Transcript
MEDICAL NUTRITION THERAPY FOR PULMONARY DISEASES
Noraishah Mohamed NorDept Nutrition SciencesIIUM
DEFINITION Bronchospasm: asthma Cor pumonale: heart condition characterized by
right ventricular enlargement and failure that results from resistance to passage of blood through the lungs
Leukotrienes: powerful inflammatory mediators. RQ: ratio between oxygen (O2) an organism intakes
and carbon dioxide (CO2) the organism eliminates Dyspnea: Dyspnea is defined as abnormal breathing
and usually refers to the uncomfortable feeling of breathlessness. Also known as shortness of breath
NORMAL ANATOMY & PHYSIOLOGY
The respiratory system is situated in the thorax, and is responsible for gaseous exchange.
Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue.
The lungs are divided into lobes;
The left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the middle and the lower lobes.
MECHANICS OF BREATHING To take a breath in, the external intercostal
muscles contract, moving the ribcage up and out.
The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well.
This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall.
This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).
PHYSIOLOGY OF GAS EXCHANGE Each branch of the bronchial tree eventually
sub-divides to form very narrow terminal bronchioles, which end in the alveoli.
There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery.
The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.
IMPACT OF RESPIRATORY SYSTEM DISEASES ON NUTRITIONAL STATUS
Pulmonary disease substantially increase energy requirements.
The complication of pulmonary disease or their tx can cause difficulty in food intake and digestion.
the absorption, circulation, cellular utilization, storage, and excretion of most nutrient problematic
ADVERSE EFFECTS OF LUNG DISEASE ON NUTRITIONAL STATUS
Increased energy expenditureIncreased work of breathingChronic infectionMedical treatments (e.g. bronchodilators, chest
physical therapy
Reduced intakeFluid restrictionShortness of breathDecreased oxygen saturation when eatingAnorexia due to chronic diseaseGastrointestinal distress and vomiting
Additional limitationsDifficulty preparing food due to fatigueLack of financial resourcesImpaired feeding skills (for infants and
children)Altered metabolism
TYPES OF PULMONARY DISEASES
ACUTE PULMONARY DISORDERS
Pulmonary aspiration Pneumonia Tuberculosis Cancer of the lung Acute respiratory distress syndrome Pulmonary failure
CHRONIC PULMONARY DISORDERS
Bronchopulmonary dysplasia Cystic fibrosis Tuberculosis Bronchial asthma Chronic obstructive pulmonary disease
(COPD)
PULMONARY CONDITIONS WITH NUTRITIONAL IMPLICATIONS
Neonate Bronchopulmonary displasia (BPD)
Obstruction Cystic fibrosis (CF)Chronic obstructive pulmonary disease (COPD)
EmphysemaChronic bronchitisAsthma
Tumor Lung cancer
Infection PneumoniaTuberculosis (TB)
Respiratory Failure
Acute respiratory failureLung transplantation
Cardiovascular Pulmonary edema
PULMONARY ASPIRATION Movement of food or fluid (oral/ETF) into
the lung, can result in pneumonia or even death.
Proper body positioning when eating is essential
Increased risk in:Infant, toddlers, older adult, person with upper
GIT problem, neurologic or muscular abnormalities.
Symptoms include dyspnea, tachycardia, wheezing, rales, anxiety, agitation, cyanosis
ASTHMA
Def: Chronic inflammatory disorder of the airway involving many cells and cellular elements such as mast cell, eosinophil etc.
It is a condition of bronchial hyper-responsiveness, and airway inflammation, leading to air flow obstruction.
The syndrome appears to result from complex interactions among genetic, immunologic and environmental factors.
This inflammation causes recurrent episode of wheezing, breathlessness, chest tightness, and coughing usually in the early morning or late night.
Pathopysiology: When asthma occur, bronchi and bronchioles respond
to the stimuli by contraction of smooth muscle (bronchoconstriction).
The mucosa is inflamed and edematous with increased production of mucus.
This result in partial or total air way obstruction.
