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Pulmonary Medical History Form

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					Medical Nutrition Therapy
in Pulmonary Disease
Malnutrition and the
Pulmonary System
Malnutrition impairs
 Respiratory muscle function

 Ventilatory drive

 Response to hypoxia

 Pulmonary defense mechanisms
Effects of Malnutrition in
Pts without Lung Disease
    Respiratory muscle strength ↓ by 37%
    Maximum voluntary ventilation ↓ by
     41% (1)
    Vital capacity (lung volume)↓ 63% (1)
    Diaphragmatic muscle mass ↓ to 60%
     of normal in underweight patients who
     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 Pts
with Pulmonary Disease
   Decreased cough and inability to
    mobilize secretions
   Atelectasis and pneumonia
   Prolonged mechanical ventilation and
    difficulty weaning with prolonged ICU
    stay
Effects of Malnutrition in Pts
with Pulmonary Disease
   Altered host immune response and
    cell-mediated immunity
   Contributes to chronic or repeated
    pulmonary infections
   Decreased surfactant production
   Decreased lung elasticity
   Decreased ability to repair injured lung
    tissue
Normal Lung Anatomy
Selected Airway Disorders
Chronic Pulmonary
Disorders
 Bronchopulmonary displasia
 Cystic fibrosis

 Tuberculosis

 Bronchial asthma

 Chronic obstructive pulmonary
  disease (COPD)
Acute Pulmonary
Disorders
 Pulmonary aspiration
 Pneumonia

 Tuberculosis

 Cancer of the lung

 Acute respiratory distress
  syndrome
 Pulmonary failure
Pulmonary Conditions w/
Nutritional Implications
Neonate     Bronchopulmonary displasia
            (BPD)
Obstruction Cystic fibrosis (CF)
            Chronic obstructive pulmonary
            disease (COPD)
            Emphysema

            Chronic bronchitis

            Asthma

Tumor       Lung cancer
Pulmonary Conditions w/
Nutritional Implications
Infection     Pneumonia
              Tuberculosis (TB)

Respiratory   Acute respiratory failure
Failure       Lung transplantation

Neuro-        Muscular dystrophy
muscular      Paralysis
Abnormalities
Pulmonary Conditions w/
Nutritional Implications
Skeletal         Osteoporosis
                 Scoliosis

Cardiovascular   Pulmonary edema


Endocrine        Severe obesity
                 Prader-Willi syndrome
Adverse Effects of Lung
Disease on Nutritional Status
Increased energy expenditure
 Increased work of breathing

 Chronic infection

 Medical treatments (e.g.
  bronchodilators, chest physical therapy
Adverse Effects of Lung
Disease on Nutritional Status
Reduced intake
 Fluid restriction

 Shortness of breath

 Decreased oxygen saturation when
  eating
 Anorexia due to chronic disease

 Gastrointestinal distress and vomiting
Adverse Effects of Lung
Disease on Nutritional Status
Additional limitations
 Difficulty preparing food due to fatigue

 Lack of financial resources

 Impaired feeding skills (for infants and
  children)
 Altered metabolism
Chronic Lung Disease
Bronchopulmonary
Dysplasia: Pathophysiology
   Chronic lung condition in newborns
    that often follows respiratory distress
    syndrome (RDS) and treatment with
    oxygen
   Characterized by broncheolar
    metaplasia and interstitial fibrosis
   Occurs most frequently in infants who
    are premature or low birth weight
BPD: Signs and
Symptoms
   Hypercapnea (CO2 retention)
   Tachypnea
   Wheezing
   Dyspnea
   Recurrent respiratory infections
   Cor pulmonale (right ventricular
    enlargement of the heart)
Growth Failure in BPD

   Increased energy needs
   Inadequate dietary intake
   Gastroesophageal reflux
   Emotional deprivation
   Chronic hypoxia
Goals of Nutritional
Management in BPD
   Meet nutritional needs
   Promote linear growth
   Develop age-appropriate feeding skills
   Maintain fluid balance
Energy Needs in BPD

   REE in infants with BPD is 25-50% higher
    than in age-matched controls
   Babies with growth failure may have needs
    50% higher
   Energy needs in acute phase (PN, controlled
    temperature) 50-85 kcals/kg
   Energy needs in convalescence (oral feeds,
    activity, temperature regulation) as high as
    120-130 kcals/kg
Protein Needs in Babies
with BPD
   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
Macronutrient Mix in BPD

