LLL Session - Nutritional support in respiratory diseases ... · Baarends et al. Am J Respir Crit Care Med 1997;155:549-54 ... Nutritional needs in COPD 5 • Acute effects of ONS,

ESPEN Congress Leipzig 2013

LLL Session - Nutritional support in respiratory diseases

New findings of meta-analysis in nutrition interventions for COPD and multimodal approaches

C. Pison (FR)

Nutritional Support in

Respiratory Diseases – LLL 38

New findings of meta-analysis in nutrition

interventions for COPD

and multimodal approaches

Pr. Ch. Pison, MD, PhD

Pulmonary Division

Lung transplantation group

University Hospital, Grenoble

Inserm1055, Grenoble

Joseph Fourier University

Grenoble, France

2 Leipzig, 4th of September 2014

Participation Quality of life - Morbidity

Mortality

FEV1

SpO2

Lungs Oxidant stress,

Hypoxia, Inflammation

Deficiency Systemic Oxidant stress,

Hypoxia, Inflammation

BMI

Skeletal muscles

International Classification of Functioning ICF-2, WHO, 2001

Activities Dyspnea 6 MWD

Obstructive Lung Diseases

3

IV: Very Severe III: Severe II: Moderate I: Mild

FEV1/FVC < 70% FEV1 > 80% predicted

FEV1/FVC < 70%

50% < FEV1 < 80% predicted

FEV1/FVC < 70%

30% < FEV1 < 50% predicted

FEV1/FVC < 70% FEV1 < 30%

predicted or FEV1 < 50%

predicted plus chronic respiratory failure

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation

Add inhaled glucocorticosteroids if repeated exacerbations

Active reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator (when needed)

Add long term oxygen if chronic respiratory failure. Consider surgical

treatments

Therapy at Each Stage of COPD

4

• Depending on their condition COPD patients can need up to 600 kcal /day more than healthy individuals

• “Nutritional supplementation should initially consist of adaptations in the patients’ dietary habits and should be extended to administration of energy-dense supplements”

Baarends et al. Am J Respir Crit Care Med 1997;155:549-54

Baarends et al. 1997;52:780-5

Schols et al. JPEN 1992;16: 364-8

Schols al. Am J Clin Nutr 1991;54:983-7

Nici et al. AJRCCM 2006;173:1390-1413

Nutritional needs in COPD

5

• Acute effects of ONS, fat vs. carbohydrate, 11 subjects

COPD, 62±8 yrs, FEV1 34±12% pred., BMI 22.6±2.3.

Vermeeren et al. AJCN 2001;73:295-301

Post prandial dyspnoea:

fat vs. carbohydrate

250 kcal fat rich oral

supplement

250 kcal carbohydrate rich

oral supplement

6

More not always better!

• Energy intake, 568 kcal/d vs. 800 kcal/d, 2 severe depleted

groups of COPD, 19 vs. 20, 8-weeks in-pulmonary rehabilitation

Broekhuizen et al. British Journal of Nutrition 2005;93:965-71

7

Weekes et al. Thorax 2009;64:326-31

+ 194 kcal/d, + 11.8 g protein/d vs. Controls

no changes in muscle strength and respiratory function

St Georges + 10. 1, MRC score + 1 , ADL score + 1.5

Nutritional intervention

8

Nutritional support

in COPD treatment - Guidelines

• 2006 ERS /ATS guidelines. Nici et al. AJRCCM

2006;173:1390-1413

– BMI < 21

– involuntary weight loss: >10% during last 6 months or

>5% in the past month)

– depletion in FFMI, <16 males, <15 females

• 2010 SPLF guidelines. RMR 2010;27:522-48

– No attempt to lose weight

– Rehabilitation > nutritional supplementation in any cases,

especially if under nutrition

• 2014 – ERS statement on Nutrition and COPD

9

• Risk of nutritional depletion in subjects, even normal weighted,

undergoing Pulmonary Rehabilitation

Steiner et al. Thorax 2003;58:745-51.

Goris et al. The British journal of nutrition 2003;89:725-31.

Slinde et al. Clinical nutrition 2003;22:159-65.

Creutzberg et al. Nutrition 2003;19:120-7

Weekes et al. Thorax 2010;64:326-31

Nutritional support:

essential during rehabilitation

10

11



changes body weight, kg

17 studies,

8 combined

with

exercise,

increased

body

weight

13


changes fat-free mass, kg

14


changes in 6-MWD, m

Nutritional intervention alone

is not enough

15

ORGAN FAILURE

SPECIFIC DISTURBANCES Hypoxia, Acidosis,

Oxidative stress,

Growth factor impairments …

Evans WJ et al.

