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S. Sunatrio 1
Department of Nutrition , Faculty of Medicine,University of Hasanuddin Makassar
Andi FaradilahHaerani Rasyid
S. Sunatrio 2
UNDERSTAND NUTRITION AND RESPIRATORY SYSTEM
UNDERSTAND NUTRITION AND PULMONARY DISEASES
APPLY NUTRITIONAL CARE IN PULMONARY DISEASES
S. Sunatrio 3
S. Sunatrio 4
The respiratory system can be divided into 3 component :
- A control mechanism located in CNS
- A pump made up of respiratory muscles - A gas exchange organ : lung
Malnutrition affect all of these components and produce profound changes in respiratory homeostasis
S. Sunatrio 5
Imbalance between synthesis and breakdown of lung surfactants
Alteration in intra alveolar surface tension
Decrease in lung protein synthesis
The muscle of resp is subject to the catabolic effect of malnutrition
Malnutrition is an adaptive mechanism to decrease VO2 & work of breathing
Medications & co-morbidities appetite, diet selection & metabolism
S. Sunatrio 6
BW, diaphragmatic
muscle mass ,
contractile strength ,
endurance , VC
ability to breath
deeply, effectively
cough up secretion
atelectasis & pulmonary
infection
Ventilatory drive,
endurance, work of
breathing
Acute Resp Failure
Resp muscle weakness &
altered ventilatory drive
failure to wean from
ventilator
S. Sunatrio 7
Altered host immune response chronic or repeated pulmonary infection
Diminished cell mediated immunity
Alteration in immunoglobulin turnover, surfactant prod , ability for repair following injury
Chronic fatigue & hypoxia work & activity restrictions negative impact on overall quality of life
S. Sunatrio 8
Increased Energy Expenditure
Reduced Intake Effect medication
S. Sunatrio 9
CH, fat and protein each utilize specific quantity of oxygen and produce a specific quantity of CO2 during metabolism. If VCO2 is divided by VO2, we obtain the
RESPIRATORY QUOTIENT ( RQ )
RQ = VC02 / V02
◦ RQ CH = 1◦ RQ Fat = 0.7◦ RQ Protein = 0.8
S. Sunatrio 10
Ingestion of insufficient calories1
Hypermetabolic state (increased resting energy expenditure)2
Loss of appetite1
Malabsorption1
S. Sunatrio 11
VISCOUS CIRCLE BETWEEN IMPAIRMENT AND MALNUTRITION IN COPD:
COPD
Difficulty consuming food
Increased metabolic rate
Chronic inadequate intake
Impaired aerobic capacity
Malnutrition
worsening
Increased caloric needs
Decreased muscle strength
worsening
( Kwiatkowski, et al. 1999)
S. Sunatrio 12
COPD patients are unable to regulate blood concentrations of O2 and CO2
Respiratory failure is confirmed when PaCO2>50 mm Hg and/or when PaO2<50 mm Hg
Treatment goals are to decrease PaCO2 levels and increase oxygenation (PaO2)
Overfeeding and high carbohydrate diets can increase PaCO2
S. Sunatrio 13
Decrease CHO consumption to minimize respiratory quotient (RQ)
Fullfill energy requirements without overfeeding (increases CO2 production)
Avoid excessive protein intake (in some cases)
Monitor fluid requirements
S. Sunatrio 14
In clinically stable COPD patients, optimal efficacy of ONS is best achieved not by manipulating macronutrient composition
but by giving EN in small frequent doses thereby avoiding complications & improving compliance composition
S. Sunatrio 15
Any metabolic stress, including nutrient adm, will augment CO2 prod act as a ventilatory stress to pt with impaired resp function
Immune-enhancing diets : modulate the dysfunctional inflammatory response by preventing the severe delayed immuno-suppresion
S. Sunatrio 16
Th/ goals: 1) improve VO2 & provide hemodynamic support,2) reduce VCO2
3) individualized NS 4) optimize gas exchange
NS is essential weaning from prolong mechanical ventilator
