Medical Nutrition Therapy

in Pulmonary Disease
Malnutrition and the
Pulmonary System
Malnutrition impairs
 Respiratory muscle function

 Ventilatory drive

 Response to hypoxia

 Pulmonary defense mechanisms

Effects of Malnutrition in
Pts without Lung Disease
 Respiratory muscle strength ↓ by 37%
 Maximum voluntary ventilation ↓ by
41% (1)
 Vital capacity (lung volume)↓ 63% (1)
 Diaphragmatic muscle mass ↓ to 60%
of normal in underweight patients who
died of other ailments (2)
1. Aurora N, Rochester, D. Am Rev Respir Dis 126:5-8, 1982
2. Aurora N, Rochester D. J Appl Physiol: Respirat Environ Exercise physiol 52:64-70, 1982
Effects of Malnutrition in Pts
with Pulmonary Disease
 Decreased cough and inability to
mobilize secretions
 Atelectasis and pneumonia
 Prolonged mechanical ventilation and
difficulty weaning with prolonged ICU
stay
Effects of Malnutrition in Pts
with Pulmonary Disease
 Altered host immune response and cell-
mediated immunity
 Contributes to chronic or repeated
pulmonary infections
 Decreased surfactant production
 Decreased lung elasticity
 Decreased ability to repair injured lung
tissue
Normal Lung Anatomy
Selected Airway Disorders
Chronic Pulmonary
Disorders
 Bronchopulmonary displasia
 Cystic fibrosis

 Tuberculosis

 Bronchial asthma

 Chronic obstructive pulmonary

disease (COPD)
Acute Pulmonary
Disorders
 Pulmonary aspiration
 Pneumonia

 Tuberculosis

 Cancer of the lung

 Acute respiratory distress syndrome

 Pulmonary failure
Pulmonary Conditions w/
Nutritional Implications
Neonate Bronchopulmonary displasia
(BPD)
Obstruction Cystic fibrosis (CF)
Chronic obstructive pulmonary
disease (COPD)
Emphysema

Chronic bronchitis

Asthma

Tumor Lung cancer

Pulmonary Conditions w/
Nutritional Implications
Infection Pneumonia
Tuberculosis (TB)

Respiratory Acute respiratory failure

Failure Lung transplantation

Neuro- Muscular dystrophy

muscular Paralysis
Abnormalities
Pulmonary Conditions w/
Nutritional Implications
Skeletal Osteoporosis
Scoliosis

Cardiovascular Pulmonary edema

Endocrine Severe obesity

Prader-Willi syndrome
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
Adverse Effects of Lung
Disease on Nutritional Status
Reduced intake
 Fluid restriction

 Shortness of breath

 Decreased oxygen saturation when

eating
 Anorexia due to chronic disease

 Gastrointestinal distress and vomiting

Adverse Effects of Lung
Disease on Nutritional Status
Additional limitations
 Difficulty preparing food due to fatigue

 Lack of financial resources

 Impaired feeding skills (for infants and

children)
 Altered metabolism
Chronic Lung Disease
Bronchopulmonary
Dysplasia: Pathophysiology
 Chronic lung condition in newborns that
often follows respiratory distress
syndrome (RDS) and treatment with
oxygen
 Characterized by broncheolar
metaplasia and interstitial fibrosis
 Occurs most frequently in infants who
are premature or low birth weight
BPD: Signs and
Symptoms
 Hypercapnea (CO2 retention)
 Tachypnea
 Wheezing
 Dyspnea
 Recurrent respiratory infections
 Cor pulmonale (right ventricular
enlargement of the heart)
Growth Failure in BPD

 Increased energy needs

 Inadequate dietary intake
 Gastroesophageal reflux
 Emotional deprivation
 Chronic hypoxia
Goals of Nutritional
Management in BPD
 Meet nutritional needs
 Promote linear growth
 Develop age-appropriate feeding skills
 Maintain fluid balance
Energy Needs in BPD
 REE in infants with BPD is 25-50% higher
than in age-matched controls
 Babies with growth failure may have needs
50% higher
 Energy needs in acute phase (PN, controlled
temperature) 50-85 kcals/kg
 Energy needs in convalescence (oral feeds,
activity, temperature regulation) as high as
120-130 kcals/kg
Protein Needs in Babies
with BPD
 Protein: within advised range for
infants of comparable post-
conceptional age
 As energy density of the diet is
increased by the addition of fat and
carbohydrate, protein should still
provide 7% or more of total kcals
Macronutrient Mix in BPD
 Fat and carbohydrate should be added
to formula only after it has been
concentrated to 24 kcals/oz to keep
protein high enough
 Fat provides EFA and energy when
tolerance for fluid and carbohydrate is
limited
 Excess CHO increases RQ and CO2
output
Fluid in BPD

