1. Medical Nutrition Therapy for Pulmonary Disease
Chapter 38
Medical Nutrition Therapy for Pulmonary Disease

2. Anatomy of the Pulmonary System

3. Normal Lung Anatomy

4. Selected Airway Disorders

5. Key Terms Pulmonary aspiration Asthma Bronchopulmonary dysplasia (BPD)
Chronic obstructive pulmonary disease (COPD)
Cystic fibrosis (CF)

6. Selected Pulmonary Conditions Having Nutritional Implications

7. Adverse Effects of Lung Disease on Nutritional Status

8. Impact 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 2

9. Impact 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 3

10. Bronchopulmonary Dysplasia
Definition: chronic lung disorder seen in early infancy and usually follows intensive therapy for respiratory difficulties in the neonatal period
Assessment
—Linear growth
—Dietary intake
—Gastroesophageal reflux
—Chronic hypoxia
—Emotional deprivation

11. Goals of Nutritional Care
Adequate nutrient intakes
Promote linear growth
Maintain fluid balance
Develop age-appropriate feeding skills

12. Cystic Fibrosis Inherited autosomal recessive
Epithelial cells and exocrine glands secrete abnormal mucus (thick)
Affects respiratory tract, sweat, salivary, intestine, pancreas, liver, reproductive tract

13. 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

14. Nutritional 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 6

15. Nutritional 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).

16. Nutritional Problems in Cystic Fibrosis
Pancreatic enzyme insufficiency
Malabsorption
—Decreased HCO3 secretion
—Decreased bile acid reabsorption (fat malabsorption)
—Excessive mucus

17. Symptoms of Cystic Fibrosis Malabsorption
Bulky, foul-smelling stools
Cramping
Obstruction
Rectal prolapse
Liver damage
Other problems
—Impaired glucose tolerance

18. Nutritional 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)

19. Nutrient 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

20. Medical 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)

21. Lung Transplantation
Prior to transplant, children with CF are typically at the 5th percentile for weight

22. 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 5

23. Components of Nutritional Assessment for Adults with Chronic Obstructive Pulmonary Disease

24. Nutritional Status
Nutritional requirements increased from maldigestion, malabsorption
Complications—SOB; coughing; GI distress; anorexia during infections; altered smell; retarded growth

25. Nutritional Requirements
Energy
—HB x AC x IF
— maintenance
— repletion
Macronutrient mix
—DO NOT OVERFEED!
—RQ = CO2/O2 CHO = 1, fat = , mixed diet = 0.87 7

26. Nutritional Requirements—cont’d
Omega-3 fatty acids
—May protect smokers from COPD
—May be antiinflammatory
Vitamin C supplement for smokers
—16-30 mg/d 8

27. Treatments Bronchodilators—theophylline and aminophylline
Antibiotics—secondary infections
Respiratory therapy
Exercise to strengthen muscles 9

28. Categories 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

29. Medical Nutrition Therapy
Monitor side effects of food-drug interactions
Aminoglycosides lower serum Mg++ —may need to replace
Prednisone—monitor nitrogen, Ca++, serum glucose, etc.

30. Cellular 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.

31. Oxidative Stress and Critical Illness
Mounting evidence exists that oxidative stress plays a pivotal role in critical illness.
Decreased antioxidant defenses

32. Respiratory Failure
There may be some benefit to offering antioxidant therapy to patients with respiratory failure.
Studies are ongoing 10

33. Respiratory Failure—cont’d
Patient usually on ventilator
Laboratory values indicating RF—ABGs
—PCO2 >50 mm Hg (35-45 mm Hg)
—PO2 <60 mm HG ( mm Hg)
—pH < ( )
—HCO3– (22-26 mEq/L)
—O2 saturation >95% 10

34. Respirator 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 11

35. Summary
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