The role of omega 3 the immune syst by competing with arachidonic acid for cyclo-oxygenase metabolism
Omega 3 minimized the reaction of T cells to inflammatory process
S. Sunatrio 17
ACUTE RESP FAILURE (ARF) In pt with pulmonary dysfunction resp distress inability
to wean from mech.Ventilator Moderate malnutrition & resp muscle weakness resp
failure & delay transition back to spont. ventilation
S. Sunatrio 18
Conservative estimate of calorie need for all critically ill :REE = 25 – 30 kcal/kg/d
Harris –Benedict equation x stress factor of 1.2 – 2.0
Greater severity of illness: indirect calorimetry
S. Sunatrio 19
Dextrose, PRO & fat CO2
Dextrose >> RQ RQ > 1.0 VCO2 work of breathing
Metabolic stress, nutrient adm CO2 : ventilatory stress to pt with impaired pulmonary function
Nutrient intake must be monitored closely Adjust the proportion of NPC as fat & CHO
S. Sunatrio 20
Nutrition care during acute illness◦ Supply adequate
energy and protein
◦ Fluid restrictions may be necessary to reverse pulmonary edema
◦ Enteral nutrition is preferred over parenteral nutrition
Energy◦ Harris-Benedict
equation
Fluids◦ Watch for
dehydration
◦ Edema may make it difficult to assess accurate weight
S. Sunatrio 21
Nutrition support◦Nutrient-dense
formula – if on fluid restriction
◦ Pulmonary formulas – less carbohydrate and more fat
◦Parenteral nutrition if risk of aspiration too high to continue enteral feedings
© 2006 Thomson-Wadsworth
S. Sunatrio 22
S. Sunatrio 23
• Counter regulatory hormone• Pro inflammatory cytokines• Acidosis• Loss of appetite• Inactivity
BREAKDOWN of BODY PRO STORES
• Immune dysfunction• Infections rates• Tissue repair • Wound healing • Skeletal muscle function
S. Sunatrio 24
Increase
d protein intake
CO2 production (effects negligible)
Ventilatory-drive mechanism
Minute ventilation
-
Beneficial for patients
able to respond to stimulus
Can increase work of
breathing and dyspnea in
patients unable to increase minute
ventilation
Askanazi et al. 1984
S. Sunatrio 25
K, Ca, PO4, Mg should be provided in adequate amounts to meet muscle requirements & maintain optimal respiratory muscle force
Vit A, C & E favorable impact on immune defenses.
Fe, Zn, Cu, Mn
S. Sunatrio 26
Toxic oxygen radicals damage parenchymal and endothelial
cells
Supplemental vitamin E, vitamin C, Supplemental vitamin E, vitamin C, --carotene, taurine, selenium, molybdenum carotene, taurine, selenium, molybdenum
may attenuate lung injurymay attenuate lung injury
Endogenous antioxidant system overwhelmed
Oxidants also lead to impairment of connective tissue repair, impaired ciliary function, increased mucous
production
S. Sunatrio 27
Perform a complete nutrition assessment
Evaluate Energy needs (appropriate amount do not overfeeding or underfeed)
Ensure protein balance
Monitor fluids and electrolyte, especially phosphorus
Evaluate vitamin, mineral status as indicated Consider high fat, low CH feeding in patients
with persistent hypercapnia
S. Sunatrio 28
FLOWCHART : NUTRITIONAL SCREENING AND THERAPY
SCREENINGSCREENING
weight
Fat free mass
TREATMENTTREATMENT
FOLLOW-UPFOLLOW-UP
MAINTENANCE TREATMENT• Dietary habits• exercise
MAINTENANCE TREATMENT• Dietary habits• exercise
SUPPLEMENTAL NUTRITION• oral supplement
SUPPLEMENTAL NUTRITION• oral supplement
ANABOLIC STIMULATION• Dietary habits• exercise - type
- duration- intensity
ANABOLIC STIMULATION• Dietary habits• exercise - type
- duration- intensity
SUPPLEMENTAL NUTRITION• oral supplmental• enteral nutrition
SUPPLEMENTAL NUTRITION• oral supplmental• enteral nutrition
COMPLIANCE IMPROVEMENT
COMPLIANCE IMPROVEMENT
BMI<21 kg/m2
NUTRITIONAL THERAPYNUTRITIONAL THERAPY
