NUTRITIONAL CARE IN

RESPIRATORY DISEASE

Haerani Rasyid
Department of Nutrition , Faculty of Medicine,
University of Hasanuddin Makassar
S. Sunatrio

S. Sunatrio

OBJECTIVES
UNDERSTAND NUTRITION AND
RESPIRATORY SYSTEM
UNDERSTAND NUTRITION AND
PULMONARY DISEASES
APPLY NUTRITIONAL CARE IN
PULMONARY DISEASES

S. Sunatrio

S. Sunatrio

Effects of malnutrition on
the respiratory system
The respiratory system can be
divided into 3 component
- A control mechanism located in
the central nervous system
- 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

Adverse Effects of Lung

Disease On Nutritional
status
Increased Energy Expenditure
Reduced Intake
Effect medication

S. Sunatrio

NS & PULMONARY
PATIENTS
Malnutrition & resp failure are integrally
linked
Malnutrition causes a loss of skletal muscle
mass and alteration in respiratory muscle
function
Critically ill pt with resp failure is
vulnerable to complication of under/overfeeding
A great deal of optimism surrounds the
development of immuno-enhancing nutrient

S. Sunatrio

EFFECT of MALNUTRITION
on THE RESP SYSTEM
Imbalance between synthesis
and breakdown of lung
surfactans
Alteration in intra alveolar
surface tension
Decrease in lung protein
synthesis
S. Sunatrio

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
Nutritional support reduced mortality
rate

S. Sunatrio

EFFECT of MALNUTRITION on
THE RESP SYSTEM (short term)
The entire muscle mass of the body
including 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 further
affect appetite, diet selection &
metabolism

S. Sunatrio

10

EFFECT of MALNUTRITION on THE

RESP SYSTEM (short term)
BW, diaphragmatic muscle mass ,
contractile strength , endurance , VC
ability to breath deeply, effectively
cough up secretion atelectasis &
pulmonary infection
Ventilatory drive, endurance, work of
breathingAcute Resp Failure
Resp muscle weakness & altered
ventilatory drive failure to wean from
ventilator
S. Sunatrio

11

EFFECT of MALNUTRITION on THE

RESP SYSTEM (long term)
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

12

Nutritional support of patients with

pulmonary disease
Perform a complete nutrition assessment
Evaluate Energy needs and provide an
appopriate 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

13

Effect of nutrient administration on

the respiratory system
CH, fat and protein each utilize
spesific quantity of oxygen and
produce a spesific quantity of CO2
during metabolism. If VCO2 is divided
by VO2, we obtain the RESPIRATORY
QUOTIENT ( RQ )
RQ CH = 1
RQ Fat = 0.7
RQ Protein = 0.8
S. Sunatrio

14

CONSIDERATIONS for NUTRITION

INTERVENTION (ARF)
In some pt: resp muscle account for
50% of total VO2
In pt with pulmonary dysfunction
resp distress inability to wean
from mech.V
Moderate malnutrition & resp
muscle weakness resp failure &
delay transition back to spont.
ventilation
S. Sunatrio

15

CONSIDERATIONS for
NUTRITION INTERVENTION
(COPD)

S. Sunatrio

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, immunocompromise & resp muscle wasting &
dysfunction the need for intubation &
mechanical ventilation
16

CONSIDERATIONS for
NUTRITION INTERVENTION
(ALI)

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

17

CONSIDERATIONS for
NUTRITION INTERVENTION
(ARDS)
Th/ goals: 1) improve DO & provide
2

hemodynamic support, 2) reduce VO2,

3) individualized NS & 4) optimize gas
exchange
NS is essential for weaning from
prolong mech. V
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

18

ESTIMATING ENERGY
EXPENDITURE in RESP
FAILURE
Conservative estimate of calorie
need for all critically ill pts:
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

NS in RESP FAILURE
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 procatabolism + inadequate nutritional intake

S. Sunatrio

20

NS in RESP FAILURE
Dextrose, PRO & fat CO2
Dextrose >> RQ
RQ > 1.0 VO2 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

21

Tabel : Alterations in components of the lungs caused by oxidative stress

Airway wall

contraction of airway smooth muscle

impairment of -adrenoceptor function
stimulation of airway secretion
pulmonary vascular smooth-muscle
relaxation or contraction

