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Nutrition

and
Pulmonary Problems
Bambang Heru Handojo
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Pulmonary Problems
• Infection - Immunocompromised
• Acute Respiratory Failure
• Acute Respiratory Distress Syndrome
• Chronic Obstructive Pulmonary Disease
• Pneumonia
• Mechanical Ventilation
• Weaning From Mechanical Ventilation
• Pulmonary Aspiration
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Starvation



 respiratory epithelium:
 integrity 
 ciliary's function 

 pulmonary defense mechanism 
Malnutrition in Pulmonary
Problem
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Short-term starvation

surfactant:
secretion 
synthesis 
Edelman NH, Rucker RB, Peavy HH. Nutrition and the
respiratory system. Rev Respir Dis. 1986:134:347–352
Malnutrition in Pulmonary Problem
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Malnutrition in Pulmonary Problem
Malnutrition

System Immune Mechanism 

Susceptible to Infection

Pulmonary Tuberculosis, Mycosis et al
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Malnutrition in Pulmonary
Problem
Malnutrition

respiratory muscle endurance 
loss of strength
fatigue

alveolar ventilation 
hypercarbia
Hagaman M, Christian JW. Nutrition support in acute
respiratory failure. Cont Intern Med. 1994;6(7):29–41.
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Malnutrition + Critical illness

expansion ECF
reduction ICF

anasarca
interstitial lungs water
Hagaman M, Christian JW. Nutrition support in acute
respiratory failure. Cont Intern Med. 1994;6(7):29–41.
Malnutrition in Pulmonary
Problem
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Goals of Nutrition Therapy
Preventing malnutrition
Energy supply for breathing
Prevent or minimized loss of respiratory
muscle mass
Weaning from Mechanical Ventilation

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ACUTE RESPIRATORY FAILURE
is the absence of the normal homeostatic state of
ventilation as it relates to acid-base status of the
blood and the exchange of O2 and CO2

PaO2 < 60 mm Hg, FiO2 > 0.5
PaCO2 > 50 mmHg, pH < 7.25



MECHANICAL VENTILATION
Acute Respiratory Failure
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Score of ALI:
Chest Radiograph (1-4 quad>: 0-4
Hypoxemia Score <PaO2/FiO2>: 0-4
PEEP Score: 0-4
Respiratory System Compliance: 0-4

No Lung Injury: 0
Mild to Moderate Lung Injury: 0.1 – 2.5
Severe Lung Injury (ARDS): > 2.5
Acute Lung Injury
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ARDS
Acute Respiratory Distress
Syndrome
• Direct insult
aspiration of gastric content, inhalation of toxic
substances, high inspired oxygen, drugs,
pneumonitis, pulmonary contusion, radiation

• Indirect insult
sepsis syndrome, multisystem trauma, shock,
pancreatitis, pulmonary embolism, disseminated
intravascular clotting, fat embolism, bypass
surgery
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EPA & DHA
Anti inflammatory effect
1. displacing AA from the cell membrane of alveolar
macrophage and neutrophils, thereby decreasing
its release by PLA
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2. competing with AA for metabolism by COX & LO
3. inhibiting release of AA from membrane
phospholipids and its further metabolism
4. decreasing cytokine-mediated induction of
inflammatory gene expression ( eg. COX-2, TNF,
IL-1, adhesion molecules)
Grimble, Proc Nutr Soc1998
Graber et all, J Lipid Mediat Cell Sig 1994
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Therapeutic Goals ARDS
1. Improve oxygen delivery & provide
hemodynamic support
2. Reduce oxygen consumption
3. Individualize nutritional support
4. Optimize gas exchange
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CHO
Fat
Protein
O
2

(L/g)

0,7
2
1
CO
2
prod
(L/g)

0,7
1,4
0,8
E pot
(Kkal/g)

4
9
4
O
2
Consumption & CO
2

Production
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Recommendations for ARDS
• Prevent over and under-feeding
• Energy needs 25 – 30 kcal/kg BW
• Protein needs 1.2 – 1.5 g /kg IBW
• Enteral nutrition if possible
• Diet supplemented with EPA or EPA+GLA for 4-7 days
• Provide certain micronutrients
• Prevent fluid overload
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INDICATION
• Acute Respiratory Failure
• After major surgery
• Therapeutic hyperventilation (intracranial
hypertension)
Mechanical Ventilation
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• The process of withdrawing from
mechanical ventilatory support
• True weaning is required in patient in whom
the respiratory muscles are weakened and
detrained
• Complication: malnutrition, stress &
immobility
Weaning From Mechanical
Ventilation
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• Controlled Mechanical Ventilation (CMV)
• Pressure Control