Clin Nutr 2008

Schols et al. AJRCCM 1995;152;1268-74

• Patients 233, FEV1 35 ± 5 %

• Duration 8 weeks, in-patient rehabilitation

• Intervention - exercise + education

- exercise + education + nutrition + placebo

- exercise + education + nutrition + anabolic steroids

• Results

• Increase in body weight with nutrition alone

& anabolic steroids

• Enhanced increase in FFM / Pi-max with anabolic steroids

Exercise training: - endurance

- low impact conditioning exercises

- no strength training

Multimodal Intervention

16

Schols et al. AJRCCM 1998;157;1791-7

weight gain

17


• Patients 102, 66±9 yrs, FEV1 58±17 %, BMI 26.1±4.4

97, 67±9 yrs, FEV1 60±15 %, BMI 27.3±4.7

Wmax < 70%, 20% depleted

• Duration 2 years

• Intervention 4 months home multimodal intervention,

20 maintenance care

versus usual care

• Results

• 4 months: better FFM, QoL, Wmax, endurance, MRC

dyspnea score, hand grip, 6MWD

• 2 years : better QoL, MRC score, endurance, 6MWD 18

INTERCOM. van Wetering et al. J Am Med Dir Assoc

2010;11:179-187


19

INTERCOM. van Wetering et al. J Am Med Dir Assoc

2010;11:179-187


INTERCOM muscle wasted

INTERCOM muscle non-wasted

Usual Care muscle non-wasted

Usual Care muscle wasted

Casaburi et al. Am J Crit Care Med 2004;170;870-8

20

47 male patients

with COPD, mean

FEV1 = 40%

randomized,

double blind,

controlled

4 groups,

resistance

exercise, 100 mg

testosterone

IM/week, 10 weeks


testosterone

Brokhuizen et al. Thorax 2003;124:1733-42

21

80 COPD, 8 weeks rehabilitation

plus oral nutritional supplement

(Respifor)

Double blind, controlled design:

oral n-3 PUFA, 9 g/day

during 8 weeks


PUFA

• Patients 60, 66.6±9.6 yrs, BMI 21.5±3.8

62, 65.1±9.6 yrs, BMI 21.4±4.0

• Duration 12 weeks, 12 months follow-up

• Intervention - Education + Exercise + ONS + oral Testosterone

- Education

• Results

• 3 months: increases in body weight, FFM,QF, Hb,

endurance, Wmax, QoL in women

• 15 months : better survival per-protocol analysis

IRAD2 study in Chronic Respiratory Failure

Pison et al. Thorax 2011;66:953-60

22


• IRAD2 study in Chronic Respiratory Failure


23 Rehabilitation group

Dinclusion: first

investigations

Drandom.

Control group

D10 D30 D45 D60 D75 D89

D1: first day of

education (Home)

D270=M9 D450=M15

D90=M3: last investigations

(Hospital)

D1: first day of rehabilitation

(Home)

D90=M3: last investigations

(Hospital)




24




25




26


Budweiser et al. Respir Care 2006;51:126-32

27


NIV

Mineo et al. Eur Respir J 2011;36:408-16

28


LVRS


lung transplantation

0

,2

,4

,6

,8

1

0 2 4 6 8 10

Temps, années

après XII-2001, n = 39

avant XII-2001, n = 15

All indications, n = 204

CF, n = 54

0

,2

,4

,6

,8

1

0 2 4 6 8 10

Temps, années

après XII-2001, n = 134

avant XII-2001, n = 68

Multimodal

approach of

undernutrition

Low energy intake

Inactivity

Hypogonadism

Inflammation

Insulin-resistance

Others, hypoxia, ..

Integrated care

Counseling

ONS

Exercise

Androgens

others:

• n-3 FA

• N-acetylcysteine

• anti-TNF

• etc.


• Patient perspectives and objectives

• Smoking

• Infection

• Respiratory mechanical disadvantages : long-acting

bronchodilators

• Hypoxemia

• Energy intake deficit

• Promotion of Daily Physical Activities

• Modulation of systemic inflammation, omega-3

• Lung volume reduction

• Lung transplantation

Personalized &

Comprehensive Cares

31

Conclusions

• Multimodal Evaluation

• Multimodal Intervention

• Interventions at early and advanced disease, to be

tailored to the patient perspective

• Role of home disease management

32

Documents

LLL Session - Nutritional support in respiratory diseases ... · Baarends et al. Am J Respir Crit Care Med 1997;155:549-54 ... Nutritional needs in COPD 5 • Acute effects of ONS,