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???