7: Pulmonary Disease

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Questions and Answers

What dietary consideration is particularly crucial for COPD patients to avoid re-feeding syndrome?

Ensure adequate fluid intake

Monitor levels of phosphorus, potassium, and magnesium (correct)

Increase calcium intake

Monitor levels of Vitamin D

What is the preferred head of bed (HOB) position for patients receiving enteral feeding?

60 degrees

45 degrees (correct)

30 degrees

Flat position

Which of the following is NOT a common sign of re-feeding syndrome?

Hypokalemia

Hyperglycemia

Dehydration (correct)

Hypophosphatemia

What is the recommended fluid intake for a patient over 60 years old?

30ml/kg Signup and view all the answers

Which factor may necessitate dietary modifications in a COPD patient?

Poor financial resources Signup and view all the answers

What is the prevalence rate of malnutrition in COPD patients?

30-60% Signup and view all the answers

Which factor is NOT associated with inadequate oral intake in COPD patients?

Increased physical activity Signup and view all the answers

What is a consequence of malnutrition specifically related to pulmonary physiology?

Surfactant deficit Signup and view all the answers

What additional energy requirement is seen in COPD patients due to the work of breathing?

Tenfold increase compared to normal breathing Signup and view all the answers

What complication may result from malnutrition and is more likely in ventilated COPD patients?

Difficulty weaning off the ventilator Signup and view all the answers

What effect does malnutrition have on individuals with COPD in terms of mortality?

Lower exercise capacity and higher mortality Signup and view all the answers

Which of the following describes cor pulmonale as it relates to COPD?

Fluid retention due to right-sided heart failure Signup and view all the answers

Which of the following is a sign of impairment in immunocompetence due to malnutrition in COPD patients?

Decreased levels of IgA Signup and view all the answers

What is the normal range for partial pressure of CO2 (PCO2) in mm Hg?

35-45 Signup and view all the answers

Which condition indicates that pH and PaCO2 change in opposite directions?

Respiratory disorders Signup and view all the answers

What is the normal value range for bicarbonate (HCO3) in mEq/L?

21-28 Signup and view all the answers

In metabolic acidosis, what is the primary problem related to HCO3?

Decrease in HCO3 Signup and view all the answers

What does O2 saturation reflect in arterial blood gas analysis?

The percentage of hemoglobin saturated with O2 Signup and view all the answers

In which condition do pH and PaCO2 change in the same direction?

Metabolic acidosis Signup and view all the answers

What is the normal value range for PaO2 in mmHg?

80-100 Signup and view all the answers

In metabolic alkalosis, what happens to PaCO2 levels?

Increases Signup and view all the answers

What is a common complication of underfeeding in patients with ARDS?

Immunosuppression Signup and view all the answers

Which symptom is primarily associated with chronic bronchitis in COPD?

Excess mucous production Signup and view all the answers

Which of the following is NOT a complication of overfeeding in ARDS?

Nosocomial infections Signup and view all the answers

What is the primary cause of airflow obstruction in COPD?

Smoking Signup and view all the answers

Patients with which type of COPD are more likely to experience cachexia and dyspnea?

Emphysema Signup and view all the answers

Which condition is a risk factor for immunosuppression in the context of ARDS?

Underfeeding Signup and view all the answers

What is a significant factor correlated with energy intake in COPD patients?

Dyspnea Signup and view all the answers

Which of the following statements about COPD is correct?

COPD is the third most common cause of death worldwide. Signup and view all the answers

What is a potential consequence of long-term use of glucocorticosteroids?

Osteoporosis Signup and view all the answers

When should antibiotics be administered in the context of respiratory failure management?

When bacterial infection is suspected Signup and view all the answers

What is the primary goal of nutritional management therapy (MNT) in patients with respiratory failure?

To achieve adequate intake to prevent loss of lean body mass Signup and view all the answers

How many meals per day are recommended for patients to help maintain their nutritional status?

5-6 small frequent meals Signup and view all the answers

What should be considered when determining protein requirements for patients undergoing nutritional management?

Increased needs with malnutrition/muscle wasting Signup and view all the answers

What is an appropriate calorie intake recommendation for patients on mechanical ventilation?

25-30 kcals/kg Signup and view all the answers

Which of the following strategies is beneficial for optimizing nutrient intake at mealtimes?

Limit fluid intake at mealtime Signup and view all the answers

When should enteral nutrition be initiated for patients with respiratory issues?

