Pulmonary Diseases Part I PDF

Diseases of the Respiratory System: Pulmonary Diseases PART - ONE Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible webs...

Diseases of the Respiratory System: Pulmonary Diseases PART - ONE Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Introduction Nutritional status and pulmonary function are interdependent Metabolic fuels such as carbohydrate, protein, and lipid are metabolized using oxygen and producing carbon dioxide Malnutrition can evolve from pulmonary disorders and contribute to declining pulmonary status Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Normal Anatomy and Physiology of the Respiratory System Pulmonary system divisions Upper (nose, nasal cavity, frontal and maxillary sinuses, larynx, and trachea.) and lower respiratory tract (lungs, bronchi, and alveoli). Right and left lungs Bronchi Alveoli Small air sacs Capillaries are responsible for the exchange of oxygen and carbon dioxide Alveolar epithelium consists of type 1 (participates in gas exchange) and type 2 cells (produce surfactant) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Figure 21.1: Anatomy of the Pulmonary System Source: R. Rhoades and R. Pflanzer, Human Physiology, 4e, copyright © 2003, p. 633. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Respiratory System: Gas Exchange Lungs allow the body to obtain oxygen for cellular metabolism Carbon dioxide is removed Lungs Synthesize surfactant Regulate body acid–base balance Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Figure 21.2: Gas Exchange between Alveoli and Capillaries Gas exchange occurs in the alveolar–capillary unit which, in the adult lung, covers approximately the area of a tennis court and contains more than 100 million capillaries Source: From the Merck Manual of Medical Information—Home Edition, edited by Robert S. Porter. Copyright 2006 by Merck & Co., Inc., Whitehouse Station, NJ. Available at: http://www.merck.com/mmhe. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Respiratory System: Surfactant Type 2 alveolar cells secrete surfactant Fluid that reduces surface tension of pulmonary fluids and contributes to elasticity of pulmonary tissue Surfactant is a mixture of lipids and proteins. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Respiratory System: Lungs Lungs protect against infection and toxins Inhaled particles are trapped by sticky mucus substance, which keeps the airway moist Cilia propel mucus and unwanted cells upward to be coughed out or swallowed cells that line the trachea, bronchi, and bronchioles possess tiny, hair-like structures called cilia (Figure 21.3) Alveoli cells engulf and destroy bacteria Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Figure 21.3: Mucociliary Transport System Source: R. Rhoades and R. Pflanzer, Human Physiology, 4e, copyright © 2003, p. 635. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Table 21.2: Normal Blood Gas Values Blood Gas Normal Values Partial pressure of oxygen (P a O2) ≥80 m m H g Partial pressure of carbon dioxide (P a C O2) 35–45 m m H g pH 7.35–7.45 Oxygen saturation (Sa O2) >95% Bicarbonate—(H C O3) 24–28 m E q/L Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition and Pulmonary Health: Malnutrition Malnutrition is associated with poor intake Reduces strength and endurance of respiratory muscles Causes reductions in lung parenchyma Continued malnutrition increases risk of infection may result from depressed immune function. Many studies: the role of dietary antioxidants such as vitamin C, vitamin E, beta-carotene, and selenium with healthy lung function. Antioxidants: protecting the lungs from oxidant injury as the result of the inflammatory process caused by the inhalation of cigarette smoke and other pollutants. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition and Pulmonary Health: Malnutrition… Cont’d It is recommended that people who smoke consume an additional 35 mg/day of vitamin C beyond the DRI. Smokers have been shown to have depleted levels of serum ascorbate, a-tocopherol, beta-carotene, and selenium. Respiratory disease often includes a variety of symptoms that may affect dietary intake, including early satiety, anorexia, weight loss, cough, and dyspnea during eating. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Asthma Definition Chronic airway inflammation leading to airflow obstruction (involving many cells and cellular elements, such as mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells). Primarily immunoglobulin E (Ig E) mediated Episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. Epidemiology 25 million individuals including 6 million children worldwide Third leading cause of hospitalization and chronic illness among children under 15 years of age Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Asthma: Etiology Allergic (most common) Triggered predominantly by inhaled indoor and outdoor allergens (such as dust mite allergen, pet dander, pollen, and mold.) Other risk factors: obesity, genetic, gender, ethnicity, tendency to develop allergies (atopy) Nonallergic Caused by anxiety, stress, exercise, cold air, dry air, hyperventilation, passive smoke, viruses, or other irritants Patients are at greater risk for life-threatening allergic reactions to foods Research indicates an association with obesity Obesity is associated with low level of inflammation. Insulin resistance and this impact asthma treatment Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Asthma: Pathophysiology Smooth muscle contraction of bronchi and bronchioles in respiratory tract. Inflamed and edematous mucosa Partially or totally obstructed airway due to mucus formation Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Asthma: Clinical Manifestations Initial symptoms