Battling ARDS

A Clinical Case Study

Kelly Lonergan
DHEC Dietetic Intern 2014

Introducing M.B.B.
56 year old
Male
African-American
Admitted 10/14 for this admission
Length of Stay: 29 days so far
MICU
Vent-Dependent, on Tube Feeds

Admissions

October 14th Current

[LOS: 28+ days]
September 9th October 3rd [LOS: 24 days]
June 25th July 10th
[LOS: 15 days]
June 6th June 16th
[LOS: 10 days]
January 27th April 11th
[LOS: 74 days]

Chief Complaints

Altered Mental Status

Nonverbal
Confusion
Fever
Short of Breath
Weakness
Chest Pain
Cough w/ green septum
Decreased consciousness
Loose Stool

Diagnoses

ACUTE RESPIRATORY DISTRESS FAILURE

SEPSIS/HCAP
LEFT FOOT UCLER/CELLULITIS/OSTEOMYELITIS
HYPERTENSION
HYPERNATREMIA
HYPOKALEMIA
CHRONIC KIDNEY DISEASE STG 3
METABOLIC ENCEPHALOPATHY
CHRONIC ANEMIA
POSSIBLE SEIZURE
POOR NUTRITION

Focus: ARDS
(Acute Respiratory Distress Syndrome)
Definition: The inflammation of the lung
parenchyma and increased pulmonary capillary
permeability leading to impaired gas exchange.
Specifically, ARDS is defined as the PaO2 (arterial
partial oxygen tension) to the fraction of FiO2
(inspired oxygen) ratio of below 200 mmHg with
bilateral alveolar infiltrates on the chest x-ray and
a normal pulmonary capillary wedge pressure.
Gehlbach, Hill. 2008. Acute Respiratory Distress Syndrome (ARDS). Merck Manuals.

Focus: ARDS
Essentially, the portion of
the lung involved in gas
exchange is severely
inflamed which causes
pulmonary edema.

The lungs are filled with

fluid which prevents
them from functioning
properly.

Focus: ARDS
This then increases
the distance oxygen
must diffuse to reach
the blood. In general,
the lungs have to
work much harder to
oxygenate the body.

Symptoms

Shortness of breath
Low, rapid breathing
Crackling, wheezing sounds in lungs
Mottled, blue skin d/t lack of oxygen
Possible heart, brain malfunction d/t lack of
oxygen
Arrhythmia, rapid heart rate
Confusion
Lethargy

Diagnosing
Blood sample revealing low levels of oxygen in
the blood
Chest x-ray showing fluid in places where air
should be
White Out

White Out

Treatment
Mechanical ventilation
Nutrition support
Enteral formula enriched with EPA, DHA, and
enhanced levels of antioxidant vitamins
Research

Research
Omega-3 Fatty Acids have many anti-inflammatory
properties
EPA and DHA have beneficial effects on pulmonary
neutrophil recruitment and gas exchange
Can the addition of omega-3 fatty acids in nutrition
improve the disease process of ARDS?

Research
Randomized study had ARDS patients receiving either
a high-lipid enteral formula with EPA or a standard
pulmonary formula.
The testing patients experienced improved oxygenation,
fewer days ventilation, and shorter length of stay in the
ICU
Another study did a similar test with ARDS/sepsis
patients and found the testing group to have a reduced
mortality rate, less days on the vent, and fewer days in
the ICU as well
Raoof, et al. 2010. Severe hypoxemic respiratory failure: part 2--nonventilatory strategies. Chest

Applying Research
Current:
Jevity 1.2 @ 60 ml/hr + 2 packs propass
1788 calories, 92 g protein
High-calorie, high-protein formula
Possible Change:
Pivot 1.5 @ 50 ml/hr
1800 calories, 113 g protein
3.12 g EPA, 1.32 g DHA

Nutritional Implications
Increased calorie needs d/t increased work on
lungs and hypermetabolism
Increased protein requirements to 1.5-2.0 g/kg
BW
Fluid restriction if patient is volume overloaded

Prognosis
Majority of ARDS patients will require
mechanical ventilation and nutrition support
Average length of mechanical ventilation with
ARDS is 10-14 days
MBB on 9 days, with prior intubations

10-20% patients remain ventilator dependent for

> 3 weeks
With appropriate treatment, ~75% ARDS
patients survive

Patient Medical/Surgical History

Adult Respiratory Distress Syndrome

Right AKA 9/30/14 Dr. Moore
PEG Tube placement 2/06/14 Dr.
Richter
CAD
HTN
MI
CKD Stage 3
Right Frontal Lobe Parenchymal
Intracerebral Hemorrhage 01/2014
Hepatitis B, Hepatitis C
Ischemic Stroke
Anemia 6/06/14
Seizures
Acute Hypoxic Respiratory Failure
Dysphagia/Aphasia r/t Stroke

Seizure-like Activity 11/03/14

Cellulitis of Left Foot (possibly
osteomyelitis?)
Healthcare Associated Pneumonia
Aspiration Pneumonia
Sepsis
Acute Encephalopathy
Atelectasis (Left)
Hypernatremia
Hypokalemia
Acute Kidney Injury
Ascites
Anasarca

11/02/14 CODED: Not breathing, no

pulse--Mayday, CPR

Social Background

Married x 14 years, Divorced

Tobacco use
EtOH use
No reported drug useOpioid overdose 9/09/14
No further Medical History d/t absent family
Family finally surfacingawaiting decisions for
plan of care