When oral intake is insufficient and GI function is adequate Signup and view all the answers

Study Notes

Acute Respiratory Distress Syndrome (ARDS)

ARDS is characterized by inflammation of the lungs and fluid build-up in the alveoli, leading to reduced oxygen exchange. This potentially life-threatening condition can be a complication of various illnesses.
Overfeeding and underfeeding in ARDS both have associated complications.
- Overfeeding
  - Nosocomial infections
  - Hypercapnia
  - Immunosuppression
  - Failure in weaning from mechanical ventilation
  - Stress hyperglycemia
  - Poor wound healing
  - Electrolyte imbalance
  - Azotemia
- Underfeeding
  - Nosocomial infections
  - Immunosuppression
  - Depressed respiratory muscle strength
  - Failure in weaning from mechanical ventilation
  - Low ventilatory drive

Chronic Obstructive Pulmonary Disease (COPD)

The third most common cause of death worldwide.
COPD involves chronic inflammation and narrowing of the airways, leading to airflow obstruction.
There are two main conditions contributing to COPD:
- Chronic bronchitis: Inflammation of the bronchial tubes, accompanied by excessive mucus production, chronic cough, difficulty breathing. It can lead to cardiac enlargement and failure.
- Emphysema: Abnormal, permanent enlargement and destruction of the alveoli, resulting in chronic mild cough and nutritional depletion.
These conditions can co-exist in varying degrees. Individuals with primarily emphysema experience greater dyspnea and cachexia, while those with bronchitis are prone to hypoxia, hypercapnia, pulmonary hypertension, and right heart failure.
Causes of COPD:
- Primary cause: Smoking (cigarettes, pipes, cigars)
- Environmental factors: Second-hand smoke, air pollution, chemical fumes, dust.
- Rarely: Gene-environment interactions, such as alpha-1 antitrypsin deficiency combined with exposure to smoke or other lung irritants.
COPD is irreversible, so it is vital to prevent the disease through smoking cessation and environmental protection.
Patients with COPD are at increased risk for nutritional depletion due to:
- Dyspnea (shortness of breath) significantly correlated with energy intake making consuming sufficient calories a challenge.
- Increased work of breathing elevates energy requirements.
- Frequent acute exacerbations worsen chronic inflammation and increase nutritional needs.
COPD exacerbations are more common in malnourished individuals, which leads to shorter survival times.
Malnutrition prevalence in COPD patients is 30-60%. The factors contributing to it include:
- Inadequate oral intake:
  - Low appetite
  - Increased breathlessness while eating
  - Difficulty shopping and preparing meals
  - Dry mouth
  - Altered taste perceptions
  - Early satiety
  - Fatigue
- Increased metabolic rate: Necessary for the body to function despite the challenges of COPD.
- Extra energy required for the work of breathing: Breathing is significantly more energy-intensive for individuals with COPD.
- Frequent and recurrent respiratory infections: These can further strain energy stores and reduce appetite.
Ventilated COPD patients are more susceptible to malnutrition and may find it difficult to wean off the ventilator.
The effects of malnutrition on pulmonary physiology are detrimental:
- Muscle compromise: Affecting the diaphragm, intercostal muscles, accessory muscles, impacting breathing ability.
- Impaired immunocompetence: Decreased IgA levels, cell-mediated immunity, epithelial integrity, and T/B cell dysfunction, making the individual more vulnerable to infections.
- Surfactant deficit: Surfactant is essential for lung function and preventing atelectasis (collapsed lung). Malnutrition can lead to a decrease in surfactant production.
Individuals with COPD and low body weight have compromised pulmonary status, reduced exercise capacity, and a higher mortality rate than those adequately nourished.
Malnutrition can lead to cor pulmonale: Increased blood pressure in the pulmonary arteries leads to enlargement of the right ventricle and right-sided heart failure, causing fluid retention and masking weight loss through "weight gain" from fluid retention.

