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Respiratory Diseases:
Chronic Obstructive Pulmonary Disease
Case Study
Kevin Hernandez
October 7th, 2013
Mrs. Stella Bernhardt is a 62-year-old Caucasian female admitted to the hospital with an acute
exacerbation of chronic obstructive pulmonary disease, including an increased shortness of
breath and a possible upper respiratory infection. She lives with her husband, aged 68 with a past
medical history of CAD. Mrs. Bernhardt is 5’ 3” and weighs 119 lbs, with a BMI of 21.1. Her
education includes two years of college, she is a retired office manager, and she is Methodist.
She has four children, and had two miscarriages in the past.
Mrs. Bernhardt has never been exposed to occupational hazards related to COPD. However, she
smoked a pack of cigarettes a day for 46 years, recently quitting a year ago. She was diagnosed
with stage 1 chronic obstructive pulmonary disease (emphysema) five years ago and has a
history of bronchitis and upper respiratory infections.
Her mother and two of her aunts passed away from lung cancer. She currently takes Combivent –
a mixture of ipratropium bromide (18mcg per inhalation) and albuterol sulfate (130 mcg per
inhalation) – at home, two inhalations four times a day.
Mrs. Bernhardt complains that her shortness of breath has recently worsened to the point where
she can “hardly do anything for herself.” For example, her husband has to help her out of the
shower at times. She states she has been coughing a lot of dark-colored phlegm. She also states
her husband mentioned to her that she seemed confused and wonders if that has anything to do
with her COPD.
Mrs. Bernhardt states that she has a poor appetite. She feels too tired to eat after preparing a
meal. Additionally, her coughing makes it very difficult for her to eat. Her appetite has also
decreased in general; stating food simply does not taste good to her. She states her family
believes she has become thin and although she has not weighed herself recently, her clothes fit
her big. Her last recorded weight was 139 lbs a year ago, and she claims her usual body weight is
145-150 lbs. She wears dentures, although they fit loosely. She purposely avoids milk products
because she was informed that they can cause an increase in mucus production. COPD patients
are at risk for osteoporosis; vitamin D and calcium should be monitored to reduce the risk.
According to her 24-hour recall, Mrs. Bernhardt is consuming 710 calories, 164 g carbohydrates,
5 g fiber, 9 g protein (5% of calories), 6 g fat (7.5% of calories). The Mifflin St. Jeor equation
estimates she requires approximately 1350 kcals. The Harris-Benedict predicts approximately
1550 as her energy requirement. Providing 25-30 kcal/kg of weight, she would require 1600
calories. She should consume anywhere from 1350-1600 calories a day. Mrs. Bernhardt should
consume 70-90 grams of protein per day. She should consume approximately 1 mL per calorie,
however since she is retaining, fluid, she may need to be placed on a fluid-restricted diet.
Nutrition Diagnosis:

Impaired ability to prepare meals (NB-2.5) related to patient’s shortness of breath and
fatigue during mealtimes as evidenced by a 20 lb weight loss in one year and a 24-hour
recall revealing an intake significantly less than her required energy, nutrients, and fluid
needs.

Food and nutrition-related knowledge deficit (NB-1.1) related to misinformation about
milk and dairy products as evidenced by an absence of calcium-rich foods in patient’s
diet and confirmation of avoidance of these foods.
Nutrition Intervention:
Goals:
o Remove challenges to a healthy diet. Patient will increase her energy and protein
intake to at least 80% of her requirements.
o Patient will learn about osteoporosis among COPD patients and preventative
strategies. Patient will increase vitamin intake per day, particularly calcium intake
to at least 900 mg per day
Interventions:


Skill development (E-2.5) to teach patient how to prepare smaller portions and to
rest before eating. Goal: to combat fatigue and shortness of breath and increase
intake. Recommend modifications (E-2.2) of types of food eaten and
fortification of foods. Goal: patient will learn about consuming more nutrientdense food and fortifying food in order to consume more energy and protein.
Comprehensive nutrition education (E-2.1) on importance of calciumcontaining foods and risk of osteoporosis among COPD patients. Goal: patient
will consume more dairy foods and will learn about other calcium-containing
foods. Supplement a multivitamin/mineral (ND-3.2.1) in order to reduce risk of
vitamin deficiencies possible in COPD. Goal: patient will begin a multivitamin
supplement regiment and increase her daily intake of important vitamins such as
vitamins A, E, D, calcium, iron, and selenium.
