Chronic Obstructive Pulmonary Disease (COPD) is a serious lung condition characterized by obstruction of the airways. Mr. C, a COPD patient, was admitted to the hospital with COPD as well as other health issues including hypertension, depression, obesity, and sleep apnea. Due to his declining respiratory status in the hospital, Mr. C was intubated to deliver sufficient oxygen and support his breathing. Nutritional therapy is an important part of COPD treatment to maintain energy balance and nutrition status given that COPD patients are often malnourished.

1. Unit 9 Final Project
NS335-01
Kaplan University
Gabriel J. Wigington
June 16, 2014
“COPD Nutritional Care”

2. Chronic Obstructive Pulmonary Disease is a serious, chronic disorder characterized by
slow and progressive obstruction of the airways. There are two sub-categories of this condition:
emphysema and chronic bronchitis. Emphysema deals with an abnormal and permanent
enlargement of the alveoli while chronic bronchitis deals with inflammation of the bronchi along
with lung symptoms that produces a productive cough. Causative primary factors include second
hand smoke and smoking while other secondary factors include environmental pollution and
genetic susceptibility. The approaches of medical and surgical treatments are always being
updated according to latest research from the Global Initiative for Chronic Obstructive Lung
Disease, 2009. Management of this disease consists of four primary goals. These are assessing
and monitoring, reduction of risk factors, stabilization of COPD, and managing anything that
would exacerbate the condition of the patient. As with most conditions, an early and accurate
diagnosis is key! Outside of rehabilitation programs and oxygen therapy, many medications can
often be prescribed to coincide with these therapy methods in the form of bronchodilators, gluco-
corticosteroids, antibiotics, and mucolytic agents. Surgical lung transplantation might be
necessary for advanced patients (1).
Mr. C is a COPD patient who has been admitted to a hospital with a complex history
including COPD, HTN, depression, obesity, and sleep apnea. He has symptoms of shortness of
breath which could be explained most likely by his being a chronic smoker since his young
teenage years. The medical advice he has received thus far are to eat a heart healthy diet in order
to decrease weight which would improve his overall health status and combat the issue of obesity
as well. He currently is taking a blood pressure medication along with an antidepressant, a
diuretic, and usage of an inhaler at times. Due to his sleep apnea he wears a breathing mask to
bed and is taking an omega-based multivitamin supplement as well. His respiratory status went

3. south after hospital admittance which appears to be quite common in patients. He has been
given intubation which means a tube is placed inside the trachea of the patient to maintain the
airway. This is done in order to deliver sufficient oxygen to the patient, protect against
aspiration, gastric insufflation, provide more efficient ventilation, oxygenation, facilitate
suctioning, anaesthetic drugs through an endotracheal tube(2). According to EBMedicine.net,
mechanical ventilation should be a last resort as studies have shown it to increase mortality rates
significantly from 1.7%-28% during intubation. On the flip side however, it has shown to be a
lifesaving procedure for many patients which is why the correct and thoughtful judgment of the
clinical practitioner is always of utmost importance. The timing of the intubation needs to be
precise and is somewhat of an art. Once the decision to ventilate has been made, it is imperative
to continue speedily. Needle and tube thoracostomy equipment should be available and pre-
oxygenation with high blood flow is advised. Post-intubation complications may occur in some
patients which lead to the management of these occurrences. Dynamic hyperinflation is one
such occurrence that leads to elevated end-expiratory pressures labeled PEEP or auto-PEEP.
This reveals an exacerbation of the COPD symptoms which lead to the disease. The limited
expiratory flow results in increased lung volume, incomplete exhalation, increase in airway and
intra-thoracic pressure (3). Now that we have discussed the reasons for intubation, ventilation,
and their benefits and setbacks, let us take a look at the goals and specifics of medical nutrition
therapy for the COPD patient. According to the American Dietetic Association, the primary
goals of medical nutrition therapy for the COPD patient include facilitating their well-being
nutritionally, achieve a healthy lean body mass (LBM) to fat mass (adipose) ratio, correct fluid
imbalance, management of drug-nutrient interactions, and prevention of osteoporosis. Taking an
aggressive approach to this disorder’s treatment with sound protocol focuses on energy balance

4. maintenance since many patients are malnourished in some way, shape, or form. The evaluation
of energy expenditure and intake is a critical first step. Assessments the clinician may take to
gauge energy intake are blood oxygen saturation, anorexia, fatigue, difficulty
chewing/swallowing from dyspnea, diarrhea, and constipation. Energy expenditure tends to be
elevated from airflow obstruction. Gas diffusing capacity, CO2 retention, respiratory
inflammation, and biochemical mediators like cytokines may have an impact on energy
expenditure also. Protein and overall calories would need to be altered to the individual’s bodily
needs depending on their situation. Energy and nitrogen balance seem to be intertwined
according to latest research from the ADA. A protein amount within the range of 1.2-1.7 g/kg of
dry body weight is needed to restore lung and muscular strength along with boosting immune
function. An increase in vitamin C (Ascorbate) is needed for smokers daily. A critical element
of vitamins and minerals playing a significant role are the interrelationship between calcium, D,
K, and magnesium which are vitally critical to bone, joint, and even heart health. In terms of
keeping electrolyte balance and dealing with fluid retention, sodium and potassium need to be in
proper balance as well. If gut function is healthy, then enteral nutrition can be administered while
done with parenteral method if the patient does not tolerate feeding (4).
Since this patient was recorded as not able to consume an oral diet while on ventilator
support along with nothing by mouth for 4 days, I suggest he receive nutrition via parenteral due
to the lack of toleration of real food at this time. I would prefer to proceed with caution with
procedures that minimize adverse effects from his body that may exacerbate an issue present. As
time progresses, I may change to a differing method of feeding based upon changes in his lab
work, oxygenation, and other vital signs. Keeping up the fluid balance is an area I would focus
on through IV because when fluids are low it can cause a cascade of negative reactions on the

