Nutritional Management of

Chronic Obstructive Pulmonary

Disease
Queens College Dietetic Internship
Acute Care Hospital Facility
Ivonnet Asencios
 • 76-yr old female admitted to ER due to respiratory failure, COPD
exacerbation
• Primary disease: Chronic Obstructive Pulmonary Disease

Overview • Comorbidities: Respiratory failure, HTN, Breast Cancer

• Evidence Analysis Library MNT Recommendations
• Nutrition Care Process:
• Assessment, Diagnosis, Intervention, Monitoring & Evaluation
Primary Disease: Chronic Obstructive Pulmonary
Disease1
Chronic Obstructive Bronchitis1

• Bronchitis with airflow obstruction

• Diagnosed with productive cough for days,
weeks for at least 3 months in 2 successive
years
• Predominantly in smokers
Emphysema1
• Destruction of the tissue and elastic coil of the lung alveoli
• Leads to airway traction and airflow limitation
• Causes alveoli to enlarge and develop blebs
Pathology 1

1) Inflammation in the airways and alveoli

• Due to ↑ protease activity ↓antiprotease activity
• Protease breakdown elastin and connective tissue
• This activity is normalized by antiprotease alpha-1 antitrypsin
• In COPD, protease activity > antiprotease activity
• Leading to destruction of lung parenchyma
• Lung parenchyma is involved in gas exchange
Pathology1 (Continued)
2) Respiratory infection may amplify progression
• Due to bacteria colonization in the airways

3) Airflow limitation
• Narrowing/obstruction of airways
• Due to inflammation-mediated mucus, mucosal
edema, bronchospasm
• Loss of elastic coil → enlarged alveolar spaces
• Can lead to hypercapnia, hypoxia
Etiology1,3
§ Inhalation exposures
• Primary risk is cigarette smoking: 40 packs or
more for years

§ Genetic factors
• Alpha-1 Antitrypsin deficiency is the lack of lung
antiprotease
• Lack of antiprotease destroys alveoli tissue
• Causing emphysema in nonsmokers
Epidemiology1,2
• 15 million people are affected by COPD in the US
• COPD is the fourth leading cause of death
• Resulting in 140,000 deaths every year
• 155,000 deaths due to COPD in 2015
Clinical Signs & Symptoms1,11
• Productive cough in smokers
• Persistent dyspnea, wheezing
• Decreased heart and lung sounds
• Barrel chest
• Weight loss, muscle wasting
• Prevalence of malnutrition 30%
Medical Treatment in Acute COPD
Exacerbation13
• Oxygen supplementation
• Bronchodilators
• Corticosteroids
• Antibiotics
• Ventilatory assistance
Comorbidities: Respiratory Failure13
• Impairment of oxygenation, carbon dioxide elimination, or both
• Due to gas exchange impairment, decreased ventilation, or both
• Manifestations:
• Dyspnea
• Altered consciousness
• Respiratory arrest
Comorbidities: Hypertension4
• Affects 75 million people within the U.S
• Could be a primary or secondary disease
• Risk Factors:
• Excessive consumption of dietary sodium
• Obesity
• Lack of physical activity
• Stress
 PmHx: Breast Cancer5
• Secondary leading cause of death in women within the U.S
• Affects both females and males with the same
manifestations
• Characterized by epithelial tumors invading cells
• Diagnosis consists of a biopsy
• Cancer treatment:
• Surgery
• Radiation therapy
• Chemotherapy
Evidence Analysis Library (EAL)
Medical Nutrition Therapy for COPD 11

Suggests Registered Dietitians implement MNT to improve quality of life, body

weight status, body composition, and exercise ability

Nutrition • Assess energy intake

• Assess body weight status
Assessment • Assess exacerbations

Nutrition • Provide MNT evidenced-based

• Energy prescription
Intervention • Macronutrient composition

Nutrition Monitoring • Monitor energy intake

& Evaluation • Monitor body weight for needs
Case Presentation
• 76-year old Caucasian female admitted to ER
• Chief complaint of shortness of breath
• Past medical Hx: COPD, HTN, breast cancer
• Presented respiratory failure upon COPD
exacerbation
• Transferred to intensive care unit (ICU)
• Placed on ventilator, NPO status, NGT
NUTRITION ASSESSMENT
Client & Social History:
• EMR: Lives with current partner
• EMR: Frequent tobacco smoker
• Patient was nonverbal, not alert at time
of visit
• Limited family history information
NUTRITION ASSESSMENT
Food and Nutrition Related History:
• Appetite: unable to determine
• Food allergies: apple, tree nuts, and rice
• From EMR six months ago, poor appetite
• Patient was NPO x 5 days
 Criteria for Malnutrition Diagnosis6
2 out of 6 clinical characteristics must be met to diagnose malnutrition

