Case Study: Nutrition Management of Aspiration Pneumonia

Case Study: Nutrition Management of Aspiration

PneumoniaRenee (Pik Shan) Fung

Dietetic InternARAMARK Healthcare

Distance Learning Dietetic InternshipMaple Grove Hospital

Disease Description

Aspiration- the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract

Aspiration Pneumonitis- Chemical injury caused by the inhalation of sterile gastric contents

Aspiration Pneumonia- Infectious process caused by the inhalation of oropharyngeal secretions that are colonized by pathogenic bacteria

Definitions

Aspiration can cause serious illnesses and even death.

Four common problems of aspiration: 1. Failure to distinguish aspiration pneumonitis from

aspiration pneumonia 2. Tendency to consider all pulmonary complications

of aspiration as infectious 3. The failure to identify the spectrum of pathogens in

patients with infectious complications 4. Misconception that aspiration must be witnessed

for it to be dx.

Aspiration

Half of all healthy adults aspirate. The human body is capable of removing

foreign objects by coughing Individuals who have problem with removing

foreign objects properly are at risk of developing aspiration pneumonia/ pneumonitis

Etiology

Common cause of aspiration pneumonia is the inhalation of Haemophilus influenza and Streptococcus Pneumonia.

They are colonized in the nasopharynx or oropharynex before they are aspirated.

Pathophysiology

Since aspiration pneumonitis is the inhalation of sterile gastric contents, bacterial infection does not play an important role at early stage.

At a later stage of aspiration pneumonitis, bacterial colonization may occur if the individual has gastroparesis, small-bowel obstruction, receives enteral feedings, or has higher pH gastric acids. In this case, the individual has aspiration pneumonia.

Pathophysiology

Signs/symptoms: (signs of aspiration) Persistent cough and fever. However, many times silent aspiration can develop. In aspiration pneumonia, the episode of aspiration is generally not witnessed.

Swallowing evaluation by an SLP CT scan- radiographic evidence of foreign

material infiltrating in patient’s lungs (some may be undetectable)

Aspiration Pneumonia Diagnosis

Currently, there are no recognized guidelines for risk factors of aspiration pneumonia

Elderly Neurologic Dysphagia Unconscious individuals Individuals at hospitals Disruption of the gastroesophageal junction Abnormalities of the upper GI tract Poor oral care individuals Patients with stroke After the removal of an endotracheal tube due to residual effects or

sedative drugs, the presence of an NG tube, and swallowing dysfunction related to alterations of upper-airway sensitivity, glottic injury, and laryngeal muscular dysfunction

Individuals who are at risk of aspiration pneumonia

Increased LOS Increased cost Increased morbidity and mortality

Co-morbidity

Early detection of patents who are at risk of or have aspiration pneumonia SLP evaluation

Barium swallow CT scan

Provide appropriate care

Decrease aspiration pneumonia complication

Evidenced Based Nutrition Recommendations for Aspiration

Pneumonia

30-45 degree head of bed elevation position Promotility agents

AND: if >500 mL GRV A.S.P.E.N: If >250 mL GRV

E.g. Metoclopramide and Erythromycin Associated with reduced GRV in critically ill pts Recommend to be used in critically ill pts who

experience feeding intolerance (high gastric residuals, emesis)

AND Evidence Analysis Library

and the A.S.P.E.N

Hypothesis: Elemental diets may be useful for the prevention of aspiration pneumonia possibly through more rapid gastric emptying than standard liquid diets.

This study is separated into 2 different parts.

Horiuchi A, et al (2013) – Elemental diets may reduce the risk of aspiration pneumonia

in bedridden gastrostomy-fed patients

Participants: 128 Bedridden PEG participants Age: Average 80 years old Gender: 60 of the participants were male.

Method:60 subjects were assigned to elemental diet group67 subjects were assigned to the standard liquid diet group.Record subjects who experienced aspiration and aspiration pneumonia

Horiuchi A, et al – Elemental diets may reduce the risk of aspiration pneumonia in bedridden gastrostomy-fed patients

PART 1

Result: The number of patients who had diet

aspirated from the trachea or who developed new aspiration pneumonias in the elemental group was significantly less than the standard liquid diet group.


PART 1

Randomized, crossover trial which focused on identifying the gastric emptying velocity differences between the two diets via PEG

Participants: 19 PEG subjects


PART 2

Result: Elemental diets were associated with more

rapid gastric empting.Possibly due to:

Fatty diet takes longer time to empty and is associated with gastroesophageal regurgitation. Standard liquid diet has higher fat content than elemental diet.