Antiproteases

activation of mast cells

inactivation of 1-proteinase inhibitor

Lung matrix

inactivation of secretory
leukoprotease inhibitor
elastin synthesis and fragmentation
collagen synthesis and
fragmentation

Pulmonary
microcirculation

Alveolar epithelial cell

layer

depolymerisation of proteoglycans
permeability
PMN sequestration
PMN adhesion to endothelium of
arterioles and venules
permeability by detachment,
adherence and cell lysis
Dekhuijzen PNR et al, Pnews

S. Sunatrio

22

CHO
Limit CHO calories to
35% to 45% of the
parenteral nutrition
prescription

S. Sunatrio

23

Counter regulatory hormone

Pro inflammatory cytokines
Acidosis
Loss of appetite
Inactivity

BREAKDOWN of BODY PRO STORES

S. Sunatrio

24

Immune dysfunction
Infections rates
Tissue repair
Wound healing
Skeletal muscle function

PRO
A 0.8 g of PRO/kg BW/d is
adequate for 95% of the
population consuming an
adequate energy intake
Pt with SIRS: 1.5 g of
PRO/kgBW/d
S. Sunatrio

25

Increase
d
protein
intake

S. Sunatrio

26

CO2
production
(effects
negligible)
Ventilatorydrive
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

FAT
Hypermetabolic pt : 30-40%
NP = fat to minimize
hyperglycemia
In pts with severe O2 debt 1gr/kg
Continuously 30-50 mg/kg/h
High fat formula may reduce
ventilatory requirement duration
of mechanical ventilation
S. Sunatrio

27

MICRONUTRIENT
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, Ca, Mg, Mn
S. Sunatrio

28

Role of antioxidants in the

prevention of lung injury

Toxic oxygen radicals damage

parenchymal and endothelial
cells
Endogenous antioxidant
system overwhelmed

also lead to impairment of

Oxidants
connective tissue repair, impaired
ciliary function, increased mucous
production

Supplemental vitamin E, vitamin C, carotene, taurine, selenium, molybdenum

may attenuate lung injury
S. Sunatrio

29

Early intervention as
part of initial care
Enteral nutrition
oral supplements
Tube feeding
Parenteral nutrition
Total ( TPN )
Perifer

S. Sunatrio

30

PARENTERAL
NUTRITION

ENTERAL
NUTRITION
FOOD
FORTIFICATION

ORAL
NUTRITIONAL
SUPPLEMENT

ENTERAL
NUTRITION
S. Sunatrio

31

TPN
Supplies partial or total nutrition through
venous access
Supllies practically all essential nutrients
Safe & effective medical therapy if
prescribed appropriately & monitored
closely
Indications parenteral nutrition : GI tract be
nonfunctional, impossible to use the GIT,
need for intestinal rest
Contraindication parentral nutrition :
Ability to adequately receive and absorb
necessary foods orally or by gastric or
enteral tube, hemodynamic instability
S. Sunatrio

32

Definition
Parenteral nutrition is partial or total nutrition
administered intravenously. A peripheral or central vein is
used for access.

S. Sunatrio

33

Indications:
Parenteral Nutrition

Non-functional gastrointestinal tract

Inability to use the gastrointestinal tract

intestinal obstruction
peritonitis
intractable vomiting
severe diarrhea
high-output enterocutaneous fistula
short bowel syndrome
severe malabsorption.

Need for bowel rest

Palliative use in terminal patients is controversial.
S. Sunatrio

34

ASPEN Board of Directors. JPEN 2002; 26 Suppl 1: 83SA

Contraindications:
Parenteral Nutrition

S. Sunatrio

35

Ability to consume and absorb adequate nutrients orally

or by enteral tube feeding
Hemodynamic instability

Formulas: Parenteral
Nutrition

S. Sunatrio

36

Central Parenteral Nutrition

Selection depends on caloric requirements, volume to be
administered and patient condition, as well as final
concentration of components:

Amino acids > 5%

Dextrose > 20%
Lipids
Includes vitamins, minerals, and trace elements
Osmolality > 700 mOsm/kg H2O
S. Sunatrio