MEDICAL NUTRITION THERAPY (MNT)
Asthma prevalence increase in obese individualProvide healthy diet and maintain healthy weight
Food and individual nutrients are being studies:Omega- 3 & Omega -6 : role in reducing the
production of bronchoconstrictive leukotrienes.Antioxidant : role in protecting the airway tissue from
oxidative stress.Mg : role as smooth muscle relaxant and anti-
inflammatory agent Methylxanthines (caffeine): role as bronchodialators
Food sensitivities may be triggers for asthmatic episodes (sulfites, shrimp, herbs) but not the most common causes.
Some studies shows: breast feeding demonstrate a protective effects against asthma development
Tx: moving any items from the pt’s environment that are known to be the triggers
If this don’t works: use medication which usually cause dry mouth, throat irritation, nausea, vomiting & diarrhea.
BRONCHOPULMONARY DYSPLASIA (BPD)
Chronic lung condition in newborns that often follows respiratory distress syndrome (RDS) and treatment with oxygen
Characterized by pulmonary inflammation, & impaired growth and development of the alveoli
Occurs most frequently in infants who
are premature or low birth weight
Sign & symptoms: Hypercapnea (CO2 retention) Tachypnea (rapid breathing) Wheezing Dyspnea (symptom of breathlessness) Recurrent respiratory infections Cor pulmonale (right ventricular enlargement of the
heart)
Growth Failure in BPD due to: Increased energy needs Inadequate dietary intake Gastroesophageal reflux Emotional deprivation Chronic hypoxia (reduce the amount of oxygen
available in the blood )
MNT Meet nutritional needs (appropriate with
wt & length)
Promote linear growth
Develop age-appropriate feeding skills
Maintain fluid balance
The Energy needs in infants with BPD is 15-25% higher than same age healthy, normal infants (Denne, 2001)
Estimated energy needs of 120 – 130 kcal/kg – for appropriate growth.
Energy needs 130 -160 kcal/day for those with increase metabolic demand
Babies with growth failure may have needs 50% higher
Protein: within advised range for infants of comparable post- conceptional age
As energy density of the diet is increased by the addition of fat and carbohydrate, protein should still provide 7% or more of total kcals
Protein intake of 3 – 4 g/kg have been recommended (Carlson 2004)
Intake > 4g/kg should be avoided risk to develop acidosis in infant with immature kidney.
Fat and carbohydrate should be added to formula only after it has been concentrated to 24 kcal/oz to keep protein high enough
Fat provides EFA and energy when tolerance for fluid and carbohydrate is limited
Excess CHO increases respiratory quotient (RQ) and CO2 output
MINERALS NEEDS
Lack of mineral stores as a result of prematurity (iron, zinc, calcium)
Growth delay
Medications: diuretics, bronchodilators, antibiotics, cardiac antiarrhythmics, corticosteroids associated with loss of minerals including chloride, potassium, calcium
VITAMINS NEEDS
Interest in antioxidants, including vitamin A for role in developing epithelial cells of the respiratory tract
Provide intake based on the DRI, including total energy, to promote catch up growth
FLUID NEEDS
Infants with BPD may require fluid restriction, sodium restriction, and long term treatment with diuretics
Use of parenteral lipids or calorically dense enteral feeds may help the infant meet energy needs
FEEDING STRATEGIES IN BPD
Calorically dense formulas or boosted breast milk (monitor fluid status and urinary output)
Small, frequent feedings
Use of a soft nipple
Nasogastric or gastrostomy tube feedings
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Characterized by airway obstructionTypes of COPD:
Emphysema (type 1): abnormal, permanent enlargement of alveoli, accompanied by
destruction of their walls without obvious fibrosis Cor pulmonale developes late in the course of disease patients are thin, often cachectic; older, mild hypoxia, normal
hematocrits
Chronic bronchitis (type 2): chronic, productive cough with inflammation of one or more
of the bronchi and secondary changes in lung tissue Cor pulmonale developes early in the course of disease of normal weight; often overweight; hypoxia; high
hematocrit Decrease air flow rate (FEV)
COPD SEVERITY SCALEWe've included this chart so that you will know what your doctor means when he or she tells you how severe your COPD is. Make sure to have your condition explained clearly to you, and find out everything you can about how to keep from progressing higher on this scale.
