Pulmonary Disease Flashcards
What is considered prolonged mechanical ventilation?
Vent dependence greater than 21 days for at least 6 hours per day
True or false: An enteral formula characterized by anti-inflammatory lipid profile should be used in patients with ARDS
In ARDS, APSEN/SCCM did NOT make a recommendation for the routine use an enteral formula characterized by anti-inflammatory lipid profile in patients with ARDS
To identify malnutrition, ASPEN recommends which characteristics be present?
ASPEN recommends 2 of the following be present:
1. insufficient energy intake
2. weight loss
3. loss of muscle mass
4. loss of subcutaneous fat
5. localized or generalized fluid accumulation that may sometimes mask weight loss
6. diminished functional status measured by hand grip strength.
What are the four types of respiratory failure?
- Hypoxemic
- Hypercapnic
- Mixed Hypoxic-hypercapnic
- Shock Related Respiratory Failure
In which type of pulmonary patient is a fluid restricted formula appropriate?
Patients with ARDS (severe type I respiratory failure)
What defines chronic critical illness?
- ICU stay > 14 days with low grade organ dysfunction
- Vent dependence and malnutrition
How often should CF patients should be screened for malnutrition and vitamin deficiency? What are the most common deficiencies seen?
Quarterly; fat soluble vitamins should be checked yearly.* Most common deficiencies include ADEK b/c patients with CF are prone to malabsorption secondary to pancreatic insufficiency,
How often does ASPEN/SCCM recommend energy expenditure be evaluated in critically ill patients?
More than weekly,however no specific time intervals are outlined
What causes malnutrition in CF?
Pancreatic insufficiency or steatorrhea with nutrient deficiencies; patients with CF have greater overall energy requirements then individuals without CF who are of similar height/weight
What should not be given to critically ill or pulmonary failure patients?
Glutamine supplementation
What defines the term pulmonary cachexia syndrome?
BMI < 17 in men and < 14 in women; malnutrition in COPD may be as high as 60% for inpatients
True or false: Gut peristalsis is inhibited by paralytic medications and sedatives
False; peristalsis is NOT inhibited by paralytic medications or sedatives
What situation improves EFA profiles in patients with CF?
Lung transplant
Although supplementation with omega 3 fatty acids are sometimes used in the management of CF, results from clinical trials have shown mixed results and further trials are needed to determine the efficacy of routine EFA supplementation in the management of CF
Which type of EN formula should be considered for patients with Chyle leaks?
Elemental enteral formulas, which contain individual amino acids and contain <2-3% of total calories from long-chain fatty acids
Common Causes of Hypoxemia
- Pulmonary edema
- Pneumonia
- Inflammation
- Chronic pulmonary disease
- Hypoventilation leads to CO2 retention (hypercapnia)
Common Causes of Hypercapnia
- Obstructive pulmonary disease
- Sleep apnea
- Obesity leading to collapse of upper airways (obesity hypoventilation syndrome)
Define Type I: Hypoxemic Respiratory Failure
Partial pressure of oxygen (PaO2) in arterial blood is＜60 mm Hg. (occurs at level of alveoli)
Define Type II: Hypercapnic Respiratory Failure (high CO2)
Partial pressure of arterial carbon dioxide (PaO2) is elevated and causes blood pH to be ＜ 7.37
Define Type III: Mixed Hypoxic-Hypercapnic Respiratory Failure
Perioperative because of anesthesia
Always acute and frequently secondary to atelectasis (Complete or partial collapse of lung segments)
Define Type IV: Shock-Related Respiratory Failure
Caused by sepsis, hypovolemia (low blood volume), cardiogenic shock
Acute Respiratory Distress Syndrome (ARDS)
Severe form of Type I Respiratory failure
ARDS defined by Berlin criteria
1) Respiratory symptoms within 7 days of clinical insult (PNA or sepsis)
2) Bilateral lung opacities on chest radiograph or CT scan
3) Respiratory failure and lung opacities are not explained by heart failure or fluid overload
4) Oxygenation impairment present defined by PaO2:FiO2 ratio
Common Causes of ARDS
Direct or indirect lung injury
1. Direct: gastric aspiration leading to PNA
2. Indirect: sepsis, trauma, acute pancreatitis
The 3 Phases of ARDS
- Exudative (0-7 days)
Widespread lung inflammation and injury causing fluid to leak into alveolar spaces, contributing to hypoxia
Places patient at risk for PMV (prolonged mechanical ventilation) - Proliferative (7-10 days)
- Fibrotic (>10 days)
Name common Obstructive Lung Diseases
1) Asthma- chronic inflammatory disorder of airways leads to recurrent but REVERSIBLE airway obstruction
2) Cystic fibrosis-
3) COPD- persistent airflow limitation that is progressive and associated with enhanced chronic inflammatory response
Pulmonary cachexia syndrome (BMI < 17 in M; <14 in F)
BMI is significant independent predictor of all cause mortality
Name Malnutrition Factors in COPD
- Aging
- Hypoxia
- Increased REE
- Low grade inflammation
- Systemic treatment with glucocorticoids
Restrictive Lung Disease defined and common causes
Interstitial lung disease (ILD) cause lung restriction (limit expansion)
Commonly cause chronic hypoxemic respiratory failure
Causes include occupation/environmental agents, drugs, radiation, connective tissue disorders, idiopathic causes
Define Cystic Fibrosis
Genetic disorder that affects the lungs, pancreas, and other organs
- Malnutrition should be treated aggressively with ONS and GT placement if necessary
What is Persistent inflammatory and immunocompromised catabolic syndrome (PICS)?
