Medical Nutrition Medical Nutrition Therapy in Pulmonary Therapy in Pulmonary DiseaseDisease

Malnutrition and the Malnutrition and the Pulmonary SystemPulmonary System

Malnutrition impairs Malnutrition impairs Respiratory muscle functionRespiratory muscle function Ventilatory driveVentilatory drive Response to hypoxiaResponse to hypoxia Pulmonary defense mechanismsPulmonary defense mechanisms

Effects of Malnutrition Effects of Malnutrition in Pts without Lung in Pts without Lung DiseaseDisease Respiratory muscle strength Respiratory muscle strength ↓↓ by 37% by 37% Maximum voluntary ventilation Maximum voluntary ventilation ↓↓ by by

41% (1)41% (1) Vital capacity (lung volume)Vital capacity (lung volume)↓↓ 63% (1) 63% (1) Diaphragmatic muscle mass Diaphragmatic muscle mass ↓↓ to 60% to 60%

of normal in underweight patients who of normal in underweight patients who died of other ailments (2)died of other ailments (2)

1. Aurora N, Rochester, D. Am Rev Respir Dis 126:5-8, 1982

2. Aurora N, Rochester D. J Appl Physiol: Respirat Environ Exercise physiol 52:64-70, 1982

Effects of Malnutrition in Effects of Malnutrition in Pts with Pulmonary Pts with Pulmonary Disease Disease Decreased cough and inability to Decreased cough and inability to

mobilize secretionsmobilize secretions Atelectasis and pneumoniaAtelectasis and pneumonia Prolonged mechanical ventilation Prolonged mechanical ventilation

and difficulty weaning with and difficulty weaning with prolonged ICU stayprolonged ICU stay

Effects of Malnutrition in Effects of Malnutrition in Pts with Pulmonary Pts with Pulmonary DiseaseDisease Altered host immune response and Altered host immune response and

cell-mediated immunitycell-mediated immunity Contributes to chronic or repeated Contributes to chronic or repeated

pulmonary infectionspulmonary infections Decreased surfactant productionDecreased surfactant production Decreased lung elasticityDecreased lung elasticity Decreased ability to repair injured Decreased ability to repair injured

lung tissuelung tissue

Normal Lung Normal Lung AnatomyAnatomyNormal Lung Normal Lung AnatomyAnatomy

Selected Airway Selected Airway DisordersDisordersSelected Airway Selected Airway DisordersDisorders

Chronic Pulmonary Chronic Pulmonary DisordersDisorders Bronchopulmonary displasiaBronchopulmonary displasia Cystic fibrosisCystic fibrosis TuberculosisTuberculosis Bronchial asthmaBronchial asthma Chronic obstructive Chronic obstructive

pulmonary disease (COPD)pulmonary disease (COPD)

Acute Pulmonary Acute Pulmonary DisordersDisorders Pulmonary aspirationPulmonary aspiration PneumoniaPneumonia TuberculosisTuberculosis Cancer of the lungCancer of the lung Acute respiratory distress Acute respiratory distress

syndromesyndrome Pulmonary failurePulmonary failure

Pulmonary Conditions Pulmonary Conditions w/ Nutritional w/ Nutritional ImplicationsImplicationsNeonateNeonate Bronchopulmonary displasia Bronchopulmonary displasia

(BPD)(BPD)

ObstructioObstructionn

Cystic fibrosis (CF)Cystic fibrosis (CF)

Chronic obstructive Chronic obstructive pulmonary disease (COPD)pulmonary disease (COPD)EmphysemaEmphysemaChronic bronchitisChronic bronchitisAsthmaAsthma

TumorTumor Lung cancerLung cancer

Pulmonary Conditions Pulmonary Conditions w/ Nutritional w/ Nutritional ImplicationsImplicationsInfectionInfection PneumoniaPneumonia

Tuberculosis (TB)Tuberculosis (TB)

Respiratory Respiratory FailureFailure

Acute respiratory failureAcute respiratory failure

Lung transplantationLung transplantation

Neuro-Neuro-muscular muscular AbnormalitiAbnormalitieses

Muscular dystrophyMuscular dystrophy

ParalysisParalysis

Pulmonary Conditions w/ Pulmonary Conditions w/ Nutritional ImplicationsNutritional Implications