Cough, dyspnea, and tight feeling in chest Signs Wheezing, increased respiratory rate, labored breathing, increased heart rate (tachycardia), and hypoxia Asthma may result in respiratory alkalosis If left untreated, it can progress to respiratory acidosis Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Asthma: Treatment Includes: Immediate dilation of the airway to improve oxygenation in cases of acute asthma Achieved with the use of bronchodilators Corticosteroids (systemic and inhaled) and leukotriene receptor antagonists for long-term asthma (chronic) Environmental trigger control Controlled breathing techniques Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Asthma: Nutrition Therapy Leukotrienes are chemical mediators produced by the body that contribute to the development of asthma. Leukotrienes, which are synthesized from arachidonic acid, modulate the inflammatory response resulting in tissue edema, mucus secretion, smooth-muscle proliferation, and powerful bronchoconstriction. Leukotriene agonists and inhibitors Leukotriene inhibitors that interfere with the actual synthesis of leukotrienes (Zyflo®), and leukotriene antagonists that block their action at the receptor level (Accolate® and Singulair®). Normally, human inflammatory cells contain high amounts of the omega-6 fatty acid, arachidonic acid, and low amounts of omega-3 fatty acids. Because both omega-6 and omega-3 fatty acids are metabolized by a common pathway, an excess of omega-3 fatty acids interferes with the metabolism of the omega-6 fatty acids and reduces their incorporation into tissue lipids. Increase omega-3 fatty acids that interfere with metabolism of omega-6 fatty acids. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Asthma: Nutrition Therapy…cont’d The Mediterranean dietary pattern emphasizes increased fruits, vegetables, and food sources higher in omega-3- fatty acids… reduced asthma prevalence. Identification of drug–nutrient interactions and providing interventions to counteract: Including dry mouth, throat irritation, nausea, vomiting, and diarrhea. Long-term use of corticosteroids has been associated with increased serum glucose levels and sodium retention. The short-term use of inhaled corticosteroids at conventional or usual doses (for 2–3 years) has not been associated with loss of bone mineral density (BMD) or fractures in adult patients with asthma or mild chronic obstructive pulmonary disease and actually may improve BMD by reducing the overall level of chronic inflammation Weight loss Encourage nutritionally adequate diet Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Bronchopulmonary Dysplasia (BPD) called chronic lung disease of prematurity Definition Chronic lung disease of prematurity characterized by pulmonary inflammation, impaired growth, and development of alveoli Etiology Complex and multifactorial (premature < 30 wks, surfactant deficiency,…etc) Genetic predisposition affects susceptibility to development Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  B P D: Treatment Mechanical ventilation Systemic and inhaled corticosteroids Medical interventions for BPD use combinations of bronchodilators and pulmonary vasodilators Antioxidants Physical therapy and occupational therapy to facilitate the development of gross and fine motor skills Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Figure 21.5: Infant Receiving Supplemental Oxygen Infants with immature lungs receive supplemental oxygen via a nasal cannula Source: iStock.com/garymilner. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition Therapy for BPD Nutrition assessment and diagnosis Weight gain trends, linear growth, head circumference, growth charts, and clinical laboratory values are used to measure nutrient intake Energy recommendations for preterm infants are 110– 130 k cal/k g/day Requirements may be higher Growth failure is due to decreased nutrient intake, increased requirements, hypoxemia, delayed skeletal mineralization, and osteopenia Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  B P D: Nutrition Intervention Energy and macronutrient needs 15–20% higher than healthy infants 120–150 k cal/k g/day or higher 3.5–4.5 g/k g of protein per day Vitamins and minerals Vitamin A 1500–2800 I U/k g per day Closely monitor electrolyte balance Sufficient minerals for bone growth Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Table 21.4 Nutritional Needs for Infants with Bronchopulmonary Dysplasia. Energy 120–150 kcal/kg/day May be 15%–25% higher than normal but follow closely for adjustments if weight is increasing without increase in linear growth Protein 3.5-4.5 g/kg/day Monitor linear growth Fluids 135-200 ml/kg/day May be restricted if fluid overload is present Electrolytes (sodium, potassium, Monitor and supplement when Diuretic therapy may increase and chloride) required urinary losses. Vitamin D Will need to supplement for 400-1000 IU/day breast-fed infants Calcium Monitor and supplement when Diuretic therapy may increase required urinary losses. Iron Monitor and supplement when 2-3 mg/kg/day required Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  BPD: Nutrition Intervention Continued May need fluid and sodium restriction Specialty infant formulas Breast milk preferred to reduce sepsis and necrotizing enterocolitis Use of human milk fortifiers added to breast milk to meet needs of premature infant Education and support to caregivers Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Chronic Obstructive Pulmonary Disease (COPD) Definition Progressive disease that limits airflow through inflammation of bronchial tubes (bronchitis) or destruction of alveoli (emphysema) Lower respiratory disease Table 21.5: Classifications of COPD by Severity Classification Description Spirometry Results GOLD 1 Mild F E V1 ≥ 80% predicted GOLD 2 Moderate 50% ≤ F E V1 < 80% predicted GOLD 3 Severe 30% ≤ F E V1 < 50% predicted GOLD 4 Very severe F E V1 < 30% predicted Note: F E V1, forced expiratory volume in 1 second; F V C, forced vital capacity. