient of .83.
5. Do nutrition support and nutritional status play a role in enabling a patient
to be weaned from a respiratory ventilator? Explain.
Yes, a diet lower in carbs will decrease CO2 build up which will
decrease the amount of time of the ventilator. This needs to be
balanced however because if it is too low in carbs and high in fat
it could cause GI bloating and constipation. We need to keep in
mind that he has increased energy needs as well.
6. Evaluate Mr. Hayatos admitting anthropometric data.
Height: 64
CBW: 122#
UBW: 135#
%UBW: 90%; SEVERE WEIGHT LOSS
IBW: 130#
%IBW: 94%
BMI: 21 (normal)

2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

27-3

7. Determine Mr. Hayatos energy and protein requirements using the MifflinSt. Jeor, Ireton-Jones, and COPD predictive equations. Compare them. As
Mr. Hayatos clinician, which would you set as your goal for meeting his
energy needs?
Mifflin-Jeor (AF 1.3): 1,705 kcal/day
Ireton-Jones: 1,588 kCal/d
COPD predictive equations: (Mifflin Jeor X 1.25-1.56) 2,129-2,659
kCal/d
Protein: 66-82.5 (1.2-1.5 g/kg for pulmonary disease)
I would recommend 2,300 kCal per day and between 66 and 82
grams of protein daily
8. Determine Mr. Hayatos fluid requirements.
1650 mL/d (30ml/kg)
9. Evaluate Mr. Hayatos biochemical indices relevant to nutritional status on
3/26.
Bilirubin is (.8) high because many red blood cells have died due
to lack of oxygen.
HDL is low (32) and HDL is high (142), possibly due to high fat
intake or trouble metabolizing fat
Hemoglobin is low (13.2) and hematocrit low (39) possibly related
to his condition
10. Select two high-priority nutrition problems and complete the PES
statement for each.
Unintentional weight loss related to lack of appetite and increased
energy needs secondary to COPD AEB 10% weight loss, increased
heart rate and increased respiratory.
Inadequate oral intake RT lack of appetite (secondary to COPD) AEB
10% weight loss in past several weeks and 24-hour recall
indicating very little caloric consumption.
11. A nutrition consult was completed on 3/27, and enteral feedings were
initiated. Mr. Hayato was started on Isosource HN @ 25 cc/hr continuously
over 24 hours.
a. At this rate, how many kcal and grams of protein should he receive per
day?
He would be receiving 720 kCal and 32 g protein per day
(1.2 kcal/mL x 25 ml x 24 hr) (720 kcal x .18 x 1g/4kcal)

2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

27-4

b. Calculate his nutrition prescription utilizing this enteral formula. Include


the goal rate, free water requirements, and the appropriate
progression of the rate.
Since I recommended him to consume 2,300 kCal/day I found
the goal rate to be about 80 ml/hr (2300 kcal/d x 1 ml/1.2 kcal
x 1 d/24 hours). This provides him with 1570 ml so he will need
80 ml additional water to meet fluid requirements. I think he
should start at 40 ml and progress 5 ml an hour for 8 hours to
bring him to the goal weight.
12. What type of formula is Isosource HN? What are the percentages of
kilocalories from carbohydrate, protein, and lipid? What is the rationale for
formulas that have additional nutrients added to assist with pulmonary
function? List these nutrients and the proposed rationale.
Isosource is a standard formula with high protein. Carbs account
for 53%, protein accounts for 18%, and fat accounts for 29% total
caloric intake. Formulas for COPD have extra nutrients because
many times COPD patients are deficient and/or need extra
nutrients to repair damage. Mineral and electrolytes such as
potassium, magnesium, phosphate, calcium and sodium are
added to decrease chance of osteoporosis and help with muscle
contractions. Also formulas that are higher in fat and lower in
carbohydrates are good because they have lower CO2 production.
13. Examine the intake/output record. How much enteral feeding (kcal,
protein) did the patient receive?
It seems that he had a total intake of 400 mL of formula equaling to
480 kCal and 21.6 g of protein.
14. You read in the physicians orders that the patient experienced high
gastric residual volume (GRV) and the enteral feeding was discontinued.
Define high GRV. What is the probable cause for this patient?
Gastric residual volume is the amount aspirated from the
stomach during EN. This is due to delayed gastric emptying
related to pain medications, lack of activity and lying down
during feeding.
15. Were any additional signs of EN intolerance documented? Do you
agree with the decision to discontinue the feeding? Why or why not?
There were no other indications of EN intolerance such abdominal
pain, cramping, bloating elevated blood glucose levels (refeeding
syndrome). Bowel movements were also normal. I would not
recommend discontinuing feeding all together rather I would
suggest decreasing the amount on intake and raising it to the
recommended level very slowly because if he discontinues