 Infants with BPD may require fluid

restriction, sodium restriction, and
long term treatment with diuretics
 Use of parenteral lipids or calorically
dense enteral feeds may help the
infant meet energy needs
Mineral Needs in BPD
 Often driven by the baby’s premature status
 Lack of mineral stores as a result of
prematurity (iron, zinc, calcium)
 Growth delay
 Medications: diuretics, bronchodilators,
antibiotics, cardiac antiarrhythmics,
corticosteroids associated with loss of
minerals including chloride, potassium,
calcium
Vitamin Needs in BPD

 Interest in antioxidants, including

vitamin A for role in developing
epithelial cells of the respiratory tract
 Provide intake based on the DRI,
including total energy, to promote
catchup growth
Feeding Strategies in BPD

 Calorically dense formulas or boosted

breast milk (monitor fluid status and
urinary output)
 Small, frequent feedings
 Use of a soft nipple
 Nasogastric or gastrostomy tube
feedings
Feeding Strategies in
Gastroesophageal Reflux
 Thickened feedings (add rice cereal to
formula)
 Upright positioning
 Medications like antacids or histamine
H2 blockers
 Surgical fundoplication
Long Term Feeding
Problems in BPD
 History of unpleasant oral experiences
(intubation, frequent suctioning, recurrent
vomiting)
 History of non-oral feedings
 Delayed introduction of solids
 Discomfort or choking associated with
eating solids
 Infants may tire easily while breast-feeding
or bottle feeding
 May require intervention of interdisciplinary
feeding team
Cystic Fibrosis
 Inherited autosomal recessive disorder
 2-5% of the white population are
heterozygous
 CF incidence of 1:2500 live births
 30,000 people treated at CF centers in the
U.S.
 Survival is improving; median age of
patients has exceeded 30 years
Cystic Fibrosis
 Epithelial cells and exocrine glands secrete
abnormal mucus (thick)
 Affects respiratory tract, sweat, salivary,
intestine, pancreas, liver, reproductive tract
Diagnosis of Cystic
Fibrosis
 Neonatal screening provides
opportunity to prevent malnutrition in
CF infants
 Sweat test (Na and Cl >60 mEq/L)
 Chronic lung disease
 Failure to thrive
 Malabsorption
 Family history
Nutritional Implications
of CF
 Infants born with meconium ileus are
highly likely to have CF
 85% of persons with CF have
pancreatic insufficiency
 Plugs of mucus reduce the digestive
enzymes released from the pancreas
causing maldigestion of food and
malabsorption of nutrients
Nutritional Implications
of CF
 Decreased bicarbonate secretion
reduces digestive enzyme activity
 Decreased bile acid reabsorption
contributes to fat malabsorption
 Excessive mucus lining the GI tract
prevents nutrient absorption by the
microvilli
Gastrointestinal
Complications of CF
 Bulky, foul-smelling stools
 Cramping and intestinal obstruction
 Rectal prolapse
 Liver involvement
 Pancreatic damage causes impaired
glucose tolerance (50% of adults with CF)
and development of diabetes (15% of
adults with CF)
Nutritional Care Goals
 Control malabsorption
 Provide adequate nutrients for
growth
or maintain weight for height or
pulmonary function
 Prevent nutritional deficiencies
Common Treatments
 Pancreatic enzyme replacement
 Adjust macronutrients for symptoms
 Nutrients for growth
 Meconium ileus equivalent: intestinal
obstruction (enzymes, fiber, fluids,
exercise, stool softeners)
Pancreatic Enzyme
Replacement
 Introduced in the early 1980s
 Enteric-coated enzyme microspheres
withstand acidic environment of the
stomach
 Release enzymes in the duodenum,
where they digest protein, fat and
carbohydrate
Pancreatic Enzyme
Replacement
Dosage depends on
 Degree of pancreatic insufficiency

 Quantity of food eaten

 Fat, protein, and carbohydrate content

of food eaten
 Type of enzymes used
Pancreatic Enzyme
Replacement
 Enzyme dosage limited to 2500 lipase units
per kilogram of body weight per meal
 Adjusted empirically to control
gastrointestinal symptoms, including
steatorrhea, and promote growth
 Fecal fat or nitrogen balance studies may
help to evaluate the adequacy of enzyme
supplementation
Distal Intestinal
Obstruction Syndrome
 AKA recurrent intestinal impaction
 Occurs in children and adults
 Prevention includes adequate enzymes,
fluids, dietary fiber, and regular exercise
 Treatment involves stool softeners,
laxatives, hyperosmolar enemas,
intestinal lavage
Estimation of Energy
Needs in CF
 Use WHO equations to estimate BMR
 Multiply by activity coefficient +
disease coefficient
 TEE – BMR X (AC + DC)
 Disease coefficient is based on lung
function
Disease Coefficient in CF