ADIME Format
A(Assessment): Total Energy Intake (FH 1.2.1.1) ~ 710 kcals Total protein intake
(FH 1.6.2.1) 9 grams and 5% of calories Knowledge (FH-3.1.1) about milk and mucus
production is inaccurate Mealtime behavior (FH-4.4.7) patient fatigue during feeding
process resulting in inadequate intake Height/weight/BMI (AD 1.1) Ht 5’3”; Wt 119 #
BMI 21.1 Albumin (BD-1.11.1) 3.3 Nutrition-focused physical findings (PD-1.1.3)
Cardio-pulmonary: shortness of breath, coughing, excessive phlegm Client History
(CH-1.1.8) Tobacco use for 46 years, quit 1 year ago, 1 pack per day Estimate energy
needs (CS 1.1.1) Current calorie intake is ~50% of her required 1550 kcal according to
Harris-Benedict equation (CS 1.1.2) with activity factor of 1.3 Total protein needs (CS2.2.1) of 70-90 grams per day Estimated calcium needs (CS-4.2.1) of 1200-1500 mg per
day.
D (Diagnosis): (P) Self-feeding difficulty (NB-2.6) (E) related to patient’s shortness of
breath and fatigue during mealtimes (S) as evidenced by a 20 lb weight loss in one year
and a 24-hour recall revealing an intake significantly less than her required energy,
nutrients, and fluid needs.
(P) Food and nutrition-related knowledge deficit (NB-1.1) (E) related to
misinformation about milk and dairy products (S) as evidenced by an absence of calciumrich foods in patient’s diet and confirmation of avoidance of these foods
I (Intervention): Skill development (E-2.5) to teach patient how to prepare smaller
portions and to rest before eating. Goal: to combat fatigue and shortness of breath and
increase intake. Recommend modifications (E-2.2) of types of food eaten and
fortification of foods. Goal: patient will learn about consuming more nutrient-dense food
and fortifying food in order to consume more energy and protein.
Comprehensive nutrition education (E-2.1) on importance of calcium-containing foods
and risk of osteoporosis among COPD patients. Goal: patient will consume more dairy
foods and will learn about other calcium-containing foods. Supplement a
multivitamin/mineral (ND-3.2.1) in order to reduce risk of vitamin deficiencies possible
in COPD. Goal: patient will begin a multivitamin supplement regiment and increase her
daily intake of important vitamins such as vitamins A, E, D, calcium, iron, and selenium.
M&E (monitoring & evaluation): Patient fatigue (FH-4.4.7) and Amount of Food (FH1.3.2.1) Criteria: Patient should be eating smaller meals so she can comfortably eat
without fatigue. Total Protein intake (FH-1.6.2.1) Criteria: Patient requires protein to
help her respiratory muscles breathe more effectively and avoid malnutrition.
Multivitamin/multimineral intake (FH-1.7.1.12/1.7.2.9) , milk/dairy foods intake
(FH-1.3.2.2) and avoidance of these foods (FH-4.2.1) Criteria: Patient requires
adequate amounts of vitamin D and calcium to prevent risk of osteoporosis, but has
history of avoiding foods that provide these nutrients.
1. Mrs. Bernhardt was diagnosed with stage 1 emphysema/COPD five years ago. What
criteria are used to classify this staging?
COPD is a progressive disease, worsening over time. As the disease progresses, the
patient moves into different stages based on their symptoms and lung function. Lung
function is measured as forced expiratory volume (FEV1), a measure of how fast air is
expired from the lungs, and therefore, airflow obstruction.
The FEV will measure >80% of normal function in stage I,
50-80% in stage II
30-50% in stage III
<30% or <50% with symptoms in stage IV. Symptoms can range
from a chronic cough with mucus in stage I to severe SOB, weight
loss, and cyanosis in stage IV.
A criterion for diagnosing COPD in general is a FEV1/FVC ratio of less than 70%; Mrs.
Bernhardt’s ratio is at 46%.
2. COPD includes two distinct diagnoses. Outline the similarities ad differences
between emphysema and chronic bronchitis.
COPD is an umbrella term that consists of two separate coexisting conditions: chronic
bronchitis and emphysema. They both create breathing difficulties and develop similar
symptoms in the patient and are caused by similar factors including tobacco smoke and
environmental pollutants.