Occurs in patients who survive acute critical illness and enter a state of chronic critical illness characterized by low grade organ dysfunction, immune suppression with malnutrition, muscle weakness, recurrent infections and poor wound healing
Pulmonary Disease Energy Requirements
SCCM/ASPEN recommend evaluating energy expenditure more than weekly (IC) and do not recommends a single equation to calculate needs
Monitor for signs of both under and overfeeding
Underfeeding and Overfeeding with Pulmonary Disease
Prolonged underfeeding may lead to deficits in LBM, increased risk of mortality
COPD patients have increased REE secondary to their disease
Monitor weight and BMI as at risk for developing pulmonary cachexia syndrome
In critically ill patient’s, early, short-term trophic feeding for 7 days (then adv to meet EEN) may result in less GI intolerance than full feeding in patients with acute lung injury or ARDS who are NOT high nutrition risk
No evidence to support trophic feeding in ARDS patients who are underweight or overweight
Overfeeding can cause hyperglycemia, lipogenesis, liver dysfunction, azotemia, fluid overload and respiratory compromise
Excessive energy intake can lead to increased CO2 production
Most CO2 production in critical illness is from metabolism by-products, not CHO intake
Evidence suggests that EN via GT in prone position patient’s is SAFE and WITHOUT complications
Micronutrients
Closely monitor for possible electrolyte deficiencies such as phosphorus, calcium and magnesium
Deficiencies can lead to diaphragm weakness and prolonged mechanical vent dependence
Glutamine supplementation NOT recommended
Risk for Refeeding Syndrome
Major surgery patient’s
Alcoholics
Receiving Chemotherapy
Poor intake PTA
How to support pts at risk of refeeding syndrome
Monitor first 2-3 days
Slowly advancing nutrition support over 2-3 days (½ their EEN) helps to avoid RS
Supplement with water-soluble B vitamins, in particular Thiamine
Symptoms of hypophosphatemia
Paresthesia, confusion, seizure, muscle weakness, cardiac dysfunction
Obesity
Traditional nutrition assessment does not accurately predict malnutrition or nutrition risk in obese
Higher BMI considered a risk factor for malnutrition
Use Penn state equation if IC not available
Provide hypocaloric, high protein
Benefits of EN with Pulmonary Failure
Preserve gut mucosa and immune function
Modulate stress in critically ill
Maintain functional integrity of gut by preserving tight junctions and maintaining villous height w/i gut
Provide gut prophylaxis against GI bleeding
Supports secretory immunoglobulin-A producing immunocytes that compose the gut-associated lymphoid tissue (GALT)
Parenteral Nutrition Support
Patients with nonfunctioning gut may require PN to maintain EEN completely or as a supplement if EN fails to meet EEN for prolonged period
ESPEN suggests starting PN within 24-48 hours of admission if patients are not expected to fully tolerate EN by Day 3 of admission
ASPEN/SCCM guidelines recommend holding PN for the initial 7 days of critical illness if not at nutrition risk
Recent study suggests early PN may be associated with increased infections and days of mechanical ventilation dependence
Aspiration and Ventilator-Associated Pneumonia (VAP)
Thought to involve colonization of the oral pharynx, larynx, and upper esophagus with bacteria as well as microaspiration of secretions with bacteria
Trach provides entry-way for secretions and bacteria into the lower respiratory tract
Some studies suggest jejunum-delivered EN compared with GT or duodenal feeding shown decreased rates of VAP
Strategies to Prevent VAP
Minimized sedation and analgesia if possible/ sedation vacation
Continuous subglottic suctioning to decreased pooling of oral secretions
Elevated HOB >45 degrees when possible
Provide oral care with chlorhexidine
Consider probiotic use in select patient populations (chapter 4)
Limit broad spectrum antibiotics