Acute Illness Injury Chronic Illness Injury

Moderate Severe Moderate Severe
Energy intake <75% for <7 days ≤ 50% for ≥ 5 days <75% for ≥ 1 month ≤ 75% for ≥ 1 month
Weight loss 1% to 2% 1 week >2% 1 week 5% 1 month >5% 1 month
5% 1 month >5% 1 month 7.5% 3 months >7.5% 3 months
7.5% 3 months >7.5% 3 months 10% 6 months >10% 6 months
20% 1 year >20% 1 year
Fat wasting Mild Moderate Mild Severe
Muscle wasting Mild Moderate Mild Severe
Fluid accumulation Mild Moderate to Severe Mild Severe
Handgrip strength N/A Reduced N/A Reduced
NUTRITION ASSESSMENT
Nutrition Focused Physical Findings:
• No NFPE was conducted due to unstable condition
• No visible signs of muscle or fat wasting
• Patient did not have fluid accumulation
• No barrel chest was noted
NUTRITION ASSESSMENT
Anthropometric Measurements:
• Admission weight – per bed scale: 136 lbs. / 62 kg
• Height: 5’ 5”
• BMI: 22.6 - normal
• UBW: 110 lbs. 6 months ago
• Weight gain: + 26 lbs. x 6 months possibly due to fluids
• Weight change: 24% wt gain in 6 months
 NUTRITION ASSESSMENT
Biochemical Data7
Lab Values from 03/13/2019 Ref Range & Units Result Interpretation

Sodium 136-145 mmol/L 137

Potassium 3.5-5.1 mmol/L 3.4 ↓ Possibly due to fluid overload, side effect of
medication (corticosteroids)
Chloride 98-108 mmol/L 9.3 ↓ Side effect of medication (corticosteroids) or
metabolic alkalosis
CO2 22-29 mmol/L 27
Glucose 74-110 mg/dL 127 ↑ Inflammatory response, NPO status
BUN 6-23 mg/dL 19
Creatinine 0.50-1.20 mg/dL 0.38 ↓ Result of decreased muscle mass
Calcium 8.6-10.3 mg/dL 8.7

eGFR Non-African American >= 60 ml/min/1.73m2 > 60

NUTRITION ASSESSMENT
Medications12
Drug Name Given via: Function/ Food and Nutrition Interaction

Acetylcysteine Nebulization

Aspirin12 Oral Analgesic/ Limit caffeine

Azithromycin12 NG Tube Antibiotic

Duloxetine NG Tube Antidepressant

Heparin12 Subcutaneous Anticoagulant

Ipratropium-albuterol12 Nebulization Bronchodilator

Meropenem12 IV Infusion Antibiotic

Methylprednisolone12 Intravenous Corticosteroid

Fentanyl Citrate12 Analgesic/ Avoid alcohol

Dextrose IV infusion

Glucagon Hyperglycemic agent

MNT Recommendations in COPD7,9,10

• High-calorie diet of 30-35 kcal/kg/day

• Prevent overfeeding: no more than 35 kcal/kg/day
• High-protein diet of 1.2-1.7 g pro/kg/day
• Fluid: 1 mL/kcal
• Enteral nutrition: prevents weight loss, malnutrition or cachexia
• Polymeric or hydrolyzed enteral formula preferable
NUTRITION ASSESSMENT
Nutrient Needs:
Nutrient Estimated Needs Based on (Facility’s Guidelines) TF: Jevity 1.5 @ 45 ml/hr x 24 hrs
Energy 1550-1860 kcal/day 25-30 kcal/kg (adm wt 62 kg) 1620 kcal/day

Protein 62-93 g. pro/day 1-1.5 g. pro/kg (adm wt 62 kg) 69 g. pro/day

Fluid 1550-1860 mL/day 1 mL/kcal – per MD’s order 820 mL/day

NOTE: EF 40% + 150 ml water flush Q 6 hrs (4x/day)

NUTRITION DIAGNOSIS
Problem, Etiology, Signs & Symptoms (PES):

• Inadequate oral intake (NI-2.1)8 RT respiratory failure due to COPD

exacerbation AEB NPO status x 5 days.