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  COPD: Epidemiology & Etiology Epidemiology Primary risk factor is smoking Other risk factors include: Air pollution, second-hand smoke, history of childhood infections, and occupational exposure to certain industrial pollutants Etiology Chronic bronchitis: one of the principal classifications of COPD Productive cough and shortness of breath for 3 months each year for 2 or more years Occur in all ages , more common > 45 yrs Emphysema Develops gradually over years. Characterized by inflammation causing oxidative stress In rare cases, deficiency of a protein called alpha 1-antitrypsin (ATT) is a cause A T T travels to the lungs to protect them from destructive actions of common illnesses and exposures, particularly tobacco smoke. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Chronic Bronchitis: Pathophysiology Generalized inflammatory response to cigarette smoke and other pollutants This includes: decreased cilia function, increased phagocytosis, and suppressed Ig A The walls of the airways thicken Hyperplastic mucus glands Inability to increase the work of breathing enough to overcome the signs and symptoms of the disease. Bacterial growth. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Chronic Bronchitis: Clinical Manifestations Decreased pulmonary function, dyspnea, hypoxemia, and hypercapnia (increase in carbon dioxide in the bloodstream) Cyanosis (blue-tinged mucous membranes and skin due to inadequate oxygen supply) Clubbing (changes in fingers and toes due to hypoxemia; fingers and toes show a curve at a tip of the nail with flattening surface) secondary polycythemia (an excessive number of red blood cells are produced; occurs in response to compensation for chronic hypoxemia) Figure 21.6 Quality of life diminishes with the progression of disease Malnutrition is common Requirement for supplemental oxygen Cor pulmonale (an increase in size of the right ventricle of the heart caused by resistance to the passage of blood through the lungs; can lead to heart failure) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Figure 21.6: Cyanosis Source: SPL/Science Source Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Emphysema: Pathophysiology Destruction of lung tissue (differentiates emphysema from chronic bronchitis) Loss of surface area Decreased surfactant Bronchioles collapse during exhalation Trapping of air in the lungs Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Emphysema: Clinical Manifestations Decreased FEV1 Dyspnea (shortness of breath) and orthopnea (difficulty breathing while lying down) Hypercapnia ( elevated carbon dioxide (CO2) levels in the blood) and respiratory acidosis Barrel chest (due to the use of accessory muscles for expiration) Extreme fatigue and exhaustion Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Emphysema: Treatment Lifestyle changes, smoking cessation, and avoidance of other pollutants Exercise as tolerated Good nutrition Pharmacologic treatment Bronchodilators (β- 2agonists) and steroids Pulmonary rehabilitation Program (Box 21.4) Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Table 21.6 Medications Used in Diseases of the Respiratory System Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition Therapy for COPD Nutrition assessment and diagnosis Malnutrition is common Complete nutrition assessment is required, including: Anthropometric measurements Food-/nutrition-related history Medication use Physical activity and functional status Pages: 657-658 Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Table 21.7 Nutrition Assessment for the Respiratory System Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition Therapy for COPD: Intervention Energy and nutrient needs 125–156% (average 140%) energy above Basal Energy Expenditure (BEE) 1.2–1.7 g/k g protein (average 1.2 g/kg) are adequate to avoid protein losses in patients admitted to the hospital with exacerbation of their COPD. When indirect calorimetry is not available, providing 25–30 kcal/kg of body weight appears appropriate with approximately 20% of total kcalories from protein (1.2–1.7 grams of protein/kg body weight), depending on the patient’s individual needs and with special attention to the degree of inflammation and activity Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Nutrition Therapy for COPD: Intervention Continued Food and/or nutrient delivery Foods that are good sources of both k cal and protein and are also nutrient dense Coordination of nutrition care: Physical exercise Exercise is an equally important component of treatment Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.  Table 21.8: Planning Nutrition Interventions for Individuals with COPD Interventions Recommendations Diet Composition Use patient preference to guide food suggestions; limited evidence supports a specific macronutrient mix but the Mediterranean diet pattern may guide food choices Medical Food Use a variety of high-calorie, high-protein supplements to Supplements increase overall nutritional intake. These can include modular supplements added to foods or liquid supplements as an addition to the regular diet Vitamin/Mineral Assess ability to meet nutritional needs from a variety of Supplements foods and then make recommendations for additional micronutrient supplementation. Specific attention should be given to calcium, vitamin D, and sources of antioxidants Marcia Nelms, Nutrition Therapy and Pathophysiology, 4th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.