Medical Nutrition Therapy for Pulmonary Disease PDF

Medical Nutrition Therapy for Pulmonary Disease Based on Krause’s Food and the Nutrition Care Process Chapter 33 FNES 366 Medical Nutrition Therapy Allison Charny, MSEd, RDN, CDCES, CDN Anatomy of the Pulmonary System 2 Gas Exchange in the Pulmonary Syst...

Medical Nutrition Therapy for Pulmonary Disease Based on Krause’s Food and the Nutrition Care Process Chapter 33 FNES 366 Medical Nutrition Therapy Allison Charny, MSEd, RDN, CDCES, CDN Anatomy of the Pulmonary System 2 Gas Exchange in the Pulmonary System 3 Nutrition and Lung Immune Defense Mechanisms 4  Alveolar Macrophages and Systemic Immune Response 5  Functions of the Lungs  Acid-base balance  Synthesis of arachidonic acid  ACE conversion of Angiotensin I to Angiotensin II Copyright © 2017 by Elsevier Inc. All rights reserved. 6 Nutrition and the Pulmonary System  Effect of malnutrition on the pulmonary system Adversely affects: Lung structure, elasticity, and function Respiratory muscle mass, strength, and endurance Lung immune defense mechanisms Control of breathing  Effect of pulmonary disease on nutritional status Substantially increases energy requirements Weight loss is significantly correlated with a poor prognosis Complications of pulmonary diseases or their treatments can make adequate food intake and digestion difficult 7 Selected Pulmonary Conditions with Nutritional Implications Category Examples Neonatal Bronchopulmonary dysplasia Chronic lung disease of prematurity Obstructive Cystic fibrosis Chronic obstructive pulmonary disease Emphysema Chronic bronchitis Asthma Aspiration (foreign body, food, fluid) Tumor Lung cancer Infection Pneumonia Tuberculosis 8  Selected Pulmonary Conditions with Nutritional Implications (Cont.) Category Examples Primary Tuberculosis Bronchial asthma Lung cancer Secondary Associated with: Cardiovascular disease Obesity Sickle cell disease Acute Aspiration pneumonia Airway obstruction Allergic anaphylaxis Chronic Cystic fibrosis (CF) Chronic obstructive pulmonary disease (COPD) 9  Adverse Effects of Lung Disease on Nutritional Status Increased Energy Expenditure Increased work of breathing Chronic infection Medical treatments (e.g., bronchodilators, chest physical therapy) Reduced Intake Fluid restriction Shortness of breath Decreased oxygen saturation when eating Anorexia resulting from chronic disease Gastrointestinal distress and vomiting Additional Limitations Difficulty preparing food because of fatigue Lack of financial resources Impaired feeding skills (for infants and children) Altered metabolism Food-drug interaction 10  Cystic Fibrosis  Inherited autosomal recessive disorder causes impaired transport of chloride, sodium, and bicarbonate  Epithelial cells and exocrine glands secrete abnormal mucus (thick)  Affects respiratory tract, sweat, intestine, pancreas, liver, reproductive tract  Neonatal screening provides opportunity to prevent malnutrition in CF infants  “Classic” presentation (sweat Cl > 60 mmol/L) 11  Pathophysiology of Cystic Fibrosis  Pulmonary and sinus disease  Pancreatic disease Pancreatic insufficiency Pancreatitis CF-related diabetes  Bone disease Inadequate Ca, Mg, vit D, K Poor intake, malabsorption, corticosteroids  Other conditions Biliary disease, infertility, musculoskeletal disorders, SIBO (small intestine bacterial overgrowth) 12  Medical Management of Cystic Fibrosis  Multidisciplinary management of respiratory and gastrointestinal systems  Pharmaceutical intervention Ivacaftor – restores fxn of gene mutation Treatment for recurrent chest infections Pancreatic enzyme replacement therapy (PERT)  Intestinal abnormalities Malabsorption  Hepatobiliary problems  Glucose regulation 13  Medical Nutrition Therapy in Cystic Fibrosis  Calories Individualize based on BMI (%IBW not used)  Fat-soluble vitamins and salt Deficiencies of fat-soluble vitamins A, D, E, and K Excessive sodium loss in perspiration  Enzyme therapy Individualize according to degree of pancreatic insufficiency and food consumed  Overnight enteral pump feedings are often required 14 15  Asthma  Complex interaction between environmental exposures and genetics  Inflammation and swelling  Smooth muscle tightening that results in smaller airways  Characterized by airflow obstruction  Allergic and nonallergic  Corticosteroids commonly prescribed 16  Medical Management for Asthma  Routine monitoring of symptoms and lung function  Patient education  Control of environmental triggers  Pharmacotherapy 17  Medical Nutrition Therapy for Asthma  Address dietary triggers Gastroesophageal reflux disease (GERD) Food allergens i.e. sulfites  Correct energy and nutrient deficiencies and excesses Educate on personalized diet with optimal levels of nutrients Monitor growth in children Monitor food-drug interactions i.e. steroids High BMI associated with increase in asthma Anti-inflammatory diet (antioxidants, omega 3 FA) 18 Chronic Obstructive Pulmonary Disease (COPD)  Obstruction of airways  Two types Emphysema: destruction of lung parenchyma with lack of elastic recoil Chronic bronchitis: productive cough with inflammation of bronchi and other lung changes  Most often caused by tobacco smoking, sometimes also environmental air pollution, genetic factors  Often causes dyspnea, hypoxemia, cor pulmonale (right ventricular enlargement and failure of the heart), pulmonary hypertension 19  Medical Management of COPD  Assess and monitor disease  Reduce risk factors Smoking, air pollution, occupational smoke, dust  