SkeletalSkeletal OsteoporosisOsteoporosis

ScoliosisScoliosis

CardiovasculaCardiovascularr

Pulmonary edemaPulmonary edema

EndocrineEndocrine Severe obesitySevere obesity

Prader-Willi syndromePrader-Willi syndrome

Adverse Effects of Lung Adverse Effects of Lung Disease on Nutritional Disease on Nutritional StatusStatus

Adverse Effects of Lung Adverse Effects of Lung Disease on Nutritional Disease on Nutritional StatusStatusIncreased energy expenditureIncreased energy expenditure Increased work of breathingIncreased work of breathing Chronic infectionChronic infection Medical treatments (e.g. Medical treatments (e.g.

bronchodilators, chest physical bronchodilators, chest physical therapytherapy

Adverse Effects of Lung Adverse Effects of Lung Disease on Nutritional Disease on Nutritional StatusStatusReduced intakeReduced intake Fluid restrictionFluid restriction Shortness of breathShortness of breath Decreased oxygen saturation when Decreased oxygen saturation when

eatingeating Anorexia due to chronic diseaseAnorexia due to chronic disease Gastrointestinal distress and Gastrointestinal distress and

vomitingvomiting

Adverse Effects of Lung Adverse Effects of Lung Disease on Nutritional Disease on Nutritional StatusStatusAdditional limitationsAdditional limitations Difficulty preparing food due to Difficulty preparing food due to

fatiguefatigue Lack of financial resourcesLack of financial resources Impaired feeding skills (for infants Impaired feeding skills (for infants

and children)and children) Altered metabolismAltered metabolism

Chronic Lung DiseaseChronic Lung Disease

Bronchopulmonary Bronchopulmonary Dysplasia: Dysplasia: PathophysiologyPathophysiology Chronic lung condition in newborns Chronic lung condition in newborns

that often follows respiratory distress that often follows respiratory distress syndrome (RDS) and treatment with syndrome (RDS) and treatment with oxygen oxygen

Characterized by broncheolar Characterized by broncheolar metaplasia and interstitial fibrosismetaplasia and interstitial fibrosis

Occurs most frequently in infants who Occurs most frequently in infants who are premature or low birth weightare premature or low birth weight

BPD: Signs and BPD: Signs and SymptomsSymptoms Hypercapnea (CO2 retention)Hypercapnea (CO2 retention) TachypneaTachypnea WheezingWheezing DyspneaDyspnea Recurrent respiratory infectionsRecurrent respiratory infections Cor pulmonale (right ventricular Cor pulmonale (right ventricular

enlargement of the heart)enlargement of the heart)

Growth Failure in BPDGrowth Failure in BPD

Increased energy needsIncreased energy needs Inadequate dietary intakeInadequate dietary intake Gastroesophageal refluxGastroesophageal reflux Emotional deprivationEmotional deprivation Chronic hypoxiaChronic hypoxia

Goals of Nutritional Goals of Nutritional Management in BPDManagement in BPD Meet nutritional needsMeet nutritional needs Promote linear growthPromote linear growth Develop age-appropriate feeding Develop age-appropriate feeding

skillsskills Maintain fluid balanceMaintain fluid balance

Energy Needs in BPDEnergy Needs in BPD

REE in infants with BPD is 25-50% REE in infants with BPD is 25-50% higher than in age-matched controlshigher than in age-matched controls

Babies with growth failure may have Babies with growth failure may have needs 50% higherneeds 50% higher

Energy needs in acute phase (PN, Energy needs in acute phase (PN, controlled temperature) 50-85 kcals/kgcontrolled temperature) 50-85 kcals/kg

Energy needs in convalescence (oral Energy needs in convalescence (oral feeds, activity, temperature regulation) feeds, activity, temperature regulation) as high as 120-130 kcals/kgas high as 120-130 kcals/kg

Protein Needs in Protein Needs in Babies with BPDBabies with BPD Protein: within advised range for Protein: within advised range for

infants of comparable post-infants of comparable post-conceptional ageconceptional age

As energy density of the diet is As energy density of the diet is increased by the addition of fat increased by the addition of fat and carbohydrate, protein should and carbohydrate, protein should still provide 7% or more of total still provide 7% or more of total kcalskcals

Macronutrient Mix in Macronutrient Mix in BPDBPD Fat and carbohydrate should be Fat and carbohydrate should be

added to formula only after it has added to formula only after it has been concentrated to 24 kcals/oz been concentrated to 24 kcals/oz to keep protein high enoughto keep protein high enough

