MNT FOR PULMONARY

DISEASES PART 1

CLEONARA YANUAR DINI, M.Sc., RD

Respiratory Structures

ü The respiratory structures

include the nose, pharynx,
larynx, trachea, bronchi,
bronchioles, alveolar ducts,
and alveoli.
ü Supporting structures
include the skeleton and the
muscles (e.g., the
intercostal, abdominal, and
diaphragm muscles).
 Pulmonary System Respiratory Center
• The air traverses through
upper and lower airways
(see Figure 34-1, A) and
reaches alveoli (see Figure
34-1, B). Electrical impulse
• The alveoli are surrounded
by capillaries where gas
exchange takes place (see
Figure 34-1, C). diaphragm and other
• The large pulmonary blood respiratory muscles
vessels and the conducting
airways are located in a
welldefined connective
tissue compartment—the increases the intrathoracic
pleural cavity. volume

negative intrathoracic pressure

allows air to be sucked in
Function of Gas Exchange

Pulmonary The lungs enable the body to obtain the oxygen needed to meet its cellular metabolic
demands and to remove the carbon dioxide (CO2) produced.
System Healthy nerves, blood, and lymph are needed to supply oxygen and nutrients to all
tissues.

Filter, warm, and humidify inspired air

Part of the body’s immune defense system

Mucus keeps the airways moist and traps the particles and microorganisms from inspired air.
The airways have 12 types of epithelial cells, and most cells that line the trachea, bronchi, and
bronchioles have cilia, The epithelial surface of the alveoli contains macrophages, The alveolar
cells also secrete surfactant
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 à most
wellness programs and offer
ideal settings for nutrition
education
Sign symptom
Most burdensome cancer symptom, occurs in 15% to 55% of lung cancer
patients at diagnosis
Dyspnea [shortness of Other factors pericardial effusion, anemia, fatigue, depression, anxiety,
metastatic involvement of other organs, aspiration, anorexia-cachexia
breath] syndrome, and pleural effusion.

weight loss is associated with increasing mortality

Progressive weight weight loss of even 5% indicates a poor prognosis.
Malnutrition impairs the contractility of the respiratory muscles, affecting
loss endurance and respiratory mechanics.

present in 50% to 75% of lung cancer

Cough occurs most frequently in squamous cell and small cell carcinoma because of their tendency to involve central airways
(Huhmann and Camporeale, 2012).

tumor may produce pleuritic pain because of tumor extension into the
Pain and fatigue pleura, or musculoskeletal type pain because of extension

defined by a BMI of less than 20 or a weight less than 90% of IBW (Bellini,
Pulmonary cachexia 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.
NUTRITIONAL ASESSMENT IN LUNG CANCER
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)
PART ONE HAS ENDED

PLEASE FIND NEXT PART-2

MNT FOR PULMONARY
DISEASES PART
2

CLEONARA YANUAR DINI,

M.Sc., RD
MNT FOR LUNG
CANCER Accepted components of oral nutrition
therapy are the following:
1. Small frequent meals that are high in
fat and protein and low in carbohydrate
2. Provision of adequate calories that
meet or exceed the resting energy
expenditure (REE)
3. Rest before meals
4. Meals that require minimal
preparation
5. Oral supplements with the ratio of
fat: carbohydrate of 3:1 that are better
tolerated because the respiratory
quotient for carbohydrates is 1.0 and for
fats is only 0.7 and thus results in
decreased work of breathing (Bellini,
2013)
MNT FOR LUNG • Increase consumption of fruits
and vegetables may beneficial
CANCER • Providing foods and beverages
and nutritional supplements in
the forms and at the times best
tolerated by the patients is
essential
• Administering oral medications
with calorically dense
nutritional supplements is
another means of supplying
needed nutrients

Nutritional interventions include

• dietary advice
• oral nutritional supplements (ONS)
• enteral tube feeding (ETF)
• parenteral nutrition (PN)
• Certain chemotherapy agents require an
empty stomach to optimise absorption
• Avoid eating one hour before or up to
two hours after taking such medication

• Help patients to maintain
weight, improve tolerance to
treatment, maximise
outcomes and improve QoL.
• Patients may require
nutritional support from the
onset at diagnosis, during
treatment and throughout the
whole patient journey, with
early use of oral nutritional
supplements (ONS).
• ONS can improve energy
intake and reduce weight loss
in cancer
NUTRITIONAL SUPPORT
• Nutritional intervention with ONS
can also improve QoL in patients
who are malnourished and may
also result in cost savings
• Systematic reviews and NICE
Clinical Guidance 32 have
demonstrated ONS clinical efficacy
and cost-effectiveness of ONS in
the management of malnutrition,
particularly amongst those patients
with a low Body Mass Index
(BMI<20kg/m2)
 PNEUMONIA

An inflammatory condition of the lungs that

Infection/
causes chest pain, fever, cough, and dyspnea foreign
material

Alveoli
inflamed

Air sacs fill

with fluid
or pus
cough,
fever, chills
and
labored
breathing
• Objective: provide adequate fluids and energy
• Small, frequent meals of nourishing foods
usually are better tolerated, coupled with
proper positioning during eating
• EFAà ingestion of alfa linolenic and linoleic
acidsà protective effects against pneumonia

Society of Critical Care Medicine and American

Society for Parenteral and Enteral Nutrition
(SCCM/ASPEN) guidelines,2009.