Manage stable COPD: bronchodilators, steroids, oxygen  Manage complications: respiratory failure due to pneumonia, CHF, narcotic sedatives  Treatment: pulmonary rehabilitation programs, oxygen therapy, medications (bronchodilators, glucocorticosteroids, mucolytic agents, antibiotics), surgery, mechanical ventilation 20 Nutritional Assessment for Adults with COPD Historical Medical history Nutritional history Usual weight Medical Respiratory status Oxygen saturation Dental status Senses of smell and taste Gastrointestinal function 21 Nutritional Assessment for Adults with COPD (Cont.) Nutritional Weight, Height Skinfold measurements NFPE; criteria for malnutrition / pulmonary cachexia Hemoglobin and hematocrit values Serum electrolytes Serum proteins Additional biochemical tests as needed (e.g., immunologic testing, creatinine height index, nitrogen balance) 22  MNT for COPD  Energy Malnutrition a common problem in COPD Determine individual needs; adequate w/o overfeeding.  Macronutrients 1.2 to 1.5 g/kg protein Protein 15% to 20% kcal, fat 30% to 45% kcal, carbohydrate 40% to 55% kcal for satisfactory RQ (CO2 expired / O2 consumed) (Be aware of above guideline however not noted in text as RQ is now considered to have limited clinical usefulness) Replete but do not overfeed 23  MNT for COPD (Cont.)  Vitamins and minerals - Individualize Vitamin C (smoking) Magnesium and calcium (muscle contraction) Vits D and K (steroids) Sodium and fluid 30-35 ml/kg (cor pulmonale) Potassium (diuretics) Iron deficiency anemia is seen in 10% to 30% of patients  Feeding strategies Individualize, interdisciplinary team May need enteral feedings 24  Pulmonary Hypertension*  High BP in pulmonary circulation leading to progressive SOB, hypoxia and enlarged rt ventricle.  5 Categories of PH (WHO), based on underlying causes of PH  Medical Management – based on underlying cause  MNT - No evidence-based guidelines; individualize based on underlying cause i.e. causes that require sodium, fluid restriction; increased or decreased intake 25 * No recorded lecture; no significant MNT  Parenchymal Lung Disease PLD*  AKA Interstitial Lung Disease ILD. Primary or secondary to other condition. Progressive SOB, hypoxia  Idiopathic. Associated with progressive lung scarring.  Risks: smoking, exposure to metals, organic dusts, GERD.  Medical Management: Chronic: Antifibrotics Acute: ICU for oxygen tx; lung transplant  MNT: No evidence-based guidelines. Individualize based on nutrition abnormalities * No recorded lecture; no significant MNT 26  Tuberculosis  Multidrug-resistant TB on the rise  May have high energy and fluid needs  TB drugs commonly have food-nutrient interactions and timing concerns Give isoniazid (INH) 1 hour before or 2 hours after meals (food decreases absorption) Isoniazid depletes pyridoxine and interferes with vitamin D metabolism, which can decrease absorption of calcium and phosphorus 27  Lung Cancer  Detection (x-ray) often in asymptomatic patients  Cough, dyspnea common symptoms  Pulmonary cachexia syndrome (BMI45 mm Hg Alveolar hypoventilation related to obesity: OSA, ↑ work of breathing, ↓ resp muscle, ↓ ventilation Obstructive sleep apnea (OSA) Medical management: CPAP MNT: Weight management 10-13% wt loss - ↓ apnea / hypopnea 29  Pleural Effusion*  Accumulation of fluid in the pleural space  Due to CHF, liver, kidney diseases, infection, cancer, autoimmunue disease  Medical management: fluid drainage; treatment of symptoms  MNT: No evidence-based guidelines. Treat based on underlying disorder i.e. CHF; associated malnutrition * No recorded lecture; no significant MNT 30  Chylothorax  Pleural effusion caused by the disruption or obstruction of the thoracic duct Surgical trauma, sarcoidosis, idiopathic  Leakage of chyle (lymphatic fluid of intestinal origin) into the pleural space  Very high (110 mg/dl) pleural triglyceride levels  MNT: long-chain fatty acid restricted diet, and medium-chain triglyceride (MCT) supplements 31  Acute Respiratory Distress Syndrome (ARDS)  Diffuse alveolar damage, severe hypoxia, and respiratory failure  Commonly caused by sepsis, trauma, aspiration, infectious pneumonia  Malnutrition common with mechanical ventilation  High risk of complications due to underfeeding or overfeeding 32  Aspiration  Movement of food or fluid into lungs  Can cause pneumonia or even death  Proper positioning when eating  High risk: infants, toddlers, and older adults; persons with oral, upper GI, neurologic, or muscular abnormalities  Most easily aspirated: liquids, foods with a round shape (nuts, popcorn, hot dog pieces), chunks of inadequately chewed foods (meat or raw vegetables)  Enteral tube feedings 33  Pneumonia  Commonly infectious or aspiration  Ventilator associated pneumonia (VAP)  Result is inflamed alveoli and fluid accumulation  Watch for conditions that predispose a patient to pneumonia  TF to duodenum 34  Covid – 19 (Not in Krause Text)  Coronovirus: A term for many virus that cause mild colds, with some severe  This virus is actually SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)  COVID-19 is the illness caused by SARS- CoV-2 (ie HIV gives you AIDS)  In severe cases, it leads to acute respiratory distress syndrome (ARDS). 35  Covid - 19  Obesity is a major risk factor for poor outcome - not seen as much in China  Various onsets - 1. Fast onset like flu 2. Mild symptoms 3. Severe respiratory failure Admitted to ICU and intubated Guidelines for nutrition support for critically ill with ARDS / respiratory failure. 36