Nutritional care practice in the patients receiving non-invasive positive pressure ventilation (NIPPV) therapy in an intensive care unit (ICU)

Author: Sowha Jeong

Jeong, Sowha, 2017 Nutritional care practice in the patients receiving non-invasive positive pressure ventilation (NIPPV) therapy in an intensive care unit (ICU), Flinders University, School of Nursing

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Background: Non-invasive positive pressure ventilation (NIPPV) is increasingly and widely used for respiratory support in critical care settings around the world. While many studies have examined the effect of NIPPV, there is a paucity of data on nutrition in patients undergoing NIPPV therapy in an intensive care unit (ICU). Adequate nutrition is essential for critically ill patients to improve patients’ outcomes such as reducing mortality, morbidity or length of hospital or ICU stay. Despite this, it is challenging for critically ill patients to meet their nutrient requirements. Current nutritional care guidelines for the critically ill exclude NIPPV patients completely as many of them rely on oral nutrition. Aspiration pneumonia is a serious complication, and the fear of aspiration may interrupt nutrient intake of the patients while receiving NIPPV therapy. However, there is a lack of evidence about aspiration or aspiration pneumonia during NIPPV therapy.

Objective: The aim of this study is to explore clinical nutritional care practice in patients undergoing NIPPV therapy and to investigate whether these patients are adequately nourished while in the ICU.

Methods: An exploratory prospective observational study of adult patients (≥ 18yrs) admitted to the study ICU and commenced NIPPV therapy were included. Observational forms consisting of clinical reporting form and food and fluid chart were used to collect nutrition- related data regarding NIPPV therapy. The diagnosis of aspiration pneumonia was confirmed/excluded by reviewing chest x-ray results. Welch's t test was used to investigate whether the patients were adequately nourished in the ICU while comparing the actual energy and protein intakes to estimated requirements. Cross-tabulation analysis was used to identify the differences in variables between patients receiving <50% of energy or protein requirements and the patients receiving ≥ 50% of energy or protein requirements.

Results: Thirty patients were enrolled in the study from December 2014 to February 2015. Eighty-three percent of the patients commenced some type of nutrition including enteral, parenteral or oral nutrition within 48 hours after the initiation of NIPPV therapy. The most common type of nutrition was oral nutrition (73%). Only eight of 30 patients (27%) had an ICU dietitian consult during NIPPV therapy. Patients seen by an ICU dietitian were more likely to receive estimated protein requirements compared to the patients without a dietitian consult. The most common reasons for not eating were anorexia (57%) and respiratory distress (50%). Ninety-seven percent of the patients did not meet estimated energy or protein requirements. Furthermore, a majority of the patients failed to receive 50% of energy or protein requirements. Patients who were a longer time on NIPPV (BIPAP, CPAP or NHF), a longer time on NHF, less hours for fasting, and starting nutrition within 24hours of the initiation of NIPPV were more likely to consume ≥ 50% of estimated energy requirements. Whereas patients who received parenteral nutrition and the patients who had an ICU dietitian consult were more likely to receive ≥ 50% of estimated protein requirements. All patients were found to be undernourished prior to the NIPPV therapy and according to haematological biomarkers undernourishment became worse during NIPPV therapy. No patients developed aspiration pneumonia during NIPPV therapy although the patients were assessed as an increased risk of aspiration.

Conclusion: The results from this study indicated that patients undergoing NIPPV therapy were inadequately nourished. The clinical nutritional care practice reflected patients’ lack of adequate nutritional care during NIPPV therapy and that patients were poorly nourished in ICU. Providing artificial nutrition is an essential component of medical and nursing care of patients on NIPPV yet the practice of when to commence nutrition is highly variable. Nursing and medical staff accept and do not assess the nutritional status of patients prescribed NIPPV just having sips of water for first 24hrs and minimal nutritional intake throughout their ICU admission. This is despite an abundance of robust data supporting the benefits of nutritional screening, need for early nutrition and valid and reliable formulas for calculating and individualising the energy and protein requirements for each patient. Although the literature suggests that issues related to air leaks and gastric distention should be addressed, the advice for both of these was ambiguous perhaps because solving gastric distension by the insertion of large bore vented naso-gastric tube (NGT) may lead to small air leaks. The literature on resolution of air leaks was supported by research however the management of stomach and abdominal distension caused through insufflation (NIPPV) revealed a lack of evidence and interventions were ambiguous and based on local opinion. Although none of the patients developed aspiration pneumonia, aspiration is a high risk during NIPPV and should be taken into account when providing nutritional care. Multiple gaps exist in both knowledge and practice related to oral nutrition in patients prescribed NIPPV. Research is required on multiple aspects of the provision of oral nutrition, including the roles, knowledge and attitudes of the interdisciplinary ICU team, development, implementation and research on the clinical efficacy of NIPPV policies and protocols which include attention to nutritional status and clear rationales, prevention of gastric sulfation and the appropriateness of either large vented NGT or small bore NGT in the management of gastric distension and EN.

Keywords: NIPPV, nutrition, critically ill patients, aspiration pneumonia, hospital under-nutrition and nutritional barriers

Subject: Nursing thesis

Thesis type: Masters
Completed: 2017
School: School of Nursing
Supervisor: Diane Chamberlain