• Assist/Control
• Intermittent Mandatory Ventilation (IMV/SIMV)

• Pressure Support (PS)
• Continuous Positive Airway Pressure (CPAP)
MECHANICAL VENTILATION MODE
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• 20% of mechanically ventilated patients fail their
first attempt at weaning
• > 40% of the time on mechanical ventilation spent
for weaning
• The causes of prolonged ventilator dependency
are:
 Hypoxemic respiratory failure
 Respiratory muscle pump failure
 Psychological factors (frustration, uncertainty,
hopelessness, fear, and lack of mastery)
Apostolakos MJ. Weaning from mechanical ventilation.
In Critical Care The Requisites in Anesthesiology 2005:190-194
The Weaning from Mechanical
Ventilation
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• Central Nervous System – Unconciousness
• Infection – Uncontroled
• Bronchodilator – Insufficient
• Physiotherapy
• Nutrition
• Fluid – Imbalanced
• Blood & Electrolyte - disturbance
The Common Problems in Weaning
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• Fluid overload
• Acid-base changes
• Electrolyte disturbances
– Hypocalcemia, hypophosphatemia &
hypomagnesemia
Apostolakos MJ. Weaning from mechanical ventilation.
In Critical Care The Requisites in Anesthesiology 2005:190-194
The Common Problems in Weaning
- Relation to Nutrition Therapy
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• Nutritional repletion:
  muscle mass &  fatigability of non-
respiratory muscles
 facilitate weaning

Apostolakos MJ. Weaning from mechanical ventilation.
In Critical Care The Requisites in Anesthesiology 2005:190-194
The Common Problems in Weaning
- Relation to Nutrition Therapy
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The Risk of Nutrition
Therapy
Tube Feeding  ASPIRATION
Refeeding Syndrome
Hypercapnia


Tube Feeding
Risk factors of aspiration in tube feeding:
• Malpositioned feeding tube
• Improper feeding site
• Large gastric volume
• Supine position
• Volume of Feeding
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Overfeeding
Overfeeding

High CO
2
production
+
respiratory function 

respiratory failure
• Hyperglycemia
• Dyslipidemia
• Hepatic steatosis
• Hypophosphatemia
• Hypokalemia
• Hypomagnesemia
• Fluid overload

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Chronic Obstructive Pulmonary Disease
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COPD
Causes of COPD
 airflow obstruction
 hyperinflation and air trapping
 flattening of the diaphragm
 increased residual volume
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Nutrition depletion in COPD
Anorexia
Hyper-metabolism (WOB )
+
Inadequate calorie + protein intake

primary lung parenchymal disease
immunocompromise
respiratory muscle wasting
respiratory dysfunction

intubation & mechanical ventilation
The recommended daily diet
for COPD
• should be:
• - 28% calorie intake from carbohydrates
• - 55% calorie intake from Fat
• - 12-20% calorie intake from protein



• The 44th International Respiratory Congress Abstracts-On-Disk®, November 7 - 10, 1998, Atlanta, Georgia.

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Clinical Nutrition 2006
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Micronutrient Requirement



Phosphorus
Magnesium
Potassium
Vitamin A
Pyridoxine
Zn
Co
Se
Vit E, vit C, beta carotene

Gizi dan Rehabilitasi Paru
• Insidens malnutrition yg tinggi pada
Pasien Rehabilitasi Paru, akan
meningkatkan suseptibilitas infeksi
dan mengakibatkan tingginya
mortalitas dan morbiditas
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Pulmonary Problems
• Infection - Immunocompromised
• Acute Respiratory Failure
• Acute Respiratory Distress Syndrome
• Chronic Obstructive Pulmonary Disease
• Pneumonia
• Mechanical Ventilation
• Weaning From Mechanical Ventilation
• Pulmonary Aspiration
• Prolonged Nasogastric tube - cough
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Pulmonary Problems
• Calori in Ventilated Patient – Incr or Decr
• PEG – in Prolonged NGT