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Nutritional Assessment of Patients with Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure
Nutritional Assessment of Patients with Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure* Albert G. Driver, M.D.; Merle T. McAlevy, M.D.; and Jack L. Smith, Ph.D. Ia order to determine the liketihood of pre-eDtin& nutrltioaal de&dfs in medical patients with acute respiratory fllllare, a nntrltional assessment mrvey was performed oa 18 control patients with stable COPD and nine patients with COPD and acnte respiratory fallore. SJpUlcant dUferences were noted with the respiratory failure poup having deficits in percentage of ideal body weight (mean dUference 19 percent), triceps sldnfold thlclm- (mean dUference 4.4 mm), and arm muscle circumference (mean dUference 3.3 em). Slgnlficant
deficits were also found in measurements of serum transferrin and retinol binding proteins, creatinine height index and total lymphocyte counts. Body protein and fat stores were markedly depleted in almost half of the patients with respiratory failure. These data suggest that protein-calorie malnutrition is likely to be present in patients with COPD and acute respiratory failure. Nutritional support for this population should be initiated at the onset of the illness. Nutritional repletion should be considered one goal of such therapy.
Nutritional support for the medical patient with respiratory failure has received relatively little attention in the medical literature. In a recent review of nutritional support for medical patients re-
Center during the month of August, 1979 for problems related to COPD. Criteria for inclusion into the control group included compensated clinical status with chronic airflow limitation or chronic bronchitis. Chronic airflow limitation was defined as a forced expiratory volume in one second ( FEV) of 60 percent or less than the predicted value and 60 percent or less than a simultaneously obtained forced vital capacity ( FVC) before administration of bronchodilator drugs. Chronic bronchitis was defined as a productive cough with sputum production over a preceding two-year period. Asthmatic patients were included. Fourteen of the 18 control patients were admi·tted because of increased shortness of breath and sputum production. The remainder were admitted for evaluation of supraventricular arhythmias, dizziness, chest pain, and pneumonia. Two patients had respiratory failure but did not require intubation. While pulmonary function tests were not performed on all patients, the average prebronchodilator FEV 1 level was 1.38 L/sec (13 patients). The respiratory failure group consisted of nine consecutively admitted men patients with COPD and acute respiratocy failure. These patients entered the study over a 22-month period from August, 1979, until June, 1981. Patients in this group were accepted if they fulfilled the criteria for COPD on a previous admission and had an exacerbation of their lung disease to such a degree that mechanical ventilatory assistance was required. Criteria for ventilatory assistance included a Po 2 < 50 on room air with a Pco2 50, a pH 7.38 with mental obtundation and/or respiratory muscle fatigue. The decision to intubate and mechanically ventilate was made by the patient's primary physician. Four patients in this group had pneumonia, two had respiratory arrests, and three had severe dyspnea related to deteriorating lung function. Only one patient had required ventilatory assistance on a previous hospitalization. Patients were excluded if their health was impaired primarily by some disease process other than their lung disease. Patients with lung neoplasms were excluded. Patients with respiratory failure were excluded if surgery had been performed within two months, or if a previous episode of respiratory failure had occurred in the preceding six months. Patient records were examined one year after termination of the study to determine mortality rates.
For editorial comment see page 518 qumng prolonged ventilatory assistance, it was found that feeding practices were inadequate in almost all cases. 1 Evidence was found to suggest that pre-existing nutritional deficits were common in this population. In studies of patients with chronic obstructive pulmonary disease ( COPD), a group which is at a high risk for developing respiratory failure, it has been established that weight loss is associated with declining lung function in many individuals. 2 In this population, inadequate nutritional support during episodes of acute respiratory failure may have particularly deleterious effects. Because feeding strategies should be markedly different in well-nourished and malnourished patients with respiratory failure, we were prompted to assess prospectively the nutritional status of patients with stable COPD and those with COPD and acute respiratory failure. METHODS
The control group was comprised of 18 men patients admitted to the Omaha Veterans Administration Medical
•From the Departments of Medicine and Biochemistry, University of Nebraska Medical Center, and the Omaha VeteraDS Adminiatration Medical Center, Omaha. Manuscript received August 31; revision accepted March 26. llsprint requem: Dr. Smith, Biochemistry Department, Unioenitv of Nebrtl8ka Medical Center, Omaha 68105
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Nutritional Aaaeaament In COPD and ARF (Driver, lllcAievy, Smith)
deficits were also found in measurements of serum transferrin and retinol binding proteins, creatinine height index and total lymphocyte counts. Body protein and fat stores were markedly depleted in almost half of the patients with respiratory failure. These data suggest that protein-calorie malnutrition is likely to be present in patients with COPD and acute respiratory failure. Nutritional support for this population should be initiated at the onset of the illness. Nutritional repletion should be considered one goal of such therapy.