responder Non-responder
FOLLOW-UPFOLLOW-UP
21<BMI<25 kg/m2 25<BMI,30 kg/m2
Weight loss Weight lossWeight stable Weight stable
FFMI<16/15 kg/m2 FFMI>16/15 kg/m2
Flowchart of nutritional screening and therapy. BMI, body mass index; FFMI, fat-free mass index
Schols AMWJ, Wouters EFMPulmonary Rehabilitation 2000 : 247-59
S. Sunatrio 29
S. Sunatrio 30
S. Sunatrio 31
Ingestion of insufficient calories1
Hypermetabolic state (increased resting energy expenditure)2
Loss of appetite1
Malabsorption1
S. Sunatrio 32
Multifactorial including tissue hypoxia, ageing, physical exercise, increased resting metabolic rate, chronic inflammatory processes drugs,
S. Sunatrio 33
COPD patients are unable to regulate blood concentrations of O2 and CO2
Respiratory failure is confirmed when PaCO2>50 mm Hg and/or when PaO2<50 mm Hg
Treatment goals are to decrease PaCO2 levels and increase oxygenation (PaO2)
Overfeeding and high carbohydrate diets can increase PaCO2
S. Sunatrio 34
Decrease CHO consumption to minimize respiratory quotient (RQ)
Fullfill energy requirements without overfeeding (increases CO2 production)
Avoid excessive protein intake (in some cases)
Monitor fluid requirements
S. Sunatrio 35
In clinically stable COPD patients, optimal efficacy of ONS is best achieved not by manipulating macronutrient composition
but by giving EN in small frequent doses thereby avoiding complications & improving compliance composition
S. Sunatrio 36
High CHO dietContinued erosion of tissues, resulting in:Impaired respiratory function hypoxic ventilatory response resistance to infection Deteriorated lung function
Pulmonary insufficiency
Decreased caloric intake; Increased caloric requirement
MALNUTRITION
CO2 production; RQ
Inability to excrete CO2
CO2 retention RESPIRATORY FAILURE
High fat dietImproved nutritional status; Reduced CO2 production and retention
High CHO dietIncreased CO2 production and retention
S. Sunatrio 37
FLOWCHART : NUTRITIONAL SCREENING AND THERAPY
SCREENINGSCREENING
weight
Fat free mass
TREATMENTTREATMENT
FOLLOW-UPFOLLOW-UP
MAINTENANCE TREATMENT• Dietary habits• exercise
MAINTENANCE TREATMENT• Dietary habits• exercise
SUPPLEMENTAL NUTRITION• oral supplement
SUPPLEMENTAL NUTRITION• oral supplement
ANABOLIC STIMULATION• Dietary habits• exercise - type
- duration- intensity
ANABOLIC STIMULATION• Dietary habits• exercise - type
- duration- intensity
SUPPLEMENTAL NUTRITION• oral supplmental• enteral nutrition
SUPPLEMENTAL NUTRITION• oral supplmental• enteral nutrition
COMPLIANCE IMPROVEMENT
COMPLIANCE IMPROVEMENT
BMI<21 kg/m2
NUTRITIONAL THERAPYNUTRITIONAL THERAPY
responder Non-responder
FOLLOW-UPFOLLOW-UP
21<BMI<25 kg/m2 25<BMI,30 kg/m2
Weight loss Weight lossWeight stable Weight stable
FFMI<16/15 kg/m2 FFMI>16/15 kg/m2
Flowchart of nutriional screening and therapy. BMI, body mass index; FFMI, fat-free mass index
Schols AMWJ, Wouters EFMPulmonary Rehabilitation 2000 : 247-59
S. Sunatrio 38
S. Sunatrio 39
Malnutrition & resp failure are integrally linked
Malnutrition causes a loss of skeletal muscle mass and alteration in respiratory muscle function
Critically ill pt with resp failure is vulnerable to complication of under/over-feeding
A great deal of optimism surrounds the development of immuno-enhancing nutrient
S. Sunatrio 40
BODY WEIGHT LOSS IN CHRONIC PULMONARY DISEASE
• Adaptive Mechanism to reduce O2 consumption
• Body weight loss and underweight are poor prognostic, but not close related with the degree of lung function impairment
• 5% of ABW within 3 months or 10% within 6 months) is found in 25–40% of all cases when lung function is severely impaired (FEV1o50%)
• Nutritional support reduced mortality rate