 Normal lung function = 0.0

 Moderate lung disease = 0.2
– FEV1 40-79% of that predicted
 Severe lung disease = 0.3
– FEV1 <40% of that predicted

 FEV = forced expiratory volume

Example Equation TEE in
CF
 Male patient 22 years old, weight 54
kg, relatively sedentary
 FEV1 is 60% of predicted (moderate
lung disease)
 TEE = BMR X (1.5 + 0.2)
 TEE = [(15.3 (54) + 679] X 1.7
 TEE = 2559 kcals
Calculate the Daily Energy
Requirement (DER)
 Takes into account steatorrhea
 Pancreatic sufficiency: TEE = DER
– Pancreatic sufficiency is Coefficient of fat
absorption >93% of intake
 Pancreatic insufficiency: DER = TEE
(0.93/CFA)
– CFA is a fraction of fat intake based on
stool collections
Calculation of DER in CF

 72-hour fecal fat collections reveals

that CFA is 78% of intake
 DER = TEE X (.93/CFA)
 = 2559 X (0.93/.78)
 = 2559 X 1.19
 DER = 3045 kcals/day
Protein in CF

 Protein needs are increased in CF due

to malabsorption
 If energy needs are met, protein
needs are usually met by following
typical American diet (15-20% protein)
or use RDA
Fat Intake in CF
 Fat intake 35-40% of calories, as tolerated
 Helps provide required energy, essential
fatty acids and fat-soluble vitamins
 Limits volume of food needed to meet
energy demands and improves palatability
of the diet
 EFA deficiency sometimes occurs in CF
patients despite intake and pancreatic
enzymes
Symptoms of Fat
Intolerance
 Increased frequency of stools
 Greasy stools
 Abdominal cramping
Carbohydrate in CF

 Eventually intake may need to be

modified if glucose intolerance
develops
 Some patients develop lactose
intolerance
Vitamins in CF

 With pancreatic enzymes, water

soluble vitamins usually adequately
absorbed with daily multivitamin
 Will need high potency
supplementation of fat soluble
vitamins (A, D, K, E)
Minerals in CF

 Intake of minerals should meet DRI

for age and sex
 Sodium requirements increased due to
loss in sweat
– North American diet usually provides
enough
– Infants need supplementation (1/4-1/2
teaspoon/day)
Minerals in CF

 Decreased bone mineralization, low

iron stores, and low magnesium levels
have all been described in CF
Feeding Strategies in CF:
Infants
 Breast feeding with supplements of
high-calorie formulas and pancreatic
enzymes
 Calorie dense infant formulas (20-27
kcals/oz) with enzymes
 Protein hydrolysate formulas with MCT
oil if needed
Feeding Strategies in CF:
children and adults
 Regular mealtimes
 Large portions
 Extra snacks
 Nutrient-dense foods
 Nocturnal enteral feedings
– Intact or hydrolyzed formulas
– Add enzyme powder to feeding or take
before and during
Nutritional Implications
of Tuberculosis
 TB is making a
comeback
 Many patients are
developing drug-
resistant TB
Nutritional Factors that
Increase Risk of TB
 Protein-energy malnutrition: affects
the immune system; debate whether it
is a cause or consequence of the
disease
 Micronutrient deficiencies that affect
immune function (vitamin D, A, C,
iron, zinc)
Nutritional Consequences
of TB
 Increased energy expenditure
 Loss of appetite and body weight
 Increase in protein catabolism leading
to muscle breakdown
 Malabsorption causing diarrhea, loss of
fluids, electrolytes
Nutritional Needs in TB

