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PULMONARY
DISORDER
C L E O N A R A YA N U A R D I N I , S . G Z . , M . S C . , R D
PULMONARY SYSTEM
• The electrical impulses generated by the
respiratory center are carried by the phrenic
nerves to the diaphragm and other
respiratory muscles.
• Contraction of diaphragm and other muscles
increases the intrathoracic volume, which
creates negative intrathoracic pressure and
allows air to be sucked in.
• The air traverses through upper and lower
airways (see Figure 34-1, A) and reaches
alveoli (see Figure 34-1, B).
• The alveoli are surrounded by capillaries
where gas exchange takes place (see Figure
34-1, C).
• The large pulmonary blood vessels and the
conducting airways are located in a
welldefined connective tissue compartment—
the pleural cavity.
PULMONARY SYSTEM
• The airways have 12 types of epithelial cells,
• The primary function of the respiratory system and most cells that line the trachea, bronchi,
is gas exchange. The lungs enable the body and bronchioles have cilia move the
to obtain the oxygen needed to meet its superficial liquid lining layer from deep within
cellular metabolic demands and to remove the lungs, toward the pharynx to enter the
the carbon dioxide (CO2) produced. gastrointestinal tract, thereby playing an
important role as a lung defense mechanism by
Healthy nerves, blood, and lymph are needed clearing bacteria and other foreign bodies.
to supply oxygen and nutrients to all tissues.
• The epithelial surface of the alveoli contains
• The lungs also filter, warm, and humidify macrophages. By the process of phagocytosis,
inspired air these alveolar macrophages engulf inhaled inert
materials and microorganisms and digest them.
• The lungs are an important part of the
• The alveolar cells also secrete surfactant, a
body’s immune defense system, because compound synthesized from proteins and
inspired air is laden with particles and phospholipids that maintains the stability of
microorganisms. Mucus keeps the airways pulmonary tissue by reducing the surface
moist and traps the particles and tension of fluids that coat the lung.
microorganisms from inspired air.
EFFECT OF MALNUTRITION ON THE PULMONARY SYSTEM
• Malnutrition adversely affects lung structure, elasticity, and function; respiratory muscle mass,
strength, and endurance; lung immune defense mechanisms; and control of breathing.
• Protein and iron deficiencies result in low hemoglobin levels that diminish the oxygen-carrying
capacity of the blood.
• Low levels of calcium, magnesium, phosphorus, and potassium compromise respiratory muscle
function at the cellular level.
• Hypoalbuminemia, contributes to the development of pulmonary edema by decreasing colloid
osmotic pressure, allowing body fluids to move into the interstitial space. Decreased levels of
surfactant contribute to the collapse of alveoli, thereby increasing the work of breathing.
• The supporting connective tissue of the lungs is composed of collagen, which requires ascorbic
acid for its synthesis.
• Normal airway mucus is a substance consisting of water, glycoproteins, and electrolytes,and
thus requires adequate nutritional intake.
EFFECTS OF LUNG
DISEASE ON
NUTRITION STATUS
• Pulmonary disease substantially increases
energy requirements.
• This factor explains the rationale for including
body composition and weight parameters in
nutrition assessment.
• Weight loss from inadequate energy intake is
significantly correlated with a poor prognosis
in persons with pulmonary diseases.
• Malnutrition leading to impaired immunity
places any patient at high risk for developing
respiratory infections.
• Malnourished patients with pulmonary disease
who are hospitalized are likely to have lengthy
stays and are susceptible to increased
morbidity and mortality.
LUNG CANCER
• The primary sites of lung cancer are usually the bronchi, with subsequent metastasis to other
organs
• Lung cancer associated with persistent tobacco smoking for many years, inhaled pollutants may
initiate malignant condition.
• Routine chest radiograph in an asymptomatic smoker.