• Unintended weight gain (NC-3.4)8 RT possibly fluid overload due to

COPD exacerbation AEB 24% wt gain in 6 months.
INTERVENTIONS
• Medical Interventions:
• Ventilator → nasogastric tube, medications

• Nutritional Interventions: Enteral Nutrition (ND-2.1)8

• Initiate Jevity 1.5 at 45 mL per hour in 24 hours (1pm to 1 pm)
• Formula provides 1080 mL volume, 1620 kcal, 69 g. pro, 820 mL water
MONITORING & EVALUATION
• Monitor enteral nutrition intake (FH-1.3.1)8
• Goal: Pt will meet at least 75% of estimated nutrient requirements in the next 24-48
hours

• Monitor weight (AD-1.1.2)8

• Goal: Pt will achieve dry weight in the following 3-7 days to prevent fluid
accumulation

• Monitor Glucose (BD-1.5),8 Electrolyte and Renal Profile (BD-1.2)8

• Goal: Pt will achieve nutrition-related labs within normal limits in the following 3-7
days to improve status
MONITORING & EVALUATION
Follow-up Care
• No discharge plan at present
• Follow-up at the next re-assessment in 3 days due to high-risk
• No referral to outpatient department at the moment
 References
1. Wise RA, By, Wise RA, Last full review/revision Nov 2018| Content last modified Nov 2018. Chronic Obstructive Pulmonary Disease (COPD) - Pulmonary Disorders. Merck Manuals
Professional Edition. https://www.merckmanuals.com/professional/pulmonary-disorders/chronic-obstructive-pulmonary-disease-and-related-disorders/chronic-obstructive-pulmonary-
disease-copd#v914588. Accessed March 30, 2020.
2. COPD. Centers for Disease Control and Prevention. https://www.cdc.gov/dotw/copd/index.html. Published November 5, 2019. Accessed March 30, 2020.
3. Wise RA, By, Wise RA, Last full review/revision Nov 2018| Content last modified Nov 2018. Alpha-1 Antitrypsin Deficiency - Pulmonary Disorders. Merck Manuals Professional Edition.
https://www.merckmanuals.com/professional/pulmonary-disorders/chronic-obstructive-pulmonary-disease-and-related-disorders/alpha-1-antitrypsin-deficiency. Accessed March 30,
2020.
4. Bakris GL, By, Bakris GL, Last full review/revision Oct 2019| Content last modified Oct 2019. Hypertension - Cardiovascular Disorders. Merck Manuals Professional Edition.
https://www.merckmanuals.com/professional/cardiovascular-disorders/hypertension/hypertension. Accessed March 30, 2020.
5. Kosir MA, By, Kosir MA, Last full review/revision Jul 2019| Content last modified Jul 2019. Breast Cancer - Gynecology and Obstetrics. Merck Manuals Professional Edition.
https://www.merckmanuals.com/professional/gynecology-and-obstetrics/breast-disorders/breast-cancer. Accessed March 30, 2020.
6. Clinical Criteria for Malnutrition Diagnosis. Journal of the Academy of Nutrition and Dietetics. https://www.andeal.org/vault/2440/web/files/ONC/Table Clinical Characteristics to
Document Malnutrition-White JV et al 2012.pdf. Accessed March 28, 2020.
7. Width Mary, Reinhard, Tonia. The Essential Pocket Guide for Clinical Nutrition. Second Edition. Wolters Kluwer.
8. Electronic Nutrition Care Process Terminology. https://www.ncpro.org. Accessed March 7, 2020.
9. ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology. http://espen.info/documents/ENCardioPulm.pdf. Accessed March 29, 2020.
10. The most trusted diet manual since 1981. - Nutrition Care Manual.
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5538&lv2=22249&lv3=267663&ncm_toc_id=267663&ncm_heading=Nutrition Care. Accessed March 30, 2020.
11. Chronic Obstructive Pulmonary Disease. EAL. https://www.andeal.org/topic.cfm?cat=1476&evidence_summary_id=250518&highlight=COPD&home=1. Accessed March 30, 2020.
12. Pronsky, Z. M. Food Medication Interactions. 17th ed.
13. Patel BK, By, Patel BK, Last full review/revision Mar 2020| Content last modified Mar 2020. Overview of Respiratory Failure - Critical Care Medicine. Merck Manuals Professional
Edition. https://www.merckmanuals.com/professional/critical-care-medicine/respiratory-failure-and-mechanical-ventilation/overview-of-respiratory-failure. Accessed April 17, 2020.
 Thank You J
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