Can a patient with pulmonary embolism (PE) be fed?

Feeding Patients with Pulmonary Embolism

Patients with pulmonary embolism can and should be fed orally if they are hemodynamically stable and able to eat, as there are no specific contraindications to feeding in PE patients who are not in respiratory distress. 1

Assessment of PE Severity and Feeding Approach

Hemodynamic Status Assessment

• High-risk PE (hemodynamically unstable with shock or hypotension)

  • Focus on stabilization first with vasopressors, oxygen, and possible thrombolysis 1
  • Delay oral feeding until hemodynamic stability is achieved
  • Consider early enteral nutrition (within 48h) via nasogastric tube once stabilized 1

• Intermediate-risk PE (hemodynamically stable with RV dysfunction)

  • Can typically be fed orally if alert and without respiratory distress
  • Monitor for clinical deterioration during meals

• Low-risk PE (hemodynamically stable without RV dysfunction)

  • Safe to feed orally without restrictions

Respiratory Assessment

• Assess respiratory rate and oxygen saturation before feeding
• If respiratory rate >30/min or significant dyspnea, consider:
  • Small, frequent meals to reduce respiratory effort
  • Semi-upright position (30-45°) during feeding to optimize respiratory mechanics

Specific Feeding Recommendations

For Hemodynamically Stable PE Patients:

1. Oral diet is preferred when patients can eat safely 1

   • Position patient upright (30-45°) during meals to reduce diaphragmatic pressure
   • Offer smaller, more frequent meals if patient experiences dyspnea with eating

2. If oral intake is inadequate:

   • Consider oral nutritional supplements first 1
   • Progress to enteral nutrition if oral intake remains insufficient

3. For patients with dysphagia (e.g., post-stroke PE patients):

   • Perform swallowing assessment
   • Offer texture-adapted food if safe 1
   • If swallowing is unsafe, initiate enteral nutrition 1

For Hemodynamically Unstable PE Patients:

1. Prioritize hemodynamic stabilization 1

   • Initiate anticoagulation, vasopressors if needed, oxygen therapy
   • Avoid aggressive fluid challenges 1

2. Once stabilized (within 48h):

   • Initiate early enteral nutrition rather than delaying nutritional support 1
   • Early EN has been shown to reduce infectious complications 1

3. If EN is contraindicated:

   • Consider parenteral nutrition within 3-7 days 1
   • For severely malnourished patients, early progressive PN can be provided 1

Important Considerations

• Avoid overfeeding in critically ill PE patients - early full EN or PN should not be used but prescribed within 3-7 days 1

• For mechanically ventilated PE patients:

  • Be cautious with positive end-expiratory pressure as it may reduce venous return and worsen RV failure 1
  • Use low tidal volumes (approximately 6 mL/kg lean body weight) 1
  • Maintain end-inspiratory plateau pressure <30 cm H₂O 1

• For patients receiving ECMO support (severe PE cases):

  • Early EN should still be performed when possible 1

• For patients managed in prone position:

  • Early EN can still be performed with careful monitoring 1

Common Pitfalls to Avoid

1. Delaying nutrition unnecessarily - early nutrition (within 48h) is beneficial for most critically ill patients 1

2. Aggressive fluid administration - can worsen RV failure in PE patients 1

3. Keeping patients NPO without clear indication - most stable PE patients can safely eat

4. Failing to reassess - regularly evaluate for clinical deterioration, especially during the first 24-48 hours after PE diagnosis

In summary, most patients with PE who are hemodynamically stable can safely receive oral nutrition. For unstable patients, focus on hemodynamic stabilization first, then initiate enteral nutrition within 48 hours. The key is to match the feeding approach to the patient's clinical status and respiratory capabilities while monitoring for any signs of deterioration.