• Medical treatment: radiation therapy, chemotherapy, surgery
• Smoking cessation most wellness programs and offer ideal settings for nutrition education
SIGN SYMPTOM
• Dyspnea is the most burdensome cancer symptom, and occurs in 15% to 55% of lung cancer
patients at diagnosis. In addition to the tumor, other factors contribute to the symptom of dyspnea
– factors such as pericardial effusion, anemia, fatigue, depression, anxiety, metastatic involvement of
other organs, aspiration, anorexia-cachexia syndrome, and pleural effusion.
• Progressive weight loss with changes in body composition. Malnutrition impairs the contractility
of the respiratory muscles, affecting endurance and respiratory mechanics. weight loss is associated
with increasing mortality, and weight loss of even 5% indicates a poor prognosis.
• Cough is present in 50% to 75% of lung cancer patients at presentation and occurs most
frequently in squamous cell and small cell carcinoma because of their tendency to involve central
airways (Huhmann and Camporeale, 2012).
• Pain and fatigue are common symptoms associated with lung cancer. The tumor may produce
pleuritic pain because of tumor extension into the pleura, or musculoskeletal type pain because of
extension into the chest wall
• Pulmonary cachexia syndrome affects patients with advanced lung disease and is defined by a
BMI of less than 20 or a weight less than 90% of IBW (Bellini, 2013).
CONSEQUENCES OF
MALNUTRITION
• Patient quality of life (QoL) is an
extremely important outcome
measure for cancer patients, their
carers and families.
• How patients feel, physically and
emotionally, whilst living with cancer
can have an enormous effect on their
recovery, ability to carry out normal
daily functions, as well as their
interpersonal relationships and ability
to work.
The National Comprehensive Cancer Network (NCCN) guidelines include
nutritional assessments, medications, and nonpharmacologic approaches to
achieve the following:
1.Treat the reversible causes of anorexia such as early satiety
2. Evaluate the rate and severity of weight loss
3. Treat the symptoms interfering with food intake: nausea and vomiting, dyspnea,
mucositis, constipation, and pain
4. Assess the use of appetite stimulants like megestrol acetate and Decadron
(corticosteroids)
5. Provide nutritional support (enteral or parenteral)
(Del Ferraro et al, 2012)
MNT FOR LUNG CANCER
Accepted components of oral nutrition therapy • Increase consumption of fruits and
arethe following: vegetables may beneficial
• Providing foods and beverages and
1. Small frequent meals that are high in fat and nutritional supplements in the forms
protein and low in carbohydrate and at the times best tolerated by
2. Provision of adequate calories that meet or the patients is essential
exceed the resting energy expenditure (REE) • Administering oral medications with
calorically dense nutritional
3. Rest before meals supplements is another means of
4. Meals that require minimal preparation supplying needed nutrients
• EFA ingestion of alfa linolenic and linoleic • Elevate the head of the patient’s bed to 45 degrees
acids protective effects against pneumonia • Use prokinetic agents
• Minimize use of sedatives
• Optimize oral hygiene
• Use naloxone to improve gut motility (Allen et al,
2013)
RESPIRATORY FAILURE
Goals:
• meet basic nutritional requirements
• preserve lean body mass
• restore respiratory muscle mass and strength,
• maintain fluid balance
• Improve resistance to infection
• Facilitate weaning from oxygen support and mechanical ventilation by providing energy
subtrate without exceeding the capacity of the respiratory systems to clear CO2
Methods: depend on underlying disease (acutely/chronically ill), ventilator support is necessary
Energy
• Elevated due to hyper-catabolism and hyper-metabolism, sufficient energy must be supplied to prevent the use
of the body’s own reserves of protein and fat
• Energy requirements fluctuate and thus are best determined by continuous individual assessment
Protein
• 1.5-2 g/kg dry BW
• Enterally supplied protein does affect the RQ
• Depletion of protein and vital minerals such as calcium, magnesium, potassium, and phosphorus
contribute to respiratory muscle function impairment.
• In severe malnutrition inadequate electrolyte repletion during aggressive nutrition repletion can
lead to severe metabolic consequences related to refeeding syndrome
MACRONUTRIENTS
• In stable COPD, requirements for water, protein, fat, and carbohydrate are determined by the
underlying lung disease, oxygen therapy, medications, weight status, and any acute fluid fluctuations.