MNT FOR
PNEUMONIA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
• COPD is now the third most common cause of death in the world and is
predicted to be the fifth most common cause of disability by 2020
(Burney et al, 2014).
• Patients with COPD suffer from decreased food intake and malnutrition
that causes respiratory muscle weakness, increased disability, increased
susceptibility to infections, and hormonal alterations.
 Pathophysiology
• COPD is a term that encompasses • COPD exacerbations can be caused
chronic bronchitis and emphysema by Haemophilus influenzae,
• These conditions may coexist in Moraxella catarrhalis, S.
varying degrees and are generally not pneumonia, rhinovirus, coronavirus,
reversible. and to a lesser degree, organisms
• Patients with primary emphysema such as P. aeruginosa, S. aureus,
suffer from greater dyspnea and Mycoplasma spp., and Chlamydia
cachexia. pneumoniae.
• Patients with bronchitis have hypoxia, • Allergies, smoking, congestive heart
hypercapnia and complications such failure, pulmonary embolism,
as pulmonary hypertension and right pneumonia, and systemic infections
heart failure (Papaioannou et al, are the reason for 20% to 40% of
2013). COPD exacerbations (Nakawah et
• Chronic bronchitis: a long-term condition of al, 2013).
COPD in which inflamed bronchi lead to mucus,
cough and difficulty breathing
• Emphysema: a form of long-term lung disease
characterized by the destruction of lung
parenchyma with lack of elastic recoil.
• Hypercapnia : increased amount of carbon
dioxide
Let’s start the
third part
MNT FOR PULMONARY
DISEASES PART 3

CLEONARA YANUAR DINI,

M.Sc., RD
COPD AND INADEQUATE FOOD
INTAKE
Prevalence rates of 30% to 60%
Extra energy required by the work of breathing
MALNUTRITION and frequent and recurrent respiratory
infections
inadequate electrolyte repletion related to
refeeding syndrome
• independent predictor of increased mortality in
LOW BODY WEIGHT COPD patients
• Poor nutritional intake, an increased metabolic
rate, or both
• independent risk factor for mortality,
WEIGHT LOSS • weight gain reverses the negative effect of
decreased body weight (Berman, 2011).

DEPLETION OF PROTEIN • calcium, magnesium, potassium, and

phosphorus
AND VITAL MINERALS
• respiratory muscle function impairment.
 Osteoporosis on COPD

Osteoporosis in COPD patients not only predisposes

patients to painful vertebral fractures but also affects
lung function by altering the configuration of the
chest wall.

• Frequent acute exacerbations in COPD patients

increase the severity of chronic system
inflammation.
• This leads to bone loss by inhibiting bone
metabolism.
• Lack of sun exposure and physical activity with
COPD leads to a lack of 25-hydroxy vitamin D (25-
OHD), which regulates bone metabolism by
promoting the absorption of calcium (Xiaomei et
al, 2014).
 NUTRITION INTERVENTION
• In stable COPD, requirements
for water, and macronutrient
are determined by the • Repletion but not overfeeding is
underlying lung disease, oxygen particularly critical in patients
therapy, medications, weight
status, and any acute fluid with compromised ability to
fluctuations. exchange gases as excess
feeding of calories results in
• Determination of a specific CO2 that must be expelled.
patient’s macronutrient needs is • Other concurrent disease
made on an individual basis, processes such as
with close monitoring of
outcomes cardiovascular or renal disease,
cancer, or diabetes affect the
total amounts, ratios, and kinds
of protein, fat, and
carbohydrate prescribed.

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
 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
• In theory, intake of long-chain omega-3 PUFAs, which reduces
inflammation, should improve the efficacy of COPD treatments.
• PUFA supplementation is beneficial in COPD, but various factors such as
supplement adherence, comorbidities, and duration of the
supplementation play vital roles(Fulton et al, 2012).

• Dietary supplementation of DHA and AA has been shown to delay and

reduce risk of upper respiratory infections and asthma, with lowering the
incidence of bronchiolitis during the first year of life. Data from various
studies have shown the positive impact of long-chain PUFAs in initiating
and providing resolution of inflammation in respiratory diseases (Shek et
al, 2012).
Protein
• Sufficient protein
of 1.2 to 1.5 g/kg
of dry body
weight is
necessary to
maintain or
restore lung and
muscle strength,
as well as to
promote immune
function.