Nutritional support for the medical patient with respiratory failure has received relatively little attention in the medical literature. In a recent review of nutritional support for medical patients re-
Center during the month of August, 1979 for problems related to COPD. Criteria for inclusion into the control group included compensated clinical status with chronic airflow limitation or chronic bronchitis. Chronic airflow limitation was defined as a forced expiratory volume in one second ( FEV) of 60 percent or less than the predicted value and 60 percent or less than a simultaneously obtained forced vital capacity ( FVC) before administration of bronchodilator drugs. Chronic bronchitis was defined as a productive cough with sputum production over a preceding two-year period. Asthmatic patients were included. Fourteen of the 18 control patients were admi·tted because of increased shortness of breath and sputum production. The remainder were admitted for evaluation of supraventricular arhythmias, dizziness, chest pain, and pneumonia. Two patients had respiratory failure but did not require intubation. While pulmonary function tests were not performed on all patients, the average prebronchodilator FEV 1 level was 1.38 L/sec (13 patients). The respiratory failure group consisted of nine consecutively admitted men patients with COPD and acute respiratocy failure. These patients entered the study over a 22-month period from August, 1979, until June, 1981. Patients in this group were accepted if they fulfilled the criteria for COPD on a previous admission and had an exacerbation of their lung disease to such a degree that mechanical ventilatory assistance was required. Criteria for ventilatory assistance included a Po 2 < 50 on room air with a Pco2 50, a pH 7.38 with mental obtundation and/or respiratory muscle fatigue. The decision to intubate and mechanically ventilate was made by the patient's primary physician. Four patients in this group had pneumonia, two had respiratory arrests, and three had severe dyspnea related to deteriorating lung function. Only one patient had required ventilatory assistance on a previous hospitalization. Patients were excluded if their health was impaired primarily by some disease process other than their lung disease. Patients with lung neoplasms were excluded. Patients with respiratory failure were excluded if surgery had been performed within two months, or if a previous episode of respiratory failure had occurred in the preceding six months. Patient records were examined one year after termination of the study to determine mortality rates.
For editorial comment see page 518 qumng prolonged ventilatory assistance, it was found that feeding practices were inadequate in almost all cases. 1 Evidence was found to suggest that pre-existing nutritional deficits were common in this population. In studies of patients with chronic obstructive pulmonary disease ( COPD), a group which is at a high risk for developing respiratory failure, it has been established that weight loss is associated with declining lung function in many individuals. 2 In this population, inadequate nutritional support during episodes of acute respiratory failure may have particularly deleterious effects. Because feeding strategies should be markedly different in well-nourished and malnourished patients with respiratory failure, we were prompted to assess prospectively the nutritional status of patients with stable COPD and those with COPD and acute respiratory failure. METHODS
The control group was comprised of 18 men patients admitted to the Omaha Veterans Administration Medical
•From the Departments of Medicine and Biochemistry, University of Nebraska Medical Center, and the Omaha VeteraDS Adminiatration Medical Center, Omaha. Manuscript received August 31; revision accepted March 26. llsprint requem: Dr. Smith, Biochemistry Department, Unioenitv of Nebrtl8ka Medical Center, Omaha 68105
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Nutritional Aaaeaament In COPD and ARF (Driver, lllcAievy, Smith)