Chronic bronchitis refers to inflammation, irritation, and scarring of the bronchioles and
increased production of mucus. Patients are usually normal weight. It is characterized by
decreased airflow, dyspnea, hypoxemia, hypercapnia, and possibly cyanosis, clubbing,
and secondary polycythemia.
Emphysema refers to permanent structural damage and destruction of the alveoli.
Emphysema patients tend to be thinner than those suffering from bronchitis. Aside from
the typical causal factors of COPD, emphysema may be caused by a genetic deficiency of
alpha-1-anytrypsin, a protein that protects the alveoli from hazards like tobacco smoke.
Emphysema mostly impairs expiration, which then leads to dyspnea, shortness of breath,
hypercapnia, and respiratory acidosis. Hypoxemia due to fatigue and exhaustion usually
appears in the final stages of the illness.
3. What risk factors does Mrs. Bernhardt have for this disease?
The most prominent risk factor for COPD is smoking. Although she has not smoked for a
year, Mrs. Bernhardt smoked a pack a day for 46 years. She has a history of bronchitis
and upper respiratory infections. Additionally, family history of lung cancer and COPD
may be overlooked as a risk factor.
4.
a. Identify symptoms described in the MD’s history and physical that are
consistent with Mrs. Bernhardt’s diagnosis. Then describe the
pathophysiology that may be responsible for each symptom.
i. Dyspnea – caused by inflammation of brochioles and damage to alveoli.
ii. Hypercapnia – elevated CO2 levels caused by the lack of gas exchange
occurring in the alveoli
iii. Confusion – elevated CO2 (hypercapnia)
iv. Fatigue – increased energy expenditure due to breathing efforts
v. Increased phlegm production – irritation and inflammation causing
hyperplasia of mucus glands
vi. Early satiety – caused by hyperinflation of the lungs within thoracic cavity
vii. Dysgeusia and bitter tasting food – breathing through the mouth and
medications may alter taste perception
viii. Weight loss – increased breathing efforts and nutrient utilization
b. Now identify at least four features of the physician’s physical examination
consistent with admitting diagnosis. Describe the pathophysiology that might
be responsible for each physical finding.
i.
ii.
iii.
iv.
1+ bilateral pitting edema – renal response to hypercapnia
Decreased breathing sounds – destruction of alveoli
Wheezing – obstruction in the airway
Prolonged expiration – damaged alveoli from emphysema
5. Mrs. Bernhardt’s medical record indicates previous pulmonary function tests as
follows: baseline FEV1=0.7 L, FVC=1.5 L, FEV1/FVC= 46%. Define FEV, FEV,
and FEV/FVC, and indicate how they are used in the diagnosis of COPD. How can
these measurements be used in treating COPD?
a. FEV1 (forced expiratory volume) – volume of air exhaled in the first second of
expiration
b. FVC (forced vital capacity) – total volume of air expired after a respiration
c. FEV/FVC – percentage of air expelled in the first second
The values are representative of the presence or absence and degree of obstruction
of the airways. The FEV decreases as COPD progresses. A normal FEV/FVC
ratio is a approximately 70-80%; a smaller value indicates obstructive disease.
6. Look at Mrs. Bernhardt’s arterial blood gas values from the day she was admitted.
a. Why would arterial blood gases (ABGs) be drawn for this patient?
Blood gases would be evaluated because gas exchange is a concern among COPD
patients. ABG values can measure lung function determine if the patient requires
assisted ventilation.
b. Define each of the following and interpret Mrs. Bernhardt’s values:
i. pH: measure of hydrogen ion concentration in the blood, indicating
acidity or alkalinity. Mrs. Bernhardt’s value was 7.29 upon admission,
slightly acidic.
ii. pCO2: partial pressure of CO2 dissolved in the blood; it measures how
well CO2 moves from blood to lungs for exhalation. Mrs. Bernhardt’s
value upon admission is 50.9, indicating her aveoli’s inability to exchange
gases and retention of CO2 in her system.
iii. SO2: percentage of hemoglobin saturated with oxygen. Mrs. Bernhardt’s
SO2 value low upon admission, indicating her blood is inefficiently
carrying oxygen to tissues.
iv. HCO3-: a buffer to prevent acidosis; Mrs. Bernhardt’s elevated level of
29.6 at admission may indicate her body was trying to prevent her
respiratory acidosis.
c. Mrs. Bernhardt was placed on oxygen therapy. What lab values tell you the
therapy is working?