37

Formulas: Parenteral
Nutrition
Dextrose

Provides 3.4 kcal/g

Can be the only source of energy
Dextrose infusion rate should not exceed 5 mg/kg/min
Closely related to solution osmolality

Hill GL, et al. Br J Surg 1984;71:1

S. Sunatrio

38

Formulas: Parenteral
Nutrition
Amino Acids

S. Sunatrio

39

Standard concentrations can vary between 5% and 15%

Energy value of amino acids (4 kcal/g)
Nitrogen (g) = protein (g) / 6.25

Sources of Protein:
Parenteral Nutrition

Customize this slide for your

situation. Indicate the available
parenteral protein solutions for
your country; i.e., standard and
specialized solutions

S. Sunatrio

40

Formulas: Parenteral
Nutrition
Lipids

S. Sunatrio

41

Prevent essential fatty acid deficiency

Non-protein source of kcal. Recommended dose
1 g/kg/day
Available in 10%, 20% and 30% concentrations
Included as LCT or a mix of MCT/LCT at 10% and 20%
Added to basic parenteral nutrition solutions or
administered individually

Trimbo SL, et al. Nutr Supp Serv 1986;6:18

Formulas: Parenteral
Nutrition
Lipids

Less hyperglycemia
Lower concentrations of serum insulin
Less risk of hepatic damage
High doses can interfere with immune functions
High infusion rates can affect respiratory functions
Should be used with care in:
Hyperlipidemia
Symptomatic atherosclerosis
Acute pancreatitis with hypertriglyceridemia

S. Sunatrio

42

Formulas: Parenteral
Nutrition
Electrolytes

Calcium, magnesium, phosphorus, chloride, potassium,

sodium, and acetate
Forms and amounts are titrated based on metabolic
status and fluid/electrolyte balance
Must consider calcium-phosphate solubility

Alpers DH, et al., eds. In: Manual of Nutritional Therapeutics. Little, Brown and Company; 1995
S. Sunatrio

43

Formulas: Parenteral
Nutrition
Vitamins and Minerals

S. Sunatrio

44

In general, amounts below daily recommended intake

for healthy people, but nonetheless sufficient to cover
requirements, are added to oral or enteral formulas
Added daily to parenteral nutrition
Acute illness, infection, preexisting malnutrition, and
excessive fluid loss increase vitamin requirements

Formulas: Parenteral
Nutrition
Trace Elements

S. Sunatrio

45

Include daily zinc, copper, chromium, and manganese

for patients with kidney or liver failure
Different requirements dictated by patient and pathology
Patients under extended parenteral nutrition require the
addition of iron and selenium

Peripheral Parenteral
Nutrition
Selection of peripheral access depends on clinical situation,
requirements, tolerance to volume, and final formula
concentration

Osmolality < 700 mOsm/kg

Total kcal limited by concentration and ratio to

volume being administered

Include of the recommended electrolytes for PN
Torosian MH, ed. In: Nutrition for the Hospitalized Patient. Marcel Dekker Inc.; 1995
S. Sunatrio

46

PN: Types of Infusion

S. Sunatrio

47

Continuous Total volume of formula is administered

over a 24 hour period
Cyclic Volume is administered in one period, with
infusion adjustments and a period of rest
Selection of infusion type depends on patients condition
Use a parenteral infusion pump

Monitoring Patient on
Parenteral Nutrition

S. Sunatrio

Metabolic

Assessment

Glucose
Fluid and electrolyte balance
Renal and hepatic function
Triglycerides and cholesterol

Body weight
Nitrogen balance
Plasma protein
Creatinine/height
index

Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics.
Yale University Press, 1992
48

DISADVANTAGES of TPN
Impairs the basic immunologic
system
Altering GALT cell population
Decreasing intestinal & resp IgA
levels
Impairs established IgA mediated
upper respiratory tract immunity
S. Sunatrio

49

2% GLUTAMINE SUPPLEMENT
in an ISOCALORIC,
ISONITROGENOUS TPN
Glutamine enriched TPN may
offer benefits in maintaining
GALT function & mucosal
immunity

S. Sunatrio

50

DISADVANTAGES of TPN
Catheter related infection
Mechanical, metabolic
complication

