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/Relevanc e 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 Pressure ulcer, sacral spine, stage I
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 tube placed 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
Non-Invasive Diastolic 68
B/P Site Left Arm
B/P Position Supine
Heart Rate (beats/min)
Device Ventilator
Temp (degrees F)
Temp (degrees C)
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
Reference Range
BUN
7-18 mg/dl
Blood Glucose
mg/dl
Protein
mg/dl
Albumin
3.2-5 mg/dl

17. Biochemistry Assessment: Lab Values

18. Nutrition Assessment Using current weight of 44 kg, BMI: 16.2 kg/m^2:
kcal (35-40 kcal/kg)
57-66 g protein ( g protein/kg)
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 ml/hr
1152 kcal + 52 g protein
65% of estimated kcal needs and 79% of estimated protein needs
4/3/15
Fibersource 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:
kcal (35-40 kcal/kg)
57-66 g protein ( g protein/kg)
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 ml free water over 24 hours
4/3/15
Recommend to continue current TF order of Fibersource 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
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!
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. Published Accessed April 4, What To Expect While on a Ventilator. National Heart, Lung, and Blood Institute Web site. Published Accessed April 4, 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; / 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; 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; Rowat A. Enteral tube feeding for dysphagic stroke patients. British Journal of Nursing. 2015;