Mrs. Bernhardt’s pH and HCO3- have returned to normal, meaning her blood is
less acidic, and indication of a decrease in CO2 in her blood. Her pCO2 is also
back to normal, indicating the ratio of oxygen to carbon dioxide is normalized.
7. Mrs. Bernhardt has quit smoking. Shouldn’t her condition now improve? Explain.
Mrs. Bernhardt was exposed to tobacco smoke for the majority of her life. The
inflammatory response will continue to damage the lungs even after quitting. Although
the symptoms can be treated, the damage in the alveoli is permanent. Her condition will
not improve, but she has at least, eliminated the main cause of damage.
8. What is respiratory quotient? How is this figure related to nutritional intake and
respiratory status?
The RQ is ratio of the amount CO2 produced to the amount of O2 consumed. A diet high
in carbohydrates will increase the RQ. The closer the RQ is to 1.0, the more CO2 is being
produced, which places a strain on the respiratory system. Nutritional intake should be at
a balance between macronutrients so the RQ does not reach too high of a value. Some
evidence has shown diets higher in fat can help keep the RQ low enough to not cause
additional damage.
RQ is also a measure of indirect calorimetry, the gold standard of assessing energy needs.
9. What are the most common nutritional concerns for someone with COPD? Why is
the patient diagnosed with COPD at higher risk for malnutrition?
Nutritional concerns for COPD include osteoporosis, anemia, vitamin deficiencies and
malnutrition. Malnutrition is of particularly importance because it is associated with
increased mortality among COPD patients. Malnutrition affects more than just skeletal
muscles; respiratory muscles begin wasting as well, creating a decreased capacity to
breathe properly and exacerbating the initial breathing problems. The patient’s body is
increasing the effort to breathe, therefore expending more energy than it is receiving.
Patients tend to decrease their intake for a variety of reasons including shortness of
breath, early satiety, altered tastes, and physical exhaustion.
However, a COPD patient should not be overfed. Too many total calories can result in
added stress to the respiratory system. Obesity can also place added stress onto the lungs,
so weight reduction should be a priority among obese patients.
10. Is there specific nutrition therapy prescribed for these patients?
While there is not a specific diet for COPD patients, there are many recommendations to
reduce the stress on the respiratory system.








COPD patients should receive up to 130% of resting energy expenditure to avoid
malnutrition, but should never exceed 150% of REE as this can result in
overfeeding and added stress. A mix of nutrients is essential to preserve lean body
mass and general well-being.
COPD patients should receive plenty of protein, about 1.2-1.5 g/kg/day and 1520% of their diet. This amount will help them maintain respiratory muscles and
avoid malnutrition.
Although carbohydrates contribute the greatest CO2 production after being
metabolized, COPD patients require these nutrients to function. The intake should
be monitored so it does implement too much stress on the patient’s breathing.
Since too many carbohydrates can place additional stress on a COPD patient, they
should receive plenty of calories from healthy fats. A recommendation for the
amount of fat is 30-45% of total calories.
Diets rich in fruits, vegetables, and fish have resulted in a lower incidence of
COPD when compared to a diet consisting of refined grains, red meat, sweets, and
fried foods.
Antioxidants can help prevent damage caused by pollutants and tend to be
depleted in COPD patients
Diets higher in fat and lower in carbohydrates result in a lower RQ, meaning less
stress on the lungs.
COPD patients are at risk of osteoporosis and should monitor their calcium and
phosphate levels


Fluid intake should not be too high since edema can occur, but should be adequate
to prevent dehydration
Resting before meals and eating smaller meals can help with fatigue and feeling
full
11. Calculate Mrs. Bernhardt’s %UBW and BMI. Does either of these values indicate
she is at nutritional risk? How would her 1+ bilateral pitting edema affect
evaluation of her weight?
UBW = 145-150 lbs
%UBW = 119/145 x 100
119/150 x 100
Current wt = 119 lbs
= 82%
= 79%
%UBW = 79 to 82%
BMI = 54kg/1.62 = 21.1
Since she has gradually lost weight over time, the change does not seem
significant. Her BMI is normal. The fluid retention evidenced by her edema could
cause her weight to be higher than it actually is. This would cause a greater
difference in her weight change and a falsely high BMI even though she may be
malnourished.