 Energy: 35-40 kcals/kg of ideal body

weight
 Protein: 1.2-1.5 grams/kg body
weight, or 15% of energy or 75-100
grams/day
 Multivitamin-mineral supplement at
100-150% DRI
Chronic Obstructive
Pulmonary Disease (COPD)
Characterized by airway obstruction
 Emphysema: abnormal, permanent
enlargement of alveoli, accompanied by
destruction of their walls without
obvious fibrosis
 Chronic bronchitis: chronic, productive
cough with inflammation of one or more
of the bronchi and secondary changes in
lung tissue
Chronic Obstructive
Pulmonary Disease (COPD)
 Emphysema: patients are thin, often
cachectic; older, mild hypoxia, normal
hematocrits
 Chronic bronchitis: of normal weight;
often overweight; hypoxia; high
hematocrit
Chronic Obstructive
Pulmonary Disease (COPD)
 Bronchospasm: asthma
 Cor pumonale: heart condition
characterized by right ventricular
enlargement and failure that results
from resistance to passage of blood
through the lungs
Chronic Bronchitis
Emphysema
Bronchial Asthma
 Food sensitivities may be triggers for
asthmatic episodes (sulfites, shrimp,
herbs) but not the most common
causes
 Provide healthy diet and maintain
healthy weight
 Be aware of drug nutrient interactions
(steroids)
MNT Assessment in COPD
 Fluid balance and requirements
 Energy needs
 Food intake (decreased intake common)
 Morning headache and confusion from
hypercapnia (excessive CO2 in the
blood)
 Fat free mass
MNT Assessment in COPD
 Food drug interactions
 Fatigue
 Anorexia
 Difficulty chewing/swallowing because of
dyspnea
 Impaired peristalsis secondary to lack of
oxygen to the GI tract
 Underweight patients have the highest
morbidity/mortality
Nutrient Needs in Stable
COPD
 Protein: 1.2-1.7 grams/kg (15-20% of
calories) to restore lung and muscle
strength and promote immune function
 Fat: 30-45% of calories
 Carbohydrate: 40-55% of calories
 Maintain appropriate RQ
 Address other underlying diseases
(diabetes, heart disease)
Nutrient Needs in Stable
COPD
 Vitamins: intakes should at least meet the
DRI
 Smokers may need more vitamin C (+16-32
mg) depending on cigarette use
 Minerals: meet DRIs and monitor
phosphorus and magnesium in patients at
risk for refeeding during aggressive nutrition
support
Treatments for COPD

 Bronchodilators—theophylline and
aminophylline
 Antibiotics—secondary infections
 Respiratory therapy
 Exercise to strengthen muscles
MNT in COPD Based on
Weight/Height
 Routine care
 Anticipatory guidance: 90% IBW
 Supportive intervention: 85% to 90% IBW
 Resuscitative/palliative: below 75% IBW
 Rehabilitative care: consistently below
85% IBW
 JADA—1997
MNT in COPD
 GI motility: adequate exercise, fluids,
dietary fiber
 Abdominal bloating: limit foods
associated with gas formation
 Fatigue: resting before meals, eating
nutrient-dense foods, arrange
assistance with shopping and meal
preparation
MNT in COPD

Suggest that patient

 Use oxygen at mealtimes
 Eat slowly
 Chew foods well
 Engage in social interaction at mealtime
 Coordinate swallowing with breathing
 Use upright posture to reduce risk of
aspiration
MNT in COPD

 Oral supplements
 Nocturnal or supplemental tube
feedings
 Specialized pulmonary
products generally
not necessary
Food Drug Interactions

 Aminoglycosides lower serum Mg++

—may need to replace
 Prednisone—monitor nitrogen, Ca++,
serum glucose, etc.
MNT in Respiratory
Failure
Causes of Acute Lung
Injury (ALI)
 Aspiration of gastric contents or inhalation
of toxic substances
 High inspired oxygen
 Drugs
 Pneumonitis, pulmonary contusions,
radiation
 Sepsis syndrome, multisystem trauma,
shock, ,pancreatitis, pulmonary embolism
Aspiration

 Movement of food or fluid into the

lungs
 Can result in pneumonia or even death
 Increased risk for infants, toddlers,
older adults, persons with oral, upper
gastrointestinal, neurologic, or
muscular abnormalities
Aspiration
 Reported incidence of aspiration in tubefed
patients varies from .8% to 95%. Clinically
significant aspiration 1-4%
 Many aspiration events are “silent” and
often involve oropharyngeal secretions
 Symptoms include dyspnea, tachycardia,
wheezing, rales, anxiety, agitation, cyanosis
 May lead to aspiration pneumonia
Acute Respiratory Distress
Syndrome (ARDS)
 Most severe form of acute lung injury
 Sepsis usually the underlying cause
 Increasing pulmonary capillary
permeability
 Pulmonary edema
 Increased pulmonary vascular resistance
 Progressive hypoxemia
Goals of Treatment of ALI
and ARDS
 Improve oxygen delivery and provide
hemodynamic support
 Reduce oxygen consumption
 Optimize gas exchange
 Individualize nutrition support
Nutrition Assessment in
ALI and ARDS
 Indirect calorimetry best tool to
determine energy needs in critically ill
patients
 In absence of calorimetry, use predictive
equations with stress factors
 Avoid overfeeding
 Patients may need high calorie density
feedings to achieve fluid balance
Nutrition Support in ARDS
 In one randomized, controlled trial in 146 patients
with ARDS, enteral nutrition with omega-3 fatty
acids (eicosapentaenoic acid) gamma-linonenic
acid, and antioxidants appeared to reduce days on
mechanical ventilation, new organ failure, and ICU
length of stay
 This study was sponsored by Ross Laboratories,
makers of Oxepa
 Have been unable to locate further studies since
then
 Gadek JE et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic
acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral
Nutrition in ARDS Study Group. Crit Care Med 1999;27:1409.