0: At RiskThis classification comes before major damage is really done. Your doctor has determined that you have the risk factors associated with developing COPD later in life, and he or she will probably recommend lifestyle changes and regular testing.• Normal spirometry at every physician visit• Symptoms (cough, sputum production) may be present, but not yet serious
I: Mild COPDIn this case, spirometry has shown mild airflow limitations due to chronic cough, mucus production, and the beginning of damage to your lungs. You may not be aware of your symptoms. Some characteristics of this stage include:• FEV1/FVC < 70%• FEV1 >= 80% predicted• Starting to suffer from chronic symptoms (cough, sputum productio)
II: Moderate COPDAt this stage, your airflow is getting worse. You have very noticeable symptoms, and dyspnea occurs with everyday exertion. This is when most people go to their doctor for the first time. Characteristics include:• FEV1/FVC < 70%• 50% <= FEV1 < 80% predicted • Chronic symptoms (cough, sputum production)
III: Severe COPDVery limited airflow. Dyspnea occurs after minimal exertion, to the point where even small tasks like leaving the house or going upstairs are a major issue. Characteristics include:• FEV1/FVC < 70%• 30% <= FEV1 < 50% predicted• Chronic symptoms (cough, sputum production)
IV: Very Severe COPDAt this stage, complications such as respiratory failure and heart failure begin to develop. Quality of life is extremely impaired and the symptoms become life threatening. Characteristics include:• FEV1/FVC < 70%• FEV1/FVC <30% predicted or FEV1< 50% predicted plus chronic respiratory failure• Classification based on post-bronchodilator FEV1• Respiratory Failure: arterial partial pressure of oxygen PaO2 less than 60mmHg with or without PaCO2 greater than 50mmHg while breathing at sea level
FEV stands for Forced Expiratory Volume, or the amount of air you can blow out of your lungs in one second.FVC stands for Forced Vital Capacity, or the total amount of air you can blow out.FEV1/FVC is the ratio that compares the amount you can blow out
quickly to the total amount your lungs can blow out.
MNT ASSESSMENT Fluid balance and requirements Energy needs Food intake (decreased intake common) Morning headache and confusion from hypercapnia
(excessive CO2 in the blood) Fat free mass Food drug interactions Fatigue Anorexia Difficulty chewing/swallowing because of dyspnea Impaired peristalsis secondary to lack of oxygen to the GI
tract Underweight patients have the highest morbidity/mortality
MNT Malnutrition occur in 24 – 35% with moderate
to severe COPD pt, with average wt loss of 5 to 10 % of initial body weight
Higher BEE due to breathing difficulties and inflammation hypermetabolism.
Energy intake of 125 – 156% (average 140%) above BEE
protein 1.2 – 1.7 g/kg (average 1.2 g/kg) enough to avoid protein losses.
Malnourished pt need higher energy & protein to provide for repletion
Do not over feed pt, may increase CO2 production which can complicate the ventilation
The production of excess CO2 occur when pt overfed >1.5 x REE
Balanced ratio of macro nutrients: Protein : 15 – 20% (1.2 – 1.7 g/kg) Fat : 30 – 45 % CHO: 40 – 55 %
Maintain appropriate RQ
Address other underlying diseases (diabetes, heart disease)
Vitamins: intakes should at least meet the DRI
Smokers may need more vitamin C (+16-32 mg) depending on cigarette use
Minerals: meet DRIs and monitor phosphorus and magnesium in patients at risk for refeeding during aggressive nutrition support
GI motility: adequate exercise, fluids, dietary fiber
Abdominal bloating: limit foods associated with gas formation
Fatigue: resting before meals, eating nutrient-dense foods, arrange assistance with shopping and meal preparation
Suggest that patient Use oxygen at mealtimes Eat slowly Chew foods well Engage in social interaction at mealtime Coordinate swallowing with breathing Use upright posture to reduce risk of aspiration
Oral supplements Nocturnal or supplemental tube feedings Specialized pulmonary products generally not
necessary
FOOD DRUG INTERACTIONS
Aminoglycosides lower serum Mg++
—may need to replace Prednisone—monitor nitrogen, Ca++, serum
glucose, etc.