   Fat and carbohydrate should be added
    to formula only after it has been
    concentrated to 24 kcals/oz to keep
    protein high enough
   Fat provides EFA and energy when
    tolerance for fluid and carbohydrate is
    limited
   Excess CHO increases RQ and CO2
    output
Fluid in BPD

   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
Mineral Needs in BPD

   Often driven by the baby’s premature status
   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
Vitamin Needs in BPD

   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
    catchup growth
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
Feeding Strategies in
Gastroesophageal Reflux
   Thickened feedings (add rice cereal to
    formula)
   Upright positioning
   Medications like antacids or histamine
    H2 blockers
   Surgical fundoplication
Long Term Feeding
Problems in BPD
   History of unpleasant oral experiences
    (intubation, frequent suctioning, recurrent
    vomiting)
   History of non-oral feedings
   Delayed introduction of solids
   Discomfort or choking associated with
    eating solids
   Infants may tire easily while breast-feeding
    or bottle feeding
   May require intervention of interdisciplinary
    feeding team
Cystic Fibrosis

   Inherited autosomal recessive disorder
   2-5% of the white population are
    heterozygous
   CF incidence of 1:2500 live births
   30,000 people treated at CF centers in
    the U.S.
   Survival is improving; median age of
    patients has exceeded 30 years
Cystic Fibrosis
   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
Nutritional Implications
of CF
   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 of CF
   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)
Nutritional Care Goals
   Control malabsorption
   Provide adequate nutrients for
    growth
    or maintain weight for height or
    pulmonary function
   Prevent nutritional deficiencies
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
Pancreatic Enzyme
Replacement
Dosage depends on
 Degree of pancreatic insufficiency

 Quantity of food eaten

 Fat, protein, and carbohydrate content
  of food eaten
 Type of enzymes used
Pancreatic Enzyme
Replacement
   Enzyme dosage limited to 2500 lipase units
    per kilogram of body weight per meal
   Adjusted empirically to control
    gastrointestinal symptoms, including
    steatorrhea, and promote growth
   Fecal fat or nitrogen balance studies may
    help to evaluate the adequacy of enzyme
    supplementation
Distal Intestinal
Obstruction Syndrome
   AKA recurrent intestinal impaction
   Occurs in children and adults
   Prevention includes adequate
    enzymes, fluids, dietary fiber, and
    regular exercise
   Treatment involves stool softeners,
    laxatives, hyperosmolar enemas,
    intestinal lavage
Estimation of Energy
Needs in CF
   Use WHO equations to estimate BMR
   Multiply by activity coefficient +
    disease coefficient
   TEE – BMR X (AC + DC)
   Disease coefficient is based on lung
    function
Disease Coefficient in CF

   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


   FEV = forced expiratory volume
Example Equation TEE in
CF
   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
Calculate the Daily Energy
Requirement (DER)
   Takes into account steatorrhea
   Pancreatic sufficiency: TEE = DER
    – Pancreatic sufficiency is Coefficient of fat
      absorption >93% of intake
   Pancreatic insufficiency: DER = TEE
    (0.93/CFA)
    – CFA is a fraction of fat intake based on
      stool collections
Calculation of DER in CF

   72-hour fecal fat collections reveals
    that CFA is 78% of intake
   DER = TEE X (.93/CFA)
        = 2559 X (0.93/.78)
        = 2559 X 1.19
   DER = 3045 kcals/day
Protein in CF

   Protein needs are increased in CF due
    to malabsorption
   If energy needs are met, protein
    needs are usually met by following
    typical American diet (15-20% protein)
    or use RDA
Fat Intake in CF

   Fat intake 35-40% of calories, as tolerated
   Helps provide required energy, essential
    fatty acids and fat-soluble vitamins
   Limits volume of food needed to meet
    energy demands and improves palatability
    of the diet
   EFA deficiency sometimes occurs in CF
    patients despite intake and pancreatic
    enzymes
Symptoms of Fat
Intolerance
   Increased frequency of stools
   Greasy stools
   Abdominal cramping
Carbohydrate in CF

   Eventually intake may need to be
    modified if glucose intolerance
    develops
   Some patients develop lactose
    intolerance
Vitamins in CF