PART 2

Limitation: Study 1 had increased risk of bias because it

was neither randomized nor blinded Study 2 could not prove the hypothesis by itself Participants in study 1 included those who had

pervious experience of aspiration which suggested that they can be generalized.

Study 2 might have “carry-over” issues between treatments.


In summary, this study found elemental diets to be associated with reduced episodes of aspiration and more rapid gastric empting among bedridden PEG patients. Nevertheless, further research is needed to prove whether or not there is a causation effect existing between rapid gastric empting and reduced episodes of aspiration and aspiration pneumonia.


Examined the effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients.

Method: 2 reviewers reviewed and selected studies searched from MEDLINE,

EMBASE, Web of Science, and CCTRD. The reviewers then compared gastric and post-pyloric feeding in critically ill patients.

Selection Criteria: Trails should report at least one of the following outcomes: incidence of

pneumonia, vomiting, or aspiration, and studies that were published in any language. Selected studies were all published in English and were from Canada, Australia, Italy, Spain, Taiwan, and the USA. The selected studies included patients from general ICUs, pediatric ICU, neurological ICU, and severe acute pancreatitis from gastroenterology.

Jiyoung J, et al (2013) - Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients: observations from traditional

and Bayesian random-effects meta-analysis.

Result: The incidences of pneumonia were 16.3% in the post-

pyloric feeding group and 26.1% in the gastric feeding group (P = 0.001).

There was no significant differences in the beneficial effect of the post-pyloric feed location (duodenum (P=0.03) versus jejunum (P= 0.07).

there was no significant difference between post-pyloric feeding group and gastric feeding group in the amount of aspiration (P= 0.55) and vomiting (P = 0.56) incidence.

Jiyoung J, et al - Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically

ill patients: observations from traditional and Bayesian random-effects meta-analysis.

Limitation Not all outcomes in the selected studies were reported. Many of the studies were not good qualities.

For example, potential biases may exist in the selected studies, clinical heterogeneity in the studies that may account for the statistical heterogeneity that were found in this study which could have affected the result, and not all studies reported adequate concealment, blinding of participants, and outcome assessment.

The amount of eligible studies was relatively small. (757 pts; 15 studies)



In summary, Jiyong J, et al suggested that critically ill patients with post-pyloric feeding is associated with reduced incidence of pneumonia when compared with gastric feedings. Meanwhile, there is no significant difference in incidence of neither aspiration nor vomiting between the two groups. Finally, no significant beneficial difference was found between post-pyloric feeds to the jejunum or duodenum.



Case Presentation

58 yrs old F Lives at group home Aspiration noted by group home manager.

Patient had continuous coughing and developed a fever. Patient was admitted to the ER the next day

Case Presentation

Client Hx Mental Retardation Epilepsy Schilder’s cataract Hypothyroidism

Family HxUnknown; pt was in foster care since the age of 2

DNR status

Nutrition Care Process- Assessment

Food/ Nutrition-Related Hx Patient consumes a ground diet (Dysphagia 2)

with honey thickened liquids for the past 15 yrs due to recurrent aspirations

NKFA Upon admission, patient was provided with

calcium + vit D pills, D5W NS @ 125 mL/hr, Colace, Synthroid, Protonix, Miralax, and Propofol ranging 7-10 mL/hr


Nutrition-Focused Physical Findings Patient had gained 14 lbs in 2 days. Patient has fluid retention. Skin integrity: minor impairment Appetite: Fine prior to aspiration episode SLP recommended patient to be NPO besides

medications are crushed into applesauce. Patient unable to self-feed


Anthropometric Measurements UBW: Unable to obtain d/t patient’s mental

state Height: 4’10” IBW: 95 lbs +/- 10% BMI: 28.5 – overweight *Patient is retaining fluid, weight may not be

a good indicator for nutrition status


Biochemical Data, Medical Tests, and Procedures

A swallowing evaluation was performed by the SLP. The SLP noted signs and symptoms of aspiration

The patient will have an OJ tube placed for short-term nutrition support.

A chest x-ray was done before patient being intubated.