Fat provides EFA and energy when Fat provides EFA and energy when tolerance for fluid and tolerance for fluid and carbohydrate is limitedcarbohydrate is limited

Excess CHO increases RQ and Excess CHO increases RQ and CO2 outputCO2 output

Fluid in BPDFluid in BPD

Infants with BPD may require fluid Infants with BPD may require fluid restriction, sodium restriction, restriction, sodium restriction, and long term treatment with and long term treatment with diureticsdiuretics

Use of parenteral lipids or Use of parenteral lipids or calorically dense enteral feeds calorically dense enteral feeds may help the infant meet energy may help the infant meet energy needsneeds

Mineral Needs in BPDMineral Needs in BPD

Often driven by the baby’s premature Often driven by the baby’s premature statusstatus

Lack of mineral stores as a result of Lack of mineral stores as a result of prematurity (iron, zinc, calcium)prematurity (iron, zinc, calcium)

Growth delayGrowth delay Medications: diuretics, bronchodilators, Medications: diuretics, bronchodilators,

antibiotics, cardiac antiarrhythmics, antibiotics, cardiac antiarrhythmics, corticosteroids associated with loss of corticosteroids associated with loss of minerals including chloride, potassium, minerals including chloride, potassium, calciumcalcium

Vitamin Needs in BPDVitamin Needs in BPD

Interest in antioxidants, including Interest in antioxidants, including vitamin A for role in developing vitamin A for role in developing epithelial cells of the respiratory epithelial cells of the respiratory tracttract

Provide intake based on the DRI, Provide intake based on the DRI, including total energy, to promote including total energy, to promote catchup growth catchup growth

Feeding Strategies in Feeding Strategies in BPDBPD Calorically dense formulas or Calorically dense formulas or

boosted breast milk (monitor fluid boosted breast milk (monitor fluid status and urinary output)status and urinary output)

Small, frequent feedingsSmall, frequent feedings Use of a soft nippleUse of a soft nipple Nasogastric or gastrostomy tube Nasogastric or gastrostomy tube

feedingsfeedings

Feeding Strategies in Feeding Strategies in Gastroesophageal Gastroesophageal RefluxReflux Thickened feedings (add rice Thickened feedings (add rice

cereal to formula)cereal to formula) Upright positioningUpright positioning Medications like antacids or Medications like antacids or

histamine H2 blockershistamine H2 blockers Surgical fundoplicationSurgical fundoplication

Long Term Feeding Long Term Feeding Problems in BPDProblems in BPD History of unpleasant oral experiences History of unpleasant oral experiences

(intubation, frequent suctioning, (intubation, frequent suctioning, recurrent vomiting)recurrent vomiting)

History of non-oral feedingsHistory of non-oral feedings Delayed introduction of solidsDelayed introduction of solids Discomfort or choking associated with Discomfort or choking associated with

eating solidseating solids Infants may tire easily while breast-Infants may tire easily while breast-

feeding or bottle feedingfeeding or bottle feeding May require intervention of May require intervention of

interdisciplinary feeding teaminterdisciplinary feeding team

Cystic FibrosisCystic Fibrosis

Inherited autosomal recessive disorderInherited autosomal recessive disorder 2-5% of the white population are 2-5% of the white population are

heterozygousheterozygous CF incidence of 1:2500 live birthsCF incidence of 1:2500 live births 30,000 people treated at CF centers in 30,000 people treated at CF centers in

the U.S.the U.S. Survival is improving; median age of Survival is improving; median age of

patients has exceeded 30 yearspatients has exceeded 30 years

Cystic FibrosisCystic Fibrosis

Epithelial cells and exocrine glands Epithelial cells and exocrine glands secrete abnormal mucus (thick)secrete abnormal mucus (thick)

Affects respiratory tract, sweat, Affects respiratory tract, sweat, salivary, intestine, pancreas, liver, salivary, intestine, pancreas, liver, reproductive tractreproductive tract

Diagnosis of Cystic Diagnosis of Cystic FibrosisFibrosis Neonatal screening provides Neonatal screening provides

opportunity to prevent opportunity to prevent malnutrition in CF infantsmalnutrition in CF infants

Sweat test (Na and Cl >60 mEq/L)Sweat test (Na and Cl >60 mEq/L) Chronic lung diseaseChronic lung disease Failure to thriveFailure to thrive MalabsorptionMalabsorption Family historyFamily history

