medical nutrition therapy for pulmonary disease chapter 38

Medical Nutrition Therapy for Pulmonary Disease

Medical Nutrition Therapy for Pulmonary Disease

Chapter 38Chapter 38

© 2004, 2002 Elsevier Inc. All rights reserved.

Anatomy of the Pulmonary SystemAnatomy of the Pulmonary System

© 2004, 2002 Elsevier Inc. All rights reserved.

Normal Lung AnatomyNormal Lung Anatomy

© 2004, 2002 Elsevier Inc. All rights reserved.

Selected Airway DisordersSelected Airway Disorders

© 2004, 2002 Elsevier Inc. All rights reserved.

Key TermsKey Terms

Pulmonary aspiration

Asthma

Bronchopulmonary dysplasia (BPD)

Chronic obstructive pulmonary disease (COPD)

Cystic fibrosis (CF)

Pulmonary aspiration

Asthma

Bronchopulmonary dysplasia (BPD)

Chronic obstructive pulmonary disease (COPD)

Cystic fibrosis (CF)

© 2004, 2002 Elsevier Inc. All rights reserved.

Selected Pulmonary Conditions Having Nutritional ImplicationsSelected Pulmonary Conditions Having Nutritional Implications

© 2004, 2002 Elsevier Inc. All rights reserved.

Adverse Effects of Lung Disease on Nutritional StatusAdverse Effects of Lung Disease on Nutritional Status

© 2004, 2002 Elsevier Inc. All rights reserved.

Impact of MalnutritionImpact of Malnutrition

Decreased

—Vital capacity (lung volume)

—Minute ventilation (volume exhaled/minute)

—Efficiency of ventilation

Structure and function

—Increased compliance (dispensability)

—Decreased elasticity

—Decreased surfactant

Decreased

—Vital capacity (lung volume)

—Minute ventilation (volume exhaled/minute)

—Efficiency of ventilation

Structure and function

—Increased compliance (dispensability)

—Decreased elasticity

—Decreased surfactant

© 2004, 2002 Elsevier Inc. All rights reserved.

Impact of Malnutrition—cont’dImpact of Malnutrition—cont’d

Pulmonary edema

—Decreased O2 transport

—Decreased respiratory muscle strength

—Decreased energy substrates in the cell

—Decreased ventilatory drive with hypoxia

—Decreased immune function

Pulmonary edema

—Decreased O2 transport

—Decreased respiratory muscle strength

—Decreased energy substrates in the cell

—Decreased ventilatory drive with hypoxia

—Decreased immune function

© 2004, 2002 Elsevier Inc. All rights reserved.

Bronchopulmonary DysplasiaBronchopulmonary Dysplasia

Assessment

—Linear growth

—Dietary intake

—Gastroesophageal reflux

—Chronic hypoxia

—Emotional deprivation

Assessment

—Linear growth

—Dietary intake

—Gastroesophageal reflux

—Chronic hypoxia

—Emotional deprivation

Definition: chronic lung disorder seen in early infancy and usually follows intensive therapy for respiratory difficulties in the neonatal period

Definition: chronic lung disorder seen in early infancy and usually follows intensive therapy for respiratory difficulties in the neonatal period

© 2004, 2002 Elsevier Inc. All rights reserved.

Goals of Nutritional CareGoals of Nutritional Care

Adequate nutrient intakes

Promote linear growth

Maintain fluid balance

Develop age-appropriate feeding skills

Adequate nutrient intakes

Promote linear growth

Maintain fluid balance

Develop age-appropriate feeding skills

© 2004, 2002 Elsevier Inc. All rights reserved.

Cystic FibrosisCystic Fibrosis

Inherited autosomal recessive

Epithelial cells and exocrine glands secrete abnormal mucus (thick)

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

Inherited autosomal recessive

Epithelial cells and exocrine glands secrete abnormal mucus (thick)

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

© 2004, 2002 Elsevier Inc. All rights reserved.

Diagnosis of Cystic FibrosisDiagnosis of Cystic Fibrosis

Neonatal screening provides opportunity to prevent malnutrition in CF infants

Sweat test (Na and Cl >60 mEq/L)

Chronic lung disease

Failure to thrive

Malabsorption

Family history

Neonatal screening provides opportunity to prevent malnutrition in CF infants

Sweat test (Na and Cl >60 mEq/L)

Chronic lung disease

Failure to thrive

Malabsorption

Family history

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutritional AssessmentNutritional Assessment

List of important assessment points

—Significant findings

• Recent weight loss or <90% IBW

• Is weight fluid or adipose or LBM?

• Indirect calorimetry

• Edema lowers TP and albumin

List of important assessment points

—Significant findings

• Recent weight loss or <90% IBW

• Is weight fluid or adipose or LBM?