• Attention to the metabolic side effects of malnutrition and the role of individual amino acids is
necessary.
• Determination of a specific patient’s macronutrient needs is made on an individual basis, with close
monitoring of outcomes
• A balanced ratio of protein (15% to 20% of calories) with fat (30% to 45% of calories) and
carbohydrate (40% to 55% of calories) is important to preserve a satisfactory respiratory
quotient (RQ) from substrate metabolism use
• Repletion but not overfeeding is particularly critical in patients with compromised ability to exchange
gases as excess feeding of calories results in CO2 that must be expelled.
• Other concurrent disease processes such as cardiovascular or renal disease, cancer, or diabetes
affect the total amounts, ratios, and kinds of protein, fat, and carbohydrate prescribed.
ENERGY
• Meeting energy needs can be difficult.
• For patients participating in pulmonary rehabilitation programs, energy
requirements depend on the intensity and frequency of exercise therapy and can
be increased or decreased.
• Energy balance and nitrogen balance are intertwined. Consequently, maintaining
optimal energy balance is essential to preserving visceral and somatic proteins.
• Caloric needs may vary significantly from one person to the next and even in the
same individual over time
FAT
• Vitamin and mineral requirements for individuals • Depending on bone mineral density test results,
with stable COPD depend on the underlying coupled with food intake history and
pathologic conditions of the lung, other glucocorticoid medications use, additional
concurrent diseases, medical treatments, weight vitamins D and K also may be necessary
status, and bone mineral density. • Patients with cor pulmonale and subsequent fluid
• For people continuing to smoke tobacco, retention require sodium and fluid restriction.
additional vitamin C is necessary Depending on the diuretics prescribed, increased
• The role of minerals such as magnesium and potassium supplementation may be required. And
calcium in muscle contraction and relaxation may other water soluble vitamins, particularly thiamin,
be important for people with COPD. may need to be supplemented.
• Malnutrition is common in patients with • Malnutrition increases the risk of infection and
pulmonary TB, and nutritional supplementation is early progression of infection to produce active
necessary. TB.
• Markers of protein nutritional status are low • In the long term, malnutrition increases the risk
levels of the inflammatory proteins, of reactivation of the TB disease.
anthropometric indices, and the micronutrient • Malnutrition also can lower the effectiveness of
status of TB patients (Miyata et al, 2013). the anti-TB drug regime, which patients have to
• TB leads to or worsens any preexisting condition be on for several months.
of malnutrition and increases catabolism. • The efficacy of Bacillus Calmette-Guerin (BCG)
• Active TB is associated with weight loss, cachexia, vaccine can also be impaired by malnutrition.
and low serum concentration of leptin.
Energy Protein
• Current energy recommendations are • Protein is vital in preventing muscle tissue
those for undernourished and catabolic wastage and an intake of 15% of energy
patients, 35 to 40 kcal/kg of ideal body needs or 1.2 to 1.5 g/kg ideal body weight,
weight. approximately 75 to 100 g per day, is
• For patients with any concomitant recommended.
infections such as HIV, energy
requirements increase by 20% to 30% to
maintain body weight.
Vitamins and Minerals • Isoniazid is an antagonist of vitamin B6
• provides 50% to 150% of the RDA is helpful (pyridoxine) and is frequently used in TB
treatment nutritional depletion of vitamin
• Nutrients such as vitamin A, the B vitamins, B6 peripheral neuropathy
vitamins C and E, zinc, and selenium are
usually deficient in TB • Iron deficiency anemia is the most important
contributor in the development of anemia in
• Vitamin D deficiencies are common with TB TB patients (Isanaka et al, 2012). Evidence
and result because of an insufficient vitamin indicates that excess iron supplementation
D intake and limited exposure to may be dangerous to TB patients, and the
sunlightatients use of iron therapy is not universally
recommended. However, if iron studies show
iron deficiency, iron therapy is then initiated