Nutritional Nutritional Implications of CFImplications of CF Infants born with meconium ileus Infants born with meconium ileus

are highly likely to have CFare highly likely to have CF 85% of persons with CF have 85% of persons with CF have

pancreatic insufficiencypancreatic insufficiency Plugs of mucus reduce the digestive Plugs of mucus reduce the digestive

enzymes released from the enzymes released from the pancreas causing maldigestion of pancreas causing maldigestion of food and malabsorption of nutrientsfood and malabsorption of nutrients

Nutritional Nutritional Implications of CFImplications of CF Decreased bicarbonate secretion Decreased bicarbonate secretion

reduces digestive enzyme activityreduces digestive enzyme activity Decreased bile acid reabsorption Decreased bile acid reabsorption

contributes to fat malabsorptioncontributes to fat malabsorption Excessive mucus lining the GI Excessive mucus lining the GI

tract prevents nutrient absorption tract prevents nutrient absorption by the microvilliby the microvilli

Gastrointestinal Gastrointestinal Complications of CFComplications of CF Bulky, foul-smelling stoolsBulky, foul-smelling stools Cramping and intestinal obstructionCramping and intestinal obstruction Rectal prolapseRectal prolapse Liver involvementLiver involvement Pancreatic damage causes impaired Pancreatic damage causes impaired

glucose tolerance (50% of adults glucose tolerance (50% of adults with CF) and development of with CF) and development of diabetes (15% of adults with CF)diabetes (15% of adults with CF)

Nutritional Care GoalsNutritional Care Goals Control malabsorptionControl malabsorption Provide adequate nutrients for Provide adequate nutrients for

growthgrowthor maintain weight for height or or maintain weight for height or pulmonary functionpulmonary function

Prevent nutritional deficienciesPrevent nutritional deficiencies

Common TreatmentsCommon Treatments

Pancreatic enzyme replacementPancreatic enzyme replacement Adjust macronutrients for Adjust macronutrients for

symptoms symptoms Nutrients for growthNutrients for growth Meconium ileus equivalent: Meconium ileus equivalent:

intestinal obstruction (enzymes, intestinal obstruction (enzymes, fiber, fluids, exercise, stool fiber, fluids, exercise, stool softeners)softeners)

Pancreatic Enzyme Pancreatic Enzyme ReplacementReplacement Introduced in the early 1980sIntroduced in the early 1980s Enteric-coated enzyme Enteric-coated enzyme

microspheres withstand acidic microspheres withstand acidic environment of the stomachenvironment of the stomach

Release enzymes in the Release enzymes in the duodenum, where they digest duodenum, where they digest protein, fat and carbohydrateprotein, fat and carbohydrate

Pancreatic Enzyme Pancreatic Enzyme ReplacementReplacement

Dosage depends onDosage depends on Degree of pancreatic insufficiencyDegree of pancreatic insufficiency Quantity of food eatenQuantity of food eaten Fat, protein, and carbohydrate Fat, protein, and carbohydrate

content of food eatencontent of food eaten Type of enzymes usedType of enzymes used

Pancreatic Enzyme Pancreatic Enzyme ReplacementReplacement Enzyme dosage limited to 2500 lipase Enzyme dosage limited to 2500 lipase

units per kilogram of body weight per units per kilogram of body weight per mealmeal

Adjusted empirically to control Adjusted empirically to control gastrointestinal symptoms, including gastrointestinal symptoms, including steatorrhea, and promote growth steatorrhea, and promote growth

Fecal fat or nitrogen balance studies Fecal fat or nitrogen balance studies may help to evaluate the adequacy of may help to evaluate the adequacy of enzyme supplementationenzyme supplementation

Distal Intestinal Distal Intestinal Obstruction SyndromeObstruction Syndrome AKA recurrent intestinal impaction AKA recurrent intestinal impaction Occurs in children and adultsOccurs in children and adults Prevention includes adequate Prevention includes adequate

enzymes, fluids, dietary fiber, and enzymes, fluids, dietary fiber, and regular exerciseregular exercise

Treatment involves stool softeners, Treatment involves stool softeners, laxatives, hyperosmolar enemas, laxatives, hyperosmolar enemas, intestinal lavageintestinal lavage

Estimation of Energy Estimation of Energy Needs in CF Needs in CF Use WHO equations to estimate Use WHO equations to estimate