S. Sunatrio

51

Recommendation for
nutritional support in
pulmonary disease

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

52

 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 parentral formula must be
administered carefully, in a continuos 24
hour infusion. The dose should not exceed 1
gram/kg/day

S. Sunatrio

53

COPD

S. Sunatrio

54

Contributing factors
leading
to weight loss in
COPD
Ingestion of insufficient calories1
Hypermetabolic state (increased
resting energy expenditure)2
Loss of appetite1
Malabsorption1

S. Sunatrio

55

Ventilatory Concerns in
COPD
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 PaCO 2
levels and increase oxygenation (PaO 2)
Overfeeding and high carbohydrate diets
can increase PaCO2

S. Sunatrio

56

Nutritional Considerations for

COPD
Decrease CHO consumption to
minimize respiratory quotient (RQ)
Fullfill energy requirements without
overfeeding (increases CO 2
production)
Avoid excessive protein intake
Monitor fluid requirements

S. Sunatrio

57

Influence of diet composition on

respiratory status in COPD
patients
Pulmonary insufficiency
Decreased caloric intake;
Increased caloric requirement

MALNUTRITION
High CHO diet

Continued erosion of tissues, resulting in:

Impaired respiratory function
hypoxic ventilatory response
resistance to infection
Deteriorated lung function

CO2 production;
RQ

CO2 retention RESPIRATORY

FAILURE

Improved nutritional
status; Reduced CO2
production and
retention
S. Sunatrio

58

High fat diet

High CHO diet

Inability to excrete
CO2

Increased CO2
production and
retention

Components Of Nutritional
Assessment for Adults With
Chronic Obstructive Pulmonary
Disease
Historycal Parameters

S. Sunatrio

59

Medical Parameters
Nutritional Parameters
Diet history
Environmental Parameters

Historycal Parameters
Medical history
Nutritional history
Usual weight

S. Sunatrio

60

Medical Parameters

S. Sunatrio

61

Respiratory status
Oxygen saturation
Dental status
Senses of smell and taste
Gastrointestinal function

Nutritional Parameters

S. Sunatrio

62

Weight
Height
Skinfold measuresments
Hemoglobin and hematocrit
Serum electrolytes
Serum proteins
Additional biohemical tests as
needed(e.g.immunologic testing,
creatinine height index, nitrogen balance

Diet history

S. Sunatrio

63

Usual home diet

Use of supplements
Where meals are eaten
Social companionship with
meals

Environmental Parameters
Home facilities
Physical abilities
Financial resources

S. Sunatrio

64

Benefits of nutritional repletion in

COPD
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
1
S. Sunatrio

65

Irwin and Openbrier 1985; 2Larca and Greenbaum 1982

FLOWCHART : NUTRITIONAL SCREENING AND THERAPY

SCREENING
SCREENING

BMI<21 kg/m2

21<BMI<25 kg/m2

25<BMI,30 kg/m2

weight
Weight loss

FFMI<16/15 kg/m2

Fat free mass

TREATMENT
TREATMENT
FOLLOW-UP
FOLLOW-UP

MAINTENANCE
MAINTENANCE
TREATMENT
TREATMENT
Dietary habits
Dietary
habits

exercise
exercise

Weight stable

Weight loss

FFMI>16/15 kg/m2

NUTRITIONALTHERAPY
THERAPY
NUTRITIONAL

responder

SUPPLEMENTAL
SUPPLEMENTAL
NUTRITION
NUTRITION
oralsupplement
supplement
oral

Weight stable

FOLLOW-UP
FOLLOW-UP

Non-responder

ANABOLIC
ANABOLIC
STIMULATION
STIMULATION
Dietary habits
Dietary
habits

exercise
- type
exercise - type
- duration
- duration
- intensity
- intensity

SUPPLEMENTAL
SUPPLEMENTAL
NUTRITION
NUTRITION
oral supplmental
oral
supplmental

enteral
nutrition
enteral nutrition

COMPLIANCE
COMPLIANCE
IMPROVEMENT
IMPROVEMENT

Flowchart of nutriional screening and therapy. BMI, body mass index; FFMI, fat-free mass index

S. Sunatrio

66

Schols AMWJ, Wouters

EFMPulmonary Rehabilitation

S. Sunatrio

67