12. Calculate arm muscle area using the anthropometric data for mid-arm muscle
circumference (MAC) and triceps skinfold (TSF). How would this data be
interpreted?
AMA = [MAC – (π x TSF)] 2 = [19.05cm – (π x 15mm)]2 = 62.7
4xπ
4xπ
The Frishancho anthropometric standard for TSF places the patient below the 10th %ile,
meaning that 90% of women have higher body fat than her.
The Frishancho anthropometric standard for AMA places her above the 95th %ile,
showing she has above average somatic stores.
This can be interpreted as her weight loss resulting from fat loss instead of lean mass
loss.
13. Calculate Mrs. Bernhardt’s energy and protein requirements. What activity and
stress factor would you use? What is your rationale?
25-30 g/kg method: 30 kcal/kg if younger than 80 yo: 30 x 54kg ≈ 1600 kcal/day
MSJ: 10(54kg) + 6.25(160cm) – 5(62) – 161 = 1040 kcal x 1.4 ≈ 1350 kcal/day
HB: 655.1 + 9.6(54kg) + 1.9(160cm) – 4.7(62) = 1186 x 1.3 ≈ 1550 kcal/day
I multiplied the REE’s by a factor of 1.3. This is a factor seemed adequate maintain body
weight and prevent malnutrition, but it is not too high to be considered overfeeding and
excessive CO2 production, which can begin above 150% REE.
Protein 1.2-1.7g/kg/day: 1.2 x 54kg = 69; 1.7 x 54kg=92
70-90 grams protein/day
14. Using Mrs. Bernhardt’s nutrition history and 24-hour recall as a reference, does she
have an adequate oral intake? Explain.
24 hour recall:
Breakfast: ½ c coffee with non-dairy creamer, few sips of orange juice, ½ c oatmeal with
1 tsp sugar
Lunch: ¾ c chicken noodle soup, 2 saltine crackers, ½ c coffee with non-dairy creamer;
32 oz pepsi throughout the day
710 calories, 164 g carbohydrates, 5 g fiber, 9 g protein (5% of calories), 6 g fat (7.5% of
calories)
Mrs. Bernhardt does not have an adequate energy intake. With 710 calories, she is
consuming less than 50% of her estimated energy needs of 1350-1600 kcals/day. Her
protein requirements are 70-90g/kg/day, but she is only consuming 9 grams. She has lost
20 lbs in the past year and is 20% below her usual body weight.
15. Evaluate Mrs. Bernhardt’s laboratory values. Identify those that are abnormal.
Which of these may be used to assess her nutrition status?
Mrs. Bernhardt’s total protein and albumin are low, which could indicate malnutrition.
Her WBC is high, indicating a sign of infection. Her hematocrit, hemoglobin and RBC
are low, a sign of anemia, especially her hemoglobin and hematocrit. A change in her low
pH, high PCO2, low O2 saturation, high CO2 content, low O2 content indicates oxygen
therapy is working. Her high base difference and HCO3 could mean her body was trying
to counteract respiratory acidosis.
16. Why may Mrs. Bernhardt be at risk for anemia? Does her laboratory values
indicate that she is anemic?
Anemia is quite prevalent in chronic diseases including COPD. Although the exact
mechanism is not known, inflammation is believed to be the cause. Mrs. Bernhardt’s low
intake of energy may also be contributing to anemia. Her decreased hemoglobin,
hematocrit, and red blood cell values are all decreased, indicating anemia.
Although anemia is common in chronic diseases, these values may be low when excess
fluid is present. Mrs. Bernhardt also has edema, so further testing should take place to
diagnose anemia.
17. What factors can you identify from her nutrition interview that probably
contributes to her difficulty in eating?
Mrs. Bernhardt states that her appetite is poor, she fills up quickly, finds meal preparation
challenging, is often too tired to eat, coughs to the point where she cannot eat, does not
enjoy the taste of her food, and has loose dentures.