• Indirect calorimetry

• Edema lowers TP and albumin

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutritional Assessment in Cystic FibrosisNutritional Assessment in Cystic Fibrosis

(From Ramsey BW, et al. Nutritional assessment and management in cyctic fibrosis. A concensus report. Am J Clin Nutr 55: 108, 1992, p.109) * Usually consists of a 24-hour recall with assessment of dietary pattern; should be obtained by a dietician.† Includes both a diet record to determine energy and fat intake as well as a determination of stool fat excretion. this permits calculation of the coefficient of fat absorption (CFA) and assessment of the degree of malabsorption in malnourished patients.‡ If there is any evidence of iron deficiency, iron status must be measured (I.e., serum iron, iron-binding capacity, and serum ferritin levels).

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutritional Problems in Cystic FibrosisNutritional Problems in Cystic Fibrosis

Pancreatic enzyme insufficiency

Malabsorption

—Decreased HCO3 secretion

—Decreased bile acid reabsorption (fat malabsorption)

—Excessive mucus

Pancreatic enzyme insufficiency

Malabsorption

—Decreased HCO3 secretion

—Decreased bile acid reabsorption (fat malabsorption)

—Excessive mucus

© 2004, 2002 Elsevier Inc. All rights reserved.

Symptoms of Cystic Fibrosis MalabsorptionSymptoms of Cystic Fibrosis Malabsorption

Bulky, foul-smelling stools

Cramping

Obstruction

Rectal prolapse

Liver damage

Other problems

—Impaired glucose tolerance

Bulky, foul-smelling stools

Cramping

Obstruction

Rectal prolapse

Liver damage

Other problems

—Impaired glucose tolerance

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutritional Care GoalsNutritional Care Goals

Control malabsorption Provide adequate nutrients for growth

Common Treatments Pancreatic enzyme replacement Adjust macronutrients for symptoms Nutrients for growth Meconium ileus equivalent: intestinal

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

Control malabsorption Provide adequate nutrients for growth

Common Treatments Pancreatic enzyme replacement Adjust macronutrients for symptoms Nutrients for growth Meconium ileus equivalent: intestinal

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

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutrient NeedsNutrient Needs

Vitamins

—H2O soluble need not be increased (exception may be B12)

—Fat-soluble – may need a supplement

—Sodium: infants need 1/8 to 1/4 tsp/day added salt

Vitamins

—H2O soluble need not be increased (exception may be B12)

—Fat-soluble – may need a supplement

—Sodium: infants need 1/8 to 1/4 tsp/day added salt

© 2004, 2002 Elsevier Inc. All rights reserved.

Medical Nutrition TherapyMedical Nutrition Therapy

Increase energy intake

—Serving size

—Snacks

—High-calorie foods

—Supplements

—Night gastrostomy tube feeding with enzymes

—TPN only when GI not usable, or in advanced CF (monitor risks of sepsis)

Increase energy intake

—Serving size

—Snacks

—High-calorie foods

—Supplements

—Night gastrostomy tube feeding with enzymes

—TPN only when GI not usable, or in advanced CF (monitor risks of sepsis)

© 2004, 2002 Elsevier Inc. All rights reserved.

Lung TransplantationLung Transplantation

Prior to transplant, children with CF are typically at the 5th percentile for weight

Prior to transplant, children with CF are typically at the 5th percentile for weight

© 2004, 2002 Elsevier Inc. All rights reserved.

Chronic Obstructive Pulmonary Disease (COPD)Chronic Obstructive Pulmonary Disease (COPD)

Obstruction of airways

—Bronchospasm: asthma

—Overproduction of mucus: bronchitis

—Destruction of elastin: emphysema

—Obstruction: bronchiectasis

—Right heart failure: cor pulmonale

Obstruction of airways

—Bronchospasm: asthma

—Overproduction of mucus: bronchitis

—Destruction of elastin: emphysema

—Obstruction: bronchiectasis

—Right heart failure: cor pulmonale

© 2004, 2002 Elsevier Inc. All rights reserved.

Components of Nutritional Assessment for Adults with Chronic Obstructive Pulmonary DiseaseComponents of Nutritional Assessment for Adults with Chronic Obstructive Pulmonary Disease

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutritional StatusNutritional Status

Nutritional requirements increased from maldigestion, malabsorption

Complications—SOB; coughing; GI distress; anorexia during infections; altered smell; retarded growth

Nutritional requirements increased from maldigestion, malabsorption

Complications—SOB; coughing; GI distress; anorexia during infections; altered smell; retarded growth

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutritional RequirementsNutritional Requirements

Energy

—HB x AC x IF

—1.0-1.2 maintenance

—1.4-1.6 repletion

Macronutrient mix

—DO NOT OVERFEED!

—RQ = CO2/O2 CHO = 1, fat = 0.7, mixed diet = 0.87

Energy

—HB x AC x IF

—1.0-1.2 maintenance

—1.4-1.6 repletion

Macronutrient mix

—DO NOT OVERFEED!

—RQ = CO2/O2 CHO = 1, fat = 0.7, mixed diet = 0.87

© 2004, 2002 Elsevier Inc. All rights reserved.

