medical nutrition therapy for pulmonary disease chapter 38
TRANSCRIPT
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
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Normal Lung AnatomyNormal Lung Anatomy
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Selected Airway DisordersSelected Airway Disorders
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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)
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Selected Pulmonary Conditions Having Nutritional ImplicationsSelected Pulmonary Conditions Having Nutritional Implications
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Adverse Effects of Lung Disease on Nutritional StatusAdverse Effects of Lung Disease on Nutritional Status
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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
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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
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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
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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
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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
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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
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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
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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).
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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
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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
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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)
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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
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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)
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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
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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
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Components of Nutritional Assessment for Adults with Chronic Obstructive Pulmonary DiseaseComponents of Nutritional Assessment for Adults with Chronic Obstructive Pulmonary Disease
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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
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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
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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
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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
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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
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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.
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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.
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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
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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
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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%
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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
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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