Pulmonary Disease

Question 1

What is considered prolonged mechanical ventilation?

Answer 1

Vent dependence greater than 21 days for at least 6 hours per day

Question 2

True or false: An enteral formula characterized by anti-inflammatory lipid profile should be used in patients with ARDS

Answer 2

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

Question 3

To identify malnutrition, ASPEN recommends which characteristics be present?

Answer 3

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.

Question 4

What are the four types of respiratory failure?

Answer 4

1. Hypoxemic
2. Hypercapnic
3. Mixed Hypoxic-hypercapnic
4. Shock Related Respiratory Failure

Question 5

In which type of pulmonary patient is a fluid restricted formula appropriate?

Answer 5

Patients with ARDS (severe type I respiratory failure)

Question 6

What defines chronic critical illness?

Answer 6

1. ICU stay > 14 days with low grade organ dysfunction
2. Vent dependence and malnutrition

Question 7

How often should CF patients should be screened for malnutrition and vitamin deficiency? What are the most common deficiencies seen?

Answer 7

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,

Question 8

How often does ASPEN/SCCM recommend energy expenditure be evaluated in critically ill patients?

Answer 8

More than weekly,however no specific time intervals are outlined

Question 9

What causes malnutrition in CF?

Answer 9

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

Question 10

What should not be given to critically ill or pulmonary failure patients?

Answer 10

Glutamine supplementation

Question 11

What defines the term pulmonary cachexia syndrome?

Answer 11

BMI < 17 in men and < 14 in women; malnutrition in COPD may be as high as 60% for inpatients

Question 12

True or false: Gut peristalsis is inhibited by paralytic medications and sedatives

Answer 12

False; peristalsis is NOT inhibited by paralytic medications or sedatives

Question 13

What situation improves EFA profiles in patients with CF?

Answer 13

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

Question 14

Which type of EN formula should be considered for patients with Chyle leaks?

Answer 14

Elemental enteral formulas, which contain individual amino acids and contain <2-3% of total calories from long-chain fatty acids

Question 15

Common Causes of Hypoxemia

Answer 15

1. Pulmonary edema
2. Pneumonia
3. Inflammation
4. Chronic pulmonary disease
5. Hypoventilation leads to CO2 retention (hypercapnia)

Question 16

Common Causes of Hypercapnia

Answer 16

1. Obstructive pulmonary disease
2. Sleep apnea
3. Obesity leading to collapse of upper airways (obesity hypoventilation syndrome)

Question 17

Define Type I: Hypoxemic Respiratory Failure

Answer 17

Partial pressure of oxygen (PaO2) in arterial blood is＜60 mm Hg. (occurs at level of alveoli)

Question 18

Define Type II: Hypercapnic Respiratory Failure (high CO2)

Answer 18

Partial pressure of arterial carbon dioxide (PaO2) is elevated and causes blood pH to be ＜ 7.37

Question 19

Define Type III: Mixed Hypoxic-Hypercapnic Respiratory Failure

Answer 19

Perioperative because of anesthesia
Always acute and frequently secondary to atelectasis (Complete or partial collapse of lung segments)

Question 20

Define Type IV: Shock-Related Respiratory Failure

Answer 20

Caused by sepsis, hypovolemia (low blood volume), cardiogenic shock

Question 21

Acute Respiratory Distress Syndrome (ARDS)

Answer 21

Severe form of Type I Respiratory failure

Question 22

ARDS defined by Berlin criteria

Answer 22

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

Question 23

Common Causes of ARDS

Answer 23

Direct or indirect lung injury
1. Direct: gastric aspiration leading to PNA
2. Indirect: sepsis, trauma, acute pancreatitis

Question 24

The 3 Phases of ARDS

Answer 24

1. 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)
2. Proliferative (7-10 days)
3. Fibrotic (>10 days)

Question 25

Name common Obstructive Lung Diseases

Answer 25

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

Question 26

Name Malnutrition Factors in COPD

Answer 26

1. Aging 2. Hypoxia 3. Increased REE 4. Low grade inflammation 5. Systemic treatment with glucocorticoids

Question 27

Restrictive Lung Disease defined and common causes

Answer 27

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

Question 28

Define Cystic Fibrosis

Answer 28

Genetic disorder that affects the lungs, pancreas, and other organs - Malnutrition should be treated aggressively with ONS and GT placement if necessary

Question 29

What is Persistent inflammatory and immunocompromised catabolic syndrome (PICS)?

Answer 29

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

Question 30

Pulmonary Disease Energy Requirements

Answer 30

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

Question 31

Underfeeding and Overfeeding with Pulmonary Disease

Answer 31

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

Question 32

Micronutrients

Answer 32

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

Question 33

Risk for Refeeding Syndrome

Answer 33

Major surgery patient's Alcoholics Receiving Chemotherapy Poor intake PTA

Question 34

How to support pts at risk of refeeding syndrome

Answer 34

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

Question 35

Symptoms of hypophosphatemia

Answer 35

Paresthesia, confusion, seizure, muscle weakness, cardiac dysfunction

Question 36

Obesity

Answer 36

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

Question 37

Benefits of EN with Pulmonary Failure

Answer 37

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)

Question 38

Parenteral Nutrition Support

Answer 38

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

Question 39

Aspiration and Ventilator-Associated Pneumonia (VAP)

Answer 39

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

Question 40

Strategies to Prevent VAP

Answer 40

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