18. Select two high-priority nutrition problems and complete the PES statement for
each.
a. Self-feeding difficulty (NB-2.6) related to patient’s shortness of breath and
fatigue during mealtimes as evidenced by a 20 lb weight loss in one year and a
24-hour recall revealing an intake significantly less than her required energy,
nutrients, and fluid needs.
b. Food and nutrition-related knowledge deficit (NB-1.1) related to misinformation
about milk and dairy products as evidenced by an absence of calcium-rich foods
in patient’s diet and confirmation of avoidance of these foods.
19. What is the current recommendation on the appropriate mix of calories from
carbohydrates, protein, and lipid for this patient?
A high consumption of carbohydrates can place additional stress on the respiratory
system and the body by increasing the amount of carbon dioxide. A high-fat, lowcarbohydrate diet has been shown to provide adequate amounts of energy to avoid
maintain body weight, but not exacerbate lung distress.
COPD patients should consume a diet with a mix of 30-45% fat, and 15-20% protein, and
balance the carbohydrates lastly.
20. For each of the PES statements you have written establish an ideal goal (based on
the etiology).
Goal: Instruct patient to consume smaller, more frequent meals and rest before mealtime
to avoid fatigue Improve quality of food consumed by choosing nutrient dense food, and
nutrition supplements if necessary. Patient will be able to consume more nutrients in a
smaller amount of time with nutrient dense food..
Goal: Inform patient that milk will not increase mucus production. Instruct her on the risk
of osteoporosis in COPD and the importance of consuming enough calcium and vitamin
D per day. Education should also include alternative sources if patient continues to refuse
dairy.
21. What goals might you set for Mrs. Bernhardt as she is discharged and beginning
pulmonary rehabilitation?
Continue to avoid tobacco.
Be sure to include nutrient-dense food such as colorful fruits and vegetables, lean meats
and healthy fats in her diet.
Avoid energy-dense food like refined grains, fatty meats, fried food, and sweets.
Reduce her intake of soda.
Include vitamin supplements if necessary.
Do not avoid milk and other dairy foods, as they are important to prevent osteoporosis.
22. You are now seeing Mrs. Bernhardt at her second visit to pulmonary rehabilitation.
She provides you with the following information from her food record. Her weight is
now 116 lbs. She explains adjustment to her medications and oxygen at home has
been difficult, so she hasn’t felt like eating very much. When you talk with her, you
find she is hungriest in the morning, and often by evening she is too tired to eat. She
is having no specific intolerances, but she does tell you she hasn’t consumed any
milk products because she thought they would cause more sputum to be produced.
Monday
Breakfast: coffee, 1 c with 2 T nondairy creamer; orange ½ c; 1 poached egg; ½ slice of
toast
Lunch: ¼ tuna salad sandwich (3 T tuna salad on 1 slice wheat bread); coffee, 1 c with 2
T nondairy creamer.
Supper: cream of tomato soup, 1 c; ½ slice toast; ½ banana; pepsi-approximately 36 oz
Tuesday
Breakfast: Coffee, 1 c with 2 T nondairy creamer, orange juice, ½ c, ½ c oatmeal with 2
T brown sugar
Lunch: 1 chicken leg from Kentucky Fried Chicken; ½ c mashed potatoes; 2 T gravy;
coffee, 1 c with 2 T nondairy creamer
Supper: cheese, 2 oz; 8 saltine crackers; 1 can V8 juice (6 oz); pepsi, approximately 36
oz
a. Is she meeting her calorie and protein goals?
She consumed 1070 calories and 28 grams of protein on Monday, and 1500
calories and 40 grams of protein on Tuesday. Although she is consuming much
more than last time, she is still not meeting her goals.
b. What would you tell her regarding the use of supplements and or milk and
sputum production?
Although it is widely believed that milk causes an increase in mucus production,
there is no substantial scientific evidence that disproves that thought. She should
consider calcium and vitamin D supplements due to the risk of osteoporosis in
COPD.
c. Using information from her food diary as a teaching tool, identify three
interventions you would propose for Mrs. Bernhardt to increase her calorie
and protein intakes.
Mrs. Bernhard should consume more milk and dairy products. They will add
protein, fat, and calories to her diet.
Mrs. Bernhardt should reduce the amount of pepsi she drinks throughout the day
and increase her water intake.
Mrs. Bernhardt’s diet is still lacking protein, vitamins and minerals, and overall
energy. She should add a high calorie, high protein supplement that provides
essential vitamins and minerals.