BMRBMR Multiply by activity coefficient + Multiply by activity coefficient +

disease coefficientdisease coefficient TEE – BMR X (AC + DC)TEE – BMR X (AC + DC) Disease coefficient is based on Disease coefficient is based on

lung functionlung function

Disease Coefficient in Disease Coefficient in CFCF Normal lung function = 0.0Normal lung function = 0.0 Moderate lung disease = 0.2Moderate lung disease = 0.2

– FEV1 40-79% of that predictedFEV1 40-79% of that predicted Severe lung disease = 0.3Severe lung disease = 0.3

– FEV1 <40% of that predictedFEV1 <40% of that predicted

FEV = forced expiratory volumeFEV = forced expiratory volume

Example Equation TEE Example Equation TEE in CFin CF Male patient 22 years old, weight Male patient 22 years old, weight

54 kg, relatively sedentary54 kg, relatively sedentary FEV1 is 60% of predicted FEV1 is 60% of predicted

(moderate lung disease)(moderate lung disease) TEE = BMR X (1.5 + 0.2)TEE = BMR X (1.5 + 0.2) TEE = [(15.3 (54) + 679] X 1.7TEE = [(15.3 (54) + 679] X 1.7 TEE = 2559 kcalsTEE = 2559 kcals

Calculate the Daily Calculate the Daily Energy Requirement Energy Requirement (DER)(DER) Takes into account steatorrheaTakes into account steatorrhea Pancreatic sufficiency: TEE = DERPancreatic sufficiency: TEE = DER

– Pancreatic sufficiency is Coefficient Pancreatic sufficiency is Coefficient of fat absorption of fat absorption >>93% of intake93% of intake

Pancreatic insufficiency: DER = Pancreatic insufficiency: DER = TEE (0.93/CFA)TEE (0.93/CFA)– CFA is a fraction of fat intake based CFA is a fraction of fat intake based

on stool collectionson stool collections

Calculation of DER in Calculation of DER in CFCF 72-hour fecal fat collections 72-hour fecal fat collections

reveals that CFA is 78% of intakereveals that CFA is 78% of intake DER = TEE X (.93/CFA)DER = TEE X (.93/CFA) = 2559 X (0.93/.78) = 2559 X (0.93/.78) = 2559 X 1.19= 2559 X 1.19 DER = 3045 kcals/day DER = 3045 kcals/day

Protein in CFProtein in CF

Protein needs are increased in CF Protein needs are increased in CF due to malabsorptiondue to malabsorption

If energy needs are met, protein If energy needs are met, protein needs are usually met by needs are usually met by following typical American diet following typical American diet (15-20% protein) or use RDA(15-20% protein) or use RDA

Fat Intake in CFFat Intake in CF

Fat intake 35-40% of calories, as Fat intake 35-40% of calories, as toleratedtolerated

Helps provide required energy, essential Helps provide required energy, essential fatty acids and fat-soluble vitaminsfatty acids and fat-soluble vitamins

Limits volume of food needed to meet Limits volume of food needed to meet energy demands and improves energy demands and improves palatability of the dietpalatability of the diet

EFA deficiency sometimes occurs in CF EFA deficiency sometimes occurs in CF patients despite intake and pancreatic patients despite intake and pancreatic enzymesenzymes

Symptoms of Fat Symptoms of Fat IntoleranceIntolerance Increased frequency of stoolsIncreased frequency of stools Greasy stoolsGreasy stools Abdominal crampingAbdominal cramping

Carbohydrate in CFCarbohydrate in CF

Eventually intake may need to be Eventually intake may need to be modified if glucose intolerance modified if glucose intolerance developsdevelops

Some patients develop lactose Some patients develop lactose intoleranceintolerance

Vitamins in CFVitamins in CF

With pancreatic enzymes, water With pancreatic enzymes, water soluble vitamins usually soluble vitamins usually adequately absorbed with daily adequately absorbed with daily multivitaminmultivitamin

Will need high potency Will need high potency supplementation of fat soluble supplementation of fat soluble vitamins (A, D, K, E)vitamins (A, D, K, E)

Minerals in CFMinerals in CF

Intake of minerals should meet Intake of minerals should meet DRI for age and sexDRI for age and sex

Sodium requirements increased Sodium requirements increased due to loss in sweatdue to loss in sweat– North American diet usually provides North American diet usually provides

enoughenough– Infants need supplementation (1/4-Infants need supplementation (1/4-