CYSTIC FIBROSIS (CF) Inherited autosomal recessive disorder
CF incidence of 1:2500 live births
Survival is improving; median age of patients has exceeded 30 years
Epithelial cells and exocrine glands secrete abnormal mucus (thick)
Affects respiratory tract, sweat, salivary, intestine, pancreas, liver, reproductive tract
DIAGNOSIS 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
NUTRITIONAL IMPLICATIONS OF CF
Infants born with meconium ileus are highly likely to have CF
85% of persons with CF have pancreatic insufficiency
Plugs of mucus reduce the digestive enzymes released from the pancreas causing maldigestion of food and malabsorption of nutrients
Decreased bicarbonate secretion reduces digestive enzyme activity
Decreased bile acid reabsorption contributes to fat malabsorption
Excessive mucus lining the GI tract prevents nutrient absorption by the microvilli
GASTROINTESTINAL COMPLICATIONS
Bulky, foul-smelling stools Cramping and intestinal obstruction Rectal prolapse Liver involvement Pancreatic damage causes impaired glucose
tolerance (50% of adults with CF) and development of diabetes (15% of adults with CF)
COMMON TREATMENTS Pancreatic enzyme replacement Adjust macronutrients for symptoms Nutrients for growth Meconium ileus equivalent: intestinal
obstruction (enzymes, fiber, fluids, exercise, stool softeners)
Pancreatic Enzyme Replacement Introduced in the early 1980s Enteric-coated enzyme microspheres withstand acidic
environment of the stomach Release enzymes in the duodenum, where they digest
protein, fat and carbohydrate
NUTRITIONAL CARE GOALS Control malabsorption Provide adequate nutrients for growth
or maintain weight for height or pulmonary function
Prevent nutritional deficiencies
MNT Estimation of Energy Req:
Use WHO equations to estimate BMR Multiply by activity coefficient + disease coefficient TEE – BMR X (AC + DC) Disease coefficient is based on lung function Normal lung function = 0.0 Moderate lung disease = 0.2
FEV1 40-79% of that predicted Severe lung disease = 0.3
FEV1 <40% of that predicted
Example Male patient 22 years old, weight 54 kg, relatively
sedentary FEV1 is 60% of predicted (moderate lung disease) TEE = BMR X (1.5 + 0.2) TEE = [(15.3 (54) + 679] X 1.7 TEE = 2559 kcals
In children energy req should be based on the wt gain and growth.
Energy need for CF children without ventilation are comparable to healthy children (100 – 110% of RDA).
In case of significant lung disease, malabsorption, ER increase 120 -150% of RDA
Protein Req: Protein needs are increased in CF due to
malabsorption If energy needs are met, protein needs are
usually met by following 15-20% protein or use RDA
Fat Req:Fat intake 35-40% of calories (in fat
malabsorption), as toleratedHelps provide required energy, essential fatty
acids and fat-soluble vitaminsLimits volume of food needed to meet energy
demands and improves palatability of the dietEFA deficiency sometimes occurs in CF
patients despite intake and pancreatic enzymesFat restriction is not recommended important
energy sourcesFat used MCT oil
CHO req: Eventually intake may need to be modified if glucose
intolerance develops Some patients develop lactose intolerance
Vitamins req: With pancreatic enzymes, water soluble vitamins
usually adequately absorbed with daily multivitamin Will need high potency supplementation of fat soluble
vitamins (A, D, K, E)
FEEDING STRATEGIES: INFANTS
Breast feeding with supplements of high-calorie formulas and pancreatic enzymes
Calorie dense infant formulas (20-27 kcals/oz) with enzymes
Protein hydrolysate formulas with MCT oil if needed
FEEDING STRATEGIES: CHILDREN AND ADULTS
Regular mealtimes Large portions Extra snacks Nutrient-dense foods Nocturnal enteral feedings
Intact or hydrolyzed formulas Add enzyme powder to feeding or take before
and during
PNEUMONIA Inflammation (infection) of the lung usually
caused by bacteria, viruses or fungi. Hospital acquired pneumonia (HAP) Community acquired pneumonia (CAP)
The infection causes deterioration of lung fx resulting in fluid accumulation and breathing difficulties.