S. Sunatrio 41
Malnutrition in outpts : 25%, inpts : 50%, critically ill pt in ICU : 60%
Nutritional depletion has been attributed to anorexia & hypermetabolism as a result of work of breathing
Inadequate intake of pro-cal primary lung parenchymal disease, immuno-compromise & resp muscle wasting & dysfunction the need for intubation & mechanical ventilation
S. Sunatrio 42
Th/ goals: 1) improve VO2 & provide hemodynamic support,2) reduce VCO2
3) individualized NS 4) optimize gas exchange
NS is essential for weaning from prolong mech. Ventilator The role of omega 3 to aid the immune syst by competing
with arachidonic acid for cyclo-oxygenase metabolism Omega 3 minimized the reaction of T cells to inflammatory
process
S. Sunatrio 43
Should be simple & follow basic concepts utilized for other critically ill pts
Earlier nutrient adm is beneficial (esp pt with malnutrition & severe stress)
The hypermetabolism muscle wasting that may be aggravated by bedrest, sedation & neuromuscular blockade. Prolonged ventilator support further deconditioning
Malnutrition can occur rapidly due to pro-catabolism + inadequate nutritional intake
S. Sunatrio 44
Airway wall contraction of airway smooth muscleimpairment of -adrenoceptor functionstimulation of airway secretionpulmonary vascular smooth-muscle relaxation or contractionactivation of mast cells
Antiproteases inactivation of 1-proteinase inhibitor
inactivation of secretory leukoprotease inhibitor
Lung matrix elastin synthesis ↓ and fragmentationcollagen synthesis ↓ and fragmentationdepolymerisation of proteoglycans
Pulmonary microcirculation
↑ permeabilityPMN sequestration↑ PMN adhesion to endothelium of arterioles and venules
Alveolar epithelial cell layer
↑ permeability by detachment, ↓ adherence and ↑ cell lysis
Tabel : Alterations in components of the lungs caused by oxidative stress
Dekhuijzen PNR et al, Pnews 1998 ; 1 : 3-5
S. Sunatrio 45
Pt with acute pulmonary failure must be given nutrition support to satisfy energy requirements and limit progressive wasting of respiratory muscle
Malnourished pt with COPD can benefit from nutrition support because it produces an increase in respiratory muscle strenght
In the case pt with lung disease who are bordering upon developing respiratory failure, nutrient intake must be monitored carefully to avoid an over production of CO2 which can trigger respiratory failure. Non protein calorie distributing can be adjusted, reducing CHO and increasing fat, which will decrease CO2 production
S. Sunatrio 46
Pt with respiratory failure are on mechanical ventilator should receive nutritional support from the first day of intubation, providing sufficient calorie to cover total energy expenditure
Administration of mineral such as sodium, potassium, calsium and particularly phosphorous and magnesium should be carefully monitored to maintain good muscle function
For pt with severe ooxigenation disorders, lipid in parenteral formula must be administered carefully, in a continuos 24 hour infusion. The dose should not exceed 1 gram/kg/day
S. Sunatrio 47
Improved respiratory function◦ Increase in weight/lean muscle mass1
◦ Increase in inspiratory and expiratory pressures1
◦ Associated with successful weaning from mechanical ventilation2
Improved quality of life◦ Reduced frequency, duration, and intensity of
pulmonary-related hospitalization2
1Irwin and Openbrier 1985; 2Larca and Greenbaum 1982
S. Sunatrio 48
Historical Parameters Medical Parameters Nutritional Parameters Diet history Environmental Parameters
S. Sunatrio 49
S. Sunatrio 50
S. Sunatrio 51
Home facilities Physical abilities Financial resources