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CHRONIC
OBSTRUCTIVE
PULMONARY
DISEASE
NUTRITION POCKET CARD
Kevin Hernandez
10/07/2013
Definition
A progressive disease that limits airflow through either
inflammation of the bronchioles or destruction of alveoli.
Diagnosis
Diagnosis should be considered in patients with progressive
dyspnea, chronic cough, chronic mucus production, and a
history of exposure to tobacco smoke or other
environmental risk factors.
Spirometry
Lung function tests are used to confirm diagnosis and
monitor progression of disease.
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Forced Expiratory Volume in 1 second (FEV1):
amount of air expired in the first second of
exhalation
Forced Vital Capacity (FVC): total amount of air
expired during exhalation
FEV1/FVC: Ratio of two values
Stages of COPD
0 – at risk
I – mild
II – Moderate
III - Severe
IV – Very Severe
Normal Spirometry
FEV1 >80%
FEV1 <80%
FEV1 <50%
FEV <30% or <50% with
symptoms of respiratory
failure
Protein & Energy Requirements
Calories
o Mifflin-St Jeor:
o Women: 655.1 + 9.6(wt in kg) + 1.9(ht in cm) -4.7(age)
o Men: 66.5 + 13.8(wt in kg) + 50(ht in cm) – 6.8(age)
o
Mifflin-St Jeor:
o Women: 10 (wt in kg) + 6.25 (ht in cm) – 5(age) – 161
o Men: 5 + 10(wt in kg) + 6.25(ht in cm) -5(age) + 5
o
Kcal/kg Method: 30 kcal/kg
Protein
o High enough to stimulate protein synthesis, maintain
lung strenght and prevent wasting
o 1.2 – 1.7 g/kg/day to prevent
Lab Values to Monitor
pH
pCO2 (mm Hg)
satO2 (%)
CO2 content (mmol/L)
O2 content (%)
Base deficit (<3)
HCO3 (mEq/L)
Ref. Range
7.35-7.45
35-45
>95
25-30
15-22
3.6
24-28
Goals of COPD Management
 Discontinue smoking (if current smoker)
 Relieve symptoms
 Prevent progression
 Reduce strenuous breathing efforts
 Improve overall health
 Prevent complications
 Reduce mortality
 Minimize side effects
Nutrition Recommendations
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COPD patients should receive up to 130% of
resting energy expenditure to avoid malnutrition,
but should never exceed 150% of REE as this can
result in overfeeding and added stress.
COPD patients should receive plenty of protein,
about 1.2-1.5 g/kg/day to maintain respiratory
muscles and avoid malnutrition.
Diets rich in fruits, vegetables, and fish have
resulted in a lower incidence of COPD when
compared to a diet consisting of refined grains, red
meat, sweets, and fried foods.
Antioxidants can help prevent damage caused by
pollutants and tend to be depleted in COPD
patients
Diets higher in fat and lower in carbohydrates
result in a lower RQ, meaning less stress on the
lungs.
COPD patients are at risk of osteoporosis and
should monitor their calcium and phosphate levels
Fluid intake should not be too high since edema
can occur, but should be adequate to prevent
dehydration
Resting before meals and eating smaller meals can
help with fatigue and feeling full
Oxygen Therapy
COPD patients may require O2 therapy. Begin O2 therapy
if:
 Pa02 reaches below 55 mm Hg, or SaO2 is less than
88%, with or without hypercapnia or
 PaO2 is less than 60 mm Hg, or SO2 is 88%, and
the presence of pulmonary hypertension, peripheral
edema or polycythemia.
References
Gottschlich, M. M., DeLegge, M. H., Guenter, P., American Society for
Parenteral and Enteral Nutrition. The A.S.P.E.N. nutrition support core
curriculum: a case-based approach : the adult patient. Silver Spring,
Md: American Society for Parenteral and Enteral Nutrition; 2007.
Nahikian-Nelms M. Nutrition therapy and pathophysiology. Belmont,
Calif: Wadsworth, Cengage Learning; 2011.
Rodriguez-Roisin, R., Anzueto, A., Bourbeau, J. DeGuia, T. S., Hui,
D., Jenkins, C., Martinez, F., Mishima, M., Montes de Oca, M.,
Stockley, R., van Weel, C., & Vestbo, J. (2010) Pocket guide to COPD
diagnosis, management, and prevention, Global Initiative for Chronic
Obstructive Lung Disease