1/2 teaspoon/day)1/2 teaspoon/day)

Minerals in CFMinerals in CF

Decreased bone mineralization, Decreased bone mineralization, low iron stores, and low low iron stores, and low magnesium levels have all been magnesium levels have all been described in CFdescribed in CF

Feeding Strategies in Feeding Strategies in CF: InfantsCF: Infants Breast feeding with supplements Breast feeding with supplements

of high-calorie formulas and of high-calorie formulas and pancreatic enzymespancreatic enzymes

Calorie dense infant formulas (20-Calorie dense infant formulas (20-27 kcals/oz) with enzymes27 kcals/oz) with enzymes

Protein hydrolysate formulas with Protein hydrolysate formulas with MCT oil if neededMCT oil if needed

Feeding Strategies in Feeding Strategies in CF: children and adultsCF: children and adults Regular mealtimesRegular mealtimes Large portionsLarge portions Extra snacksExtra snacks Nutrient-dense foodsNutrient-dense foods Nocturnal enteral feedingsNocturnal enteral feedings

– Intact or hydrolyzed formulasIntact or hydrolyzed formulas– Add enzyme powder to feeding or Add enzyme powder to feeding or

take before and duringtake before and during

Nutritional Nutritional Implications of Implications of TuberculosisTuberculosis TB is making a TB is making a

comebackcomeback Many patients Many patients

are developing are developing drug-resistant TBdrug-resistant TB

Nutritional Factors Nutritional Factors that Increase Risk of that Increase Risk of TBTB Protein-energy malnutrition: Protein-energy malnutrition:

affects the immune system; affects the immune system; debate whether it is a cause or debate whether it is a cause or consequence of the diseaseconsequence of the disease

Micronutrient deficiencies that Micronutrient deficiencies that affect immune function (vitamin affect immune function (vitamin D, A, C, iron, zinc)D, A, C, iron, zinc)

Nutritional Nutritional Consequences of TBConsequences of TB Increased energy expenditureIncreased energy expenditure Loss of appetite and body weightLoss of appetite and body weight Increase in protein catabolism Increase in protein catabolism

leading to muscle breakdownleading to muscle breakdown Malabsorption causing diarrhea, Malabsorption causing diarrhea,

loss of fluids, electrolytesloss of fluids, electrolytes

Nutritional Needs in TBNutritional Needs in TB

Energy: 35-40 kcals/kg of ideal Energy: 35-40 kcals/kg of ideal body weightbody weight

Protein: 1.2-1.5 grams/kg body Protein: 1.2-1.5 grams/kg body weight, or 15% of energy or 75-weight, or 15% of energy or 75-100 grams/day100 grams/day

Multivitamin-mineral supplement Multivitamin-mineral supplement at 100-150% DRIat 100-150% DRI

Chronic Obstructive Chronic Obstructive Pulmonary Disease Pulmonary Disease (COPD)(COPD)Characterized by airway obstructionCharacterized by airway obstruction Emphysema: abnormal, permanent Emphysema: abnormal, permanent

enlargement of alveoli, enlargement of alveoli, accompanied by destruction of accompanied by destruction of their walls without obvious fibrosistheir walls without obvious fibrosis

Chronic bronchitis: chronic, Chronic bronchitis: chronic, productive cough with inflammation productive cough with inflammation of one or more of the bronchi and of one or more of the bronchi and secondary changes in lung tissuesecondary changes in lung tissue

Chronic Obstructive Chronic Obstructive Pulmonary Disease Pulmonary Disease (COPD)(COPD) Emphysema: patients are thin, Emphysema: patients are thin,

often cachectic; older, mild often cachectic; older, mild hypoxia, normal hematocritshypoxia, normal hematocrits

Chronic bronchitis: of normal Chronic bronchitis: of normal weight; often overweight; weight; often overweight; hypoxia; high hematocrithypoxia; high hematocrit

Chronic Obstructive Chronic Obstructive Pulmonary Disease Pulmonary Disease (COPD)(COPD) Bronchospasm: asthmaBronchospasm: asthma Cor pumonale: heart condition Cor pumonale: heart condition

characterized by right ventricular characterized by right ventricular enlargement and failure that enlargement and failure that results from resistance to passage results from resistance to passage of blood through the lungsof blood through the lungs