   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)
Minerals in CF

   Intake of minerals should meet DRI
    for age and sex
   Sodium requirements increased due to
    loss in sweat
    – North American diet usually provides
      enough
    – Infants need supplementation (1/4-1/2
      teaspoon/day)
Minerals in CF

   Decreased bone mineralization, low
    iron stores, and low magnesium levels
    have all been described in CF
Feeding Strategies in CF:
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 in CF:
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
Nutritional Implications
of 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
of TB
   Increased energy expenditure
   Loss of appetite and body weight
   Increase in protein catabolism leading
    to muscle breakdown
   Malabsorption causing diarrhea, loss of
    fluids, electrolytes
Nutritional Needs in TB

   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
Chronic Obstructive
Pulmonary Disease (COPD)
Characterized by airway obstruction
 Emphysema: abnormal, permanent
  enlargement of alveoli, accompanied by
  destruction of their walls without
  obvious fibrosis
 Chronic bronchitis: chronic, productive
  cough with inflammation of one or more
  of the bronchi and secondary changes in
  lung tissue
Chronic Obstructive
Pulmonary Disease (COPD)
   Emphysema: patients are thin, often
    cachectic; older, mild hypoxia, normal
    hematocrits
   Chronic bronchitis: of normal weight;
    often overweight; hypoxia; high
    hematocrit
Chronic Obstructive
Pulmonary Disease (COPD)
   Bronchospasm: asthma
   Cor pumonale: heart condition
    characterized by right ventricular
    enlargement and failure that results
    from resistance to passage of blood
    through the lungs
Chronic Bronchitis
Emphysema
Bronchial Asthma

   Food sensitivities may be triggers for
    asthmatic episodes (sulfites, shrimp,
    herbs) but not the most common
    causes
   Provide healthy diet and maintain
    healthy weight
   Be aware of drug nutrient interactions
    (steroids)
MNT Assessment in COPD

   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
MNT Assessment in COPD

   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
Nutrient Needs in Stable
COPD
   Protein: 1.2-1.7 grams/kg (15-20% of
    calories) to restore lung and muscle
    strength and promote immune function
   Fat: 30-45% of calories
   Carbohydrate: 40-55% of calories
   Maintain appropriate RQ
   Address other underlying diseases
    (diabetes, heart disease)
Nutrient Needs in Stable
COPD
   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
Treatments for COPD

   Bronchodilators—theophylline and
    aminophylline
   Antibiotics—secondary infections
   Respiratory therapy
   Exercise to strengthen muscles
MNT in COPD Based on
Weight/Height
   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
MNT in COPD

   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
MNT in COPD

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
MNT in COPD

   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.
MNT in Respiratory
Failure
Causes of Acute Lung
Injury (ALI)
   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
Aspiration

   Movement of food or fluid into the
    lungs
   Can result in pneumonia or even death
   Increased risk for infants, toddlers,
    older adults, persons with oral, upper
    gastrointestinal, neurologic, or
    muscular abnormalities
Aspiration

   Reported incidence of aspiration in tubefed
    patients varies from .8% to 95%. Clinically
    significant aspiration 1-4%
   Many aspiration events are ―silent‖ and
    often involve oropharyngeal secretions
   Symptoms include dyspnea, tachycardia,
    wheezing, rales, anxiety, agitation, cyanosis
   May lead to aspiration pneumonia
Acute Respiratory Distress
Syndrome (ARDS)
   Most severe form of acute lung injury
   Sepsis usually the underlying cause
   Increasing pulmonary capillary
    permeability
   Pulmonary edema
   Increased pulmonary vascular
    resistance
   Progressive hypoxemia
Goals of Treatment of ALI
and ARDS
   Improve oxygen delivery and provide
    hemodynamic support
   Reduce oxygen consumption
   Optimize gas exchange
   Individualize nutrition support
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
Nutrition Support in ARDS
   In one randomized, controlled trial in 146 patients
    with ARDS, enteral nutrition with omega-3 fatty
    acids (eicosapentaenoic acid) gamma-linonenic
    acid, and antioxidants appeared to reduce days on
    mechanical ventilation, new organ failure, and ICU
    length of stay
   This study was sponsored by Ross Laboratories,
    makers of Oxepa
   Have been unable to locate further studies since
    then
   Gadek JE et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic
    acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral
    Nutrition in ARDS Study Group. Crit Care Med 1999;27:1409.

				
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