Professional Documents
Culture Documents
Kasey Hutchinson
Title: Case 27 COPD with Respiratory Failure
Questions:
1. Mr. Hayato was diagnosed with emphysema more than 10 years ago.
Define emphysema and explain its underlying pathophysiology.
Emphysema is the gradual damage of alveoli in the lungs which
leads to the rupturing of alveoli in the lungs and the airspace in
the lungs decreases. Pathology associated with emphysema
includes decrease in elastic recoil and airway narrowing. Both of
these mechanisms decrease airflow and amount of oxygen being
delivered to lungs.
2. In the emergency room, a chest tube was inserted into the left thorax with
drainage under suction. Subsequently the oropharynx was cleared. A
resuscitation bag and mask were used to ventilate the patient with highflow oxygen. Endotracheal intubation was then performed, using a
laryngoscope so the trachea could be directly visualized. The patient was
then ventilated with the help of a volume-cycled ventilator. Ventilation is
15 breaths/min with an FiO2 of 100%, a positive end-expiratory pressure of
6, and a tidal volume of 700 mL. Daily chest radiographs and ABGs were
used each AM to adjust the ventilator settings. Define the following terms
found in the history and physical for Mr. Hayato:
a. Dyspnea: shortness of breath
b. Orthopnea: shortness of breath while lying down
c. Pneumothorax: collapsed lung; air leaks out and collects in the
space between lungs and chest
d. Endotracheal intubation: this is the placement of a tube into
the trachea to increase airflow and open the airway
e. Cyanosis: this refers to the a situation in which the skin and
mucous membranes turn blue due to lack of oxygen
3. Identify features of the physicians physical examination consistent with
his admitting diagnosis. Describe the pathophysiology that might be
responsible for each physical finding.
Pulse Rate: 118, this is high which is consistent with COPD
because his heart is working harder to deliver gases to and from
tissues of the body
Resp Rate: 36; this level is high as well because his lungs are
having to work harder and faster to make up for lost villi
2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
27-2
2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
27-3
7. Determine Mr. Hayatos energy and protein requirements using the MifflinSt. Jeor, Ireton-Jones, and COPD predictive equations. Compare them. As
Mr. Hayatos clinician, which would you set as your goal for meeting his
energy needs?
Mifflin-Jeor (AF 1.3): 1,705 kcal/day
Ireton-Jones: 1,588 kCal/d
COPD predictive equations: (Mifflin Jeor X 1.25-1.56) 2,129-2,659
kCal/d
Protein: 66-82.5 (1.2-1.5 g/kg for pulmonary disease)
I would recommend 2,300 kCal per day and between 66 and 82
grams of protein daily
8. Determine Mr. Hayatos fluid requirements.
1650 mL/d (30ml/kg)
9. Evaluate Mr. Hayatos biochemical indices relevant to nutritional status on
3/26.
Bilirubin is (.8) high because many red blood cells have died due
to lack of oxygen.
HDL is low (32) and HDL is high (142), possibly due to high fat
intake or trouble metabolizing fat
Hemoglobin is low (13.2) and hematocrit low (39) possibly related
to his condition
10. Select two high-priority nutrition problems and complete the PES
statement for each.
Unintentional weight loss related to lack of appetite and increased
energy needs secondary to COPD AEB 10% weight loss, increased
heart rate and increased respiratory.
Inadequate oral intake RT lack of appetite (secondary to COPD) AEB
10% weight loss in past several weeks and 24-hour recall
indicating very little caloric consumption.
11. A nutrition consult was completed on 3/27, and enteral feedings were
initiated. Mr. Hayato was started on Isosource HN @ 25 cc/hr continuously
over 24 hours.
a. At this rate, how many kcal and grams of protein should he receive per
day?
He would be receiving 720 kCal and 32 g protein per day
(1.2 kcal/mL x 25 ml x 24 hr) (720 kcal x .18 x 1g/4kcal)
2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
27-4
2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
27-5
feeding all together he will probably not eat much and his
condition will worsen.
16.
a. On the day Mr. Hayato was intubated, his ABGs were as follows: pH 7.2,
pCO2 65, CO2 35, pO2 56, HCO3- 38. What can you determine from each
of these values?
He is slightly acidic, his pCO2 is high, CO2 is high, pO2 is low and
HCO3 is high. This indicates that his lungs are not adequately
ridding the body from carbon dioxide/inhaling sufficient oxygen.
This is very typical for people with COPD.
b. On 3/28, while Mr. Hayato was on the ventilator, his ABGs were as
follows: pH 7.36, pCO2 50, CO2 29, pO2 60, HCO3- 32. What can you
determine from each of these values?
His pH is back to normal, though still on the low end of normal,
pCO2 has decreased but is still too high, CO2 is down to
normal, pO2 is higher but still too low, and HCO3 is a little
lower but still too high. This indicates that the ventilator is
working and his condition is improving but he still needs to be
monitored and continuing with treatment.
c. On 3/30, after the enteral feeding was resumed, his ABGs were as
follows: pH 7.22, pCO2 66, pO2 57, CO2 36, HCO3- 37. In addition,
indirect calorimetry indicated an RQ of 0.95 and his measured energy
intake was 1350 kcal. How does the patients measured energy intake
compare to your previous calculations? What does the RQ indicate?
It seems that all of his values have become worse; pH dropped
to belowe normal, pCO2, CO2 and HCO3 have risen, pO2 has
dropped. He is also eating nearly 1,000 calories less than
recommended. His RW, or respiratory quotient, is a measure of
2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
27-6
2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.