Nutritional Requirements—cont’dNutritional Requirements—cont’d

Omega-3 fatty acids

—May protect smokers from COPD

—May be antiinflammatory

Vitamin C supplement for smokers

—16-30 mg/d

Omega-3 fatty acids

—May protect smokers from COPD

—May be antiinflammatory

Vitamin C supplement for smokers

—16-30 mg/d

© 2004, 2002 Elsevier Inc. All rights reserved.

TreatmentsTreatments

Bronchodilators—theophylline and aminophylline

Antibiotics—secondary infections

Respiratory therapy

Exercise to strengthen muscles

Bronchodilators—theophylline and aminophylline

Antibiotics—secondary infections

Respiratory therapy

Exercise to strengthen muscles

© 2004, 2002 Elsevier Inc. All rights reserved.

Categories of Medical Nutrition Therapy ManagementCategories of Medical Nutrition Therapy Management

Routine care

Anticipatory guidance: 90% IBW

Supportive intervention: 85% to 90% IBW

Resuscitative/palliative: below 75% IBW

Rehabilitative care: consistently below 85% IBW

JADA—1997

Routine care

Anticipatory guidance: 90% IBW

Supportive intervention: 85% to 90% IBW

Resuscitative/palliative: below 75% IBW

Rehabilitative care: consistently below 85% IBW

JADA—1997

© 2004, 2002 Elsevier Inc. All rights reserved.

Medical Nutrition TherapyMedical Nutrition Therapy

Monitor side effects of food-drug interactions

Aminoglycosides lower serum Mg++

—may need to replace

Prednisone—monitor nitrogen, Ca++, serum glucose, etc.

Monitor side effects of food-drug interactions

Aminoglycosides lower serum Mg++

—may need to replace

Prednisone—monitor nitrogen, Ca++, serum glucose, etc.

© 2004, 2002 Elsevier Inc. All rights reserved.

Cellular DamageCellular Damage

Cellular damage causes oxidative stress.

Excessive accumulation of oxygen free radicals (superoxide anions; hydrogen peroxide; hydroxy radicals; singlet molecular oxygen)

Cellular injury may lead to systemic inflammatory response (SIRS)

Results of trials with antioxidants are mixed.

Cellular damage causes oxidative stress.

Excessive accumulation of oxygen free radicals (superoxide anions; hydrogen peroxide; hydroxy radicals; singlet molecular oxygen)

Cellular injury may lead to systemic inflammatory response (SIRS)

Results of trials with antioxidants are mixed.

© 2004, 2002 Elsevier Inc. All rights reserved.

Oxidative Stress and Critical IllnessOxidative Stress and Critical Illness

Mounting evidence exists that oxidative stress plays a pivotal role in critical illness.

Decreased antioxidant defenses

Mounting evidence exists that oxidative stress plays a pivotal role in critical illness.

Decreased antioxidant defenses

© 2004, 2002 Elsevier Inc. All rights reserved.

Respiratory FailureRespiratory Failure

There may be some benefit to offering antioxidant therapy to patients with respiratory failure.

Studies are ongoing

There may be some benefit to offering antioxidant therapy to patients with respiratory failure.

Studies are ongoing

© 2004, 2002 Elsevier Inc. All rights reserved.

Respiratory Failure—cont’dRespiratory Failure—cont’d

Patient usually on ventilator

Laboratory values indicating RF—ABGs

—PCO2 >50 mm Hg (35-45 mm Hg)

—PO2 <60 mm HG (80-100 mm Hg)

—pH <7.30 (7.35-7.45)

—HCO3– (22-26 mEq/L)

—O2 saturation >95%

Patient usually on ventilator

Laboratory values indicating RF—ABGs

—PCO2 >50 mm Hg (35-45 mm Hg)

—PO2 <60 mm HG (80-100 mm Hg)

—pH <7.30 (7.35-7.45)

—HCO3– (22-26 mEq/L)

—O2 saturation >95%

© 2004, 2002 Elsevier Inc. All rights reserved.

Respirator WeaningRespirator Weaning

Information monitored

—Concentration of inspired O2 (FIO2)

—Positive end-expiratory pressure (PEEP)

Nutrition balance important to success

—Muscle strength

—Albumin levels

—RQ

—Phosphate depletion corrected

Information monitored

—Concentration of inspired O2 (FIO2)

—Positive end-expiratory pressure (PEEP)

Nutrition balance important to success

—Muscle strength

—Albumin levels

—RQ

—Phosphate depletion corrected

© 2004, 2002 Elsevier Inc. All rights reserved.

SummarySummary

Pulmonary—affect of nutrition on lungs, and lung status on nutrition

High metabolic rate can occur—will need extra kcal; less from carbohydrate than usual

Pulmonary—affect of nutrition on lungs, and lung status on nutrition

High metabolic rate can occur—will need extra kcal; less from carbohydrate than usual