2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

27-5

feeding all together he will probably not eat much and his
condition will worsen.
16.

What options are available to improve tolerance of the tube feeding?

Some things we can do to improve his tolerance for tube feeding


is to make sure head is at 30 to 45 degrees angle from the lower
body, turn to right side, check tube placement, keep an eye on
residuals and make sure he is on continuous feeding.
17. On 3/29, the enteral feeding was restarted at 25 mL/hr and then
increased to 50 mL/hr after 12 hours. What were Mr. Hayatos energy and
protein intakes for 3/29?
25 ml/hr x 1.2 kcal/ml x 12 hr = 360 kcal
50 ml/hr x 1.2 kcal/ml x 12 hr = 720 kcal
= 1080 kcal
1080 kcal x .18 /4= 48.6 g protein
18.

Examine the values documented for arterial blood gases (ABGs).

a. On the day Mr. Hayato was intubated, his ABGs were as follows: pH 7.2,
pCO2 65, CO2 35, pO2 56, HCO3- 38. What can you determine from each
of these values?
He is slightly acidic, his pCO2 is high, CO2 is high, pO2 is low and
HCO3 is high. This indicates that his lungs are not adequately
ridding the body from carbon dioxide/inhaling sufficient oxygen.
This is very typical for people with COPD.
b. On 3/28, while Mr. Hayato was on the ventilator, his ABGs were as
follows: pH 7.36, pCO2 50, CO2 29, pO2 60, HCO3- 32. What can you
determine from each of these values?
His pH is back to normal, though still on the low end of normal,
pCO2 has decreased but is still too high, CO2 is down to
normal, pO2 is higher but still too low, and HCO3 is a little
lower but still too high. This indicates that the ventilator is
working and his condition is improving but he still needs to be
monitored and continuing with treatment.
c. On 3/30, after the enteral feeding was resumed, his ABGs were as
follows: pH 7.22, pCO2 66, pO2 57, CO2 36, HCO3- 37. In addition,
indirect calorimetry indicated an RQ of 0.95 and his measured energy
intake was 1350 kcal. How does the patients measured energy intake
compare to your previous calculations? What does the RQ indicate?
It seems that all of his values have become worse; pH dropped
to belowe normal, pCO2, CO2 and HCO3 have risen, pO2 has
dropped. He is also eating nearly 1,000 calories less than
recommended. His RW, or respiratory quotient, is a measure of
2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

27-6

CO2 produced vs O2 consumed. His is only slightly below 1,


therefore I think he should be on a higher fat, lower
carbohydrate formula since carbohydrates will increase his RQ
more than the other macronutrients.
19. The patient was weaned from the ventilator on 4/2 and discharged to
home on 4/5. As Mr. Hayato is prepared for discharge, what nutritional
goals might you set with him and his wife to improve his overall
nutritional status?
I think he should make sure he is eating around 2300 calories per
day and between 66 and 82 g of protein per day. This can be
accomplished by continuing EN or if he is ready, start taking in food
by mouth. Smoothies and shakes are a good place to start when
coming off EN.

2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.