• Vitamin and mineral requirements for
individuals with stable COPD depend on the
underlying pathologic conditions of the lung,
other concurrent diseases, medical
treatments, weight status, and bone mineral
density.
• For people continuing to smoke tobacco,
additional vitamin C is necessary
• The role of minerals such as magnesium and
calcium in muscle contraction and relaxation
may be important for people with COPD.
• Intakes at least equivalent to the dietary
reference intake (DRI) should be provided.
Vitamins and
Minerals
• Depending on bone mineral density test
results, coupled with food intake history and
glucocorticoid medications use, additional
vitamins D and K also may be necessary
• Patients with cor pulmonale and subsequent
fluid retention require sodium and fluid
restriction. Depending on the diuretics
prescribed, increased potassium
supplementation may be required. And other
water soluble vitamins, particularly thiamin,
may need to be supplemented.
 Water Requirement
• Drink adequate fluids and stay • COPD patients report difficulties with
hydrated to help sputum consistency eating because of low appetite,
and easier expectoration. increased breathlessness when
eating, difficulty shopping and
preparing meals, dry mouth, early
• The Parenteral and Enteral Nutrition satiety and bloating, anxiety and
Group (PENG) recommends a fluid depression, and fatigue.
intake of 35 ml/kg body weight daily
for adults 18 to 60 years and 30 ml of
fluid/kg body daily for adults over 60 • In addition to the above, inefficient
years (PENG, 2011). and overworking respiratory muscles
lead to increased nutritional
requirements
Patients in the Advanced Stage of COPD
• Patients with advanced COPD are
undernourished and in a state of
pulmonary cachexia.
• Osteoporosis exists as a significant
problem in 24% to 69% of patients
with advanced COPD (Evans and
Morgan, 2014) because of
immobility, which also leads to
deconditioning and dyspnea.
• Smoking, low BMI, low skeletal
muscle mass, and corticosteroid
usage can lead to bone loss along
with low serum vitamin D levels
(Evans and Morgan, 2014)
The End of Part 3
LETS GO TO THE
PART 4
 PART 4
MNT FOR PULMONARY
DISEASES

CLEONARA YANUAR DINI,

M.Sc., RD
 TUBERCULOSIS
• Mycobacterium tuberculosis: an intracellular bacterial parasite, has
a slow rate of growth, is an obligate aerobe, and induces a
granulomatous response in the tissues of a normal host.

• When an infectious TB patient coughs, the cough droplets contain

tuberculous bacilli. Small particles penetrate deep into the lungs.
Each of these tiny droplets may carry 1 to 5 bacilli, which are
enough to establish infection. This is the reason why cases of active
TB must be isolated till they become noninfectious.

• Chest radiograph, chronic cough, prolonged fever, night sweats,

anorexia and weight loss.

• As soon as the diagnosis is established, treatment with four anti-TB

medications - INH, rifampin, pyrazinamide and thambutol - is
started.

• These medications are continued for 2 months, and then only

rifampin and INH are continued for 4 more months.
 MALNUTRITION AND TUBERCULOSIS
• Malnutrition is common in
patients with pulmonary TB,
and nutritional
supplementation is necessary.
• TB leads to or worsens any
preexisting condition of
malnutrition and increases
catabolism.
• Active TB is associated with
weight loss, cachexia, and low
serum concentration of leptin.
• Malnutrition increases the risk of infection,
early progression of infection to produce
active TB.
• In the long term, malnutrition increases the
risk of reactivation of the TB disease.
• Malnutrition also can lower the effectiveness
of the anti-TB drug regime, which patients
have to be on for several months.
• The efficacy of Bacillus Calmette-Guerin
(BCG) vaccine can also be impaired by
malnutrition.
 DIETARY INTERVENTION
Energy
• Current energy
recommendations are those for
undernourished and catabolic Protein
patients, 35 to 40 kcal/kg of • Protein is vital in preventing
ideal body weight. muscle tissue wastage and
• For patients with any an intake of 15% of energy
concomitant infections such as needs or 1.2 to 1.5 g/kg
HIV, energy requirements ideal body weight,
increase by 20% to 30% to approximately 75 to 100 g
maintain body weight. per day, is recommended.
 Vitamins and Minerals
• Provides 50% to 150% of the RDA is helpful
• Nutrients such as vitamin A, the B vitamins, vitamins C and E, zinc,
and selenium are usually deficient in TB
• Vitamin D deficiencies are common with TB and result because of
an insufficient vitamin D intake and limited exposure to sunlight
• Isoniazid is an antagonist of vitamin B6 (pyridoxine) and is frequently
used in TB treatmentà nutritional depletion of vitamin B6 àperipheral
neuropathy

• Iron deficiency anemia is the most important contributor in the

development of anemia in TB patients (Isanaka et al, 2012). Evidence
indicates that excess iron supplementation may be dangerous to TB
patients, and the use of iron therapy is not universally recommended.
However, if iron studies show iron deficiency, iron therapy is then
initiated
Respiratory failure
• RF occurs when the pulmonary system is unable to
perform its functions
• Traumatic, surgical, medical
• Acute respiratory distress syndrome is a common
complication of critical illness
• Patients requires oxygen provided through a nasal
cannula or by mechanical ventilator support for
varying lengths of time and at various level of oxygen
• Hypercatabolism or hypermetabolism may be present
MNT for 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

Carbohydrate and Fat

• Affecting by underlying organ systems
decompensation, patient’s respiratory
status,ventilation method used
THE END

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