5. inside that could worsen symptoms of the condition or lead to new problems. As far as protein, I
would aim for approximately 1.5 grams per kilogram of weight as it fits in the middle of the
accepted range to promote lean muscular tissue maintenance and nitrogen balance. Muscular
tissue is extremely important and often neglected component of the body being capable of
healing itself from the inside when fighting sickness or disease. Amino acids play a pivotal role
and for example when we have a simple cut, bruise, or wound our bodies need an increase
supply of amino acids to aid the recovery process! Key amino acids include L-Arginine, L-
Carnitine, C-Carnitine, Leucine, and Glutamine. I would use indirect calorimetry to gauge
correct energy balance while adjusting with small increases or decreases depending upon the
patient’s response and hormonal imbalances. I would consider graduating to a few supplements
with clinical research to back its usage if we get to an advanced stage or if the patient shows
progress with the current methods of feeding.
Upon hospital discharge, I would advise taking COQ10 as research shows it improve
oxygen usage at the cellular level. Dr. Andrew Weil recommends 60 mg twice daily with some
dietary fat during a meal for maximal absorption. As far as herbal remedies, I love the
mushroom cordyceps which has been shown to slow chronic lung disease conditions and
improve lung efficiency (5). As far as dietary intake, I would take an aggressive, but smart
approach to shedding the excess body fat which will improve the lung condition by helping with
breathing since excess weight makes the lungs work much harder. I will prescribe eating what I
call protein-fat meals that consists of a lean, complete protein source such as Organic chicken,
turkey breast, or grass-fed bison combined with a variety of colored cruciferous vegetables like
carrots, kale, red cabbage, bell peppers, tomatoes, onions, garlic, and cucumbers. I would also
add healthy fats in a moderate amount consisting of a balance of each fat type. These foods

6. would include avocado, raw almonds, pecans, cashews, macadamia nuts, chia, pumpkin,
sunflower, and hemp seeds, and healthy saturated fat for testosterone and cell membrane
function from plant-based coconut oil and animal-based raw, unpasteurized cheddar, gouda, brie
cheeses. These foods are easily accessible at local health food stores. As far as liquid food, I
would have him start his day what I call a “Super-shake” that provides a micronutrient load via
Testosterone boosting vegetables, low glycemic fruits like berries, cherries, lemons, and limes
combined with easily digestible plant-based protein powders that help to heal the gut lining
which also aids the immune system in getting stronger since we know undigested food particles
play a role in excess belly fat and weakening of our immune function. A shake like this is full of
antioxidants, flavonoids, anthocyanins, polyphenols, and other cancer, chronic disease fighting
compounds with very little caloric value! The pros severely outweigh the cons in contrast to
most supplement drinks on the market today.
To sum up, I see COPD as a condition that is becoming more common and is important
to learn how to properly address the symptoms that go along with it for a wide range of
populations as all individuals provide unique challenges for the clinical, medical nutrition
therapy professional. Through this process we have learned much about the condition of chronic
obstructive pulmonary disease and how to assess, monitor, evaluate, and apply MNT to meet the
needs of the patient and further the healing process to restore vitality, youthfulness, and
functionality to the patient one step at a time with precision in every decision we make.

7. “Appendix”
Date/Time
06/17/14 Outstanding (2pts) Above Expectations (1pt) Below Expectations (0) Score
Assessment (2)
Weight loss/Appetite decrease (1)
Chewing/Swallowing issues (1)
Unreported food allergens (2)
Estimated protein needs (2)
Prescription drugs taken (1)
Pertinent Lab values (1)
Nutrition Diagnosis: PES statement with standardized language in nutrition care process
Intervention: Aimed at cause of nutrient dx; directed at symptom reduction
Planning: prioritize nutrient dx; jointly establish goals w/patient, define nutrition RX, identify
specific nutrient interventions
Implementation: Action phase carrying out and communicating care plan, continuing data
collection, revising, nutrient intervention as warranted based on patient response

8. Monitoring/Evaluation: Determine progress made by patient and if goals are met, track patient
outcome based on nutrient dx,
Nutrient related behavioral, environmental outcomes, Food/nutrient outcomes, Nutrient-related
physiological signs & symptom outcome; Nutrient related patient-centered outcome
Signature & Credentials
Gabriel J. Wigington

9. “References”
1. Krause’s Food and the Nutrition Care Process, 13th edition; chapter 35; pgs.789-791.
2. http://www.patient.co.uk/doctor/airways-and-intubation
3. https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=63&seg_id=1
191
4. http://www.ncbi.nlm.nih.gov/pubmed/3127108
5. http://www.drweil.com/drw/u/ART03117/Emphysema.html