Socio-Economics
Socio-economic status unknown
Resides in a nursing home
Also previously at LMC-EC

Family History
No history/genetic relevance available
Family nearly impossible to get into contact with
Family finally responding currently regarding
patients prognosis

Medical Tests
PEG Tube placement by Dr. Richter 2/06/14
Right Above Knee Amputation performed by Dr.
Moore on 9/30/14
Multiple Chest X-Rays
If family chooses aggressive care, patient needs:
PEG placement
Trach
Left Above Knee Amputation

Medications

Norvasc: treats high blood pressure

NEBS
Peridex: oral rinse
Klonopin: seizures
Catapres: HTN
Heparin: blood thinner
Apresoline: HTN
Normodyne: high blood pressure
Vimpat: seizures
Keppra: seizures
Synthroid: thyroid mgmt

Laboratory Values

11/09/14

146

109

33

3.6

32

0.86

124

GFR >60

Adequacy of Visceral Protein:

Serum Albumin [3.4-5.0]: 1.5 on 10/20,
gradually decreased

Adequacy of Somatic Protein:

Poor, gradual loss of lean muscle mass

Anthropometrics
Ht: 63 (190.5 cm)
Wt: 66.1 kg (145.5 lbs)
UBW: 198 lb
BMI: 18.2 11/05/14

Ideal Body Weight: 196 lbs.

Estimated Energy Needs

Penn State 2003b [Ve: 8.0 Temp: 37.4]: 1796
kcals/day
30-35 kcals/kg BW: 1953-2279 kcals/day
1.2-1.5 g/kg BW: 78-98g/day

Per Research: 1.5-2.0 g/kg BW

99-132 g protein/day
Volume restricted d/t volume overload + Lasix

PES Statement
Inadequate protein-energy intake relating
to decreased ability to consume sufficient
energy, nutrients as evidenced by NPO
status and vent-dependence

Clinical Nutrition Note

Evaluation: Resolved
Interventions: Enteral/Parenteral Composition/Formula; Modified
Beverage: Protein/Bariatric Supplement
Nutrition Prescription Recommendation: Jevity 1.2 @ 60 ml/hr w/ 2
packs propass and 30 ml water flushes q4hrs to provide 1788 calories
and 92 g protein/day
Goals: Meet est needs w/ TF- met, ongoing
Monitoring/Evaluation: Enteral Nutrition Order; Nutrition Focused
Physical Findings: Skin; Glucose/Endocrine Profile; Electrolyte/Renal
Profile

Previous Nutrition Diagnoses

Inadequate protein-energy intake

Inadequate oral intake
Unintentional weight loss
Increased nutrient needs- Protein
Underweight

Previous Nutrition Etiologies

Decreased ability to consume sufficient energy,
nutrients
Impaired skin integrity
Inadequate energy intake

Previous Nutrition Signs/Symptoms

NPO, failed bedside swallow eval

<Half meals consumed
PO intake remains variable
>19% body weight loss
30% wt loss in 9 months
Refusing meal assistance
Preexisting ulcers to feet and ankle
NPO on mechanical vent
NPO, BMI 14.4 upon adm

Previous Nutrition Interventions

Enteral Composition/Formula/Rate/Schedule
Commercial Beverage- Standard High Cal/High
Protein
General/Healthful diet
Commercial Beverage- Renal
Commercial Food
Composition of meals/snacks- Texture modified
Modified Beverage- Protein/Bariatric
supplement

Previous Nutrition Prescription

Recommendations

Low Sodium
TwoCal HN @ 45 ml/hr
Dysphagia Mechanically Altered w/ NTL and Ensure Plus
Soft, 2g Potassium w/ NTL
Suplena
Mechanically Altered, Low Cholesterol, Low Sodium, w/
Magic Cup
Puree w/ HTL w/ Magic Cup
Jevity 1.2 @ 55ml/hr
Increase to Jevity 1.2 @ 60ml/hr
Jevity 1.2 @ 60ml/hr w/ 2 pkts propass

Previous Nutrition Goals

Meet >75% est needs w/ TF

>50% meals consumed
NPO < 5 days
>50% intake at meals/supplements
>50% meal intake and/or 3+ supplements/day

Maintain/gain weight
No further weight loss

Previous Nutrition Monitors

Total Energy Intake

Liquid Meal Replacement/Supplement
Amount of Food
Diet Order
Weight changes
Electrolyte and Renal profile
Glucose/Endocrine profile
Nutrition Focused Physical Findings: Digestive System
Nutrition Focused Physical Findings: Skin
Enteral Nutrition Order
Enteral nutrition intake: formula

Evaluations
Improving/Resolved

No Change/Declining
Failed bedside swallow
Tolerating TF w/ PEG
study
Drinking some
VFSS w/ penetration on
supplements
thin liquids
Extubated
Lost >19% body weight
Hypernatremia resolving
Weight maintained/gained Aspiration
Intubated x 2
Significant weight loss
Coded

Outcomes of Care

GI consulted for PEG tube placement

Starting on Tube Feeding
Right Above Knee Amputation
Pt gained some weight back
No further weight loss
Meeting ~100% estimated needs with Tube
Feeding

Treatment Avoided
Avoided using an appetite stimulant drug; PO
intake encouraged when on diet
Avoided starting TPN as patients GI system had
great tolerance to Tube Feeding

Contributing RDs
Jennifer Benedetto
Kelly Nyberg
Morgan Robbins
Roxanne Poole
Susan Wilkerson

Thank you for your guidance

and instruction!