Chronic BronchitisChronic Bronchitis

EmphysemaEmphysema

Bronchial AsthmaBronchial Asthma

Food sensitivities may be triggers Food sensitivities may be triggers for asthmatic episodes (sulfites, for asthmatic episodes (sulfites, shrimp, herbs) but not the most shrimp, herbs) but not the most common causescommon causes

Provide healthy diet and maintain Provide healthy diet and maintain healthy weighthealthy weight

Be aware of drug nutrient Be aware of drug nutrient interactions (steroids) interactions (steroids)

MNT Assessment in MNT Assessment in COPDCOPD Fluid balance and requirementsFluid balance and requirements Energy needsEnergy needs Food intake (decreased intake Food intake (decreased intake

common)common) Morning headache and confusion Morning headache and confusion

from hypercapnia (excessive CO2 from hypercapnia (excessive CO2 in the blood)in the blood)

Fat free massFat free mass

MNT Assessment in MNT Assessment in COPDCOPD Food drug interactionsFood drug interactions FatigueFatigue AnorexiaAnorexia Difficulty chewing/swallowing because Difficulty chewing/swallowing because

of dyspneaof dyspnea Impaired peristalsis secondary to lack of Impaired peristalsis secondary to lack of

oxygen to the GI tractoxygen to the GI tract Underweight patients have the highest Underweight patients have the highest

morbidity/mortalitymorbidity/mortality

Nutrient Needs in Nutrient Needs in Stable COPDStable COPD Protein: 1.2-1.7 grams/kg (15-20% of Protein: 1.2-1.7 grams/kg (15-20% of

calories) to restore lung and muscle calories) to restore lung and muscle strength and promote immune functionstrength and promote immune function

Fat: 30-45% of caloriesFat: 30-45% of calories Carbohydrate: 40-55% of caloriesCarbohydrate: 40-55% of calories Maintain appropriate RQMaintain appropriate RQ Address other underlying diseases Address other underlying diseases

(diabetes, heart disease)(diabetes, heart disease)

Nutrient Needs in Nutrient Needs in Stable COPDStable COPD Vitamins: intakes should at least meet Vitamins: intakes should at least meet

the DRIthe DRI Smokers may need more vitamin C Smokers may need more vitamin C

(+16-32 mg) depending on cigarette (+16-32 mg) depending on cigarette useuse

Minerals: meet DRIs and monitor Minerals: meet DRIs and monitor phosphorus and magnesium in phosphorus and magnesium in patients at risk for refeeding during patients at risk for refeeding during aggressive nutrition supportaggressive nutrition support

Treatments for COPDTreatments for COPD

Bronchodilators—theophylline and Bronchodilators—theophylline and aminophyllineaminophylline

Antibiotics—secondary infectionsAntibiotics—secondary infections Respiratory therapyRespiratory therapy Exercise to strengthen musclesExercise to strengthen muscles

MNT in COPD Based on MNT in COPD Based on Weight/HeightWeight/Height Routine careRoutine care Anticipatory guidance: 90% IBWAnticipatory guidance: 90% IBW Supportive intervention: 85% to 90% IBWSupportive intervention: 85% to 90% IBW Resuscitative/palliative: below 75% IBWResuscitative/palliative: below 75% IBW Rehabilitative care: consistently below Rehabilitative care: consistently below

85% IBW85% IBW JADA—1997JADA—1997

MNT in COPDMNT in COPD

GI motility: adequate exercise, GI motility: adequate exercise, fluids, dietary fiberfluids, dietary fiber

Abdominal bloating: limit foods Abdominal bloating: limit foods associated with gas formationassociated with gas formation

Fatigue: resting before meals, Fatigue: resting before meals, eating nutrient-dense foods, eating nutrient-dense foods, arrange assistance with shopping arrange assistance with shopping and meal preparationand meal preparation

MNT in COPDMNT in COPD

Suggest that patient Suggest that patient Use oxygen at mealtimesUse oxygen at mealtimes Eat slowlyEat slowly Chew foods wellChew foods well Engage in social interaction at mealtimeEngage in social interaction at mealtime Coordinate swallowing with breathingCoordinate swallowing with breathing Use upright posture to reduce risk of Use upright posture to reduce risk of

aspirationaspiration

MNT in COPDMNT in COPD

Oral supplementsOral supplements Nocturnal or supplemental tube Nocturnal or supplemental tube

feedingsfeedings Specialized pulmonary Specialized pulmonary

products generally products generally

not necessarynot necessary

Food Drug InteractionsFood Drug Interactions

Aminoglycosides lower serum Aminoglycosides lower serum MgMg++++

—may need to replace—may need to replace Prednisone—monitor nitrogen, Prednisone—monitor nitrogen,

CaCa++++, serum glucose, etc., serum glucose, etc.