Aspiration pneumonia: another common causes for dev of pneumonia is aspiration of inhaled materials (saliva, nasal secretion, bacteria, foods) in to the air ways. It happened when the material causes inflammatory
response in the lung
NUTRITION IMPLICATION
Pt admitted to the hospital due to CAP, most important risk factor associated to mortality low serum albumin (<3.0 g/dl)
The depress alb is associated to the inflammation response rather than malnutrition.
Other indices of poor NS associate to death are low triceps skinfold (TSF) and low BMI.
PATIENTS WITH TRACHEOSTOMIES Tracheostomy is a surgical opening made in
trachea to assist breathing. It is done to:
To by pass an obstruction in trachea To clean and remove secretion from trachea More easily & safely deliver O2 to lung
Complication: Difficult in swallowing Inability to speak normally
High risk for pneumonia if pt is on ventilation tube feeding
When it is safe for pt to eat orally, dietitian need to work closely with speech pathologist to determined the constituency of food
RESPIRATORY FAILURE Occur when the respiratory system is no longer
able to perform its normal fx.
It result from long standing chronic lung disease like COPD, CF or as a result of an acute insult (abuse) to the lung such as acute respiratory distress syndrome (ARDS).
Categories of ARDS: Directly cause injured to the lung eg. Pneumonia,
aspiration or inhalation injury Indirectly cause injury precipitated by event outside
the lung e.g. sepsis, trauma, or pancreatitis.
MNT Energy req is based on the underlying diseases
(often hypermetabolic) 1.2 – 1.4 x BEE REMEMBER do not over feed the pt increase
CO2 production Increase ventilatory demand associated with
overfeeding; excess glucose administration (>5 mg/kg per min) and excess EI
The provision 25 kcal/kg (130% of BEE) appears to be adequate to most pt (Cerra 2002)
Fluid balanced should be monitor closely Protein req: 1.2 – 1.5 g/kg (to promote nitrogen
retention without being excessive ARDS pulmonary edema, the use of fluid
restricted enteral formulation (1.5 – 2 kcal/cc)may be helpful, for those need for fluid restiction
ARDS associate with production of oxygen free radical and inflammatory mediators, recent study shows: EPA in fish oil and GLA in borage oil can reduce the
severity of inflammatory injury by altering the availability of AA in phospholipids.
High level of antioxidant: α-tocopherol, β-carotene and vit C at higher level than DRI increase serum α-tocopherol, β-carotene & prevent further oxidative damage.
Phosphate is essential for optimal pulmonary fx and normal diaphragm contraction hypophosphatemia increase hospital stay and dependence to ventilation. Need to monitor phosphate and supplementation should be initiated in hypophosphatemia
ACUTE LUNG INJURY (ALI) Causes
Aspiration of gastric contents or inhalation of toxic substances
High inspired oxygen Drugs Pneumonitis, pulmonary contusions, radiation Sepsis syndrome, multisystem trauma,
shock, ,pancreatitis, pulmonary embolism
NUTRITION ASSESSMENT IN ALI AND ARDS
Indirect calorimetry best tool to determine energy needs in critically ill patients
In absence of calorimetry, use predictive equations with stress factors
Avoid overfeeding
Patients may need high calorie density feedings to achieve fluid balance
TUBERCULOSIS TB is making a comeback
Many patients are developing drug-resistant TB
Nutritional factors that increase risk of TB: Protein-energy malnutrition: affects the immune
system; debate whether it is a cause or consequence of the disease
Micronutrient deficiencies that affect immune function (vitamin D, A, C, iron, zinc)
Nutritional consequences: Increased energy expenditure Loss of appetite and body weight Increase in protein catabolism leading to muscle
breakdown Malabsorption causing diarrhea, loss of fluids,
electrolytes
MNT Energy: 35-40 kcals/kg of ideal body weight
Protein: 1.2-1.5 grams/kg body weight, or 15% of energy or 75-100 grams/day
Multivitamin-mineral supplement at 100-150% DRI
THANK YOU….Questions???
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