Lab Results

Component Value

Normal

Date Rationale

ALBUMIN g/dL

3.0* 3.5-5

9/25/2013 Malnutrition, acute inflammation

GLUCOSE mg/dL

94 70-110

9/27/2013

GLUCOSE 91 9/27/2013

GLUCOSE 116* 9/26/2013 Elevation due to stressed state

SODIUM mEq/L

139 136-145

9/27/2013 Check for hydration status

POTASSIUM mEq/L

3.2* 3.5-5.5

9/27/2013 GI loss, malabsorption

PHOSPHORUS

3.1 9/25/2013 Check for re-feeding syndrome risk

MAGNESIUM mg/dL

2.0 1.8-3

9/25/2013 Check for re-feeding syndrome risk

CHLORIDE mEq/L

106 95-105

9/27/2013 Check for fluid/ acid-base imbalances

CALCIUMSERUM mg/dL

7.6* 9-11 9/27/2013 Low serum calcium; Corrected Ca: 8.4*

BUNUREANRO

19* 9/27/2013 Malnutrition

CREATININE mg/dL

1.15 0.6-1.2

9/27/2013 Check for kidney function

Nutrition Need Calories: 1300 kcal (30kcal/kg IBW) Protein: 65-86 gm (1.5-2 gm/kg IBW) Fluids: 1300 mL

Nutrition Classification:Severely Compromised, Will follow up every 1-3 days

New TF (+4), Low Albumin (+2), Swallowing Problems (+3), Dysphagia (+3)


#1 Swallowing difficulty (NC-1.1) related to respiratory status as evidenced by NPO status, need for dysphagia diet, and aspiration history.

Nutrition Care Process: Nutrition Diagnoses

#1 Enteral Nutrition (ND-2.1). Recommend initiate enteral nutrition via OJ tube or NJ tube, once placement verified start Isosource 1.5 at rate of 15 mL/hr x 8 hrs; if tolerating advance by 10 mL every 8 hrs to current goal rate of 30 mL/hr x 24 hrs/day. No current free water flushes until IVF addressed. (Table 5)

#2 Collaboration and Referral of Nutrition Care: Collaboration with other providers (RC-1.4).

No residual checks with Jejunal feeding

Nutrition Care Process: Nutrition Intervention

Short-term Goal/ Expected Outcome : Maximize nutrient intake: Patient receives more

than 75% of recommended nutritional needs via PO or nutrition support.

Patient maintains admission weight.Long-term Goal/ Expected Outcome:

Patient will be able to meet more than 75% of recommended nutritional needs via PO intake or long-term tube placement in place for feeding.

Patient reduces aspiration incidence.

Nutrition Care Process: Nutrition Intervention

Monitor and Evaluation (Nutrition Intervention Performed): #1Enteral nutrition intake (FH). Formula/ solution (1.3.1).

Patient was receiving enteral support via OJ tube with Isosource 1.5 formula at 30 mL/hr x 24 hours. Patient tolerated tube feeding at goal rate. The patient is receiving 100% of recommended kcal and protein needs via nutrition support.

#2 Micronutrient Intake (1.6) Mineral/ element intake (2) Calcium (1). Patient’s corrected calcium is WNL. Phosphorus (6).

Patient is on phosphorus replacement protocol. #3 Biochemical data, medical tests and procedures (BD).

Glucose/ endocrine profile (1.5). Glucose, fasting(1). Glucose continues to be high. High glucose

possibly due to stress since Hgb A1c is WNL. Electrolyte and renal profile (1.2). Continued to monitor patient’s renal lab.

#4 Anthropometric Measurements (AD). Weight change (1.1.4).

Patient gained 9 lb since admission.

Nutrition Care Process: Monitoring and Evaluation

Short-term goal: (Achieved) Short-term goal: Maximize nutrient intake:

Patient receives more than 75% of recommended nutritional needs via PO or nutrition support.

(Not Achieved) Patient maintain current weight.

Long-term goal: (Not Achieved) Patient will be able to meet more than 75%

of recommended nutritional needs via PO intake or long-term tube placement in place for feeding.

(Not Achieved) Patient reduces aspiration incidence.


The patient was admitted to the hospital from 9.27 to 10.14. The patient was followed up everyday by a dietitian. Meanwhile, the patient had developed acute respiratory failure and was at critical condition. Her tube feeding formula was switched from Isosource 1.5 to Impact Peptide 1.5 which is an elemental formula for patients who are in stressed condition. The patient then became more stable, and had a PEG placement for long-term nutrition support. The patient was discharged with nocturnal feeds Isosource 1.5 65 mL/hr x 12 hours/day. The reason why she was discharged with Isosource 1.5 instead of Impact Peptide 1.5 was because her insurance company would not cover Impact Peptide 1.5 since it is an elemental formula and is more expensive.