MNT in Respiratory MNT in Respiratory FailureFailure

Causes of Acute Lung Causes of Acute Lung Injury (ALI)Injury (ALI) Aspiration of gastric contents or Aspiration of gastric contents or

inhalation of toxic substancesinhalation of toxic substances High inspired oxygenHigh inspired oxygen DrugsDrugs Pneumonitis, pulmonary contusions, Pneumonitis, pulmonary contusions,

radiationradiation Sepsis syndrome, multisystem trauma, Sepsis syndrome, multisystem trauma,

shock, ,pancreatitis, pulmonary shock, ,pancreatitis, pulmonary embolismembolism

AspirationAspiration

Movement of food or fluid into the Movement of food or fluid into the lungslungs

Can result in pneumonia or even Can result in pneumonia or even deathdeath

Increased risk for infants, toddlers, Increased risk for infants, toddlers, older adults, persons with oral, older adults, persons with oral, upper gastrointestinal, neurologic, upper gastrointestinal, neurologic, or muscular abnormalitiesor muscular abnormalities

AspirationAspiration

Reported incidence of aspiration in Reported incidence of aspiration in tubefed patients varies from .8% to 95%. tubefed patients varies from .8% to 95%. Clinically significant aspiration 1-4%Clinically significant aspiration 1-4%

Many aspiration events are “silent” and Many aspiration events are “silent” and often involve oropharyngeal secretionsoften involve oropharyngeal secretions

Symptoms include dyspnea, tachycardia, Symptoms include dyspnea, tachycardia, wheezing, rales, anxiety, agitation, wheezing, rales, anxiety, agitation, cyanosiscyanosis

May lead to aspiration pneumoniaMay lead to aspiration pneumonia

Acute Respiratory Acute Respiratory Distress Syndrome Distress Syndrome (ARDS)(ARDS) Most severe form of acute lung injuryMost severe form of acute lung injury Sepsis usually the underlying causeSepsis usually the underlying cause Increasing pulmonary capillary Increasing pulmonary capillary

permeabilitypermeability Pulmonary edemaPulmonary edema Increased pulmonary vascular Increased pulmonary vascular

resistanceresistance Progressive hypoxemiaProgressive hypoxemia

Goals of Treatment of Goals of Treatment of ALI and ARDSALI and ARDS Improve oxygen delivery and Improve oxygen delivery and

provide hemodynamic supportprovide hemodynamic support Reduce oxygen consumptionReduce oxygen consumption Optimize gas exchangeOptimize gas exchange Individualize nutrition supportIndividualize nutrition support

Nutrition Assessment Nutrition Assessment in ALI and ARDSin ALI and ARDS Indirect calorimetry best tool to Indirect calorimetry best tool to

determine energy needs in critically ill determine energy needs in critically ill patientspatients

In absence of calorimetry, use In absence of calorimetry, use predictive equations with stress factorspredictive equations with stress factors

Avoid overfeedingAvoid overfeeding Patients may need high calorie density Patients may need high calorie density

feedings to achieve fluid balancefeedings to achieve fluid balance

Nutrition Support in Nutrition Support in ARDSARDS In one randomized, controlled trial in 146 In one randomized, controlled trial in 146

patients with ARDS, enteral nutrition with patients with ARDS, enteral nutrition with omega-3 fatty acids (eicosapentaenoic acid) omega-3 fatty acids (eicosapentaenoic acid) gamma-linonenic acid, and antioxidants gamma-linonenic acid, and antioxidants appeared to reduce days on mechanical appeared to reduce days on mechanical ventilation, new organ failure, and ICU length of ventilation, new organ failure, and ICU length of staystay

This study was sponsored by Ross Laboratories, This study was sponsored by Ross Laboratories, makers of Oxepamakers of Oxepa

Have been unable to locate further studies Have been unable to locate further studies since thensince then

Gadek JE et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-Gadek JE et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med 1999;27:1409. syndrome. Enteral Nutrition in ARDS Study Group. Crit Care Med 1999;27:1409.