Arterial Blood Gas Analysis

Arterial blood gas analysis is crucial for assessing respiratory and metabolic status in individuals with COPD and ARDS.
It measures various parameters to evaluate oxygen levels, carbon dioxide levels, and the pH balance in the blood, reflecting pulmonary function and acid-base balance.
Key parameters and their importance:
- PCO2: The partial pressure of carbon dioxide; A direct indicator of pulmonary function and the effectiveness of mechanical ventilation. Normal values are 35-45 mm Hg.
- HCO3: Bicarbonate levels; Reflects renal regulation of acid-base balance and reacts more slowly than pulmonary mechanisms. Normal values are 21-28 mEq/L.
- PO2: Partial pressure of oxygen; An indirect measure of arterial oxygen content and the effectiveness of oxygen transfer from the lungs into the blood. Normal values are 80-100 mmHg.
- O2 saturation: The percentage of hemoglobin saturated with oxygen. Normal values for adults 95-100%, for elderly individuals 95%.
In respiratory disorders, pH and PaCO2 move in opposite directions. For example, in respiratory acidosis, pH decreases, and PaCO2 increases.
In metabolic disorders, pH and PaCO2 move in the same direction. For example, in metabolic acidosis, both pH and PaCO2 decrease.
Compensation mechanisms:
- Metabolic acidosis: Decreased pH, low HCO3- levels, and decreased PaCO2.
- Metabolic alkalosis: Elevated pH, high HCO3 levels, and increased PaCO2.
- Respiratory acidosis: Low pH, elevated PaCO2, and increased HCO3-.
- Respiratory alkalosis: High pH, low PaCO2, and decreased HCO3-.

Management of Respiratory Failure

Supportive measures are essential:
- Oxygen supplementation (nasal): Providing additional oxygen to ensure adequate oxygenation.
- Non-invasive ventilation:
  - Bilevel positive airway pressure (BiPap): Provides both inspiratory and expiratory pressure support.
  - Continuous positive airway pressure (CPAP): Provides constant pressure during both inspiration and expiration.
Invasive (mechanical) ventilation:
- Continuous mechanical ventilation: Provides constant support throughout the breathing cycle.
- Intermittent mandatory ventilation: Delivers breaths at a set rate, supplementing the patient's own respiratory efforts

Nutritional Management (MNT)

Goals of MNT: Adequate nutrient intake to prevent loss of lean body mass (LBM) and support overall recovery.
General principles:
- Small, more frequent meals (5-6 times per day) to ensure adequate energy intake.
- Consumption of the main meal when energy levels are highest, typically in the morning.
- Provision of sufficient calories and protein:
  - Determine individual needs.
  - Protein: 1.2-1.5 g/kg (potentially higher in cases of malnutrition or muscle wasting).
  - Calories: Use indirect calorimetry as the gold standard or use 25-35 kcal/kg. For patients on mechanical ventilation, aim for 25-30 kcal/kg or use a predictive formula.
- Availability of foods that require less preparation and can be heated easily.
- Eating slowly and having periods of rest before mealtimes to promote both physical and mental comfort.
- Use of oral supplements between meals to optimize total nutrient intake.
- Limiting fluids at mealtimes; fluids between meals can aid in increasing the ability to consume nutrient-dense foods.
Enteral nutrition:
- Initiation may be necessary when oral intake is insufficient for a prolonged period and the patient has adequate gastrointestinal function.
- Standard polymeric enteral formula (1 kcal/cc) is often used.
- Aspiration precautions are essential: Monitor head position, ensure the head of the bed is at least 30 degrees (45 is preferable).
Re-feeding syndrome: COPD patients are vulnerable to this condition, which is characterized by a rapid decline in serum phosphorus, potassium, and magnesium levels.
- Monitor closely for signs and symptoms.
- Typically occurs within 3 days of starting feeding.
- Other signs include: Hyperglycemia, hyperinsulinemia, interstitial fluid retention, cardiac decompensation, and arrest.
Hypercaloric feeding: May increase CO2 production, leading to hypercapnia, so avoid overfeeding while weaning from mechanical ventilation.
Additional considerations in MNT:
- Adequate fluids: 35 ml/kg for 18-60 year olds, 30 ml/kg for >60 year olds; Individualize based on fluid status. Restrict fluids and sodium in patients with cor pulmonale to prevent fluid buildup.
- Vitamins and minerals: Individualize, Vitamin C supplements for smokers. Assess calcium and vitamin D levels, particularly with poor oral intake to manage osteoporosis.
- Medication side effects: Consider possible side effects of medications on nutrient intake and absorption.
- Individualize feeding strategies: Collaborate with the interdisciplinary team, involving dietitians, nurses, respiratory therapists, and physicians.
- Factors affecting intake: Consider difficulties in food prep, fatigue, financial limitations, etc.

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Description

This quiz covers the key concepts of Acute Respiratory Distress Syndrome (ARDS) and Chronic Obstructive Pulmonary Disease (COPD). It explores the implications of overfeeding and underfeeding in ARDS, as well as the seriousness of COPD as a leading cause of death. Test your understanding of these critical respiratory conditions and their management.