The patient was re-admitted to the hospital 4 days after being discharged. The patient was re-admitted for aspiration because she was having PO intake. The patient is on DNR status. The RD recommended modifying the PEG tube to a PEG-J tube, however, IR stated that PEG needed to be in place for 3-4 weeks prior to adjust tube. During her second admission, the tube feeding was either running at a low rate or on hold for a few times due to reoccurring emesis. Finally, the patient was able to tolerate tube feeding with bolus feeds. The patient was discharged on 10/26/2013 with the same recommendation of tube feeding regimen as previous time.

Patient’s Progress after Discharge

30-45 degrees head of bed position Enteral nutrition support to decrease risk of

aspiration Jejunal feeds rather than gastric feeds Elemental formula was used

Evidence-based recommendation implemented on this case

The current recommendation for Aspiration Pneumonia care is to feed patients who are receiving tube feeding in a 30-45 degree elevation of head of bed position. Promotility agents are also encouraged to use. There are controversial in whether or not jejunal feeding is more beneficial over gastric feeding; More research need to be done to confirm this finding. Further more, research suggest that elemental formula may be a better choice than standard formula, however, elemental formulas are more expensive and many insurance do not cover it.

Conclusion

1. Horiuchi A, Nakayama Y, Sakai R, Suzuki M, Kajiyama M, Tanaka N. Elemental diets may reduce the risk of aspiration pneumonia in bedridden gastrostomy-fed patients. Am J Gastroenterol. 2013; 108: 804-810.

2. Jiyong J, Tiancha H, Huiqin W, Jingfen J. Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients: observations from traditional and Bayesian random-effects meta-analysis. Clin Nutr. 2013; 32: 8-15.

3. Echevarria IM, Schwoebel A. Development of an intervention model for the prevention of aspiration pneumonia in high-risk patients on a medical-surgical unit. Medsurg Nurs.2012; 21 (5): 303-308.

4. Marik P. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001; 344(9): 665-671.

5. Komiya K, Ishii H, Umeji K, et al. Impact of aspiration pneumonia in patients with community-acquired pneumonia and healthcare-associated pneumonia: A multicenter retrospective cohort study. Respirology.2013; 18 :514-521.

6. Garcia J, CCC, Chambers E. Managing dysphagia through diet modifications. Am J Nurs. 2010; 110(11): 26-33

7. Recommendations Summary CIU: Optimizing Enteral Nutrition Delivery. Academy of Nutrition and Dietetics Evidence Analysis Library Web site. http://andevidencelibrary.com/template.cfm?key=3256.Accessed December 14, 2013

References

http://andevidencelibrary.com/template.cfm?key=3256.Accessed

8. Bankhead R, Boullata J, Brantlet S, et al. Enteral nutrition practice recommendations. J Parenter Enteral Nutr. 2009; 33(2): 123-167.

9. Ho KM, Dobb GJ, Webb SA. A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intens Care Med. 2006; 32: 630-649

10. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003; 7: R46-R51.

11. Heyland DK, Drover JW, Dhaliwal R, Greenwood K. Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding. Jpen-Parenter Enter. 2002; 25: S51-S55

12. American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd ed. Chicago, Il: American Dietetic Association; 2009.

13. Pronsky ZM, Crowe SR. Food Medication Interactions. 17th ed. Birchrunville, PA: Food-Medication Interactions; 2012.

14. Nutrition Care Manual Web site. https://www.nutritioncaremanual.org/to pic.cfm?ncm_category_id=1&lv1=5538&lv2=255469&ncm_toc_id=255469&ncm_heading=Nutrition%20Care. Accessed Dec 15, 2013.

15. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2007.

16. White JV, Guenter P, Jensen G, et al. Consensus statement: academy of nutrition and dietetics and American society for parenteral and enteral nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Parenter Enteral Nutr. 2012; 36: 278-279

17. American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd ed. Chicago, Il: American Dietetic Association; 2009.

Reference

https://www.nutritioncaremanual.org/to%20pic.cfm?ncm_category_id=1&lv1=5538&lv2=255469&ncm_toc_id=255469&ncm_heading=Nutrition%20Care



Case Study: Nutrition Management of Aspiration Pneumonia

Documents

Transcript of Case Study: Nutrition Management of Aspiration Pneumonia